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State of emergency: Tennessee’s opioid epidemic reaches new heights
The Daily Times - 7/2/2018
Christopher Russell was going to die crumpled on the floor of a dark closet in his abandoned childhood house.
Because of opioids, he’d lost his marriage, his job, his home and with it, access to his children. His years-deep addiction even caused a seizure so violent he broke a vertebrae in his lower spine.
He couldn’t remember the last time he’d eaten. Minutes turned to hours, then turned to days. His only comfort was a handheld radio. But now even the batteries stolen from Walmart were beginning to fade, and the voice on the radio sagged in and out. His opioid withdrawal was sinking into full-blown psychosis.
Russell thought to himself that this was hell.
He was alone in that closet. But across the country, he was just one voice in a deafening choir.
The opioid addiction epidemic is the deadliest drug crisis in American history. And despite an array of new and aggressive efforts to counter it, it’s getting worse.
Last year was the worst year on record for overdose deaths, according to preliminary figures from the Centers for Disease Control and Prevention, just as 2016 was, and 2015 before it.
And the CDC cautions that preliminary figures often are underestimated.
Across the country, 46,466 people died from opioid-related causes in a 12-month period ending in November 2017. These casualties exceed the combined populations of Maryville and Alcoa by more than 7,000.
Since 1999, the crisis has killed more nationwide than the population of Nashville-Davidson County.
Tennessee is among those states bearing the brunt of the epidemic, along with most of its Appalachian neighbors. In 2016, 1,861 Tennesseans died from drug overdoses, the overwhelming majority of which were related to opioids.
Its victims are not restricted to any age group or race, but the most dramatic growth has been among young white men, particularly in rural areas.
Take Dane McCoy, for instance, who was a 22-year-old Louisville man.
Dane was a people person, said his mother, Jan McCoy, and an honor roll student. He sang in the youth choir of the church and attended Maryville First United Methodist Church most every Sunday. He was an athlete and played football all four years of high school.
But drugs presented a “whole new ballgame,” his mother said. They changed everything.
She believes her son’s relationship with pills began around 2012, when he was paid to pressure wash the house of a friend’s aunt.
The woman told Dane she could show him how to make $2,000 in a month. She paid for him to get an X-ray in Knox County, then to visit a pain clinic, then to get a prescription for a bottle of 120 oxycodone pills.
The woman took 100 and let Dane keep the rest.
“At least, this is according to Dane,” his mother said. “And he wasn’t an addict at this point, so I believe him.”
She still has the bottle. The aunt was never charged.
A flood of pills
An overabundance of prescription pills drove the national epidemic in the beginning.
Doctors freely prescribed the painkillers, encouraged by drug company reps and a health care culture desperate to give relief from chronic pain.
Prescribing a 30-day supply of pills for a three-day regimen was far from uncommon. The drugs often would sit in home medicine cabinets collecting dust. From there they would pass on to friends or family: either given, sold or simply taken.
Most people who abuse prescription opioids get them for free from a friend or relative, according to the CDC, and almost 40 percent of all opioid overdose deaths involve a prescription opioid.
Sales of prescription opioids in the United States nearly quadrupled from 1999 to 2014, peaking in 2011 with nearly 240 billion morphine milligram equivalents, the CDC reports.
During the same period, there was no overall change in the amount of pain reported by Americans.
The boon was in part fueled by an aggressive campaign funded by pharmaceutical groups like Purdue Pharma. Doctors heard from their professional groups, their hospitals and even from state medical boards that patients were suffering needlessly because of an overblown fear of addiction.
“We doctors were wrong in thinking that opioids can’t be used long term. They can be, and they should be,” a spokesperson says in a marketing video from 2000 promoting OxyContin.
An unyielding faith in painkillers, drawn up in boardrooms, eventually trickled down from exam rooms to living rooms.
Christopher Russell never had problems getting access to opioids throughout his entire life.
His first time using them was soon after he saw his sibling pour their uncle’s old Hydrocodone pills into a cigar case. Christopher took two. He was 12 years old.
