The Opioid Issue: Part 5

Part Five: Troubling Vital Signs

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The opioid epidemic is straining America’s health care and treatment resources, while opening the door for unscrupulous fraudsters to make money off those struggling to overcome addiction. How much more can emergency rooms handle? The most recent numbers from the U.S. Centers for Disease Control and Prevention (CDC), spanning 45 states, show nearly 143,000 ER visits for opioid overdoses over a 15-month period. That period ended in the third quarter of 2017 and represented a 30-percent jump from the same time span a year earlier.

“The staff isn’t sure what to do with [opioid overdose patients],” says Karl Benzio, M.D., a Christian psychiatrist and member of Focus on the Family’s Physicians Resource Council (PRC). “You don’t feel comfortable just discharging the person. The staff doesn’t know how dangerous the person is when they leave the doors, whether they will overdose—or worse—when they leave, how to find a responsible party to transfer the care and responsibility to.” Fellow PRC member W. David, Hager, M.D., agrees. “We’re seeing a lot of frustration among our providers with ‘frequent fliers,” says Hager, a practicing physician with Baptist Health Medical Group in Lexington, Kentucky. Both physicians point to different problems connected to the opioid crisis.

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Benzio notes that many overdose cases are complicated because ER staffs aren’t generally equipped to deal with mental or behavioral health. Many of those patients  should ideally be in a residential rehabilitation program, but are unable to secure health care insurance coverage. This leaves the medical personnel on the front lines of care facing a dilemma for which there are no simple answers. Between the rapid rise in overdose cases and the moral gray area of providing narcotics to so-called “frequent fliers,” America’s emergency rooms are in a precarious position when it comes to the opioid issue. The crisis threatens to break the backs of overworked ER staffs, whose efforts to help those in pain with long-term prescriptions may only be fueling the crisis.

FAKE TREATMENT CENTERS

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The overwhelming strain the opioid epidemic has placed on legitimate health care providers has also opened the doors for unscrupulous con artists looking for easy money. These fraudsters—and it’s not clear just how many there are across the country—run fake treatment centers preying on those seeking a way out of their opioid struggles.

“Several factors came together—so many people in need of addiction treatment and managed care to reduce their length of stay in the hospital—that there became a huge need for more addiction rehabs,” Benzio explains. “Certain states that had a high level of drug use made it very easy to open a rehab; not many restrictions, licensing issues or hoops to go through. Also, insurance plans needed a place to put someone who was in danger of overdosing but needed one-on-one monitoring, so entities put together minimally-trained people with a schedule and sold it to the insurance as a rehab.” With the potential to make big money and only vague criteria for what a “quality” treatment facility includes, many unqualified providers jumped into the rehab industry.

Cash from Treatment Centers

“A lot of people going through addiction thought, ‘Wow, I could put together a better program than that,’ so they developed their own after getting clean for 20 minutes,” says Benzio. Though he believes some who entered the rehab industry in this way truly wanted to help, others are outright shams and just billing insurance large sums. Some bill for services they don’t even provide. Some will encourage their patients to use drugs or supply them so they can continue to bill insurance. Many cannot get doctors or licensed therapists [on staff], which would make them accountable to higher state and national licensing standards.

UNSCRUPULOUS REHAB CENTER OPERATORS

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Somehow, even with all our laws pertaining to drug possession and use, we still find ourselves in a largely unregulated addiction treatment field. And even worse, the biggest driving force seems to be well-meaning legislation—like the Affordable Care and Parity Acts—which made treatment more accessible for more people, but unfortunately also opened the door for predators and frauds to get in on the action. They are unconscionably attempting to make a profit off our nation’s current drug epidemic with unethical and shocking practices like patient brokering, identity theft, kickbacks, and insurance fraud.

A behavioral healthcare survey on ethical concerns in the drug rehab industry identified patient brokering tactics in the form of money and gifts that some treatment centers are using to entice patients. Need sober living but can’t afford it? Some programs address this by offering free room and board and other amenities, then bill insurance excessively for unnecessary drug testing and other services to make up the cost. Sadly, many unregulated sober living homes have become unsafe and overcrowded “flophouses” where crimes like theft, human trafficking, prostitution, and illegal drug use are commonplace.

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We’re also seeing patients-turned-recruiters, people just out of treatment with very little time in recovery who can suddenly start making big money selling people they know to rehab centers, checking themselves into competitor programs to lure clients away, and collecting “finder’s fees” of $500 to $1,000 per patient or more. And if that doesn’t work, people are getting paid to relapse so that treatment centers can collect more insurance money. Shockingly, some of these practices are not per se illegal. And in situations where they are, states do not have the resources to regulate.

A Palm Beach Post investigation of the county’s $1 billion drug treatment industry found that testing the urine of recovering addicts is so lucrative that treatment centers are paying sober living homes for patients. Urine drug screen costs may be $6 once a week, but centers test every 48 hours and bill insurance companies $1,200 each time. You may have heard about treatment center owner Kenneth Chatman. A federal investigation targeted sober living homes and rehab centers founded by Chatman and others. Chatman appeared before a U.S. magistrate in West Palm Beach, Florida. The recovery businesses founded by Chatman provided illegal kickbacks, coerced residents into prostitution, threatened violence against patients, and submitted urine and saliva for screening even when no medical need existed.

