Responding to New Jersey’s Opiate Overdose Epidemic

Responding to New Jersey’s Opiate Overdose Epidemic.
To:

Barbara Longo – Superintendent of Schools

Caesar DiLiberto - Principal

Julie Hoebee – Assistant Principal

Damion Macioci – assistant Principal

Peter Davis – Security Director

Barbara Cieremans – Director of Guidance

D. Leblein – Student Assistance Counselor

P. Pawlikowski – Student Assistance Counselor

L. Cherny – Guidance Counselor

R. Ciottariello – Guidance Counselor

M. Goudreau – Guidance Counselor

T. Longo – Guidance Counselor

J. VanSyckle – Guidance Counselor

This report was prepared by Tony Emering for key district personnel. It is intended to communicate specific concerns involving the alarming and escalating death toll associated with the use of heroin and other opiates, especially as it relates to suburban youth in New Jersey. This report contains sensitive yet critical information regarding student drug use trends, and it is intended solely for the use of the recipient. This report should not be reproduced or circulated without the expressed consent of the author.


Introduction:

On February 19, 2001 the front page of the Star Ledger newspaper carried a photo of Matthew Dancy. The headline read: Teen Succumbs to Heroin’s Relentless Grip. He was only nineteen years old at the time of his death. He was a suburban kid from a very prominent family in Caldwell. He was a two sport standout athlete while at James Caldwell, H.S., and his father Joseph Dancy was a former mayor of Caldwell. Teenagers were not supposed to be using heroin, and certainly not teenagers from the suburbs. It was a big story; it was front page news. The article written by Jonathan Schuppe, gave an elaborate and particularly detailed account of Matthew’s self-destructive path. A path fueled by the use of opiate pills following a sports injury, and then to escalating use of heroin. It detailed his parents anguish as they blew through insurance benefits, and then their personal savings, as Matthew went from hospital-based detox to hospital-based detox, interspersed with costly stays in residential treatment.

I last spoke with Matthew at the Caldwell Police Station three days before he died. From behind the bars of his holding cell he pulled up his sleeves and showed me the track marks running down both arms. He told me that he was shooting up ten bags of heroin a day. Life had been excruciatingly tough for Matthew, and he had just been arrested for theft. His habit was over one hundred dollars a day, and he was compelled to get money any way he could. The next time I saw Matthew was at his wake.

The newspaper article was meant to be a gift to the community, a very courageous attempt by a grieving family to issue a warning: Heroin had made its way to the suburbs. It had a new clientele; suburban teenagers; kids with cars, money, cell phones and time on their hands. It was cheap – less than ten dollars a bag, and it was very potent. So potent, it could be heated and inhaled, or snorted. Tying off and shooting up with needles were now a thing of the past for new initiates to the drug. They even gave it a new name calling it “diesel.” This new purer form of heroin and its orgasmic high were very seductive to vulnerable teenagers.

The problem was that it was also a brutal and merciless equal opportunity killer. In the article about his son’s addiction, Joseph Dancy said; “You do not live on heroin.” “You either get off it or you die.” For far too many people in New Jersey these words were never more prophetic. Matthew is buried in Prospect Hill Cemetery on Westville Avenue, and I think of him often as I am driving by. Some fifteen years later I am left to wonder if anyone was listening to his cautionary tale. In the past fourteen months alone, three young men from the West Essex area have also met their demise at the hands of heroin. As this school year begins our nation is mired in the worse drug plague ever experienced, with a body count that includes tens of thousands of suburban teenagers each year. In New Jersey the death rate from heroin and other opiate pills is so bad it is more than three times the national average. If what is happening nationally is considered a plague, I am not sure if there is an appropriate word to describe the devastation currently taking place in New Jersey. It is my hope that the pages that follow will clearly define the scope of the problem, and ultimately offer some suggestions for combating it.

Note: I was personally interviewed by Jonathan Schuppe for the Star Ledger article on Matthew Dancy and quoted several times in the article. Mr. Joseph Dancy signed a release of information document granting permission to speak openly and in detail about the events that led to his son’s death.

Responding to New Jersey’s Opiate Overdose Epidemic.

• 
  Defining the Problem
  

The national public health crisis related to the abuse of heroin, and other synthetic and semi-synthetic opioid related medications has clearly reached epidemic proportions. This includes use of white powdered heroin; fentanyl; black tar heroin, and misuse of codeine; morphine; pills containing oxycodone (OxyContin, Roxicodone, Percocet, Percodan); pills containing hydrocodone (Zohydro, Vicodin, Lortab); and other opiate based pills containing hydromorphone (Dilaudid); methadone; buprenorphine (Suboxone, Buprenex); pills containing oxymorphone (Opana); merperidine (Demerol); and propoxyphene (Darvon - now banned in the United States).

