Rae Ellen Bichell and Virginia Garcia Pivik
Tue, 03 Oct 2023 09:00:00 +0000

Last year, a student fell unconscious after walking out of a bathroom at Central High School in Pueblo, Colorado. When Jessica Foster, the school district's lead nurse, heard the girl's distraught friends mention drugs, she knew she had to act fast.

Emergency responders were just four minutes away. “But still four minutes — if they are completely not breathing, it's four minutes too long,” Foster said.

Foster said she got a dose of naloxone, a medication that can rapidly reverse an opioid overdose, and gave it to the student. The girl revived.

Forty-five miles away in Colorado Springs, Mitchell High School officials didn't have naloxone on hand when a 15-year-old student overdosed in class in December 2021 after snorting a fentanyl-laced pill in a school bathroom. That student died.

Colorado Springs' school district has since joined Pueblo and dozens of other districts in the state in supplying middle and high schools with the lifesaving medication, often known by one of its brand names, Narcan. Since passage of a 2019 state law, Colorado has had a program that allows schools to obtain the medicine, typically in nasal spray form, for free or at a reduced cost.

Not all schools are on board with the idea, though. Though more districts have signed on since last year, only about a third of Colorado districts had enrolled in the state's giveaway program at the start of this school year. And within the dozen counties with the highest drug overdose death rates in the state, many school districts had not signed up in the face of ongoing stigma around the need for the overdose reversal medication.

The federal Substance Abuse and Mental Health Services Administration recommends that schools, including elementary schools, keep naloxone on hand as fatal opioid overdoses rise, particularly from the potent drug fentanyl. And 33 states have laws that expressly allow schools or school employees to carry, store, or administer naloxone, according to Jon Woodruff, managing attorney at the Legislative Analysis and Public Policy Association, which tracks naloxone policies across the country.

Among those, about nine states require at least some K-12 schools to store naloxone on-site, including Illinois, whose requirement goes into effect in January. Some states, such as Maine, also require that public schools offer training to students in how to administer naloxone in nasal spray form.

Rhode Island requires all K-12 schools, both public and private, to stock naloxone. Joseph Wendelken, a spokesperson for the Rhode Island Department of Health, said in the past four years naloxone was administered nine times to people ages 10 to 18 in educational settings.

In early September, the medication also became available over the counter nationally, though the $45 price tag per two-dose package has some addiction specialists worried it will be out of reach for those who need it most.

But the medicine still isn't as publicly widespread as automated external defibrillators or fire extinguishers. Kate King, president of the National Association of School Nurses, said reluctance to stock it in schools can stem from officials being afraid to provide a medical service or the ongoing cost of resupplying the naloxone and training people to use it. But the main hang-up she's heard is that schools are afraid they'll be stigmatized as a “bad school” that has a drug problem or as a school that condones bad choices.

“School districts are very careful regarding their image,” said Yunuen Cisneros, community outreach and inclusion manager at the Public Education & Business Coalition, which serves most of the state's school districts. “Many of them don't want to accept this program, because to accept it is to accept a drug addiction problem.”

That's the wrong way to think about it, King said. “We really equate it to our stock albuterol for asthma attacks, our stock epinephrine for anaphylactic reactions,” she said.

Colorado health officials could not say how often naloxone had been used on school grounds in the state. So far this year, at least 15 children ages 10 to 18 have died of fentanyl overdoses but not necessarily in schools. And in 2022, 34 children in that age group died, according to the state Department of Public Health and Environment. That included 13-year-old José Hernández, who died in August 2022 from a fentanyl overdose at home just days after starting eighth grade at Aurora Hills Middle School. His grandmother found his body over the bathroom sink in the early morning.

With the arrival of this new school year, supplies of naloxone are on hand for kids in more Colorado schools. Last year, state lawmakers appropriated $19.7 million in federal aid to the Naloxone Bulk Purchase Fund, which is accessible to school districts, jails, first responders, and community service organizations, among others.

“It's the most we've ever had,” said Andrés Guerrero, manager of the state health department's overdose prevention program.