It’s an exploitation of some of our nation’s most vulnerable individuals and it needs to stop!

FINDING REAL HELP

Amid a sea of get-rich-quick frauds, how can those struggling to overcome opioid addiction find genuine help? How can they—and their families—be sure they’re not scammed by fraudsters? Benzio says quality facilities have several standout features. He advises looking for those that are Christian-owned, apply the Bible to daily living, and emphasize the importance of growing in a relationship with God. Some of the other key elements include:

  • One of the owners is an accomplished clinician, such as a psychiatrist, counselor, or therapist. Clinicians with ownership stakes usually have professional reputations to maintain, an understanding of what great care looks like, and a desire to make clinical excellence a primary focus.
  • A psychiatrist sees the patient early in the admission process for detox purposes and to help diagnose underlying issues that contribute to the patient’s opioid use.
  • The treatment and residential facilities are located on the same campus, allowing for a higher level of accreditation and insurance approval.
  • Individual therapy is provided by masters-level and/or licensed therapists. Each patient receives several individual sessions per week.

A FAMILY AFFAIR

Between the overloaded hospitals, risky prescribing practices and minefield of rehab programs, the opioid epidemic is stretching and straining America’s health care resources like nothing we’ve ever seen. Tackling those (and many other) massive opioid-related issues will require innovative solutions.

Cece and Bobby Brown of Charleston, WV had a son who died four years ago at age 27. His parents describe him as being “just like the kid next door,” stating he was a trouble-free child who loved sports, music, skateboarding, and God. His mother said, “I sent him to college to get a degree, and he came home with an addiction.” Ryan struggled with opioids for seven years, surviving three overdoses along the way. But in April 2014, he had another—at the local mall. The Browns believe their son ran into an acquaintance there who gave him the heroin that snuffed out his life.

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The couple spent thousands on detox and rehabilitation programs for Ryan. What he really needed, they say, was a long-term facility where he could get clean for good. Instead, a typical cycle for Ryan would consist of seven days of detox and regular participation in outpatient programs, therapy groups and Narcotics Anonymous. That combination would keep him clean for about six weeks.

But he needed more.

Ryan was on waiting lists for two long-term treatment centers when he died. Having aged out of his parents’ insurance plan at 26, he had just received Medicaid benefits three days before his death. Most heartbreaking, his parents learned after his passing that a treatment facility that could have accepted Ryan was only three miles away. Now his parents can’t help but wonder, What if the wait times had been shorter, the coverage had come a bit earlier, and we had known about the facility nearby?

“That would’ve given opportunity. I can’t say that would have changed things, but opportunity is everything,” Cece says. Over the last four years, the Browns have made it their mission to make sure others with similar struggles in West Virginia have the opportunities Ryan didn’t.

INNOVATE FOR THE STATE

After a two-year effort led by Bobby and Cece, last year West Virginia lawmakers passed legislation creating the Ryan Brown Addiction Prevention and Recovery Fund. The Fund aims to expand the state’s capacity to help those struggling with opioids but lacking private insurance, Medicaid or Medicare coverage by blending public grants and private dollars. People can contribute charitable gifts.

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So far, the model has yielded promising results: The West Virginia Department of Health and Human Services has awarded $20.8 million through the Fund to nine long-term treatment facilities statewide. That’s already translated to 300 more West Virginians getting treatment than would’ve been the case otherwise. The Browns explain it’s just reality that many struggling with opioids have low-wage jobs that don’t offer insurance. Some, they say, have felonies that prevent them from securing jobs with better wages and benefits. But that doesn’t mean they should be left behind. Bobby said, “If they don’t want help, there’s nothing we can do. But if they do want help, we need to get them help.”

The Browns are also grateful West Virginia has addressed another problem: In September 2015, the state launched a resource hotline to help those combating opioid addiction.  “We didn’t have a number to call to talk to anyone; didn’t know where to get help,” Bobby recalls. “Now that number has come out.” Those needing help can simply call 1-800-HELP-4WV—and thousands have.

Bobby and Cece say they feel honored to play a role in easing the burden the opioid epidemic has placed on the health care system, and to help families struggling with the weight of it all find solid answers. They’ve been part of several White House events aimed at finding solutions, and say they’ll continue to engage the Trump administration in the hopes of keeping the heat on. As a reminder of the epidemic’s devastating toll, Cece displayed a picture of Ryan at a round table discussion with First Lady Melania Trump earlier this year.

This needs to be about people, not politics.

COUNTERFEIT OXYCODONE WARNING!

COUNTERFEIT PAIN PILLS CONTAINING DANGEROUS SYNTHETIC OPIOIDS!

Originally posted July 18, 2017
National Institute of Drug Abuse
https://www.drugabuse.gov/

Health and safety agencies in Iowa have issued an advisory to warn Iowans of counterfeit pain pills containing dangerous synthetic opioids. The Iowa Division of Criminal Investigation’s (DCI) laboratory analyzed pills made to resemble the prescription pain reliever oxycodone, finding them to contain more powerful and illicit synthetic fentanyl and U-47700, putting users at higher risk of opioid overdose. U-47700, also known as “Pink” or “U4” on the streets, is a synthetic opioid pain medication currently being distributed as a dangerous designer drug. Since 2015, reports have surfaced of numerous deaths due to street use of U-47700. Law enforcement agencies have traced illegal importation into the United States primarily from clandestine chemical labs in China. It is available through the Dark Web.