Once when he was on the high school baseball team, a 92-mph pitch broke his wrist. It was painful - very painful - but he kept playing that season. Before a game, the mother of another player passed along a bag of Hydrocodone pills to him.
“Take only one,” she told him. Russell knew better.
Later in life he could almost always find a supply from people who “did not fit the profile of a drug dealer.” At one point he knew the prescription cycles of several suppliers, and when one was dry he could always go to another.
Then there was OxyContin. When it was introduced in 1996 as a powerful, long-acting narcotic, it was a lightning rod for the crisis. Unlike Oxycodone and Hydrocodone, OxyContin had no additional drug components like Tylenol.
It was pure.
Annual sales reached $1 billion within a few years.
Purdue Pharma heavily promoted OxyContin to doctors who often had little training in the treatment of serious pain or in recognizing signs of drug abuse in patients.
Purdue contended that because of its time-release formula, the drug posed a lower risk of abuse and addiction to patients than did traditional, short-acting painkillers like Percocet or Vicodin.
But those addicted to ever-increasing highs, like Russell, soon discovered that one could peel the time release strip off, ground the pill into a powder and snort it.
In 2007, Purdue executives pleaded guilty to criminal charges of misleading the public about OxyContin’s addictive qualities. They agreed to a civil penalty of nearly $635 million.
It was the beginning of a long and slow recognition of the problem now gripping the nation.
Purdue announced in February 2018 that it was ending its marketing operation for the powerful opioid. It would no longer send representatives to doctor’s offices - although that did not mean it would stop selling the highly profitable drug.
The decision came as Purdue and other opioid manufacturers were, and are, facing lawsuits from more than 400 cities and states that allege these companies fueled addiction by misrepresenting the risks. (See sidebar: Attorney General to request Purdue lawsuit be unsealed).
The tipping point
Opioid prescriptions nationwide peaked in 2011. The decline since has been largely slow, but faster in some states. Tennessee is one of them.
The 6,709,154 opioid prescriptions filled out in Tennessee through 2017 marked a nearly 9 percent decrease in prescriptions from the year before, and a 21.3 percent drop from 2013, according to recent reports from medical research group IQVIA.
The 2017 number still nearly equals the state’s entire population.
The Tennessee Medical Association, the state’s largest professional organization for doctors, points to the steep decline as the fruits of “self-regulation.”
“Physicians for decades were told these medications were completely safe and faced potential litigation if we did not treat pain aggressively,” TMA President Nita W. Shumaker said in a statement. “Once we recognized the addictive dangers of these medications we worked hard to change the culture and improve supervision. The report confirms that we are making progress.”
Lawmakers in many states are not satisfied.
Massachusetts was the first state to pass a supply cap for opioid prescriptions. In 2016, the state forbade doctors from prescribing opioids for more than seven days, barring special exceptions.
The law’s original draft would have limited prescriptions to three days, following CDC guidelines released that year and that advised that three days is usually sufficient for patients in short-term pain.
The restriction was softened, however, following lobbying from groups such as the Academy of Integrative Pain Management, an association of doctors and pain specialists that receives much of its backing from pharmaceutical companies.
The pushback from patient advocacy groups had precedent.
According to reporting from the Center for Public Integrity, an investigative news organization, nonprofit advocacy groups led the countercharge in Tennessee in 2014 when state Rep. Ryan Williams began work to stop the state’s easy flow of painkillers. He was disturbed by the sharply increasing number of babies who were being born addicted to opioids.
“More than 900 babies had been born addicted in Tennessee the year before (2013), many of them hooked on the prescription opioids their mothers had taken,” the center reported. “That number had climbed steadily since 2001, when there were fewer than 100.”
Williams’ effort floundered, in part thanks to the efforts of groups like the academy and the Cancer Action Network, the advocacy arm of the American Cancer Society.
It was not the end of the effort to restrict prescriptions in Tennessee, however.
Under a blistering summer sun at Blount Memorial Hospital in Maryville on Friday, Gov. Bill Haslam signed legislation limiting most initial opioid prescriptions to a three-day supply.