According to data provided by Colorado's health department, 65 school districts were enrolled in the state program to receive naloxone at low or no cost at the start of the school year. Another 16 had reached out to the state for information but hadn't finalized orders as of mid-August. The remaining 97 school districts either didn't stock naloxone at their schools or sourced it from elsewhere.

Guerrero said the districts decide whom to train to administer the medicine. “In some cases, it's just the school nurses. In some cases, it's school nurses and the teachers,” he said. “And in some cases, we have the students as well.”

In Durango, the 2021 death of a high schooler galvanized students to push for the right to carry naloxone with them to school with parental permission — and to administer it if need be — without fear of punishment.

It took picketing outside a school board meeting to get permission, said Hays Stritikus, who graduated this spring from Durango High School. He's now involved in drafting legislation that would expressly allow students across the state to carry and distribute Narcan on school grounds.

“The ultimate goal is a world where Narcan is not necessary,” he said. “But that's just not where we live.”

Some health experts disagree that all schools should stock naloxone. Lauren Cipriano, a health economist at Western University in Canada, has studied the cost-effectiveness of naloxone in secondary schools there. While opioid poisonings have occurred on school grounds, she said, high schools tend to be really low-risk settings.

More effective strategies for combating the opioid epidemic are needle exchange sites, supervised drug consumption sites, and medication-assisted treatment that reduces cravings or mutes highs, Cipriano said. But those approaches can be expensive compared with naloxone distribution.

“When the state makes a big, free program like this, it looks like they're doing something about the opioid epidemic,” she said. “It's cheap and it looks like you're doing something, and that's, like, political gold.”

Denver Public Schools, the largest school district in Colorado, started stocking naloxone in 2022, said Jade Williamson, manager of the district's healthy schools program.

“We know some of the students are on the forefront of these things before older generations,” Williamson said. “To know where to find it, and to access it when needed through these adults who've trained, whether that's a school nurse or a school administrator, I think it brings them some sense of relief.”

The state's seven largest districts, with more than 25,000 students each, all participate in the state program. By contrast, a KFF Health News analysis found, only 21% of districts with up to 1,200 students have signed up for it — even though many of those small districts are in areas with drug overdose death rates higher than the state average.

Some school districts figured out a path to getting naloxone outside of the state program. That includes Pueblo School District 60, where lead nurse Foster gave naloxone to a student last year.

The Pueblo school district gets naloxone at no cost from a local nonprofit called the Southern Colorado Harm Reduction Association. Foster said she tried signing up for the state program but encountered difficulties. So she decided to stick with what was already working.

Moffat County School District RE-1 in Craig, Colorado, gets its naloxone from a local addiction treatment center, according to district nurse Myranda Lyons. She said she trains school staffers on how to administer it when she teaches them CPR.

Christopher deKay, superintendent of Ignacio School District 11Jt, said its school resource officers already carry naloxone but that the district enrolled in the state program, too, so that schools could stock the medication in the nursing office in case a resource officer isn't around.

“It's like everything — like training for fire safety. You don't know what's going to happen in your school,” said deKay. “If the unthinkable happens, we want to be able to respond in the best way possible.”

This story was produced with reporting assistance from El Comercio de Colorado.

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By: Rae Ellen Bichell and Virginia Garcia Pivik
Title: More Schools Stock Overdose Reversal Meds, but Others Worry About Stigma
Sourced From: kffhealthnews.org/news/article/schools-narcan-naloxone-overdose-reversal-colorado/
Published Date: Tue, 03 Oct 2023 09:00:00 +0000

Markian Hawryluk and Renuka Rayasam
Mon, 02 Oct 2023 09:00:00 +0000

The way Sheldon Haleck's parents see it, the 38-year-old's only crime was jaywalking. But that March night in 2015, after Honolulu police found him behaving erratically, they pepper-sprayed him, shocked him with a Taser, and restrained him. Haleck became unresponsive and was taken to a hospital. Before his parents could get from their home in Utah to Hawaii, the former Hawaii Air National Guardsman was taken off life support.

“Nobody's supposed to die from something like this,” said Haleck's father, William.

An initial autopsy ruled Haleck's death a homicide and his family filed a civil lawsuit in federal court against the three officers who tried to remove him from the street. The case should have been “one of the easiest wrongful death cases” to win, said Eric Seitz, an attorney who represented Haleck's family.

