America’s Biggest Drug Problem Isn’t Heroin, It’s Doctors
Painkillers prescribed by both well-intentioned doctors and so-called "criminals in white coats" are driving the overdose epidemic. States and cities are pioneering ways to control it.
Brendan McDonald was one of those kids you never thought would start taking drugs.
The year it began -- the 2004-2005 school year -- he was an honor-roll senior at a well-regarded Jesuit high school in Boston, a varsity baseball player who had won early admission to the college of his choice. “Quiet, handsome and charismatic,” says his mother, Nancy Holler, of her oldest child. “He was always just a really good kid.”
But by that spring, something was wrong. Brendan wasn’t himself. His GPA had fallen. He was sitting on the bench during baseball games instead of starting. The school guidance counselor thought it might just be a case of “senioritis.” Brendan’s stepfather Steve worried it might be something else. Steve had degenerative disc disease that was being treated with Percocet, a powerful prescription painkiller. Recently he’d noticed that pills were going missing. When Nancy and Steve confronted Brendan about the disappearing Percocet, he admitted that over the winter he’d started drinking beer and taking pills with some of his friends. Steve and Nancy hoped it would stop. Instead, it escalated.
Brendan went to college that fall, but after just six weeks he returned home and got a job. It wasn’t the same Brendan. The old Brendan had been a snappy dresser who cared about his appearance. The new Brendan paid no attention to his hygiene. “He was wearing the same clothes to work every day, not taking care of himself, looking like a slob,” Nancy says.
Pressed, he confessed that he’d started taking OxyContin, an even more powerful prescription painkiller. He went into detox at Thanksgiving but couldn’t stay clean. He moved to California to work in construction with Nancy’s brother. He came back addicted to heroin. By the spring of 2008, though, things seemed better. He had completed a rehab program and got a good job. His parents had allowed him to move back into his old bedroom in their home in Quincy, just outside Boston. But one afternoon in May, Brendan came home early and went straight upstairs to the bathroom. Moments later, Nancy heard a crash. She ran upstairs. Brendan was face down on the bathroom floor, unconscious with a needle in his arm. But that wasn’t what alarmed Nancy most. What was truly terrifying was that Brendan was blue.
The narcotic “high” of opioids such as heroin and its prescription painkiller cousins are well known. But opioid painkillers have another side effect: They depress respiration. Frequent users develop a tolerance to the high that leads them to continually up their dosages. However, they do not develop a similar tolerance to respiratory depression. That is why Brendan was blue. He had stopped breathing.
Nancy called 911. She knew there was an antidote for drug overdoses -- naloxone (or Narcan, as the brand-name version is called). Naloxone is an opioid inhibitor. By blocking opioid receptors, it quickly kills the high. It also quickly restores breathing. The first people to respond -- officers from the Quincy Police Department -- didn’t carry naloxone, nor did the firefighters who arrived next. By now, Brendan had been blue for nearly 10 minutes. Finally, an advanced ambulance unit showed up with the antidote. Three minutes later, Brendan was walking down the stairs en route to the hospital.
That afternoon, Brendan was lucky. Many are not. Every year, more than 38,000 Americans die of a drug overdose -- more than the number of people who die in automobile accidents or from gunshot wounds. At more than 100 deaths a day, drug overdoses are now the nation’s leading cause of injury death, according to the Centers for Disease Control and Prevention (CDC). Every year, for 11 consecutive years, the number has increased.
Public officials are beginning to take note. Earlier this year, Vermont Gov. Peter Shumlin devoted his entire State of the State address to the problem of heroin in the state. The recent death of the actor Philip Seymour Hoffman also focused attention on the problem of heroin. But heroin isn’t what’s driving the overdose epidemic. Prescription painkillers are.
“We [in the medical profession] are the drug dealers,” says Dr. Terry Cline, Oklahoma’s health commissioner and the former head of the federal Substance Abuse and Mental Health Services Administration. “We are keeping these drugs accessible.”
Since 1999, the number of prescription painkillers sold has quadrupled. Over that same time period, overdose deaths have risen more than threefold. In 2009, overdoses involving opioid painkillers such as OxyContin, Percocet and Vicodin killed some 15,500 people, more than twice as much as heroin and cocaine combined. It’s a shocking number, but the actual problem is much larger. According to the CDC, for every one opioid overdose death, 10 people are admitted to a hospital for substance abuse treatment; another 32 will visit an emergency room for a drug-related incident. That’s 475,000 patients a year, a number that has nearly doubled in just five years’ time.
