Pain Point: Taking the Opioid Addiction Problem Seriously
Is the medical community doing enough to solve the opioid addiction problem?
By Elaine Porterfield
August 2, 2016
When Rose Dennis’ 12-year-old son developed leukemia, it seemed that nothing in the world could be scarier. But she was wrong. Now 30 years old, her son is addicted to heroin, an addiction that had its roots in the opioid pain medication his physicians prescribed to help him deal with the cancer. It led to a dependency on that medication and within several swift years, to a full-blown heroin addiction.
“He essentially left the hospital cured of cancer but with a new disease called addiction,” says Dennis, a Kirkland resident and local public relations pro, who says her son was already addicted by age 13. “Opioids are so very highly addictive. Once you can’t get any more, you resort to heroin. As a country, I just don’t understand why we aren’t taking this disease more seriously.”
What happened to Dennis’ son beginning 17 years ago now appears to be a classic way in which average folks and celebrities alike can get hooked on heroin: an overdependence on prescription opioids, followed by street drugs to feed an ever-growing craving for the high. Some addiction experts actually describe prescription opioids as prep school for heroin.
Our region, like the rest of the nation, is currently experiencing a drug crisis so severe that life expectancy for one group of Americans, Caucasians, is actually declining for the first time since the AIDS epidemic. Last April, a report from the Centers for Disease Control and Prevention (CDC) analyzing data on deaths recorded in the United States in 2014, found the drop in life expectancy was occurring because of drug overdoses, liver disease (from alcoholism and drug abuse) and suicide.
And those drug overdoses aren’t due to illicit street drugs alone. Prescription opioids such as oxycodone and fentanyl appear to be a factor behind the trend, says the CDC. In 2014, according to the CDC, opioids (including prescription opioid pain relievers and heroin) killed more than 28,000 people, more than any year on record, and at least half of those deaths involved a prescription opioid.
Our hunger for these drugs is great: While Americans comprise only 5 percent of the world’s population, we take 80 percent of the prescription opioids produced. The death of music icon Prince last spring from a self-administered overdose of fentanyl is the latest evidence of this trend. The star appears to have fallen into addiction after first receiving opioids for debilitating hip pain.
According to a King County report, more people in the county now enter detox for heroin than they do for alcohol, and for many there’s no chance for recovery: In 2014, opiate overdose deaths in the county were more than triple the number of overdose deaths in 2009.
And, of course, substance abuse and addiction lead to many other issues. Substance abuse is one of the root causes of homelessness, and drug overdose is currently the leading cause of death among people who are homeless, according to an ad hoc King County heroin and prescription opioid task force created this spring to find solutions to the crisis. Burglaries and car prowls are often related to addicts attempting to find goods to sell for drugs, authorities say.
Because of how widespread opioid abuse has become, Seattle bike police now carry naloxone (Narcan), a lifesaving medication that reverses overdoses, including those of pain medicines like oxycodone.
Rose Dennis with a photo of her son who became addicted to opioids at age 13. Now 30 years old, he’s achieved remission from his addiction several times but is again waiting entry into a treatment program. PHOTO CREDIT: John Vicory
For Rose Dennis, her son’s addiction has meant three incredibly costly stays in private drug rehab facilities, stints that produced short-term sobriety but never a cure. It’s meant experencing the pain of her son stealing from her and others he knows so he could buy drugs. It’s meant the wrenching necessity of ordering him out of her house a number of times, knowing he’d likely go live on the streets. It’s meant the knowledge he was living at times in the notorious Jungle, the homeless encampment near Interstate 5, which has been the scene of robberies, assaults and even murders.
“He survived cancer, yet he can’t stay in remission with the drug addiction,” Dennis says.
Renton police chief Kevin Milosevich knows the problem all too well. Milosevich serves on that new King County ad hoc heroin and prescription opioid task force, along with more than 30 stakeholders working in multiple arenas, including public health, human services, criminal justice, cities, the University of Washington, hospitals and treatment centers.
“It’s a public health issue, and not only for the users,” Milosevich says. Heroin was involved in 156 deaths in King County in 2015, up from 99 the year before, and 49 in 2009, according to a report last year by the Alcohol and Drug Abuse Institute at the University of Washington. In addition, from 2010 to 2014, the number of treatment admissions for people hooked on heroin doubled.
Unlike the local heroin epidemic of the 1990s, which was largely centered in Seattle, this epidemic is hitting every community in King County, according to information from the task force.
Heroin, an illicit opioid, is clearly becoming the most prevalent drug used across all socio-economic strata in the state, Milosevich says. “Part of that is because of the prescription use of opioids. Because of pain issues, at some point, people can no longer can get relief…and go on to heroin.”
His own suburban city is not immune: “We see it in our homeless population and encampments. And we see it in other areas of life here…we’ve had at least one [fatal] overdose so far this year.”