But the officers' attorneys seized on a largely discredited, four-decade-old diagnostic theory called “excited delirium,” which has been increasingly used over the past 15 years as a legal defense to explain how a person experiencing severe agitation can die suddenly through no fault of the police. “The entire use of that particular theory, I think, is what convinced the jury,” Seitz said.

Haleck's case is just one legal battle in which the theory of excited delirium exonerated law enforcement despite mounting opposition to the term among most prominent medical groups. The theory has been cited as a defense in the 2020 deaths of George Floyd in Minneapolis; Daniel Prude in Rochester, New York; and Angelo Quinto in Antioch, California. It figures in a criminal trial against two police officers involved in the 2019 death of Elijah McClain in Aurora, Colorado, now underway. It has allowed defense attorneys to argue that individuals in police custody died not of restraint, not of a Taser shock, but of a medical condition that can lead to sudden death.

But now, the American College of Emergency Physicians will vote at an October meeting on whether to formally disavow its 2009 position paper supporting excited delirium as a diagnosis that helped undergird those court cases. The draft resolution also calls on ACEP to discourage physicians who serve as expert witnesses from promoting the theory in criminal and civil trials.

“It's junk science,” said Martin Chenevert, an emergency medicine physician at UCLA Santa Monica Medical Center, who often testifies as an expert witness. The theory has been used to provide a cover for police misconduct, he said. “It had an agenda.”

Passing the resolution wouldn't bring Haleck back, but his parents hope it would prevent other families from experiencing their agony. “May that excited delirium die here,” said his mother, Verdell.

Democratic California Gov. Gavin Newsom is considering signing into law a bill passed Sept. 12 that would do much of the same in his state.

“If we don't fully denounce this now, it will be there for the grasping, again,” said Jennifer Brody, a physician with the Boston Health Care for the Homeless Program, who co-authored a 2021 editorial calling on organized medicine to denounce excited delirium. “Historically, we know what happens: The pendulum swings the other way.”

Most major medical societies, including the American Medical Association and the American Psychiatric Association, don't recognize excited delirium as a medical condition. This year, the National Association of Medical Examiners rejected excited delirium as a cause of death. No blood test or other diagnostic test can confirm the syndrome. It's not listed in the “Diagnostic and Statistical Manual of Mental Disorders,” a reference book of mental health conditions, nor does it have its own diagnostic code, a system used by health professionals to identify diseases and disorders.

But the argument's pervasiveness in excessive-use-of-force cases has persisted in large part because of the American College of Emergency Physicians' 2009 white paper proposing that individuals in a mental health crisis, often under the influence of drugs or alcohol, can exhibit superhuman strength as police try to control them, and then die from the condition.

The ACEP white paper has been cited in cases across the U.S., and lawyers who file police misconduct cases said that courts and judges accept the science without sufficient scrutiny.

ACEP's position “has done a lot of harm” by justifying first responder tactics that contribute to a person's death, said Joanna Naples-Mitchell, an attorney who worked on a Physicians for Human Rights review of excited delirium. The term has also been used in cases in Australia, the United Kingdom, Canada, and other countries, according to the group.

“This is a really important opportunity for ACEP to make things right,” she said of the upcoming vote.

ACEP officials declined KFF Health News requests for an interview.

Starting in the mid-1990s, the leading proponents of excited delirium produced research with funding from Taser International, a maker of stun guns used by police, which later changed its name to Axon. The research purported to show that the technique of prone restraint, in which suspects are lying face down on the ground with the police officer's weight on top of them, and Taser shocks couldn't kill someone. That research formed the basis of the white paper, providing an alternative cause of death that defense attorneys could argue in court. Many emergency physicians say the ACEP document never lived up to the group's standard for clinical guidelines.

Axon officials did not respond to a call or email seeking comment on the white paper or the upcoming ACEP vote. In 2017, Taser officials used the American College of Emergency Physicians' position on excited delirium as evidence that it is a “universally recognized condition,” according to Reuters.

A recent review published in the journal Forensic Science, Medicine, and Pathology concluded no scientific evidence exists for the diagnosis, and that the authors of the 2009 white paper engaged in circular reasoning and faulty logic.