As awareness of the problem grows, state and local governments are beginning to respond. One of the most promising initiatives began three years ago in Quincy. Soon after Brendan’s overdose, Nancy Holler contacted Quincy’s newly elected mayor, Tom Koch, with an unusual idea: The state Bureau of Substance Abuse Services had a pilot program to train addicts and family members in how to use naloxone. Why couldn’t first responders be trained to carry naloxone as well? Koch convened a meeting with the fire and police chiefs, and the police department agreed to train its officers in how to use the product. The program went live in October 2010. Since then, Quincy police officers have successfully resuscitated some 242 people. In March, U.S. Attorney General Eric Holder called on counties and municipalities across the country to follow suit. Stanford University psychiatrist and drug policy expert Keith Humphreys estimates that by doing so, local government could save as many as 3,000 lives a year.
However, while reviving overdose victims is a strikingly cost-effective way to save lives, it doesn’t address the root causes of the opioid epidemic. That requires effective state and federal regulation of the people writing the scripts -- America’s doctors. Every year doctors write enough painkiller prescriptions to keep every American continuously medicated for an entire month, according to the federal Drug Enforcement Administration (DEA).
Yet efforts to crack down on prescription painkillers pose difficult problems. For one thing, the problem of chronic pain is real. Roughly 100 million Americans suffer from chronic pain, with some 10 million people disabled by it, according to a 2011 Institute of Medicine report. Efforts by Blue Cross Blue Shield of Massachusetts to unilaterally restrict doctors’ ability to write opioid painkiller scripts have brought protests from oncologists and other physicians that people with acute pain may not have access to the pain treatments they need.
There is also the problem of unintended consequences. A decade of abuse has created a large population of opioid-dependent people. In 2010, some 12 million people admitted to using opioids such as OxyContin “non-medically.” Of that population, an estimated 1.8 million people are considered to be “dependent.” Restrict access to prescription painkillers too dramatically, and a significant number of these people could turn to heroin. Indeed, law enforcement officials believe the Mexican cartels are currently pushing prices down and potency up in the hope of effectuating just such a shift.
“We caused this problem, and it’s incredibly important that we as a medical system try to address it without harming more people than we have already harmed,” says Dr. Phillip Coffin, director of Substance Use Research at the San Francisco Department of Public Health. “There are a thousand ways to do this wrong, and just a couple of ways we can do it without harming an undue number of people.”
The story of how the United States became a nation of opioid addicts begins with a laudable effort in the mid-1990s to treat chronic pain more effectively -- an effort that would interact in unexpected ways with welfare reform and medicine’s shift toward managed care. The U.S. Veterans Health Administration at that time realized that many veterans were suffering from chronic pain that was not being treated effectively.
Pain had long been seen as something that was arbitrary and hard to measure. The result, a growing cadre of physicians came to believe, was that patient pain was too often ignored or treated inadequately. For years, physicians had relied on medications such as Tylenol 2 and 3 to treat severe pain. These combined codeine with significant amounts of acetaminophen, which in high doses causes liver failure. That made them dangerous -- but also resistant to abuse. The only opioid painkiller in widespread use was morphine. It was often delivered via intravenous drip and was reserved for the most severe cases. Many doctors were reluctant to prescribe morphine at all because of its highly addictive nature. By the late 1990s, however, doctors in specialties such as oncology felt that these guidelines were too restrictive. According to this school of thought, it didn’t matter if a patient dying of bone cancer in excruciating pain became addicted to morphine. The most important thing was to treat that patient’s pain.
At the same time, pharmaceutical companies were beginning to develop new forms of opiates that were related to morphine and heroin but were initially heralded as having few of their drawbacks. The most famous was a controlled-release formulation of oxycodone, OxyContin. Dozens of similar products quickly entered the market.
Since doctors wanted to treat pain more effectively -- and pharmaceutical companies wanted doctors to prescribe the new medicines they were developing -- state medical boards began to push through changes to disciplinary guidelines. They stepped back from practices such as investigating physicians based solely on the number of painkiller prescriptions written. In 1999, the Veterans Health Administration declared that pain was “the fifth vital sign.” Just as doctors measured temperature, blood pressure, heart rate and respiratory rate, so too should they measure pain, primarily by asking patients to rate their pain on a scale of 1 to 10. Two years later, the influential Joint Committee, a nonprofit that accredits health-care providers, followed suit.