In the excerpt that appears below from an April 17, 2015 New Your Times editorial by Sam Quinones entitled, “Serving all Your Heroin Needs” Mr. Quinones advises the reader that heroin overdose deaths in America have tripled in the past three years. Mr. Quinones asserts that we are arguably in the midst of the worst drug plague ever recorded. He chillingly adds; “We are at a strange new place. We enjoy blissfully low crime rates, yet every year the drug-overdose toll grows. People from the most privileged groups, in one of the wealthiest countries in the world have been getting hooked and are dying in epidemic numbers, from substances meant to numb pain. Street crime is no longer the clearest barometer of our drug problem, corpses are.” Mr. Quinones also points out that this is the quietest drug plague in our history since: “the victims mostly white, well-off, and often young, are mourned in silence, because their parents are loath to speak publicly.” His Book “Dreamland the True Tale of America’s Opiate Epidemic” provides a thoughtful and detailed account of the antecedents and current forces which have propelled us to a state of unprecedented crisis.

In Dreamland, Mr. Quinones provided the following analysis: “Via pills, heroin has now entered the mainstream. The new addicts are high school football players and cheerleaders. Some of these addicts are from rough corners of rural Appalachia, but many more are from the U.S. middle class. They live in communities where the driveways are clean, the cars are new, and the shopping centers attract Starbucks, Home Depot, C.V.S. and Applebee’s. They are the daughters of preachers, the sons of cops and doctors, the children of contractors and teachers, business owners, and bankers.” As dire as the epidemic is nationally, the crisis is much worse in New Jersey. Stephen Stirling of NJ Advance Media reports that the heroin overdose death rate in New Jersey for 2013 is more than triple the exploding national rate as reported by the C.D.C., and it now eclipses homicide, suicide, car accidents, and AIDS as a cause of death in the state.  

On July 08, 2015 the Star Ledger Newspaper headline read: “As U.S. Heroin OD’s Soar, State’s Death Rate Surpasses Nation’s - Killer tightens its grip on N.J.” The article affirms that according to statistics for 2013 released by the Centers for Disease Control, the heroin overdose death rate nationally has tripled since 2010 to 2.6 deaths per one hundred thousand citizens, and the death rate in New Jersey, one of the states hit hardest by this plague is now triple that of the national rate, at an astounding 8.3 deaths per one hundred thousand citizens. In Essex County the heroin overdose death rate increased to is 8.4 deaths per one hundred thousand citizens for 2014.
All indications point to even more ominous statistics for calendar years 2014 and 2015 with a projected death rate of 8.7 per one hundred thousand citizens. The chart below graphically illustrates the precipitous rise in heroin fatalities since 2010, with New Jersey experiencing a meteoric rise in deaths that now surpasses the national rate by more than three times.


Figure : Heroin overdose death rate in NJ for 2013 is was 8.3 deaths per 100,000 citizens.

• 
  Who Abuses Heroin? 
  

As outlined in the book Dreamland referenced above, the average user of heroin has changed drastically in the last decade. In 2000, black Americans aged 45-64 had the highest death rate for drug poisoning involving heroin. Now, white people ages 18-44 have the highest rate. The number of people who say they have used heroin in the past year is actually decreasing for non-whites. Heroin has taken hold of the white suburbs, which has prompted more attention for what is now being called a "health epidemic. The heroin epidemic is hitting white young adults more than any other group. As per the charts below, the use among Americans ages 18-44 increased dramatically from 2000 to 2013 from approximately one death per 100,000 to approximately seven deaths per 100,000.



Figure 2: Heroin overdose deaths by age and ethnicity.


Figure 3: Heroin overdose deaths by age showing a dramatic increase for whites ages 18-44.


Figure 4: Heroin overdose deaths for people under the age of 35 in 2014 now accounting for 44% of all deaths.

ESSEX COUNTY



Figure 5: The 67 Heroin overdose deaths in 2014 in Essex County equate to more than three times the exploding national average of 2.6 deaths per 100,000 citizens. The death rate in Essex County now stands at 8.4 deaths per 100,000 citizens just above the unprecedented state average of 8.3 deaths per 100,000 citizens.
N.J. Heroin Deaths Mapped

This map is a heat map showing the 5,217 heroin-related deaths to occur in New Jersey from 2004 to present, by primary residence of the deceased.


