From the Medford Mail Tribune, June 30, 2013

Getting Hooked: Is overprescribing of painkillers to blame for opioid addiction?

For Jonathan Cordova, the spiral into opiate addiction began in high school, when he started taking Percocet pills he got from friends to relieve the pain of sports injuries.

Within a year, he had dropped out of high school and lost a baseball scholarship. By 21, he was experimenting with cocaine and methamphetamine, and started snorting the popular painkiller OxyContin.

“It gives you a feeling of euphoria, just like you’re floating, nothing else really matters,” says Cordova, now 26. “It just took everything away.

“We started doing them every day, and that’s all that mattered. And then we got to where if you didn’t take them, you would get sick.”

Cordova is working to kick his addiction to painkillers, called opioids for their opium-like qualities. But thousands of other Oregonians remain hooked on the medications — many of them prescribed by their health care providers.

Dr. Jim Shames, Jackson County’s top health official, says more than 20 million painkillers are prescribed in the county every year.

Out of 141 accidental drug overdose deaths from 2004 to 2011, about 80 percent involved a prescribed opiate, he says.

Overdose deaths from heroin — which some addicts turn to when they can no longer get or afford prescribed pain medications — have jumped from 18 in that eight-year span to seven in 2012 alone, he says. Two, in Ashland, came within 24 hours of each other.

“From a public health perspective, we have way too many of our citizens who are dying of overdose deaths,” Shames says.

The solution? Start with the source of the pills, he says.

“We have way too many pills; 20-plus-million painkillers prescribed in Jackson County in one year, I mean that’s absurd,” he says. “So the source is coming from prescribers — people who have the ability to write prescriptions. That is the source of the pills. There’s just no doubt about it.”

For the past two years, Shames, medical director of Jackson County Health and Human Services, has been working with more than 70 local health care providers to educate doctors and others on the dangers of overprescribing painkillers. They formed the Opiate Prescribers Group, which in May unveiled new guidelines for prescribing painkillers and recognizing the danger signs of addiction.

“What we’re trying to do is get physicians and other prescribers to understand that you can do a risk assessment on somebody,” Shames says.

Oregon in 2010-11 had the highest rate of prescription-drug abuse in the country at 6.4 percent, compared to 4.6 percent nationwide, according to the Substance Abuse and Mental Health Services Administration.

“The fact that Oregon is said to be No. 1 in the inappropriate, illicit use of opioids implies that we must be No. 1 in the inappropriate prescribing of opioids,” Shames says.

“Otherwise we wouldn’t have so many pills out there being abused. You know if we gave just the right amount to just the right people at just the right dose, they’d be done. So, yes, I think there’s a lot we all have to learn about this.”

In January, longtime Ashland residents David and Julia Pinsky lost their 25-year-old son, Max, to heroin overdose. It was the third such overdose in Ashland in six weeks, a rate never before seen in the town of 20,200.

Max had been exposed to pain pills after injuries from car accidents, his mother says. He struggled with some addiction problems that she and his father were aware of, but during the last year of his life, his condition quickly deteriorated.

“It was a surprise as to the severity of it. The rapid decline was shocking,” Pinsky says.

Max’s addiction led to run-ins with the law, which made him increasingly paranoid and nervous about serving time in prison, Pinsky says. Because of the drugs, he had a lot of trouble with decision-making, she says.

“He had driving offenses and then possession charges. It doesn’t help the person who is already unstable. Police were certainly asking him to inform. People need to be treated as though they need to be helped, and not given a carrot to inform,” Pinsky says.

Pinsky says Max came home one day after being beaten by fellow users who thought he was informing just because he had been dropped off by a police officer.

“These people are not mentally well,” she says. “Max hit a really rough patch with mental health. A year before that he was much better. This last year, he just didn’t have the strength.”

State Sen. Alan Bates, a Medford physician, believes opiate addiction stems more from mental health issues such as those with which Max struggled.

“Thirty years ago, we were told we were prescribing too many narcotics, then 10 years ago, we were told we weren’t prescribing enough. Now 10 years later, we’re prescribing too much,” he says.

“Why do people take narcotics in the first place? I firmly believe it’s a social phenomenon born out of poverty and hopelessness.”

Bates, who is co-chairman of the Ways and Means Subcommittee on Human Services, hopes to allocate more money in the state budget this legislative session for mental health services and drug and alcohol treatment programs such as Jackson County’s OnTrack Inc., an addiction and recovery center.