Guidelines changed in ways that allowed patients to receive prescriptions of opioid painkillers at home. Painkiller prescriptions began to surge. So too did the overdose rate.
The trend first emerged in largely rural places such as Appalachia, Maine and Utah. The enactment of welfare reform led to an increase in the number of people who were classified as disabled. Many of these people suffered from chronic pain. Writing them a script was cheaper than enrolling them in a pain management clinic or offering physical therapy. As users became addicted to the new medications, a black market quickly sprang up. A month-long supply of Vicodin that might cost patients a $20 copay could be sold for thousands of dollars to other users. Unlike heroin, which is mainly administered intravenously, these could be ground up and snorted. These were medications approved by the federal Food and Drug Administration, not back-alley products of uncertain provenance used by “junkies” or heroin “fiends.”
Dr. John Dreyzehner saw the epidemic emerge firsthand. Today, he is Tennessee’s health commissioner and one of the people leading the effort to turn the tide on substance abuse. Back in 2002, however, he was the local public health director based in southwest Virginia serving a four-county area in Appalachia. At the end of 2003, Dreyzehner was startled to learn from his assistant chief medical examiner that 14 people in Russell County had died of an overdose of opioids the previous year. Together with his colleagues, he decided to examine the entire 21-county area and was stunned to discover 217 deaths in 2002. The group hastily wrote a report and prepared a press release detailing the problem.
“The reaction was the opposite of what I expected,” he says. “There was a collective shrug of the shoulders. People did not care at all.”
Not everyone ignored the surge in prescription drug abuse. A small number of unscrupulous health-care providers set out to capitalize on it. The problem was particularly pronounced in Florida. Most states have laws that prevent doctors from owning pharmacies or prescription drug-dispensing pain clinics. Florida, until recently, did not. As a huge market in opioid painkillers sprang up, health-care providers in those states opened so-called “pain management clinics.”
In early 2011, several months after taking office as Florida’s attorney general, Pam Bondi read a story in the Tampa newspaper about a high school student, Brandi Meshad, who had died of a prescription drug overdose. Bondi asked her office to dig deeper into the issue. She had run for office on shutting down “pill mills,” but was startled by what she found. Roughly seven Floridians were dying every day from drug overdoses. According to the DEA, 98 of the 100 top oxycodone dispensers were located in Florida. A handful of clinics were dispensing about 300 million doses of opioid painkillers every year to people along the Southeast and Eastern seaboard. As far as Bondi was concerned, there was nothing medical about the operations of these clinics.
“They had armed guards at the door; they were often cash-only businesses,” she recalls. “You would go into a pill mill and there would be little or no medical equipment. The most you might find was a doctor back there, with a stack of prescription pills writing hundreds of scripts. It was all perfectly legal.” The parking lot outside was filled with cars sporting out-of-state plates. People were coming from all across the Southeast and along the Interstate 95 corridor to buy prescription drugs for themselves and for resale at a hefty profit, often visiting multiple “pain clinics” over the course of a single weekend.
Working with Gov. Rick Scott, Bondi formed a task force that included the state surgeon general, local law enforcement and the DEA to target what she called “criminals in white coats.” She also led the effort to push a prescription drug-monitoring program (PDMP) through the legislature. Other states had created these databases as tools doctors and pharmacists could use to monitor patients’ “painkiller consumption.” In Florida, though, this wasn’t an easy sell. A considerable number of state lawmakers objected to new government regulations on principle, among them Scott. Legislation creating a PDMP was eventually enacted but not funded. Not until 2011 did the Florida Legislature and the governor agree to appropriate $500,000 to sustain the program through its second full year. While many other states are now requiring doctors and pharmacists to check PDMPs before writing long-term painkiller scripts, Florida’s system remains voluntary.
At the same time Florida was implementing its PDMP system, the DEA mounted a crackdown on the most egregious pill mills in the state. The effect of the two efforts has been dramatic: Oxycodone deaths have declined by 52 percent; overall overdose deaths are down by 23 percent.
It’s hard to disentangle the effect of the PDMP from law enforcement actions. Nevertheless, a substantial body of evidence has emerged to suggest that PDMPs are effective. Reviews of programs in Ohio, Virginia and Wyoming have found that as doctors increase their participation by logging into state systems and checking to see what other prescriptions their patients have received, the number of medications for chronic pain declines. It’s a tool that has been particularly helpful in identifying so-called “doctor shoppers,” people who go from one provider to the next, seeking to fill a single prescription multiple times.