“Excited delirium is a proxy for prone-related restraint when there is a death,” said Michael Freeman, an associate professor of forensic medicine at Maastricht University in the Netherlands, who co-authored the review. “You don't find that people get ‘excited delirium' if they haven't also been restrained.”

Between 2009 and 2019, Florida medical examiners attributed 85 deaths to excited delirium, and at least 62% involved the use of force by law enforcement, according to a January 2020 report in Florida Today. Black and Hispanic people accounted for 56% of 166 deaths in police custody attributed to excited delirium from 2010 to 2020, according to a December 2021 Virginia Law Review article.

This year, ACEP issued a formal statement saying the group no longer recognizes the term “excited delirium” and new guidance to doctors on how to treat individuals presenting with delirium and agitation in what it now calls “hyperactive delirium syndrome.” But the group stopped short of retracting the 2009 white paper. For the past 14 years, ACEP took no steps to withdraw the document or to discourage defense attorneys from using it in court.

Even now, lawyers say, they must continually debunk the theory.

“Excited delirium has continued to come up in every single restraint asphyxia case that my partner and I have handled,” said Julia Sherwin, a California civil rights attorney. “Instead of acknowledging that the person died from the police tactics, they want to point to this alternate theory of deaths.”

Now, plaintiffs' attorneys say, if ACEP passes the resolution it would be the most meaningful step yet toward keeping the theory out of the courtroom. The resolution calls on ACEP to “clarify its position in writing that the 2009 white paper is inaccurate and outdated,” and to withdraw approval for it.

Despite the theory's lack of scientific underpinning, backers of the ACEP resolution expect heated debate before the vote scheduled for the weekend of Oct. 7-8. Emergency physicians often encounter patients with agitation and delirium, they say, and are sympathetic to other first responders who share the challenge of managing such patients. While they have tools like sedation to help them in the emergency room, law enforcement officials must often subdue potentially dangerous individuals without such help.

Most people won't die as a result of police tactics such as prone restraint or Taser use, but a small fraction do.

“It's a crappy, crappy situation, when you have someone who's out of control, who can't make decisions for himself, and is potentially a threat somewhere,” said Jared Strote, an emergency medicine professor at the University of Washington. “It's not like they have a sticker on their head that says, ‘Hey, I'm at high risk. If you hold me down, then I could go into sudden cardiac arrest.'”

Nonetheless, sentiment is growing among emergency physicians that the 2009 ACEP white paper has resulted in real harm and injustices, and it's time to set it aside.

“We'll be able to close the chapter on it and move forward to recognize explicitly that this was in error,” said Brooks Walsh, an emergency physician from Bridgeport, Connecticut, and a key player in bringing the resolution up for a vote. “We definitely have an ethical responsibility to address mistakes or evolutions in medical thinking.”

Chris Vanderveen, KUSA-TV's director of special projects, contributed to this report.

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By: Markian Hawryluk and Renuka Rayasam
Title: Police Blame Some Deaths on ‘Excited Delirium.' ER Docs Consider Pulling the Plug on the Term.
Sourced From: kffhealthnews.org/news/article/police-blame-some-deaths-on-excited-delirium-er-docs-consider-pulling-the-plug-on-the-term/
Published Date: Mon, 02 Oct 2023 09:00:00 +0000

Sarah Jane Tribble, KFF Health News
Mon, 02 Oct 2023 09:00:00 +0000

A federal program to combat the alarming rates of rural women dying from pregnancy complications has marked a first: It's supporting an organization that serves predominantly Black counties in the Deep South.

The news came Sept. 27, three months after KFF Health News' reporting raised questions about why a federal Health Resources and Services Administration program targeting rural maternal mortality hadn't sent a grant to serve mothers in majority-Black rural communities.

Non-Hispanic Black women — regardless of income or education level — die of pregnancy-related causes at nearly three times the rate of non-Hispanic white women.

The Institute for the Advancement of Minority Health in Madison, Mississippi, was one of two winners in the latest round of an initiative administered by HRSA. Mary Hitchcock Memorial Hospital in Lebanon, New Hampshire, was the other winner, according to an agency announcement.