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U-47700 has been seized by law enforcement on the street in powder form and as tablets. Typically, it appears as a white or light pinkish, chalky powder. It may be sold in glassine bags stamped with logos imitating heroin, in envelopes and inside knotted corners of plastic bags. In Ohio, authorities seized 500 pills resembling a manufacturer’s oxycodone immediate-release tablets, but they were confirmed by chemical analysis to contain “Pink.” U-47770 has also been identified and sold on the Internet misleadingly as a “research chemical” at roughly $30 per gram.

Pink is very toxic or deadly in even small doses. Labels on the packaging may state NOT FOR HUMAN CONSUMPTION or FOR RESEARCH PURPOSES ONLY, most likely to avoid legal detection. Fatalities due to U-47770 in the United States join the growing incidents of drug overdose deaths from opioid pain medication. Those who abuse U-47770 may be at high risk of addiction and substance abuse disorder, overdose and death. Fatalities have been reported in New York, New Hampshire, Ohio, Texas, Wisconsin and North Carolina.

In July 2016, a toxicology case report was published in the Annals of Emergency Medicine that detailed events in which fentanyl and U-47700 were being sold misleadingly as the prescription opioid pain medication Norco or Vicodin (acetaminophen and hydrocodone) on the streets of Northern and Central California. In one patient who presented to the emergency room, nalaxone (Narcan) was administered which reversed respiratory depression and pinpoint pupils. After additional chemical analysis, it was found the Norco contained hydrocodone, fentanyl, and U-47700.

Reports indicated that Pink and prescription fentanyl may have been contained in the drug cocktail that led to the death of pop star legend Prince in April 2016. In Utah, two 13-year old boys died in September 2016 reportedly due to use of U-47770 purchased from an Internet website. U-47700 (“Pink”) is a novel synthetic opioid agonist with selective action at the mu-opioid receptors in the brain and on the spinal column. It was originally developed by chemists at Upjohn Pharmaceuticals in the 1970’s as a potent pain reliever for use with cancer patients, post-operative patients with intractable pain, or extremely painful trauma injuries. Although it was never commercially made available, the patent and chemical details remained available, and have been produced on the black market.

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U-47700 has a similar chemical profile as morphine and other mu-opioid receptor agonists; however, it has been reported by the National Institute of Drug Abuse (NIDA) that Pink is “far more potent than morphine” –  possibly by seven to eight times. Unfortunately, the strength of the product can never be assured, and may be much stronger, especially when manufactured overseas in illicit labs as a designer drug. On November 14, 2016, the DEA placed U-47700, as well as its related isomers, esters, ethers, and salts into Schedule I of the Controlled Substances Act due to an imminent hazard to public safety and health. Substances in Schedule I have a high potential for abuse, no currently accepted medical use, and a lack of accepted safety for use under medical supervision.

Temporary emergency scheduling of dangerous illicit drugs is one tool the DEA uses to help restrict potentially fatal and new street drugs. Scheduling will last at least 24 months, with a possible 12-month extension if the DEA needs more time to determine whether the chemical should remain permanently as a Schedule I drug. According to the Federal Register, there are no current experimental or approved new drug applications for U-47700, which can typically hinder its permanent placement in Schedule I if approved. DEA’s Final Order is available in the Federal Register with details on threats to public safety. Prior to DEA’s scheduling, several states had already outlawed the drug under emergency orders, including Florida, Ohio, Wyoming and Georgia.

BOTTOM LINE

U-47700, known on the streets as “Pink” or “U4”, is a dangerous designer drug exported from illegal labs in China to the U.S. It is a strong opioid analgesic, reportedly 7 to 8 times more potent than morphine. Authorities in many U.S. cities have reported that Pink is sold on the streets or over the Internet, often falsely promoted as a prescription opioid like Norco or Percocet, or as heroin. In fact, many of these products have contained the potent designer drug Pink, as well as fentanyl. U-47700 is now illegal in all forms, and the DEA has temporarily placed the substance into Schedule I of the Controlled Substances Act, pending further review, due to an imminent hazard to public safety and health. It is considered not safe for human consumption, and has no acceptable medical use.

Clusters of overdoses and deaths of Pink were reported in U.S. cities in 2015 and 2016. Some of these deaths involved children. According to one case report, the use of naloxone (Narcan) in an emergency setting reversed the effects of U-47700, but this may not always be the case. Emergency physicians should contact their local poison control center, medical toxicologist or public health department in cases where there is a reasonable suspicion of ingestion of designer drugs to help protect the surrounding community. Special lab analysis is typically needed to identify drugs like “Pink,” leaving communities at risk.

The public should be aware that drugs obtained on the street, even though they look like an authentic prescription medication, may be fake and deadly. Don’t take any prescription drug, legal or otherwise, unless it is prescribed specifically for you by a doctor and is dispensed by a reliable pharmacy.

The Role of Science in Addiction

SPECIAL REPORT
From the New England Journal of Medicine
May 31, 2017
By Nora D. Volkow, M.D, and Francis S. Collins, M.D., Ph.D.