Hospital executives, local and state politicians, and news groups gathered to hear his address.
The aggressive restriction puts Tennessee in a narrow group of states along with Kentucky and Florida.
“All of us know somebody who has been affected by this,” said Haslam, who is from Knoxville. “Everybody that I know knows somebody.”
The legislation, known as TN Together, is a $30 million plan that combines two legislative bills and executive actions to pursue a three-pronged approach: prevention, treatment and increased law enforcement.
“We’ve come up with what I feel is one of the best opioid-related pieces of legislation in the country,” said Rep. David Hawk, R-Greenville, a sponsor for one of the two bills. “Other states will now look to us.”
The bill he sponsored contains the prescription limit but makes reasonable exceptions for some treatments.
“We will see our way through this crisis with the same indomitable spirit of the Tennesseans who have gone before us,” said Sen. Ken Yager, R-Kingston, sweat dripping in the hot afternoon.
The second bill, which Yager sponsored, creates incentives for offenders to complete intensive substance use treatment programs while incarcerated and updates the schedule of controlled substances to better track, monitor and penalize the use and unlawful distribution of opioids.
It also adds to the controlled substance schedule synthetic versions of the drug fentanyl, which since 2011 has been linked to an alarming number of overdose deaths.
The bills go into effect today.
After the ceremony, Haslam told the Daily Times that the process leading up to the bills’ passage was a “give and take” between his office, the Legislature and medical groups that sought more discretion for doctors over the subject of prescriptions.
“We just felt that the situation was so serious, we had to make certain some of that discretion had limits on it,” Haslam said.
Efforts in Blount County
The choice to hold the signing ceremony at Blount Memorial Hospital was specific, a spokeswoman for the governor’s office confirmed.
Blount Memorial is one of 11 hospitals across the state selected for the “navigator” program under the legislation, which will identify special staffers help network and keep caring watch over patients recovering from addiction beyond their time at the hospital.
There are other reasons Blount Memorial could have been chosen for the ceremony on Friday. For instance, Haslam likes to commute to his Knoxville home on weekends, Knox News reports. But also, Blount Memorial Hospital CEO Don Heinemann believes it has to do in part with the long-rooted efforts his hospital, and Blount County, have made to combat the epidemic locally.
Along with other local leaders, the hospital was instrumental in forming the 1996 Community Health initiative, which soon spawned the Substance Abuse Prevention Action Team, or SAPAT - an anti-opioid task force.
The team speaks to students and works with local law enforcement to do drug-collection efforts. Last year the group collected roughly 2,800 pounds of unused, unwanted and expired medications.
SAPAT also began an initiative in 2016 to distribute the anti-overdose medication Naloxone to police departments and schools in the area, and which reportedly were used successfully 63 times by the end of 2017.
Blount Memorial also has played its own special role.
As one of the leading prescribers in the area, the hospital several years ago hired a specialist in interventional pain medicine, a new field that uses a variety of physical procedures to manage chronic pain. Since then, they have hired two more.
The work done by these specialists earned them praise from Dr. Hal Naramore, Blount Memorial’s chief medical officer, when he spoke at the ceremony Friday. He said they were part of what he hoped would become a larger trend of effectively treating chronic pain with alternatives to painkillers.
So why are things getting worse?
The answer, in part, has to do with the rise of heroin in rural markets.
The year 2011, the same year that prescriptions peaked, also marked another turning point. Until then, most opioid overdose deaths involved prescription drugs. Since then, prescription opioid overdose deaths leveled off, but overdose deaths involving heroin began to soar.
Heroin was not new to the scene. Its use had been rising since 2004, according to research from the U.S. Department of Health and Human Services.
Contrary to some narratives, users largely did not turn to it after “crackdowns” made prescription opioids harder to obtain. Instead, the drug, once relegated to urban centers, became cheaper and easier to obtain in rural markets.
And as more young people in rural areas switched to heroin, the supply also became more dangerous. Increasingly, fentanyl, a potent and inexpensive synthetic opioid, was mixed with heroin or sold as heroin.