Figure 6: 5,217 Heroin overdose deaths in New Jersey from 2004 to present by primary residence.
When the thousands of heroin-related deaths are placed on a map, it also shows that virtually no part of New Jersey has been left unscathed. While the bulk of heroin may be sold out of urban settings like Newark, Paterson and Camden, the high concentrations of deaths occur in the suburbs surrounding those cities and along the Jersey shore. 

• 
  Nationally prescription drug abuse is a bigger epidemic. 
  

Heroin abuse is tightly tied to prescription drug abuse. On the black market opiate pills such as OxyContin, Roxicodone, Vicodin, and Percocet are sold for one dollar per milligram. A daily habit of 80 milligrams therefore would cost five hundred sixty dollars per week. A bag of heroin (1/10^th of a gram) is approximately five dollars. This would initially reduce the cost of the user’s drug habit to thirty-five dollars per week. Almost half of the people addicted to heroin are or were also addicted to opiate painkillers. People are 40 times more likely to be addicted to heroin if they are addicted to prescription painkillers. Abuse of prescription painkillers is incredibly common with one in 20 Americans age 12 and older having reported using painkillers for non-medical reasons in the past year. While it is true that heroin abuse has skyrocketed in the last four years, prescription drug abuse is more common. Nationally the number of overdose deaths from prescription pain medication is larger than those of heroin and cocaine combined. One of the main differences between the two issues is that while the issue of heroin is intertwined with border security, the abuse of prescription drugs is largely the fault of our own health system. Enough painkillers were prescribed by American doctors during one month in 2010 to medicate every American around the clock for an entire month. A majority of those who take prescription pain medicine for non-medical reasons get them free from a friend or relative. In nearly 85 percent of those cases, the friend or relative obtained them from one doctor. One in five users obtain prescriptions themselves from one doctor. 



Figure 7: National death rate for heroin and opioid pills 2000 to 2013.



Figure 8: Death rate for opioid prescriptions by age group per 100,000 citizens for 2013.
Currently every day in the United States, 44 people die as a result of prescription opioid overdose. Among those who died from prescription opioid overdose between 1999 and 2013 most were ages 25 to 54. This age group had the highest overdose rates compared to other age groups. The large majority were non-Hispanic whites. The age-adjusted rate of prescription painkiller overdose deaths among non-Hispanic white persons increased 4.3 times, from 1.6 per 100,000 in 1999 to 6.8 per 100,000 in 2013. The rates more than doubled for non-Hispanic black persons, from 0.9 per 100,000 in 1999 to 2.5 per 100,000 in 2013. The rates increased only slightly for Hispanic persons, from 1.7 per 100,000 in 1999 to 2.1 per 100,000 in 2013. Men were more likely to die from prescription opioid overdose, but the mortality gap between men and women is closing.
Deaths from prescription painkiller overdoses among women increased more than 400% during 1999–2010, compared to 237% among men. Drug overdose was the leading cause of injury death in 2013. Among people 25 to 64 years old, drug overdose caused more deaths than motor vehicle traffic crashes. There were 43,982 drug overdose deaths in the United States in 2013. Of these, 22,767 (51.8%) were related to prescription drugs. Drug misuse and abuse caused about 2.5 million emergency department (ED) visits in 2011. Nearly two million Americans, aged 12 or older, either abused or were dependent on opioid painkillers in 2013. In the United States, prescription opioid abuse costs were about $55.7 billion in 2007. Of this amount, 46% was attributable to workplace costs (e.g., lost productivity), 45% to healthcare costs (e.g., abuse treatment), and 9% to criminal justice costs.⁵



The rates reflected in the chart above include fatalities from all drugs including opiates and heroin.

• 
  What does all of this mean for West Essex High School?
  

The New Jersey Division of Addiction Services has just released data for calendar year 2014, indicating the number of individuals in each municipality who sought substance abuse treatment for opiate addiction at treatment facilities monitored by the New Jersey Department of Health. By definition these figures do not include residents of our sending districts who sought treatment at out of state facilities; those who sought treatment privately, or those residents treated at facilities not monitored by the N.J. Department of Health. It is highly likely that the numbers represented in the New Jersey Division of Addiction Services data that appears below accounts for only a small portion of the total residents who sought treatment in 2014 due to opiate use. If data for out of state admissions and other forms of private treatment were included, the numbers for more affluent towns like those serving our district would almost certainly grow dramatically. For example, during the previous school year there were several students who entered out of state residential treatment facilities in Pennsylvania, Florida, and Illinois for opiate addiction. For privacy reasons, and the need to break unhealthy and destructive relationships, residents with comprehensive insurance benefits, and those with significant financial abilities will often seek treatment out of state.