Opioid misuse and addiction is an ongoing and rapidly evolving public health crisis, requiring innovative scientific solutions. In response, and because no existing medication is ideal for every patient, the National Institutes of Health (NIH) is joining with private partners to launch an initiative in three scientific areas:

  1. developing better overdose-reversal and prevention interventions to reduce mortality, saving lives for future treatment and recovery;
  2. finding new, innovative medications and technologies to treat opioid addiction; and
  3. finding safe, effective non-addictive interventions to manage chronic pain.

Overdose-Reversal Interventions

Every day more than 90 Americans die from opioid overdoses. Death results from the opioid’s antagonistic effect on brainstem neurons that control breathing. In other words, the victim succumbs to respiratory failure. Naloxone can be used effectively to reduce the effect of opioid intoxication, thereby reversing the overdose, if it is administered in time. Although naloxone has saved tens of thousands of lives, overdoses frequently occur when no one else is around, and often no one arrives quickly enough to administer it.

Overdose fatalities have also been fueled by the increased availability of very powerful synthetic opioids such as fentanyl and carfentanil (50-100 times and 5,000-10,000 times more potent than heroin respectively). Misuse or accidental exposure to these drugs (e.g., when laced in heroin) is associated with very high overdose risk, and naloxone doses that can often reverse prescription-opioid or heroin overdoses may be ineffective. New and improved approaches are needed to prevent, detect and reverse overdoses.

Treatments for Opioid Addiction

The partnership will also focus on opioid addiction (the most serious form of opioid use disorder), which is a chronic, relapsing illness. Abundant research has shown that sustained treatment over years or even a lifetime is often necessary to achieve and maintain long-term recovery. Currently, there are only three medications approved for treatment: methadone, buprenorphine, and extended-release naltrexone. These medications, coupled with psychosocial support [such as rehab and 12-step programs] are the current standard of care for reducing illicit opioid use, relapse risk, and overdoses, while improving social function. There is a clear need to develop new treatment strategies for opioid use disorders. New pharmacologic approaches aim to modulate activity of the reward circuitry of the brain.

Non-Addictive Treatment for Chronic Pain

The third area of focus is chronic pain treatment: over-prescription of opioid medications reflects in part the limited number of alternative medications for chronic pain. Thus, we cannot hope to prevent opioid misuse and overdose without addressing the treatment needs of people with moderate-to-severe chronic pain. Though more cautious opioid prescribing is an important first step, there is a clear need for safer, more effective treatments.

Foremost is the plan to develop formulations of opioid pain medication with built-in abuse deterrent properties that are more difficult to manipulate for snorting or injecting, the routes of administration most frequently associated with misuse because of their more immediate rewarding effects. Such formulations, however, can still be misused orally and still lead to addiction. Thus, a more promising long-term avenue to addressing pain treatment will involve developing a powerful non-addictive analgesic. There are some fascinating x-ray crystallography studies going on that look promising.

Non-pharmacologic approaches being explored today, including brain-stimulation technologies such as high-frequency repetitive transcranial magnetic stimulation (rTMS, already FDA-approved for depression), have shown efficacy in multiple chronic pain conditions. At a more preliminary stage are viral-based gene therapies and transplantation of progenitor cells to treat pain. NIH researchers are investigating the use of gene therapy to deliver a potent anti-inflammatory protein directly to painful sites. Pre-clinical studies show powerful and long-lasting effects in reducing pain without side effects such as numbness, sedation, addiction, or tolerance.

Public-Private Partnerships

In April 2017, the NIH began discussions with pharmaceutical companies to accelerate progress on identifying and developing new treatments that can end the opioid crisis. Some advances may occur rapidly, such as improved formulations of existing medications, opioids with abuse-deterrent properties, longer-acting overdose-reversal drugs, and repurposing of treatments approved for other conditions. Others may take longer, such as opioid vaccines, and novel overdose-reversal medications. For all three areas, the goal is to cut in half the time typically required to develop new safe and effective therapeutics.

As noted throughout the history of medicine, science is one of the strongest allies in resolving public health crises. Ending the opioid epidemic will not be any different. In the past few decades, we have made remarkable strides in our understanding of the biologic mechanisms that underlie pain and addiction. But intensified and better-coordinated research is needed to accelerate the development of medications and technologies to prevent and treat these disorders. The scope of the tragedy of addiction and overdose deaths plaguing our country is daunting. The partnership between NIH and others will take an all hands on deck approach to developing and delivering the scientific tools that will help end the opiate epidemic in America and prevent it from reemerging in the future.

References

Volkow, N. and Collins, F. (May 31, 2017). “The Role of Science in Addressing the Opioid Crisis.” The New England Journal of Medicine. DOI: 10.1056/NEJMsr1706626

Volkow, L. (May 31, 2017). “All Scientific Hands On Deck to End the Opioid Crisis.” [Web blog comment]. Retrieved from : https://www.drugabuse.gov/about-nida/noras-blog/2017/05/all-scientific-hands-deck-to-end-opioid-crisis

Opioid Use Disorders and Suicide

The following is a guest blog taken verbatim from the monthly blog post of Dr. Nora Volkow, director, National Institute of Drug Abuse published April 20, 2017.