Dr. Jason Kuhl, clinical medical director at Providence Medford Medical Center, agrees with Shames that the overprescribing of opiates is the reason so many residents are hooked on pain pills.

“If we had 20.4 million doses of narcotics prescribed, that is indicative of a society dependent or addicted to these medications,” Kuhl says.

Doctors made assumptions that studies on acute, or short-term pain — from surgery, broken bones, dental work, burns, cuts, labor and childbirth — were the same for chronic pain, which includes headache, cancer, arthritis, nerve damage and lower back pain, Shames says.

“Those are really different phenomena. People get really addicted. We were told maybe they didn’t,” he says.

Shames says pharmaceutical companies, aware that chronic diseases pay better than acute or short-term conditions, misled physicians.

“That’s why they’re not making many antibiotics, but chronic pain? My gosh, you might take a drug for the rest of your life? Now that’s going to make a lot of money,” he says.

Purdue Pharma, the company that manufactures the popular painkiller OxyContin, downplayed some of the risks associated with the painkiller and adversely influenced licensing boards, Shames says.

In May 2007, Purdue Pharma executives pleaded guilty to misleading the public about OxyContin’s risk of addiction. The company was ordered to pay $634.5 million in fines — one of the largest financial penalties ever imposed on a drug company — for claiming that because the drug was time-released, it was less addictive and less subject to abuse than other pain medications, according to the Los Angeles Times.

“They’ve been deep into it,” Shames says. “At some point physicians were influenced to prescribe, and the public was influenced to look for a pill that was going to cure their ills.”

Opiates are the ultimate painkillers because they don’t just cure physical pain — they cure any pain, even emotional pain from trauma, Shames says. But while they’re effective for short-term, acute pain, there’s insufficient evidence to support their use for chronic, noncancer pain, officials say.

“Opiate use at best is only going to make a 50 percent reduction in chronic pain,” Kuhl says.

The drugs’ tendencies toward building tolerance and addiction can do more harm than good, Shames says.

“What’s increasingly clear is that if we’re going to get prescribers to change their behavior around chronic — how they deal with chronic pain — their patients need to have a different understanding. The public at large needs to have a different understanding,” Shames says. “So really it becomes a community issue.

“I’m interested in the community being informed because I don’t think we can do this with any one piece in and of itself.”

Health officials say some patients who get hooked on pain pills but can no longer get or afford them turn to heroin for relief.

“Meth has actually fallen off, given how hard it is to manufacture, but heroin has been making a comeback,” Kuhl says.

According to Cordova, when his OxyContin addiction was costing him between $300 and $400 a day, he started stealing from friends and family. The low cost of heroin for a better high was what led him deeper into addiction, he says.

“I was at a friend’s house, and there was all these guys doing heroin, and they said it was the same feeling but better for a quarter of the price,” Cordova says. “I was spending half the money and getting twice the amount of drugs. I started smoking it, and that lasted for a year, then I started shooting it.”

Shames admits the downside of cutting back on opiate prescriptions is that it can lead to an increase in heroin use among those already addicted.

“At least that is what the data from here, Multnomah County and the rest of the country seems to imply,” Shames says. “In the data you can see 18 deaths over eight years from heroin, and last year alone we had seven.”

But as prescribers better understand the difference in treatment for acute and chronic pain and the correlation between overprescribing and opiate addiction, the hope is fewer people will become addicted in the first place.

“I think providers have been feeling this burden for the last five years,” says Kuhl. “The (Opiate Prescribers Group) is a communitywide group with health professionals trying to standardize our processes. To make sure we are all aware of the resources to do a better job of prescribing.”

Rita Sullivan, executive director of OnTrack Inc., regularly attends OPG’s monthly meetings and says this is a key way treatment specialists, mental health professionals and doctors are coming together to try to solve the problem.

“It’s tremendous to see the growing number of people around the table,” she says. “We know what to do, we just need to redesign our systems a bit.

“We’re all working as hard as we can. We just need some mid-course corrections. I think the effort is well under way.”

After about three years of being addicted to heroin, Cordova found himself facing three to six years in prison for theft and possession crimes or the option of going through rehabilitation.

“I have a couple of little boys and I just knew it was time. I had to make a huge decision,” Cordova says.

A graduate of OnTrack’s DADS program, Cordova says he has been clean for six months.

“It will take time. I have to prove myself,” he says. “I’m really grateful I get to be clean and still be here.”