New Jersey Divisions of Addictions Services Treatment Data for 2014

Municipality	Population	# Treated for Heroin Addiction in 2014	Rate per 100,000 Residents	# Treated for other opiates in 2014
Essex Fells	2115	14	6.02	1
Roseland	5813	7	1.20	2
North Caldwell	6307	8	1.27	1
Fairfield	7491	5	.067	4

West Essex H.S. Students who Tested Positive Drugs of Choice

Figure 9: Student drug of choice showing heroin, morphine, & oxycodone ranked 3^rd, 4^th & 5^th respectively.
The chart above reflects confirmed use and or possession of substances by West Essex High School students. It was kept in very meticulous fashion from September of 2008 through December of 2014. Unfortunately it was recently discontinued. It provides vital information on trends in student substance use, and has direct implications on guiding the scope and nature of the district’s drug testing protocol. The chart was discontinued by the Student Assistance Counselor in January of 2015.

What is significant is that following student use of very ubiquitous substances - Marijuana, Alcohol, and Benzodiazepines (Xanax, Klonopin, Ativan, and Valium), the opiate drugs Heroin, Morphine, and Oxycodone, rank next. Other opiate drugs Codeine, Methadone, and Hydromorphone also appear on the chart. In figure 10 which appears on the next page, the reader can see that prior to 2010 none of the opiates were ever detected in student drug tests, or in a student’s possession in school, or by law enforcement when students were away from campus.

Confirmed Positive Opioid Tests

R.L. 12^th grade 15-16	June 2014– verbal report only	Admitted use of heroin as documented in treatment notes received from residential program located in Elmont Illinois.	Four hospitalizations
D.C.	July 15, 2013	Opiates not specified 595 Ng/Ml Urine Drug Screen received from COPE Counseling Center. Possession of hydrocodone pills in school.	Dropped out of school & Arrested by Fairfield PD
S.M.	April 15, 2013 –	Opiates not specified 510 Ng/Ml (results withheld from SAC)	Test results Info Blocked from SAC
	Feb 2015	Verbal Report – Residential stay	????????????? Info Blocked from SAC
	April 2015	Verbal Report – Second Residential stay	???????????? Info Blocked from SAC
G.L.	November 19, 2012	Morphine 399 Ng/Ml	Completed Treatment
A.S.	September 28, 2012	Morphine >3000 Ng/Ml (Heroin) IV use - 6 MAM	Inpatient – 82 days
	November 17, 2014	Morphine Codeine Oxymorphone IV use	Detox/ Inpatient signed out relocated to Florida
A.R.	May 31, 2012 - test results confirmed	Morphine 350 Ng/Ml	Dropped out of school
B.E.	May 1, 2012 - test results confirmed	Morphine 374 Ng/Ml	Completed Treatment
T.S.	April 25, 2012 - test results confirmed	Methadone > 2100 Ng/Ml	Dropped out of school
T.L.	October 19, 2011 - test results confirmed	Promethazine cough syrup with codeine (Lean)	Moved to Texas
P.L.	November 15, 2010 – Detox Summit Hospital	Oxycontin Dependence	Inpatient - 89 days
M.S.	October 21, 2010 – Detox Princeton House	Oxycontin Dependence	Inpatient – 162 days. Moved to Florida

Figure 10: Students with confirmed opiates use while attending West Essex High School.
There have been three deaths of former West Essex High School students that have been reported as heroin overdose fatalities. I attended the wakes for two of the students and spoke at length with their parents. I also spoke with police officers who were first responders on the scene. I ask that the readers of this report respect the confidentiality and privacy of the families involved as I am not certain what information they have shared with the general public. While families are entitled to their privacy, one of the dynamics of the current overdose plague is the deafening silence associated with it. Their deaths move this discussion from a mere impersonal statistical analysis to the indisputable reality that young lives continue to be lost to heroin in our own communities. Their obituaries appear below.