“At a Congressional briefing on April 6, the President of the American Psychiatric Association, Dr. Maria Oquendo, presented startling data about the opioid overdose epidemic and the role suicide is playing in many of these deaths. I invited her to write a blog on this important topic. More research needs to be done on this hidden aspect of the crisis, including whether there may be a link between pain and suicide.” – Nora

In 2015, over 33,000 Americans died from opioids—either prescription drugs or heroin or, in many cases, more powerful synthetic opioids like Fentanyl. Hidden behind the terrible epidemic of opioid overdose deaths looms the fact that many of these deaths are far from accidental. They are suicides. Let me share with you some chilling data from three recent studies that have investigated the issue.

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In a study of nearly 5 million veterans recently published in Addiction, scientists reported that presence of a diagnosis of any substance use disorder and specifically diagnoses of opioid use disorders (OUD) led to increased risk of suicide for both males and females.  The risk for suicide death was over 2-fold for men with OUD.  For women, it was more than 8-fold.  Interestingly, when the researchers controlled the statistical analyses for other factors, including co-morbid psychiatric diagnoses, greater suicide risk for females with opioid use disorder remained quite elevated, still more than two times greater than that for unaffected women.  For men, it was 30 percent greater.  The researchers also calculated that the suicide rate among those with OUD was 86.9/100,000.  Compare that with already alarming rate of 14/100,000 in the general US population.

You may be tempted to think that these shocking findings about the effects of OUD on suicide risk are true for this very special population.  But that turns out not to be the case. 

Another US study, published last month in the Journal of Psychiatric Research, focused on 41,053 participants from the 2014 National Survey of Drug Use and Health.  This survey uses a sample specifically designed to be representative of the entire US population.  After controlling for overall health and psychiatric conditions, the researchers found that prescription opioid misuse was associated with anywhere between a 40 and 60 percent increased risk for suicidal ideation (thoughts of suicide).  Those reporting at least weekly opioid misuse were at much greater risk for suicide planning and attempts than those who used less often.  They were about 75 percent more likely to make plans for a suicide, and made suicide attempts at a rate 200 percent greater than those unaffected.

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Using a different strategy, a review of the literature in the journal Drug and Alcohol Dependence estimated standardized mortality ratios for suicide.  This is a way of comparing the risk of death in individuals with a given condition compared to individuals from the general population.  The researchers found that for people with OUD, the standardized mortality ratio was 1,351 and for injection drug use it was 1,373.  This means that compared to the general population, OUD and injection drug use are both associated with a more than 13-fold increased risk for suicide death. These are stunning numbers and should be a strong call to action.

Persons who suffer from OUD are highly stigmatized. They often talk about their experience that others view them as “not deserving” treatment or “not deserving” to be rescued if they overdose because they are perceived as a scourge on society.  The devastating impact of this brain disorder needs to be addressed.  People who could be productive members of society and contribute to their families, their communities, and the general economy deserve treatment and attention.

As a country, we desperately need to overcome stigmatizing attitudes and confront the problem. We need to understand what causes some individuals to become addicted when exposed to opioids and thus study the biological basis of the disease of opioid addiction. We desperately need to know what the best treatments are for a given individual, and for that too, we need research to identify biomarkers for treatment response. Given the fact that effective medications exist but are drastically underutilized, we need to overcome institutional and attitudinal barriers to these treatments and deliver them to the 24 million people who could benefit. It can prevent not only the suffering of addiction and the danger of unintentional overdose but also help prevent the tragic outcome of opioid-related suicide.

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Anywhere, U.S.A.

You can say that drug addiction could happen to anyone’s child, because it could. You can say that it happens in every community, because it does. But what happens when it’s your neighborhood? The residents of Campbell County, Kentucky know.

When you mention Matthew W. to some of the people who knew him, when he was in high school, even if you don’t use his name at first, they’ll know who you’re talking about. “Of course,” they’ll say. “I figured you meant Matt.” And then the teacher or the counselor or whomever will smile a smile that is genuinely warm and thoughtful, and you will naturally figure that their memories of Matthew are unclouded.

And you can imagine why. His skin is pink gold, the kind of color Norman Rockwell mixed for his cherubs, and his hair has the sort of soft, nape-of-the-neck curl that mothers love to snip and save in baby books. Matthew W., Campbell County High School Class of 2002, is every kid who ever sacked your groceries or lugged an instrument across the field at halftime.

The year since Matt graduated from high school has been a hard one in Northern Kentucky’s Campbell County. This past Friday there was a dramatic community meeting held in the Alexandria fire station. The police chief called it an intervention, employing the word that therapists use when they talk about confronting a person who is an alcoholic. But it was heroin, not alcohol, that prompted the meeting. Nineteen-year-old Mark D. and eighteen-year-old Adam M. had died of drug overdoses within weeks of one another, within months of their high school graduation. The death of Casey W., 23, from Kenton County, raised the local toll.

Both the Cincinnati Enquirer and The Post wrote about the growing threat of heroin among teenagers and young adults. Reporters were careful to talk about heroin use by kids all over Greater Cincinnati, but it was pretty hard to miss the fact that the deaths of these three in Northern Kentucky had prompted their attention. Their high school graduation pictures formed a gallery of heartache. Matthew W.’s picture could have been among them. He knows that now.

When Matt tells his story, he’s still trying to make sense of it himself. Sometimes it seems like a whirlpool of events, snapshots and memories that trail off to nowhere. The part that seems clearest is the part that’s the furthest away. Growing up Catholic in an Alexandria subdivision, going to St. Mary’s School and then Campbell County High School with his friends. The same crowd that signed up for AP classes, played together in the band, and spent weekends going to movies or playing cards.