“Very happy to see Mississippi,” said Peiyin Hung, deputy director of the University of South Carolina's Rural and Minority Health Research Center. Mississippi has the highest rate of maternal deaths and injuries among Black people in the U.S., she said.

Hung, who is a member of the health equity advisory group for the maternal grant program, said the Mississippi nonprofit is an unusual awardee because it is not part of a larger health system.

In June, KFF Health News found that HRSA's Rural Maternity and Obstetrics Management Strategies Program, or RMOMS, had failed to fund any sites in the Southeast, where the U.S. Census Bureau shows the largest concentration of predominantly Black rural communities. The program began four years ago and had budgeted nearly $32 million to provide access and care for thousands of mothers and babies nationwide — including Hispanic women along the Rio Grande and Indigenous mothers in Minnesota.

The rural Southeast was omitted despite a White House declaration to make Black maternal health a priority, and despite statistics showing America's maternal mortality rate rising sharply in recent years.

Rep. Robin Kelly (D-Ill.) introduced the “CARE for Moms Act” in mid-September and — in response to KFF Health News' reporting ― called for accountability and reporting requirements for maternal health grants under the Department of Health and Human Services.

“Where is the money going?” she said during a September press conference. “Is it going where it's needed or is it going to bigger organizations who have the people who can write the grants?” She added that “maybe smaller areas or more rural areas” need it more.

HRSA spokesperson Martin Kramer declined to provide more information about the rural maternity grant awards and did not respond when asked about Kelly's bill. The legislation also would establish regional “centers of excellence,” Kelly said, to address implicit bias and cultural competency in health care providers. She said the bill would also “build up the doula workforce” and establish a state-based perinatal quality collaborative to improve care nationwide.

In an interview with KFF Health News, Kelly, co-chair of the House Maternity Care Caucus and a congressional leader in expanding Medicaid for postpartum care, suggested the lack of grants to the predominantly Black rural South could be because of “implicit bias,” and she said her bill would help “get to the heart of the matter and get [the money] to the people that really need it.”

The roughly $2 million in new rural grants are part of nearly $90 million in maternal health funding announced in late September by HRSA, an agency within HHS.

The Mississippi-based Institute for the Advancement of Minority Health was created in 2019 to reduce health disparities through partnerships, according to federal filings. Chief executive Sandra Melvin confirmed in an email that this is the first time the institute has applied for the grant, but also noted that it has been working to reduce maternal and infant health disparities since 2019.

Work performed with the grant “will be successful,” she said, because the organization plans to take a community-based approach that includes partnering with health centers, hospitals, and a university.

In past years, the grant application process skewed toward large health systems because they “have much higher capacity to form a statewide network,” Hung said. That's, in part, because grant winners were required to create a network of specific health care clinics, hospitals, and the state Medicaid office. In recent years, the agency has “become much more flexible,” Hung said.

The success of the Mississippi application is a “promising signal” for states that don't have large rural health systems focusing on maternal care, said Hung, who hopes a South Carolina applicant receives a grant in the future.

In New Hampshire — where awardee Mary Hitchcock Memorial Hospital is part of the larger Dartmouth Health system in New England ― three rural hospital labor and delivery units have closed in recent years. The closures forced pregnant women to drive up to an hour and a half to appointments or delivery services, said Greg Norman, senior director of community health at Dartmouth Hitchcock Medical Center.

Its HRSA application included the North Country Maternity Network, a collaboration of hospitals and clinics created in late 2021, Norman said. The New Hampshire group did not win the federal maternity grant the first time it applied. But this time the network was more established , he said.

The money from the New Hampshire grant — up to $1 million a year for four years — will help create standardized medical and social screening for pregnant people. It will also pay for a shared high-risk coordinator and increased use of doulas and community health workers who could do home visits, he said.

The whole project, Norman said, is “a step in the direction of more equitable care.”

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By: Sarah Jane Tribble, KFF Health News
Title: Facing Criticism, Feds Award First Maternal Health Grant to a Predominantly Black Rural Area
Sourced From: kffhealthnews.org/news/article/facing-criticism-feds-award-first-maternal-health-grant-to-a-predominantly-black-rural-area/
Published Date: Mon, 02 Oct 2023 09:00:00 +0000

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