Obituary |  

Nickolos A. Innarella Cherished son , brother, and grandson, of Roseland, 24 Nickolos A. Innarella, 24, of Roseland, N.J., passed away on July 4, 2015, in Salt Lake City, Utah. Relatives and friends are invited for visitation on Thursday from 4 to 9 p.m. at Farmer Funeral Home, 45 Roseland Ave., Roseland, N.J. 07068. A funeral service will be held at the funeral home at 8:15 p.m. Condolences and memories may be shared at www.farmerfuneral.com. Nickolos was a native of Roseland and graduated from West Essex Regional High School in 2009. In his spare time, he enjoyed surrounding himself in nature, hiking, camping and the Jersey Shore. Nickolos was a beautiful young man, kind and compassionate, generous, adventurous, loving. He had a greatness in him and was a friend to all. His best attribute was that he was "real." Nickolos was predeceased by his paternal grandfather, Joseph Innarella, and his maternal grandfather, Theodore "Duke" Gambert. Surviving are his beloved parents, Joseph and Lisa (Gambert) Innarella; devoted and loving brother, Andrew Innarella; loving grandmothers, Dorothy Pecelli and Stella Gambert; cherished aunts, Suzanne Gambert-Forst and her husband, Lou Forst, Theresa Innarella and JoAnn Dries; dear cousins, Danielle Alden, David Guerra, Devon Dries, Samantha D'Amato, Mia Guerra and Xander Alden, and loyal canine companions, Sadie and Peyote. He is also survived by many extended relatives and friends. In lieu of flowers, donations may be made in his memory to the Journey Wilderness Program, 619 North 500 West, Provo, Utah 84601. Envelopes will be available at the funeral home.

Published in Star-Ledger on July 7, 2015


Obituary

Jordan Bradley Krakauer
North Caldwell

Jordan Bradley Krakauer of North Caldwell, NJ passed away at home on February 8, 2015 after a short illness. Born in New York, Jordan resided in North Caldwell, NJ for the past 18 years. Jordan was a student at William Paterson University. He also attended West Virginia University. He was a member of the Notre Dame Church in North Caldwell.

Jordan is survived by his parents, Frances Boller of North Caldwell, NJ and Ronald Krakauer of Palm Springs, California and New York. He is also survived by his loving and devoted grandparents, Paul and Barbara Boller of Morris Plains, his beloved uncles, Paul Boller and wife, Nancy, of Dover, Emil Boller of Wharton, Thomas Boller and wife, Allison, of Denville and his loving aunt, Theresa Townsend and her husband, Michael of Randolph and his beloved aunt, Linda and uncle, David Van Pelt, and his loving friend, Rick Mina. He is also survived by his cousins David Van Pelt, Jr, Ryan Van Pelt, Michelle Boller, Matthew Boller, Andrew Boller, Thomas Boller, Jr., Alexis Boller, Michael Boller, Melissa Boller, Michael Townsend and Justin Townsend. 

Jordan was a compassionate, outgoing, and generous young man loved by so many others. He enjoyed traveling extensively around the world. He was an avid Giants and Yankee sports fan, who once had the opportunity to work at the NY Giant's Training Camp, which led to his field of study in Sports Marketing. Jordan most recently had an internship working for the Nike and Jordan's Kid's Division. 

There is no public visitation. The public is invited to the funeral mass for Jordan on Friday, February 13, 2015 at 1:00 pm at St. Virgil's Church, 250 Speedwell Avenue Morris Plains, NJ. Interment will be private.


Obituary for Matthew Grisaffi



Matthew Grisaffi, 21, of Roseland, passed away on May 29, 2014.
Friends and family are invited to gather for visiting hours on Sunday, June 1 from 6-9 pm at Farmer Funeral Home, 45 Roseland Ave., Roseland, New Jersey 07068.
A Funeral Service will take place at 8 pm on Sunday, June 1 at Farmer Funeral Home.
Memories and condolences may be shared at www.farmerfuneral.com. 
Matt was born in Staten Island and grew up in Roseland. He graduated from West Essex High School and was currently a student at Rutgers University in New Brunswick. Matt loved music and was a member of the West Essex Marching Band and participated in volleyball and fencing. He also attained the rank of Eagle Scout for Troop 3 in Caldwell.  He was a loving son and is survived by his parents, Matthew Grisaffi and Jeanine Grisaffi (Christiana); sister, Marisa Faith Grisaffi; great grandmother Claire Bottone, grandparents, Florence Christiana and her husband William, Philip Grisaffi and his wife Renee, JoAnn Recevuto and her husband William, and Matthew Johnson and his wife Judy. Matt is also survived by many aunts, uncles, cousins and friends. He is loved by all and will be dearly missed. As a loving brother and best friend to Marisa, in lieu of flowers, donations may be made in Matt’s memory to the Marisa Grisaffi Education Fund. Envelopes will be available at the funeral home. 

