America’s Deadly Opioid Epidemic: How Can We Fight It?
Michelle Marikos’ odyssey in the world of pain and addictive narcotics began 13 years ago at a party with her sorority sisters at California State University, Chico. One of them, who’d had too much to drink, shoved Marikos off a second-story balcony.
She was diagnosed with whiplash at a local hospital and sent home with a handful of pills, including muscle relaxants and morphine tablets. But she woke up the next morning in so much pain she could barely move, and in quick succession saw an osteopath and a neurologist—who told her that she had three crushed vertebrae and sent her to a surgeon in her hometown of Medford, Oregon.
The surgeon put her in a brace and gave her more drugs. He eventually advised against surgery, and Marikos spent the next eight years “in a haze”—taking ever-larger doses of medications in an endless cycle of pain and pills.
She took OxyContin, a powerful opioid; Percocet, a drug that combines oxycodone and acetaminophen for so-called breakthrough pain; muscle relaxants; anti-inflammatories, in high doses; anti-nausea pills; and stool softeners to minimize the constipation caused by the medications. Like most patients prescribed opioids, she says she was given no detailed information about the risks.
At the other end of Oregon, Sam Hancos took a different path to opioid misuse. He was 13 years old, seeking to dull the emotional anguish of his parents’ disintegrating marriage, when an older sister’s friend offered him OxyContin.
“I wanted acceptance,” he says. So he took it.
He quickly moved from taking OxyContin pills to crushing and smoking them. The high came fast that way—the drug speeding to the opioid receptors—but wore off quickly, too, surging and receding in his brain like a roller coaster. After a week of daily smoking, Hancos woke up with a fever and sweats, his brain and body craving fresh drug. “I was addicted,” he says. He hadn’t yet turned 14.
He cut classes to get high, but says no counselor or teacher ever asked after him. He kept his parents in the dark and sold possessions to get the $60 he needed to buy each OxyContin pill on the street. Then a friend offered to get him a drug for $20 that would be even better than OxyContin. Hancos tried it—and loved it. It took a week before he realized that he was using heroin, a drug he’d sworn never to try.
Hancos’ next few years were horrific: He cycled in and out of treatment and homelessness, shoplifting and “doing whatever I could to get money.” When he was 21, his best friend died of an overdose. Hancos discovered his body.
The next year, it was almost Hancos’ turn. He injected heroin with friends and suddenly found himself unable to speak. His girlfriend noticed that he was about to pass out and dragged him into the shower to keep him awake.
That day was a turning point for Hancos. The next day, he went to a treatment center in Portland to manage his withdrawal symptoms and begged his parents to help him get follow-up care. They found a Christian recovery center in Bend, where he spent eight months and, away from bad influences, stayed clean. Things looked hopeful: He returned to Portland and got a job. But then he got laid off and started the cycle of heroin and homelessness again. His battle with opioids was not over.
Stories like Marikos’ and Hancos’ are being repeated with alarming frequency throughout the nation. Since 1999, more than a quarter-million people have died from opioid drug overdoses. In 2014 (the year for which the most recent data are available), after 15 years of steady increase, almost 130 people died each day; the death toll in Oregon that year reached 522, a 13 percent spike from 2013. Most of the Oregon deaths involved opioids—whether the prescription pain relievers taken by Michelle Marikos or the black tar heroin used by Sam Hancos.
She wonders if Naloxone could have saved her son. If administered soon enough after an overdose, the drug can bring a person back to consciousness. Many substance use disorder programs give it to opiate users and some police departments issue it to patrol officers. Still, says Pinsky, "we need to get it into the hands of drug users and family members, loved ones, girlfriends. Too many people don't know what it is."
In fact, since 2009, prescription drug and heroin overdoses have been the leading cause of injury-related death in the U.S., surpassing even automobile crashes—prompting The Pew Charitable Trusts to begin, in 2014, a research and policy initiative to address the opioid epidemic.
“We saw that many states, especially those with large rural communities, were losing people to overdoses at an alarming rate,” says Cynthia Reilly, a pharmacist who is director of Pew’s substance use prevention and treatment initiative. “We knew that solving this problem would require a coordinated, multifaceted response from local, state, and federal officials.”