It was in the ninth grade that Matt’s depression began. He told his mother he was sad, but it was more than that. He felt like he was living in darkness, that everything he did was a chore. His family doctor dismissed it as a phase. Routine adolescent doldrums. But as the months plodded on, the shadows never lifted. By the time he was 16, he was “self-medicating” with alcohol. He partied at the homes of a few like-minded friends whose parents were absent, and arranged weekend sleepovers so he could sober up before facing his parents. The drinking alleviated the depression, but as a depressant itself, alcohol became a double-edged sword. Downing a whole bottle of Jim Beam in the span of two hours became almost commonplace.

In October of his senior year, Matt’s depression was deep. His grades suffered, and music became less of a passion. On a particularly miserable fall afternoon, he made not one but two suicide attempts. First, he shut himself inside the garage and ran his dad’s ’84 Thunderbird until he passed out from the fumes. The car ran out of gas and he woke up. Then, he went inside and dug through the family medicine cabinet, collecting old pills and the painkillers he’d saved from foot surgery. He arrived at a friend’s party, pockets bulging with pills, and proceeded to wash them down with swigs of Jim Beam. Then he stumbled outside and passed out near U.S. Route 27. People from the party had to drag him back to the house, tearing his clothes and scraping his head along the pavement.

When he returned home the next morning, Matt had a black eye and his clothes were in shambles. This time he didn’t use the sleepover excuse. He told his parents what he’d done. They hadn’t known about the drinking. Hadn’t the doctor said not to worry? This was “just a phase.” Matt’s parents got help immediately, taking him to a therapist who specialized in adolescents. The therapist prescribed Zoloft for Matt’s depression, and insisted he start attending AA meetings. Matt took the Zoloft and went to therapy, but continued to drink. Only after four months did he start attending AA meetings.

In January 2002, after binge drinking, Matt tried heroin for the first time with a classmate named Chad. Chad was on the fringes of Matt’s circle at high school, a brilliant guy in Matt’s estimation, who could come to class stoned and still perform well enough to rank in the top five percent of the class. Chad had been using heroin for about a year and was happy to show Matt the way. Within seconds of shooting up, Matt felt like he was saved. He was on a high that cast daily life as a mere caption to his new picture of health. Twenty milligrams, $20, one fix, and Matt had never felt better. Today, it’s hard for him to recreate the precise rationale that got him there. Only that, at the time, “putting a needle in my arm made sense.”

In the 1990s, when cocaine began to lose its cachet, Columbian drug traffickers needed to diversify, so they added heroin to their product line. Once they got into the business, they refined it, producing a purer heroin that was also cheaper. The higher-quality, more affordable powder could be snorted, which actually helped people become users. It’s one reason that heroin use rose in the United States during the ’90s. A survey by the Department of Health and Human Services found that between 1993 and 1999, overall admissions for heroin treatment at public hospitals increased by 11 percent. But that’s an average. Some parts of the country (especially the Seattle grunge scene) were especially hard-hit.

Things always seem to happen later in our part of the world, and heroin has been no exception. Police and drug rehab professionals speculate that when Northern Kentucky law enforcement started clamping down on illegal OxyContin distribution, the local Oxy traffickers phased in heroin to serve their customers’ habits. “We saw OxyContin users, and when that was being controlled there was the swing to heroin,” says Dr. Mike Kalfas, medical director of the St. Luke Alcohol and Drug Treatment Center. “I can’t prove it, but it’s sure a logical conclusion.”

Heroin changed Matt’s life instantly. Before, he had been sleeping 14 hours a day, but once he started using, he was happy and life became manageable. He took every opportunity to get high, in his room, in the garage, at Chad’s house. Once, during an AA meeting in a church basement, he shot up in the restroom. He convinced his mother that he was in control because he only used twice a week. If he forced himself to maintain some sort of schedule to his using, he reasoned, he wouldn’t become an addict.

By the first week in February 2002, Matt had spent all his savings on heroin. Stuck for cash, he asked his mother for money to get his girlfriend a Valentine’s Day gift. She gave him two twenties and asked for the change. Matt was gone for ages, and when he returned he had a card and a box of chocolates. Change from the $40? He insisted his mother had only given him two tens. The next day, Matt’s mom walked into his room when he wasn’t around and saw a cup of rubbing alcohol sitting out. Suddenly, the whole picture fell into place. She knew he was injecting heroin.

In early February of the following year, 12 months from the day Matt’s family faced his heroin addiction, 400 or so citizens of Campbell County crammed into the meeting room of the Alexandria fire house. The meeting had been called a couple of weeks after eighteen-year-old Adam M. died of an overdose. The idea was put together by law enforcement officers from several agencies, the county coroner, and the Commonwealth’s attorney, but it was Alexandria’s Chief of Police, Mike Ward, who organized it. He was sticking his neck out by hosting the meeting. Insiders said community leaders were worried about how it would make Alexandria look. But in the face of the tragedies, keeping up appearances didn’t seem so important to Chief Ward.