• 
  The importance of student drug testing
  

When concerns emerge in school, the single most effective and objective tool to determine if substance use is occurring, is a timely, medically supervised, urine screen. The Student Assistance Program has spent many hours tracking student drug use trends, and adjusting the urine drug screening protocol accordingly. In spite of all of the safeguards implemented, students have become adept at going to extreme lengths in their attempts to beat the testing. This includes everything from arguing that their Fourth Amendment rights have been violated; erroneously arguing that protections such as H.I.P.P.A. or F.E.R.P.A. shield their test results from school administrators ; out right refusing to be tested; trying to circumvent our established policies; refusing to attend state certified facilities in favor of seeing a private clinician; trying to adulterate the sample by adding chemicals to the urine (in vitro method); ingesting substances intended to dilute or mask the presence of illicit drugs (in vivo method); and attempting to substitute previously stored urine for their own. One female student who tested positive for heroin three consecutive school terms, reported that she stored donated urine in a small test tube and inserted it in her vagina just prior to testing in order to keep it at body temperature to beat a drug screening. Students also ingest creatine to artificially boost their creatinine level to avoid producing a dilute sample while aggressively flushing their system with water and diuretics. B-12 tablets are taken to return the urine to a dark yellow color. A number of validity markers are included with the urine drug screen to combat such efforts. (See Figure 12)

The current West Essex School District Testing Panel appears below: The opiate panels are in red.

Drug of Abuse: Screening Threshold: Confirmation Threshold:

Amphetamines = or > 500 Ng/ml = or > 250 Ng/ml

M.D.M.A. = or > 500 Ng/ml = or > 250 Ng/ml

Benzodiazepines = or > 200 Ng/ml = or > 200 Ng/ml

Barbiturates = or > 200 Ng/ml = or > 200 Ng/ml

Marijuana = or > 50 Ng/ml = or > 15 Ng/ml

Cocaine = or > 150 Ng/ml = or > 100 Ng/ml

Opiates = or > 2000 Ng/ml = or > 2000 Ng/ml

Phencyclidine = or > 25 Ng/ml = or > 25 Ng/ml

Methadone = or > 300 Ng/ml = or > 300 Ng/ml

Propoxyphene = or > 300 Ng/ml = or > 300 Ng/ml

Oxycodone/Oxymorphone = or > 100 Ng/ml = or > 100 Ng/ml

Alcohol .02 Mg/Dl .02 Mg/Dl

Figure 11: Shows the metabolic pathway of the opiate chemicals with codeine and morphine as the primary precursor chemicals. Although heroin will initially report as a positive for morphine and or codeine a secondary test confirming the presence of 6 mono acetyl morphine confirms use of heroin which is diacetylmorphine. This is depicted in the red boxes.

Urine drug screens are also analyzed for a number of validity markers including specimen temperature. It is imperative that the two hour window rule remain in effect; students follow all medical protocols related to sample collection; and that students submit to the cut-off and confirmation levels for all drugs of abuse contained in our testing panel to ensure the integrity of the sample to the greatest extent possible. Figure 12 Specimen Validity Markers
Color	Normal: Pale to dark yellow
	Abnormal: Many foods and medicines can affect the color of the urine. Urine with no color may be caused by long-term kidney disease or uncontrolled diabetes. Dark yellow urine can be caused by dehydration. Red urine can be caused by blood in the urine.
Clarity	Normal: Clear
	Abnormal: Cloudy urine can be caused by pus (white blood cells), blood (red blood cells), sperm, bacteria, yeast, crystals, mucus, or a parasite infection, such as trichomoniasis.
Odor	Normal: Slightly "nutty" odor
	Abnormal: Some foods (such as asparagus), vitamins, and antibiotics (such as penicillin) can cause urine to have a different odor. A sweet, fruity odor may be caused by uncontrolled diabetes. A urinary tract infection (UTI) can cause a bad odor. Urine that smells like maple syrup can mean maple syrup urine disease, when the body can't break down certain amino acids.
Specific gravity	Normal: 1.003–1.030
	Abnormal: A very high specific gravity means very concentrated urine, which may be caused by not drinking enough fluid, loss of too much fluid (excessive vomiting, sweating, or diarrhea), or substances (such as sugar or protein) in the urine. Very low specific gravity means dilute urine, which may be caused by drinking too much fluid, severe kidney disease, or the use of diuretics. Specific gravity of water is 1.000.
pH	Normal: 4.6–8.0
	Abnormal: Some foods (such as citrus fruit and dairy products) and medicines (such as antacids) can affect urine pH. A high (alkaline) pH can be caused by severe vomiting, a kidney disease, some urinary tract infections, and asthma. A low (acidic) pH may be caused by severe lung disease (emphysema), uncontrolled diabetes, aspirin overdose, severe diarrhea, and dehydration, starvation, drinking too much alcohol, or drinking antifreeze (ethylene glycol).
Creatinine	Creatinine is a waste product that the muscles produce at a steady rate as part of normal daily activity. The bloodstream carries creatinine to the kidneys, which filter it out of the blood, then creatinine passes out of the body in the urine. Most normal urine samples will have a creatinine value between 20-350 milligrams per deciliter.

