A Prescription for The Death of Generations
By Kim E. Morrison
Saint Leo University
Despite our wars on drugs and the numerous slogans we have used to try and keep people, especially our youth, off illegal drugs, drugs have always been a pervasive part of the American culture. As a matter of fact, one could argue that illegal drugs and those who used and sold them were a culture within culture because in the past not every nook and cranny of America were touched by them in the same way. Yes, you would here about the occasional drug overdose death or here about some dealer or group of people being busted for selling and distributing drugs, but many people in suburban and small-town America could say I am glad we do not have a drug problem here or say my kids would never get addicted to drugs here, so drug abuse and addiction was not something talked about around the dinner table of rural or suburban America. The average American dismissed drugs as being a problem of larger cities. Drugs were something that were sold on seedy street corners by emaciated drug dealers trying to support their own addiction, by gangs in ethnic neighborhoods trying to make a buck by first poisoning people within their own ethnic group and then reaching into other groups to increase their profit and power, by pimps trying to make more money on their prostitutes or as means to increase their production, or the pure for profit drug dealer who is always around to capitalize on the misery of others. A “Sugarman” as they were once called in song, that could be found in the shadows just waiting to take advantage of those desperately needing a fix to fend off the unrelenting agony of withdrawal, those trying to escape personal demons that haunt their every waking hour, and those who live lives of quiet desperation seeking a temporary freedom from the chains of their situation and dilution of the thoughts associated with it.
Unfortunately, the demon of drug abuse and addiction that we once believed would remain in the dark corners of American life has stepped out of the shadows into a new seemingly respectable form that is leaving no age, ethnic demographic, or socioeconomic group untouched by its consuming grip. America is in the throngs of what many are now calling an opioid epidemic that shows no signs of abating. An epidemic not fueled by illegal drugs, but by legal prescriptions drugs and the dealers are not on dingy street corners, but in fine offices wearing white coats and stethoscopes armed with nothing, but prescription pads and the best of intentions for patients in pain. As a result, prescription drug abuse, addiction, and dependence has become a repugnant addition to the drug problem in America that not only could be eliminated, but must be before we witness the death of more generations.
In less than a decade studies trying to ascertain the extent and depth of this problem as well as find viable solutions to this problem have yielded some mindboggling heart wrenching statistics and clearly explains why everyone is calling this an epidemic. Just from late 1999 to 2011 opioid overdose deaths in the United States quadrupled (Cheatle, 2015). In 2012 drug overdoses was the leading cause of deaths, surpassing automobile accidents (Barry et al., 2015). By 2016 nearly two people per day were dying of opioid overdoses (Johns Hopkins Bloomberg School of Public Health, and the Clinton Foundation, Clinton Health Matters Initiative, 2017). In just one month in 2008 they found that 4.7 million adolescents and adults in this country were misusing prescription opioids which represents about 2% of the entire U.S. Population (Cleland, Rosenblum, Fong, & Maxwell, 2011). The number for those seeking treatment for addiction in the period from 1999-to 2008 skyrocketed. The increase for heroin addiction was 69%, but the increase in those seeking treatment for prescription opioids jumped up twenty-fold to 1, 896% (Cleland, Rosenblum, Fong, & Maxwell, 2011). The number of prescribed opioids from 1999-2012 increased to 400% which is enough to supply every adult in the United States with a one-month twenty-four-hour supply of narcotics (Johns Hopkins Bloomberg School of Public Health, and the Clinton Foundation, Clinton Health Matters Initiative, 2017). In 2012 opioid pain relievers were directly involved in 470,000 hospital emergency department visits and the economic costs associated with opioids which included medical, productivity, and crime came to 50 billion dollars (Barry et al., 2015). One of the most heartbreaking of these statistics was that there has been a 400% increase in Neonatal Abstinence Syndrome just between 2000-2012. What this means in simple terms is that a baby is born addicted to drugs approximately every twenty to thirty minutes in the United States and some figures put it at every fifteen to twenty minutes (Johns Hopkins Bloomberg School of Public Health, and the Clinton Foundation, Clinton Health Matters Initiative, 2017).
In 2006 the Prescription Opioid Addiction Treatment Study, POATS, was launched in response to the epidemic level trends of prescription opioid abuse and addiction in this country, and the burgeoning number of people seeking treatment to drug programs for addiction (Weiss et al., 2010). These continuing studies have proved informative on many aspects of the opioid problem. They found that people who can no longer acquire prescription drugs will try to obtain and use heroin in place of it. As a result, along with the prescription opioid epidemic, there has been an uptick in heroin use in this country as well (Weiss et al., 2010). POATS has studied treatments for opioid drug addiction and dependence and found that there may be different outcomes for pure heroin addicts versus those who are addicted to prescription opioids and the fact that many people have used more than one drug complicates everything, including studying the problem because it makes it harder to define study groups. As a result, the statistics and figures obtained on the opioid epidemic may be conservative, so this epidemic may be even worse than the data shows. Researchers considering these factors and others have suggested that treatment programs should be tailored toward the individual and their specific drug use pattern to be more effective (Weiss et al., 2010). Another issue related to the opioid epidemic that researchers have discovered is that some portions of rural America, even when adjusting for density, have the highest rates of opioid poisoning and death. Kentucky, Oklahoma, West Virginia, and Alaska have been hit the hardest by the opioid epidemic with all having rates of poisoning and death from opioids not only greater than more populous areas, but far above the national average (Keyes, Cerdá, Brady, Havens, & Galea, 2014). The trouble is there is very little empirical data to explain why this is occurring in these areas. However, some researchers have suggested that these high rates are related to the extreme poverty levels in these states and the tight kinship between people there because statistics have shown that 70% of those who report non-medical use of prescription opioids state that they received them from friends and relatives (Keyes, Cerdá, Brady, Havens, & Galea, 2014).