To address this public health problem, Pew identified two major priorities: reducing the inappropriate use of opioids and greatly increasing the ability of people with substance use disorders to get treatment. “There’s a sizable treatment gap,” Reilly says. “Nationally, only about 10 percent of people who need treatment actually get it.”
Oregon represents a case study: It is close to the national average in the number of people struggling with dependence on illicit drugs and the number who need but are not receiving treatment. “We’re working to improve access to care, but the availability of treatment has not kept pace,” says John McIlveen, operations and policy analyst with the state’s Opioid Treatment Authority.
At the federal level, President Barack Obama signed into law in July the bipartisan Comprehensive Addiction and Recovery Act of 2016, which he termed a “modest” effort to address the opioid epidemic. Among other steps, it authorizes state grant programs to expand treatment access, and it renews a grant program to help states maintain prescription drug monitoring programs—databases that can identify patients who may be overusing opioids. Not enough doctors or other prescribers use those programs, mostly because they can be difficult to access. Pew is researching the effects of strategies intended to make these systems easier to use.
What the bill does not do, says U.S. Senator Ron Wyden (D-OR), is provide new funding for those treatment programs. “The opioid crisis has hit communities all across the nation like a wrecking ball,” he says. “With thousands of people on waiting lists for weeks or months before they can get treatment, it’s time to [provide] funds so that people actually can get help.”
He spent almost 30 years as a drug user, shoplifter, and prison inmate before getting clean eight years ago and becoming a peer counselor at a Portland recovery program. "They pay me to be myself and to help people navigate the system," he says. "I have a 9-year-old daughter that's never seen me loaded. I can't begin to tell you how grateful I am."
The explosive rise in opioid use in the U.S. began in the 1990s when doctors started prescribing them to relieve a range of pain issues. Sales of prescription opioids nearly quadrupled between 1999 and 2014, with much of that increase driven by OxyContin and other opioids.
In Oregon, more than 900,000 people were prescribed opioids in 2013—the last year for which data are available—with each person getting an average of four prescriptions during the year. Altogether, more than 100 million pain pills were prescribed in the state that year. As prescriptions spiked, the pain pills flooded the streets, where people like Sam Hancos could buy them.
Some patients who used their medicine as directed realized that they could make $40 or more for each leftover pill. A few turned it into a business. One study of so-called doctor shopping estimated that in 2008, a small group of patients—less than 1 percent of those getting the drug—filled an average of 32 prescriptions each from multiple physicians, obtaining the equivalent of 275,000 40-milligram oxycodone tablets.
The second spark for the epidemic was the emergence in the mid-1990s of cheap black tar heroin. Low-level dealers brought the drug from western Mexico to the U.S., where it flooded western and rural areas in particular. People who could no longer afford oxycodone turned to the cheaper, illegal opioid.
According to Jim Shames, a physician and addiction specialist, underlying both factors is the fact that brain physiology and environmental influences, such as childhood neglect or physical abuse, play a substantial role in the development of substance use disorders. “Childhood trauma,” Shames says, “is a remarkable predictor of people who are going to have chronic pain, lose control of opioids, and find themselves in the same amount of pain but with a monkey on their back.”
From his perch as medical director for Jackson County, of which Medford is the county seat, Shames had a front-row seat to the rise of the opioid epidemic. Like many people, he says he missed the early signs. Then, in 2006, the state’s medical examiner told him that Jackson County was losing about one citizen a week from pain pill overdoses. “I sat down in his office, and he pulled the charts,” Shames recalls. “I said, ‘Oh my God, what’s happening? Why aren’t people screaming this from the bell towers?’”
Shames, a soft-spoken man, didn’t start screaming. But he did start calling other counties and learned the same thing was happening throughout the state. His response was to invite doctors, health insurers, hospital officials, therapists, and substance-use specialists to begin working together to find ways to reduce opioid prescribing.
This effort led to the formation of Oregon Pain Guidance, a group that educates doctors on ways to work with pain patients and to limit the number, dosage, and duration of opioids they prescribe. When the Centers for Disease Control and Prevention released a similar set of prescribing guidelines in March, Shames says, he knew his group was on the right track.
“Guidelines like these are a good start as part of a broader strategy. Doctors and other prescribers may need assistance in helping their patients treat pain,” says Pew’s Reilly. “And while prescription opioids are an important tool for short-term, acute pain, we need to take a different approach when managing long-term pain. This can include using other medications that aren’t opioids alongside physical therapy and other treatments.”
Pew is helping states identify and implement policies that will promote the use of evidence-based approaches throughout a patient’s treatment.
If administered in time, naloxone can save a person who has overdosed on opioids. It is sold over the counter in Oregon and many states, and some police departments now regularly issue it to patrol officers.
It’s the kind of help that doctors desperately need, says John Kolsbun, an internist who joined a primary care practice in Ashland in 2010 and discovered that about 60 percent of his 750 patients were on pain pills. Like most doctors, he’d had little education about how to treat chronic pain and found that his efforts to manage his patients’ pain and reduce their medications were fraught.
“They’d tell me: ‘Doc, my back is going OK, but I’d do better with just a little more medication.’ Or ‘You don’t want me to hold my grandchild again.’ I was wholly unprepared.”
“I had to get a large number of patients off these drugs to do my job adequately,” Kolsbun says. “Every day was a battle. Three or four patients would be extremely disruptive, screaming at the top of their lungs if they didn’t get the drugs.”
Today, Kolsbun is the medical director for AllCare, an insurance provider with a large number of Medicaid patients covered through the Affordable Care Act. AllCare and other Oregon insurers are trying different ways to get patients off opioids or taper their doses.
Around the nation, Medicaid has programs that identify patients at risk for misuse and then direct them to designated prescribers and pharmacists who manage their use of these prescriptions. As part of the law signed in July, Medicare is now adopting a similar provision for its at-risk patients—something Pew had strongly advocated for.
The key for this and any other intervention to be successful is for doctors to engage in honest but caring conversations with their patients, Shames says. “You have to say: ‘I know this is hard, and I’m not going to abandon you. We’re going to create a plan that’s going to keep you safer, and it’s ultimately going to help your pain more.’”
Now 23, she snorted, smoked, or shot up heroin and methamphetamines for five years but has been clean for more than 8 months. She lives in a Portland treatment center and now hopes to become a peer support specialist. "It's so nice," she says, "to feel welcome, and wanted, and needed."
For years, the dominant model for addressing substance misuse has been to strive for abstinence through 12-step programs that provide social support. It’s an approach that often doesn’t work with opioids, Reilly says, because opioid use disorder is a disease that can’t be managed with just willpower.
The intensely addictive nature of opioids means that most people will need medical help to get off them, says the Opioid Treatment Authority’s John McIlveen. The constant high-low cycling makes it hard to engage a person in treatment because the cravings and withdrawal are so overwhelming, he says. “Without something to help ameliorate that, they can’t function or concentrate on treatment.”
That’s where medication-assisted treatment (MAT) comes in. With this approach, people are prescribed Food and Drug Administration-approved medications, such as methadone or buprenorphine, which are designed to curb cravings and manage withdrawal symptoms. These drugs are coupled with behavioral therapy and support services such as counseling, exercise, or yoga.
While some detractors argue that MAT swaps one addictive substance for another, substance use disorder experts say it is the most effective way to stabilize opioid-dependent patients—and then try to wean them off the drugs. Like heroin or prescription opioids, methadone and buprenorphine target the brain’s opioid receptors. But largely because they are longer acting or less potent, they do so without triggering the peaks and troughs that most opioid users experience.
“The science is clear,” says Pew’s Reilly. “MAT works because it’s a holistic approach to treatment—it’s medication and support services and behavioral therapy. It’s the most effective treatment available.”
But MAT isn’t universally available—far from it. A study published last year in the American Journal of Public Health found that while some 2.3 million Americans were grappling with opioid dependence in 2012, only 600,000 to 700,000 were getting any type of treatment.
Medication-assisted treatment should be widely available, says Reilly. One reason it’s not, she says, is that too many people, including some doctors, hold negative views toward use of these drugs.