Figure 13: Outlining the progression of addictive illness which is described as a chronic, progressive and sometimes fatal disease.

• 
  Addressing student drug use in schools
  

A great challenge for educators is determining when and if substance use is impacting the lives of students. There are always a number of political and social factors that can make addressing these concerns difficult. Parents can be hostile, and very defensive making for a very tense and uncomfortable conversation. Educators often see their primary role as addressing academic concerns, and may find it much more comfortable to implement academic supports and modifications then to raise concerns about student substance abuse. In fairness, even many medical doctors often feel inadequately trained in addictions and have difficulty with this topic. As figure 13 illustrates, there are discernable stages that unfold as the disease of addiction progresses, and students left untreated will begin to display increasing physical and psychological symptoms. Fortunately school systems gather and report a multitude of data on attendance, academic performance, visits to the school nurse, and behavior which can be analyzed and matched against previous historical performance. Student health and safety should be a primary concern. Given the current mortality rate in New Jersey for opiate use, student wellbeing should never be subordinated to academic considerations. There is no reason why specific targeted treatment cannot simultaneously accompany other academic related interventions. Academic and other educational accommodations alone serve to soften the impact of substance use, thereby enabling the student to avoid significant consequences and continue progressing in their addiction. (See figure 14) One of the most negligent steps would be to classify and send a drug using student to an out of district school without addressing substance use concerns.



Figure 14: Demonstrates that the disease of addictive illness continues to flourishes when well- intentioned, but misguided academic and behavioral interventions are implemented in the absence of specific and targeted substance abuse treatment that includes consistent medically supervised monitored urine drug screening.

• 
  Specific Recommendations:
  

1. 
   All student must be held to the requirements outlined in policy and regulation #5530 Substance Abuse without exception. Deviation from established practices regardless of intention can result in severe negative life consequences for students.
   
2. 
   The district must continue to carefully monitor attendance. When a student arrives more than 15 minutes late for school, a parent should be contacted to ascertain if they are aware, and the student has a valid reason for being tardy.
   
3. 
   Notes from physician’s excusing students from school should be reviewed for any student with ten or more absences, particularly when there is no discernable chronic medical condition.
   
4. 
   Teachers must input attendance notes in the Genesis system for attendance anomalies such as a student marked present but leaving class for inordinate amounts of time to use the restroom. This is the only way to formally document the behavior.
   
5. 
   The school nurse must remain diligent for students demonstrating signs of intoxication and withdrawal. These include for opiate use: skin rash, nausea, flu like symptoms, vomiting; chills, sweating and leg cramps, pinpoint pupils etc…
   
6. 
   The security specialist must be provided with the flexibility to monitor student traffic and interactions. The insights and knowledge he brings are invaluable.
   
7. 
   Information regarding a student’s confirmed use of substances must be disseminated to the S.A.C. counselors. This also must apply to students attending out of district schools since they are able to attend school functions and events. Lack of vital information undermines the ability to define and comprehend the extent and nature of the wider substance use problem, and indirectly allows the problem to proliferate.
   
8. 
   The CORE Team Committee must remain a viable early intervention vehicle.
   
9. 
   When students seek and receive academic plans, I&RS, 504, and I.E.P., and there is an inkling that substance use is a factor in the underperformance of the student, a referral to the CORE Team Committee must be made. There are multiple examples of parents of acutely drug affected students who initially rebuked suggestions that their child was drug involved while demanding academic and attendance related accommodations.
   