The conventional method of cleaning up a community drug problem, using informants to make controlled buys, then arrest dealers, wasn’t working. There was significant drug-fighting expertise on the south side of the Ohio River. Officers were prepared to deal with kilos of cocaine coming into the area, or an enterprising farmer harvesting marijuana. But keeping a kid from overdosing on a hit of heroin he bought five minutes before in another state seemed impossible. Unless you could keep him from using drugs in the first place. This was the intention of the intervention meeting at the fire house.

On April 2, 2003, Matt W. was one year clean. He was a freshman at a local university. During his first year of college, he attended NA meetings in Lexington, which was a two-hour round trip from campus. He continued to read books he purchased at an AA meeting. He kept busy, playing in the marching band, did tutoring for the math department, and carried 18 credit hours in the fall. In the winter, he started going home on weekends, and began rehearsing again with the band he’d put together in high school. It had fallen apart when he started using heroin.

One night he went with friends to a party where people were drinking and smoking hash. He turned on his heels and went back to his dorm. The same kind of struggle can be set off by the simplest of things. “I’ll wake up and I think it’s a gorgeous day, and I say ‘What a great day to be high!'” When that happens, he counters it with something equally simple. He simply remembers his mother crying one year ago on that February night before he went into treatment. When you talk to Matt now, he still doesn’t know everything there is to know about his addiction, or why he chose to do what he did. Nor does he know why he chose to stop when he did. But he’s learning about himself, which is one of the great gifts of recovery. He’s not afraid to go home again. After all, he comes from a good place.

References

Mandrell, L. and Vaccariello, L. (2003). Anywhere U.S.A., Cincinnati Magazine, 36(10), 62.

How Heroin Kills

The following information appeared in The Sunday Item, April 3, 2016, Sunbury, Pennsylvania.

Teresa Stoker gently pulls a sterling silver necklace from beneath the neck of her gray sweatshirt and holds it out beyond her chin. Ashes of 27-year-old Mark Stoker are piled inside a tiny cylinder, strung next to an imprint of her youngest son’s right thumbprint. His two siblings keep their brother’s ashes in keepsake key chains. Their mother has one of those, too. Mark died February 4, 2016 of a heroin overdose inside a New Columbia motel – one of 13 tri-county residents dead or suspected to have died of a drug overdose in 2016, according to coroners from Northumberland, Snyder and Union counties.

Mark was alone when motel staff found him after he failed to check out of his room. He was alone the day before, overdosed again in heroin and dumped by an acquaintance in the parking lot of a Burger King in Williamsport, PA, rain pouring onto his unconscious body, until passersby came to his aid and dialed 9-1-1.

He was supposed to be at his mother’s home in Shamokin Dam that day. They were supposed to have dinner and watch TV together. That had been the routine for days. He had stayed off heroin for six months, but he was growing irritable. His suboxone prescription was running short. He didn’t have consistent rides to counseling. He tried to make it work. He sliced the medicated film in half. As his supply dwindled, he sliced it in fours.

When Teresa pulled into her driveway on February 3rd, she could see through the blinds hung in the front window. “I knew he wasn’t in there,” she says.

Two months after his death, Mark’s family is left to reconcile love and pain, guilt and forgiveness – within themselves and within their own relationships fractured by a loved one’s fatal drug addiction. “He was the link that brought us together, and he was the one that pulled us apart,” says his sister and eldest sibling, Desiree. “He wasn’t long for this world,” adds Teresa. “He fought this to the very end,” says his brother Matt. “Mark didn’t really have a choice.”

The Stoker kids’ father died early in their lives. Mark was only 2 years old. Matt wonders if it was the impetus for mental health issues Mark would develop in life, particularly depression. Anxiety and depression are often evident in the psyche of a drug addict, according to the National Institute on Drug Awareness. “Addiction is a mental health issue,” says Dr. Rachael Levine, Pennsylvania’s physician general, who is among the officials at the forefront in addressing the Keystone State’s heroin and opioid addiction crisis. “It is not a moral failing.”

Mark sought help, and sometimes he sought it himself. He was no stranger to rehab. He’d been in and out of treatment several times, both in Pennsylvania and elsewhere. His family stood by his side the best they could, the only way they knew how. They encouraged him to lead a clean life, showed pride when he landed new jobs, sat bedside when he was hospitalized for an overdose. “Sometimes I look back and think we were fooling ourselves,” Matt says.

Matt and Desiree were the academics in the family. The former is enrolled in the physician assistant program at Pennsylvania College of Technology, and the latter is a registered nurse at Geisinger Medical Center in Danville, PA. Mark was no fool, either. His mind was for mechanics. He once rebuilt his own motorcycle after he wrecked it. Then he sold it and traded up for a better ride. His career path was in electrical work. On one job, he was hanging by a harness from a helicopter 200 feet above the ground repairing high-voltage lines. His family describes him as witty and charming, kind and sensitive, resilient and rebellious.

A quick learner, fearless in life’s pursuit, Mark hit dirt bike jumps taller than himself before he was a teen. He took quickly to Black Diamond slopes when he began to ski and bagged an eight-point buck on his first hunt. He was just 10 when he picked up on how to drive a stick shift. Accidents along the way created a need for pain relief. It’s very important to note that the American Society of Addiction Medicine found 4 in 5 new heroin users started by abusing prescription painkillers. Count Mark among the 80 percent. According to Mark’s mother, he was given pain meds at 14 when he had a wisdom tooth extracted. He took painkillers at 16 after having his gallbladder removed. Again, he took narcotic pain medication at 18 after being involved in a motorcycle accident.