“This is a disease, and we need to treat it that way,” Reilly says. “We need to address the stigma people associate with this condition.”
As overdose deaths increased, Jackson County medical director Jim Shames helped create Oregon Pain Guidance, a group that educates doctors on how to work with pain patients and limit the opioids they prescribe.
Another medication that Reilly and other experts believe should be more easily accessible is naloxone, a drug that—if given in response to an opioid overdose—can save the person’s life. Julia Pinsky of Jacksonville, Oregon, wished she had had naloxone when she discovered her 25-year-old son, Max, lifeless in an office space that she and her husband had built on their land. Max had struggled with heroin use for several years.
“I don’t know if he could have been saved by naloxone, but he might have,” Pinsky says of the night Max died in January 2013. “He was dead by the time emergency responders got there. I tried to resuscitate him, the responders did, too. He might have been alive at first; opioids suppress your breathing.”
Naloxone—which is available in both an injectable form and a nasal spray—can be sold over the counter in pharmacies in Oregon and many states. Many substance use programs give it to opioid users and their friends and families because of its lifesaving potential, and many police departments issue it to their patrol officers. Still, says Pinsky, “we need to get it into the hands of drug users and family members, loved ones, girlfriends. Too many people don’t know what it is.”
Buprenorphine plus counseling and affordable housing provided by Central City Concern, a Portland multiservice agency, have enabled Lisa Greenfield, 23, to get off the heroin and methamphetamines she’d been snorting, smoking, or injecting for nearly five years.
“I’m eight months clean,” she says. “It’s a miracle.” It’s also a miracle that she’s alive. At the peak of her disease, Greenfield was injecting a gram of heroin and half a gram of methamphetamine a day. Before coming to the CCC, as everyone calls it, she went to short-term withdrawal management programs several times, each time returning to the drugs.
Today, she’s on a daily dose of 24 milligrams of buprenorphine. “I don’t crave heroin,” she says. “If I was to try to get loaded, I couldn’t; the receptors are full, and you can’t get high.” She gets her monthly supply from the pharmacy on the ground floor of the agency’s airy, light-filled building. She goes to counseling sessions and can see doctors or therapists in the medical clinic on the second floor, where yoga, meditation, and acupuncture sessions are also held. Her room and a shared kitchen are on an upper floor.
Greenfield’s father, memorialized in a tattoo on her chest, was a heroin addict who was in and out of prison before committing suicide when she was 19. Now she goes to support groups daily, does volunteer work in the community, and hopes to get hired as a peer support specialist. “It’s so nice,” she says, “to feel welcome, and wanted, and needed.”
On Tuesdays, she meets with counselors at the agency’s satellite clinic on Portland’s East Side. Sam Hancos gets services there as well, with help from staffers such as Daniel Epting, a peer counselor who spent almost 30 years using drugs, shoplifting, and being incarcerated before becoming clean eight years ago and getting hired at another recovery program. Epting marvels at his turn of fortune.
“They pay me to be myself and to help people navigate the system,” he says. “I have a 9-year-old daughter that’s never seen me loaded. I can’t begin to tell you how grateful I am.”
Central City Concern in Portland not only provides medication and counseling to Lisa Greenfield and others recovering from opioid dependence, but also doctors, therapists, and a place to live.
Back in Medford, Michelle Marikos has also stopped taking prescription pain pills. After surgery failed to ease her pain, she went to the Mayo Clinic in Rochester, Minnesota, in 2012 and took part in a three-week program that helps chronic pain patients withdraw from prescription drugs. She still has pain, but now she rates it at 3 on a 1-10 scale instead of the 7 or 8 she used to endure when she was taking pain medications and in a state of constant panic.
In March, working with Jim Shames, she helped organize the consumer section of the fourth annual Oregon Pain Summit, providing information and inspiration for how people can deal with pain—and transition from their pills.
Her message to other pain patients is much like the message she gives herself, over and over again: “It’s OK. This pain won’t kill me. It doesn’t feel good, but I’ll get through it. And so can you.”
Photography by Thomas Patterson