Afterward

In the summer of 1971 Bob Dylan already an iconic singer-songwriter at the age of thirty, took the stage at Madison Square Garden to thunderous applause. With songs like “Blowin in the Wind”, and “The Times they are a Changin”, Dylan had arguably become the greatest single voice for social change of his generation, and a leading commentator on the civil rights movement, and the ant-war movement. That evening he would open with one of his most complex and sweeping social anthems, a song entitled, “It’s a Hard Rain A-gonna fall.” The song utilizes the biblical motif of an impending great flood, and the narrative unfolds as a dialogue between a father and his young son. The son has just completed an epic cross-country journey, and is asked to describe the things he has experienced along the way. The young son reports that he has seen and heard many troubling events. He has witnessed first-hand the impact of poverty, starvation, war, violence, abandonment, apathy, and social injustice, and he has also heard the roar of a wave that could drown the whole world. In the final stanza the father asks his son as a result of his experiences and the things he has learned; “What will you do now?” The son gives the following reply:

I’m going back out before the rain starts a falling, and I’ll walk to the depths of the deepest dark forest. Where the people are many and their hands are all empty. Where the pellets of poison are flooding their waters. Where the home in the valley meets the damp dirty prison. Where the executioners face is always well hidden. Where hunger is ugly, and souls are forgotten. Where black is the color, and none is the number. And I’ll tell it, and think it, and speak it, and breathe it, and reflect it from the mountains so all souls can see it, then I’ll stand on the ocean until I start sinking, but I’ll know my song well before I start singing. And it’s a hard rain a–gonna fall.

When Dylan wrote this song he could not have envisioned that some forty-fou years later there would be a torrent of heroin and opiate overdose deaths occurring at unprecedented levels, especially among suburban young people, and especially in New Jersey. Surely as the song suggested the pellets of poison in the form of OxyContin, Roxicodone, Percocet, Vicodin and now heroin are flooding our waters, and there is a hard rain of death that has been falling with increased intensity for a number of years. It has resulted in a tidal wave of lost lives, and in particular is killing young adults. It is my expressed hope that after reading this report district personnel will have a clear understanding of the magnitude of this problem, and the implications it poses for our students. This report is an attempt to convey a warning that we are waist deep in the flood waters of the worse drug plague this state has ever witnessed. The idea that suburban drug use is limited to a little beer and a little pot on the weekends can now officially be labeled a myth.

As one parent advised me in 2010; “You are destroying the lives of kids, all for a little marijuana.” Her son was admitted to Princeton House for detoxification from oxycodone addiction one week later. The student’s use of opiates caused him to miss eighty-nine days of school; miss the graduation ceremony; and forgo a college sports scholarship once considered a guarantee afforded to one of the most gifted athletes to step on a West Essex High School field.
A few years after Bob Dylan preformed at Madison Square Garden, another brilliant young songwriter, Jackson Browne released a song in 1973 entitled “Before the Deluge.” Like the aforementioned Dylan song, it also used the biblical motif of a great impending flood. Describing the fable of indestructability often embraced by the younger generation, Browne composed the following stanza:

Some of them knew pleasure, and some of them knew pain, and for some of them it was only the moment that mattered. And on the brave and crazy wings of youth they went flying around in the rain, and their feathers once so fine grew torn and tattered. And in the air they traded their tired wings, for the resignation that living brings, and exchanged loves bright and fragile glow for the glitter and the rouge. And in a moment they were swept before the deluge.

It is not within the prevue of school personnel to monitor and manage decisions students make when they are away from school, and under the care and guidance of their parents and guardians. However, school personnel will have contact with a given student for approximately 1,275 days from the time the student enters seventh grade, to the time they graduate high school. The challenge is to intervene in an unwavering and compassionate manner when substance use concerns arise. The stakes have never been greater.

APPENDIX


Signs and Symptoms of Opiate Use



Signs and Symptoms of Opiate Use



Signs and Symptoms of Opiate Use


Normal Pupils Class Photo Pinpoint Pupils Arrest Photo 1


Pinpoint pupils Arrest Photo 2 Pinpoint pupils Arrest Photo 3

COMMONLY ABUSED PAIN MEDICATIONS



Butabital (barbiturate) Demerol (meperidine) Dilaudid (hydromorphone)

Esgic & Fiorcet (butabital, acetaminephine, & caffine)

Lorcet, Lortab, Maxidone, Norco, & Vicodin (hydrocodone & acetaminophen)

Oxycontin & Percolone (oxycodone)

Percocet , Roxicet , Tylox, & Zydone (oxycodone & acetaminophen)

Propoxyphene (Darvon) Talacen (pentazocine) Talwin (pentazocine & naloxone)

Ultracet (tramadol & acetaminophen) Ultram (tramadol)



Black Tar Heroin:



White Powder Heroin: