Horror of opioid abuse begins with a pill bottle
States launch a war on addiction by seeking to limit pain prescriptions
Every morning Berthena Vance kisses the urn.
It has been six months since her son, Brandon Greene, died from a suspected overdose. His mother cries frequently, inconsolably.
She believes that if fewer painkillers were prescribed, countless Americans would be spared the horrors and heartache of opioid addiction she and her family have endured.
Greene, 28, of Covington, Ky., had been addicted to heroin, a fact Vance didn’t know until she was called to a hospital June 15 because her son wasn’t breathing. What she did know was that her son had acquired an opioid addiction after being prescribed painkillers for chronic back and leg pain that started about six years before he died.
Like about 75% of the people who use heroin, Greene first was addicted to prescription painkillers. He was part of a nationwide epidemic of opioid addiction and overdose deaths, a result of overprescription and misuse of painkillers.
Greene’s pain, his mother said, came from injuries he suffered while caring for — and, often, carrying — his paraplegic father, John Greene, since Brandon was 18.
Greene’s path to death is a common one, and Vance wants it cut off.
“You can’t keep prescribing pain medication,” she said, “if you’re not taking care of the problem.”
A nationwide response
State laws, public health guidelines and American Medical Association standards are forging the path to cut back the prescribing of pain pills in the USA. The hope is that fewer people will become addicted to opioids, the way Greene’s son did, and fewer will die from an overdose, as he did.
Painkiller prescriptions are dropping, according to medical societies, states keeping track and the Centers for Disease Control and Prevention.
But the shift isn’t uniform. Five states had prescription rates that were higher in
2016 — by as much as Iowa’s 12.1% — than they were in 2007, a USA TODAY NETWORK analysis of the CDC’s data shows. Prescription rates also vary, sometimes widely, within states. The CDC data note that “in about a quarter of U.S. counties, enough opioid prescriptions were dispensed for every person to have one.”
Despite the overall drop, more than
650,000 prescriptions for painkillers are dispensed on an average day across the nation, the federal Department of Health and Human Services says. “Leftovers” are out there as a temptation: They can be diverted to non-patients, scooped up by bored teenagers searching medicine cabinets, misused by patients already addicted.
National health and addiction experts say it’s imperative to keep an eye on prescriptions going to the public, and parents of addicted children have demanded a government response. The combination has more states enacting laws to try to curb overprescription.
Not all doctors are happy to see a governmental hand in their work, but many are accepting the laws and rules as a consequence of the nationwide overuse of opioids. From 1999 to 2014, sales of prescription painkillers in the USA nearly quadrupled. Overdose deaths from opioids, including heroin, have quadrupled since 1999, with prescription opioids “a driving factor in the 15year increase in opioid overdose deaths,” the CDC says.
It made sense that lawmakers stepped in, said Andrew Kolodny, founder of Physicians for Responsible Opioid Prescribing and co-director of opioid policy research at the Heller School at Brandeis University.
“Ideally, the medical community would’ve corrected itself 15 years ago,” Kolodny said. “We didn’t.”
“If I can turn my pain into helping someone else from ever going through this, that’s what I’m going to do.”
Berthena Vance
1 year, 300 million pills
To flag doctor-shoppers — people who are going from one doctor to another to get more prescriptions — while tracking doctors’ prescribing decisions, all but one state have set up prescription monitoring databases. (The holdout is Missouri.) The systems track a range of prescriptions, including opioids.
Kentucky was the first state to make its prescription monitoring database, the Kentucky All Schedule Prescription Electronic Reporting system, mandatory for prescribers. The Kentucky Office of Drug Control Policy reports that its system is doing some good.
Precisely how much is an open question. In 2016, the state tallied 301.7 million pain pills prescribed. “That’s a
70 million pill reduction in five years in the commonwealth,” said Van Ingram, executive director of the office.
Yet, “even at that number, that’s enough opioids to give every man, woman and child their own pill bottle with
70 pills,” Ingram said.
In addition, Kentucky residents continue to get opioid prescriptions more frequently than people in other states. In 2016, the state’s opioid prescription rate of 103 scripts per 100 residents was
46% higher than the national rate. The American Medical Association Task Force to Reduce Opioid Abuse encourages all physicians who are considering whether to prescribe opioids to check their state monitoring program first. Sixteen states make practitioners check their state’s database before they write a prescription, according to a Pew Charitable Trusts report in May 2016.
Patrice Harris, who chairs the AMA task force that was set up in 2014, cautioned that the databases are only one piece of a public health approach to curbing America’s opioid epidemic. Other steps are needed, such as better doctor education in pain management.
Harris, a practicing psychiatrist from Atlanta, believes a one-size-fits-all approach is not the way to treat pain, adding that doctor-patient communication is important.
“Not all patients experience pain in the same way,” she said.
Harris, a former AMA board chair who also teaches at Emory University, noted that people who do get prescription painkillers have reported to doctors that “they feel like criminals” when they go to a pharmacy — an unintended consequence of the scrutiny.
State lawmakers continue to find new ways to reduce painkiller prescribing through legislation.
In the past year, several states, including Maryland and North Carolina, have passed laws that limit the number of days for which a prescription can be written or dosages that can be prescribed for people in acute pain.
“Acute” is the kind of pain that can come from a sprained or broken ankle, from surgery or a dental health problem. It’s not a months-long problem, so, the states argue, it’s not necessary for doctors to prescribe weeks or months of pain pills for the condition.
“More cautious prescribing ... will help prevent people from becoming opioid-addicted,” Kolodny said. “Efforts to get the doses down will save lives.”
Other states that have enacted prescription limits or authorized other entities (such as health departments) to set limits are Alaska, Connecticut, Hawaii, Indiana, Kentucky, Louisiana, Massachusetts, Maine, Minnesota, Nevada, New Jersey, New York, Ohio, Oregon, Pennsylvania, Rhode Island, Utah, Vermont, Virginia and Washington.
Maine’s original law, enacted last year, restricted patients to an opioid dose of 100 morphine milligram-equivalents a day. (A doctor using an online calculator can see, for example, that a daily 25mg dose of hydromorphone equals 100mg of morphine.) But this year, the law was amended after residents who had debilitating pain complained that they needed help.
State lawmakers decided surgical procedures might require higher dosages for some patients than the original law allowed. They also added exemptions to the original rules of the law. Geoff Grat- wick, a physician and state senator representing the city of Bangor, said the amendments to the law “bring the physicians’ care for the individual patient” back into greater consideration.
To balance the concerns, Gratwick said, the legislature redefined palliative care to clarify that it isn’t only hospice care. In other words, it’s not always end-of-life care but can include “chronic, unremitting or intractable pain such as neuropathic pain.”
“I was resistant to the idea of redefining palliative care, but it puts the decision back in the hands of … the patient and the provider,” Gratwick said.
Unending suffering
Chronic pain is another piece of the addiction puzzle. More than 1 in 10 Americans have chronic pain, or “pain every day for the preceding three months,” an analysis by the National Center for Complementary and Integrative Health shows. The National Institutes of Health published the study in 2015.
The AMA opioid task force chair, Harris, said the solutions for pain management and for overprescribing should be multipronged and balanced.
That concern isn’t lost at the state level. A group of state attorneys general recently unveiled a new way to attack addiction because of chronic pain: urging insurance providers to create financial incentives for pain management without prescription pills. Treatments can include physical therapy, acupuncture and biofeedback. They don’t cause addiction like painkillers can, but they are often costly, especially when compared with inexpensive pain pills. The attorneys general are trying to ensure that insurance companies will cover alternative treatments reasonably.
To get started on that goal, the National Association of Attorneys General sent a letter on behalf of 37 state members on Sept. 18 to America’s Health Insurance Plans. They asked the insurers to “take proactive steps to encourage your members to review their payment and coverage policies and revise them, as necessary and appropriate, to encourage health care providers to prioritize non-opioid pain management options over opioid prescriptions for the treatment of chronic, non-cancer pain.”
“Unless insurance companies make non-opioid pain management available, we will continue to put millions of Americans in harm’s way,” said Massachusetts Attorney General Maura Healey. “We need to end incentives that pump pain- killers into communities and focus on treatments that will keep people safe.”
Though addiction experts believe reducing the number of prescription pills, closely monitoring who gets and prescribes what and giving patients additional pain management choices will help prevent addiction for some, those approaches combined are not a solution to the opioid epidemic.
The push doesn’t take into account other underlying reasons people become addicted, Harris noted. Kolodny said, “It will have zero effect on reducing those who are already addicted.”
That’s why states are working toward getting more medication-assisted treatment (MAT) available.
MAT is the best evidence-based treatment for those with opioid addiction. Any of the FDA-approved medications, buprenorphine, methadone or injectable naltrexone (known by its brand name, Vivitrol), combined with counseling, is the “gold standard” care, experts say. The medication stabilizes people and reduces cravings, helping them live a normal life.
States that encourage medication-assisted therapy sometimes provide incentives for doctors to become certified in addiction treatment. Some fund naloxone, the antidote to opioid overdose, and some fund criminal justice programs to provide medication and counseling.
The National Institute on Drug Abuse has reported that treatment is much less expensive than incarceration. “For example, the average cost for one full year of methadone maintenance treatment is approximately $4,700 per patient, whereas one full year of imprisonment costs approximately $24,000 per person,” an agency report states.
Anguish extends to families
Brandon Greene’s mother said she “learned so much” about her son’s addiction during the time she spent at his hospital bedside, from June 15 until he died June 26.
What she hasn’t learned, she said, is how to manage the pain it caused her.
“I can’t describe it. I honestly can’t,” Vance said through tears. “I can’t listen to his voice on the Marco Polo app. It hurts too much. I look for him. He should be there.”
But she said she will hold Brandon’s story out for others and hope that, somehow, telling it helps.
“If I can turn my pain into helping someone else from ever going through this, that’s what I’m going to do.”