There’s another, simpler reason reductions in prescriptions have not been followed with similar reductions in overdoses: Opioids continue to be overprescribed.
Americans consume prescription opioids at a greater rate than any other population in the world.
Despite suffering chronic pain at a similar rate as Italians and the French, Americans consume six to eight times as many opioid painkillers, according to data from a United Nations study.
“Chronic pain is part of the human condition,” says Mark Pew, a senior vice president at Preferred Medical and an author who has written about the opioid crisis since 2003.
Part of treating it effectively, he said, will mean looking beyond opioids, but not losing sight of the patient’s well-being.
“Resilience is an option,” he said. “Yoga, physical therapy, there are a variety of ways that teach self-management and the ability to overcome that pain.”
Less powerful drugs too, he said, such as a combination of ibuprofen and acetaminophen, have been found to be effective at treating acute, short-term pain.
Teaching these and other strategies could help prevent the onset of a new generation of opioid-dependent patients. But those saddled already with the disease of addiction face a much narrower treatment path: recovery.
It’s how Christopher Russell is alive today.
He was saved from his abandoned childhood home’s closet by a friend and fellow user who went out looking for him. After finding him. she left and returned later with a bottle of vodka, a spoon, a syringe and some dope.
It was enough to get him to sit upright.
“Get me to a f---- - hospital,” he told her.
It was not exactly the turning point for Russell’s recovery - but it was the moment the inevitable zigzag began to at least trend upwards.
Today Russell, 33, has a bed and an apartment. He has his three children - aged 13, 11, and 7 years old. He’s in his third year of school. And importantly, he has a job as a counselor at Cornerstone Recovery in Louisville.
He still keeps in his wallet an old driver’s license from his darkest days. The sullen, long-haired face barely resembles him. The photo shows a “beaten and battered guy,” he said. “Spiritually broken. Mentally broken.”
It was before Russell learned to change his thought patterns by studying cognitive behavioral psychology, a field he hopes to one day earn a doctorate in.
At Cornerstone, Russell pulls from his own experiences to connect with the addicted young adults. They’re the same age he was when he became addicted, he said. Helping others in their recovery is not just his responsibility, he said, it’s his “magnificent obsession.”
This is not to say that Russell is entirely healed. Recovery is never a straightforward or final process, he said. A childhood of abuse and other lifelong demons still haunt him. But every day, he works toward building his future, “brick by brick.”
Others are not so lucky.
Dane McCoy, the young man who had been paid to get a prescription, tried to undergo recovery.
“He didn’t want to be an addict,” his mother, Jan McCoy, said. “No one wants to be an addict.”
He seemed remorseful after his family confronted him about the prescription bought for him by a friend’s aunt. Then again, McCoy said, he kept his standing monthly appointment with the opioid-prescribing doctor.
He got worse, then better. Then he relapsed. So the inevitable zigzag went. At one point, McCoy was well enough to start taking online classes again at Pellissippi State Community College. He got a girlfriend from church, and a new job repaving tennis courts, a task that required him to wake up before dawn every day.
Then within the year, he lost his battle to addiction, and died of an overdose.
His mother thinks that if her son had been able to do a yearlong program, he would have survived.
But the nature of recovery programs means that many are unaffordable to families, or have substandard living conditions.
It’s for this reason that she helped True Purpose Ministries erect Dane’s House, a new recovery graduation house for men to live in after the rehab program.
She’s joined in the effort by others such as Sherry Petrowski, whose son Christopher Sullivan died in 2014.
Each of the eight bedrooms is named after young men who have died of addiction or alcoholism.
Helping raise the home is personally healing, McCoy said, but more importantly, it’s about establishing a legacy for her son beyond his untimely death.
“I loved my son unconditionally, and I know the stigma surrounding addiction,” she said, adding she wants those addicted and their families to know: “There is hope.”
She takes out a small picture book of her two sons, Dane and his brother, when they were young children. She points to one: “Does he look like he’s going to grow up to be an addict?”