Oklahoma, one the rural states hit the hardest by this epidemic, was among the first to begin initiating statewide policies to combat the epidemic at the pharmacy benefit or payer level. This was prompted by the fact that the costs associated with abuse and dependence diagnosis among Medicaid patients was much higher than for other patients. The policies which included quantity limits on certain drugs, pharmacy lock in programs on patients thought likely to misuse due to their medical utilization history, prior authorizations for specific drugs, step therapy program which basically requires that a physician use designated products for the first step before you go on to other steps, and other restrictions were perceived as prevention methods with the goal of reducing potential abuse and costs (Keast, Nesser, & Farmer, 2014). In the short term the strategies created by Oklahoma Medicaid, MOK, seemed to achieve some results. The CDC, Centers for Disease Control and, the NIH-NIDA, The National Institutes of Health- National Institute on Drug Abuse are now funding research to determine not just the impact of these policies, but any policies like them and the consequences from them (Keast, Nesser, & Farmer, 2014). There are a few problems with dealing with this issue on the costs side of it alone. One, it doesn’t address the problem of those already addicted to prescription opioids and two, it seems logical that just doing these cost related measures alone is sure to cause an uptick in illegal drug use, particularly heroin, so the idea of the groups above studying these measures make sense on a lot of levels.
In 2009, to find some balance between the potential effects of prescription opioids without reducing legitimate access to opioids for pain relief the FDA proposed a Risk Evaluation and Mitigation Strategy, REMS, to look at the risks and benefits of opioid medications and describe requirements and procedures to reduce the misuse and abuse of these types of medications (LING, MOONEY, & HILLHOUSE, 2011). The idea here is to put some type of restriction or create or make some arrangements controlling prescribing practices in ways that might reduce or lessen opportunities to misuse opioids (LING, MOONEY, & HILLHOUSE, 2011). Patient education on these medications would be a part of REMS as well and that is necessary because research shows that 80% of the people fail to understand just how easy it is to become addicted to prescription opioid pain relievers (Barry et al., 2015). There are some great ideas here as well because 78% of the people surveyed on this issue say doctors are responsible for a solution to this problem (Barry et al., 2015). However, once again these solutions do not address the problem of those already addicted or the 70% of the people who report non-medical use of prescription opioids that state that they got them from friends and family (Johns Hopkins Bloomberg School of Public Health, and the Clinton Foundation, Clinton Health Matters Initiative, 2017).
Every idea some states and the federal government have come up with so far to do something about the opioid epidemic in America deserves merit, but what has been done so far to address this problem is tantamount to a group of men urinating on a forest fire with the hope of keeping it from spreading. What is needed to effectively solve this problem is a full-throated approach toward every angle of the opioid epidemic and to do this you would need to get everybody that is directly involved in, connected to, or touched by this massively growing social problem to generate ideas and workable solutions to the problem. This would include bringing people together from the medical community, the police, drug enforcement, emergency medical personnel, policy makers from the state and federal level, clinicians, doctors and pain management specialists, drug rehab and treatment center specialists and counselors, people from state Medicaid agencies, health insurance providers and other payors, pharmacists, drug manufacturers and distributors, psychiatrists, psychologists from every discipline, family members of addicts, and former drug addicts themselves because no one understands the problem of drug addiction better than those who have been intimate with this demon. To some great extent the Clinton Foundation and the Johns Hopkins Bloomberg School of Public Health have done exactly this very thing and have come up with recommendations that would greatly reduce this problem if not eliminate it entirely. First, mandate prescriber registration and optimize Prescription Drug Monitoring Programs, PDMP’S, in all states. These programs if optimized would be highly effective in reducing drug abuse and diversion. Their purpose is to monitor, collect, and analyze electronic data collected from and submitted by dispensing pharmacies and prescribing physicians. This data can also be used for research for public education, and abuse prevention (Johns Hopkins Bloomberg School of Public Health, and the Clinton Foundation, Clinton Health Matters Initiative). Second, the Centers for Disease Control has had guidelines on prescribing opioids to people with chronic pain for some time, so the next obvious step is to work with medical boards to pass policies that reflect these guidelines (Johns Hopkins Bloomberg School of Public Health, and the Clinton Foundation, Clinton Health Matters Initiative, 2017). Third, expand drug take back programs and provide clear guidelines on safe disposal and storage of prescription opioids (Johns Hopkins Bloomberg School of Public Health, and the Clinton Foundation, Clinton Health Matters Initiative, 2017). Forth, work with drug manufactures to look at innovative packaging and in creating prescription opioids