But PDMPs’ comprehensiveness varies widely from state to state. While every state except Missouri now either has or is rapidly implementing a PDMP, only 16 states require doctors to check their PDMPs before writing scripts for chronic pain relief. Tennessee has gone further than most. It both requires registration for prescribers and dispensers and checking of the database before prescribing opioids or benzodiazepines in most circumstances. The state has also turned to data mining and analytics to help identify prescribers who are outliers. In late July 2013, the state health department sent out letters to the top 50 prescribers, notifying them that the state would like to better understand their prescribing patterns. The number of scripts written by this group subsequently fell by more than 10 percent. Last year, for the first time in recent memory, the number of prescription painkillers written in Tennessee did not increase from the prior year.
Just how far states should go in pushing this boundary is a matter of debate. Stanford’s Keith Humphreys believes that more robust data mining is necessary, given the depth of the crisis. “It is enough of a public health crisis that this is a cost that has to be paid,” says Humphreys. “There has to be some monitoring.”
New Mexico, one of the hardest hit states, has been searching for prescribing patterns of interest. “If you get an opioid and a benzodiazepine and then a muscle relaxant, that combination together increases the likelihood of overdose deaths by a factor of 20,” says Carl Flansbaum, the director of the New Mexico Board of Pharmacy’s PDMP program. Providers who meet those criteria are reported to the state medical board. However, New Mexico’s enforcement efforts stop there. “We try not to be specific,” says Flansbaum. “It’s not our purpose to tell them how to do things.”
Health officials in a growing number of states are hopeful that these and other initiatives can significantly reduce prescription drug use and overdose death. Oklahoma health commissioner Cline has suggested that state public health officials set as a goal a 15 percent reduction in overdose deaths by 2015.
Significant progress can be made quickly when state and local governments work together. Last year, Massachusetts passed a law, modeled on legislation passed earlier by New Mexico, expanding the state’s “Good Samaritan” law to include people who call 911 to report a drug overdose -- an act users have sometimes been hesitant to take. The law offers immunity or mitigated sentencing to these individuals. As of 2012, 17 states had passed similar legislation. According to Lt. Det. Patrick Glynn, the head of the Quincy Police Department’s narcotics squad, that’s had a big impact. “People were not afraid to call the police anymore.”
State and local officials alike have come to realize the need to build a genuine system to provide drug treatment in place of the current patchwork of programs. Earlier this spring, Massachusetts Gov. Deval Patrick declared a public health emergency. Among the steps he proposed are allowing all first responders to carry naloxone, mandating the use of the state’s PDMP by all physicians and pharmacies, and banning Zohydro, a potent new form of hydrocodone recently approved by the Food and Drug Administration. He has also asked an interagency task force led by state public health commissioner Cheryl Bartlett to bring together all the separate drug treatment programs into one true system. One of the ideas Bartlett is exploring is whether it would be possible to create some kind of central intake system, one that can get a user who is ready for rehabilitation into treatment more quickly.
The challenges, however, are daunting. “We like to say there are 2,000 beds for the 5,000 people who want them and the 25,000 people who need them,” says Robert Monahan, executive director of the Quincy-based South Shore Recovery Home. Out on the streets, the Quincy police, now trained in the use of naloxone, are seeing more heroin laced with fentanyl, a powerful opioid that is orders of magnitude more potent than morphine -- and takes more naloxone to combat the drugs’ effect.
“What we are seeing now is multiple doses of nasal Narcan being used,” says Flynn, “whereas before we were able to reverse a overdose with just one application.” Despite the fact that all squad cars in Quincy are now equipped with naloxone, the city has seen the number of fatal heroin overdoses rise this year.
As for Brendan McDonald, after his 2008 overdose, Nancy and Steve got him into a detox unit. That was followed by 30 days in a tightly supervised halfway house and 9 months in a residential program. Brandon seemed to be making progress. Earlier this year, he’d joined a church and embraced the 12-step recovery program. He was living at the Salvation Army in a so-called “sober living” program. Then, in June, he checked out. Nancy watched him pack his bag and feared she’d never see him again.
She was right. In August, he died of a drug overdose.
For more on this topic, listen to the reporter's "To The Point" interview on KCRW, an NPR affiliate.