The task force’s published mandate is broad: to work together to expand the region’s capacity for treatment and prevention, increase public awareness and understanding of addiction, and reduce overdoses and deaths from the drugs. Brad Finegood, an adviser to the task force and a drug and alcohol addiction expert, says the task force is focusing its efforts in these areas: prevention, treatment expansion and enhancement, improved access to medications used to treat opioid addiction, and better health services for people addicted to these drugs.
“We are trying to take an overarching look at the opioid epidemic,” says Finegood, who is assistant director of the King County Behavioral Health and Recovery Division. The task force will provide these recommendations, which are due in September, to mayors in King County and to King County Executive Dow Constantine.
How did we get here?
“The United States has gradually stumbled into an incredibly difficult situation in which many people are taking opioids chronically for pain,” says Sascha Dublin, M.D., a physician and associate investigator with the Group Health Research Institute who studies medication use and safety. She says our society has gotten into its current dilemma with opioid use because of both compassion and unthinking attitudes toward the safety of prescription medication among many doctors and patients alike in this country.
“A lot of [the crisis] comes from a real desire on the part of doctors and nurses to address patient suffering. But we got confused along the way and thought all suffering could be fixed with opioids,” Dublin explains.
Adding to the problem was a massive push, beginning in the 1990s, by the pharmaceutical industry, which was interested in promoting opioids as safe and effective for long-term pain, she says, something physicians grabbed onto. Many doctors saw patients with chronic pain, and the thought that the new class of opioids like oxycodone could help treat the problem was irresistible.
What got lost in the narrative at the time was how frighteningly addictive the drugs really are—even the new varieties—and how with many forms of long-term pain, people are actually better able to cope through avenues such as physical therapy, exercise, massage, chiropractic treatment or by adjusting other factors in their lives, she says.
“We have to take a look at people in pain as whole people,” Dublin says. “There are some patients who can get an opioid short term for an acute problem, get off it and be fine—such as after a tooth extraction or a major surgery. With pain we expect to go away quickly, they have a very appropriate role. But we were seeing people with back pain for 10 or 20 years come in and hope opioids would be a fix. But there’s very little evidence opioids work for very long.…There’s actually some early evidence that suggests some people’s experience with pain gets worse on opioids rather than better.”
Washington state recognized the problem years ago and made the first attempt to reduce the number of prescriptions written for opioid medications in 2007, when the state’s Agency Medical Directors’ Group (AMDG) published its first guideline for prescribing opioids, an effort that involved a number physicians and organizations. The AMDG has been a national leader in adopting prescribing guidelines. David J. Tauben, M.D., chief of the Division of Pain Medicine at the University of Washington, was involved with that initial guideline and subsequent updates. He has served as cochair of the AMDG opioid guideline since 2015—the year the most recent guideline was published.
While the guideline includes a recommended dose for pain, Tauben says that it also makes clear that there is no safe dose. Even low doses carry significant risk of addiction or overdose, he says.
The state guideline is an important step in addressing this problem, but it’s just the beginning, says Tauben. It gives doctors a framework for dosage and when to prescribe, and suggests alternatives, such as non-drug therapies, to help patients in pain. But health care systems and insurers also need to get on board in offering support and reimbursement for those alternatives, such as cognitive behavioral therapy (CBT), he notes.
There’s evidence suggesting that CBT can enable patients to find new ways to successfully cope with their own fears and negative thoughts, says Group Health’s Dublin, helping to diminish their perception of pain. With CBT, a person learns to recognize and correct negative or false recurring thoughts. “We have trained therapists [at Group Health] who can help people learn these methods,” she says.
In 2010, Group Health began a major initiative to make opioid prescribing safer for patients with chronic pain, standardizing their use without creating inappropriate restrictions for the drugs when truly needed. The initiative—which included primary care doctors, nurses, pharmacists, pain specialists and other clinical leaders—included new guidelines, among them standardized care plans for all patients receiving opioids long-term for chronic non-cancer-related pain.
And what about patients already addicted? The AMDG guideline includes information on how physicians can reduce opioid doses, identify addiction when it occurs and how to best treat addiction.
These legacy patients, who have become physiologically and psychologically dependent on the drugs, need to be treated with compassion and care, Tauben says. “You can’t just pull the rug out from under them. You need to develop a plan that will bring them slowly down to safer levels.…We can bring them down—but it may take six or seven years.”
None of that was available for Rose Dennis’ son. To this day, Dennis can’t shake the memory of watching powerful opioids drip into her son’s arm during his cancer treatment. Each time they returned for chemo treatment, she would ask his doctors about the opioid use.
“We went back once a month, every three months, every six months,” she said. “Every time we’d go, I’d say, ‘What can you do help my son?’ And they’d say, ‘There’s nothing we can do.’ It shows how our approach to [addiction] is not where it should be at. It’s a chronic illness, and we are at a crisis level. We cannot continue to ignore this.”