Mark was 23 in 2012 when he developed painful kidney stones. His behavior suddenly changed. He became withdrawn, choosing to spend more time than normal alone in his bedroom. He was in legitimate need of relief from pain, but looking back, this is when his family says they first recognized signs of addiction. He’d been abusing oxycodone he was getting from three separate doctors. Maybe he needed relief the next summer when he stole Vicodin from his mother’s medicine cabinet.

It was September of that same year when Mark’s family first saw him experience a heroin overdose. He had borrowed his sister’s car. She found him slumped over in the driver’s seat as the engine idled – eyes glazed, sweat pooled in a cup holder. Mark’s sister dialed some of his recent calls on his cell phone. Someone told her, “He might be doing heroin.” She flipped out. The pock marks on the back of Mark’s hands weren’t bug bites as she thought on first glance. They were injection sites.

There would be more overdoses for Mark between September 2013 and the night he died in February 2016. Once his mother got a call from a Virginia state trooper. Mark overdosed in a hotel room while he was out of state on a job. Another time he was dumped at the doors of Evangelical Community Hospital in Lewisburg, PA, “dead on arrival,” as Teresa says. Attempts at recovery followed. Twenty-eight days at a Virginia facility didn’t take. The Stokers were more hopeful after a 28-day stay at Father Martin’s Ashley in Maryland, but again it didn’t help. He walked out of a rehab in White Deer, PA one week after he checked himself in.

Jobs, friendships, girlfriends – all lost by Mark to addiction, an addiction that strained an already complicated relationship, and ultimately led to his loss of parental rights to his daughter. He spoke often about the little girl, wrote about her in his journal. Teresa holds dear the few photographs she has of the two together.

A study on addiction by the Center for Rural Pennsylvania determined only 1 in 8 Pennsylvanians can afford treatment services. Geisinger Health System’s latest needs assessment says lack of insurance, cost of care, and transportation are barriers to treatment. More importantly, there simply aren’t enough providers to meet demand.

Mark had health insurance through the Health Insurance Marketplace. His mother says it didn’t cover the $150 monthly cost for suboxone, or the $100 cost per session for addictions counseling. His mother was in counseling herself, and with Mark out of work, she was covering all the bills. “We all knew he should be on [suboxone]…but we couldn’t afford it,” Teresa says.

And so the afternoon of February 4th, one day after Mark’s life was saved after he was found in the parking lot of the fast-food restaurant, came a familiar phone call to Teresa. One the whole family expected and equally feared. It was the state police. They didn’t tell her, but she knew. This time, Mark was dead.

Crucial New Guidance on Opioids and Pain

From the blog of Dr. Nora Volkow, Director, National Institute of Drug Abuse
April 6, 2016

Millions of Americans suffer from opioid use disorders involving prescription pain medications, and each day more than 40 people fatally overdose on them. Although these medications have a legitimate and important role in the treatment of severe acute pain and some severe chronic pain conditions, it is clear that they are also over-prescribed or prescribed without adequate safeguards and monitoring, a situation that has significantly contributed to the alarming rise in opioid use disorders, and to the related resurgence of heroin use we are also seeing in many communities.

Last month, the Centers for Disease Control and Prevention took a major step toward addressing these intertwined crises by issuing new guidelines for prescribers about the use of opioids for treating patients with chronic pain—who according to some studies now account for 70 percent of the opioids dispensed in this country. The CDC recommends that opioids should not be the first line or only treatment for patients who present with chronic non-cancer pain.

It is not simply an issue of safety. Recent reviews of the science have found surprisingly little evidence supporting the effectiveness of opioids in the treatment of chronic pain conditions (defined as pain lasting longer than 3 months). In some cases, opioids may even contribute to a worsening of pain (hyperalgesia), leading to a vicious cycle of taking more opioids to treat a condition that the medication itself has made less tractable.

The new guidelines thus recommend that non-opioid therapies, such as non-steroidal anti-inflammatory drugs (NSAIDs) like aspirin and ibuprofen, as well as non-drug treatments like exercise and cognitive behavioral therapy, should be considered in lieu of or in conjunction with opioid medications. When opioids are prescribed, physicians should prescribe the lowest effective dose, and closely monitor and follow-up with their patients.  Notably, the new guidelines do not apply to treatment of cancer pain or end-of-life care.

Of course, reducing the use of opioids by primary care physicians must be balanced against the efficacy of these drugs for some patients. The aim is not to take these powerful analgesics away from those who need and safely benefit from them, but to ensure they are only used where they are effective, and at the same time reduce the risk of both diversion and the development of substance use disorders.

As in so many other areas, pain is an area where we need more science. The lack of evidence regarding opioids in chronic pain is matched by a lack of evidence for any treatment in these disorders. Other available pain relievers like NSAIDs also have their liabilities and potential safety issues, and their efficacy for treating chronic pain conditions will also require further study. Recognizing the liabilities and limitations of opioids is also an impetus to redouble our efforts to develop new pain treatments that would be safer and more effective than currently available medications. Compounds that modulate signaling in the body’s endocannabinoid system, for example, are an active area of research and may yield new pain pharmacotherapies in coming years.