that are more difficult to abuse (Johns Hopkins Bloomberg School of Public Health, and the Clinton Foundation, Clinton Health Matters Initiative, 2017). The have already shown that they can reformulate oxycodone, so it can used without being abused. The savings in costs and in lives alone with be worth researching this more and doing it to other opioid medications (Kirson et al., 2014). Fifth, work to obtain funding to build more drug addiction treatment centers in those rural areas or any other areas where addictions rates are high (Johns Hopkins Bloomberg School of Public Health, and the Clinton Foundation, Clinton Health Matters Initiative, 2017). Sixth, work with developers to reformulate Naloxone, Narcan, the drugs that can reverse opioid or opiate drug overdose, so they can be used by non-medical professionals to prevent drug overdose deaths and work to get them distributed to schools, clinics, all first responders, and any where else they might be needed (Johns Hopkins Bloomberg School of Public Health, and the Clinton Foundation, Clinton Health Matters Initiative, 2017). Naxolone, Narcan, should be easy to utilize and as easily available as epi pens because it could prevent a death and give someone another chance at life. Seventh, work to create more public awareness on the opioid epidemic issue and work to avoid and end stigmatizing language with relation to drug users, treatment, and everything else associated with it (Johns Hopkins Bloomberg School of Public Health, and the Clinton Foundation, Clinton Health Matters Initiative, 2017).
Dear Mr. and Mrs. not my children, not in my neighborhood please be advised that the opioid epidemic in America is a lot closer than you think if it isn’t already at your door. The time for national complacency on this issue has long past. We can no longer afford to declare another meaningless war on this problem and try to incarcerate it away or simply just say no to the problem with our eyes closed wishing and hoping that drug abuse and addiction goes away. What we must do is call this opioid epidemic what it is and that is a national health crisis. A crisis that is shattering and destroying families and communities in every corner of our country, costing our country billions upon billions of dollars, and taking human lives at a staggering rate of one every twelve hours of every day. We can no longer afford to say not my clowns, not my circus because we are all in this clown car of hell and it is headed for a cliff. We can no longer just nibble at the edges of this massive social problem. There are no quick fixes for what we are facing, no single approach that will even begin to put a dent in it. What is needed are real solutions to solve this issue and we will not get them if all the voices, even those remotely connected to this issue, are not heard and our approach to it is not a multifaceted effort with every idea considered and utilized if good and every possible consequence of the actions taken thought through. The opioid epidemic has already cost us a couple of generations and it is poised to insure the death and destruction of more generations if concrete action is not taken now.
Our mission will not be considered complete if teenagers who were prescribed pain medications for injuries are getting addicted to them and when they cannot get them are searching for illegal alternatives before the sickness and agony of withdrawal begins to kick in. Our job will not be done if mothers and fathers or grandfathers and grandmothers in chronic pain from injuries or illness are getting addicted to prescribed pain medications and requiring rehab to free them from addiction. We will not have done enough if young people of any age are able to buy prescription drugs like oxycontin from neighborhood drug dealers under street names like hillbilly heroin, kickers, and killers. Our task will not be over if people addicted to prescription opioids are replacing them with heroin or a lethal cocktail of opiates and benzodiazepines and dropping dead from overdoses in homes and streets across our country. We will not have done all we could if one person dies of an opioid overdose just because there was no access to Naloxone, Narcan, to reverse it. This will not be over if distraught parents with tearsoaked eyes and a hole in their heart are still picking out little pink and blue coffins for children who could not be helped before the relentless grip of drug addiction drained the light of life from their eyes. If one infant somewhere in our country lays in a neonatal intensive care unit (NICU) inconsolable, screaming an agonizing shrill, twitching, seizing or shaking like a tuning fork involuntarily as he or she awaits a nurse to administer a baby sized dose of methadone or morphine to fend off the painful agonizing sickening effects of narcotics withdrawal our job is not done, our mission will not be complete.
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Johns Hopkins Bloomberg School of Public Health, and the Clinton Foundation, Clinton Health Matters Initiative. (2017). THE OPIOID EPIDEMIC from Evidence to Impact. Retrieved from https://www.jhsph.edu/events/2017/americas-opioid-epidemic/report/2017-JohnsHopkins-Opioid-digital.pdf
A special thanks to all those recovering from drug addiction that I transported to Operation Par Inc and other drug addiction treatment centers over the course of several years in my position as a Non-Emergency Medical Transport driver because without the many casual conversations I had with you over that time the parts of this paper where I did not point directly to a peer reviewed or secondary reference would not have been possible. I truly hope you are all living large and free from the chains of drug addiction.