Over the course of two days, residents and local healthcare providers got a dose of reality about the prescription narcotic drug addiction epidemic facing the nation – and that – includes Eastern Sierra communities.
At an Aug. 5 public symposium and an Aug. 6 meeting of the Inyo County Addiction Task Force, California Department of Alcohol and Drug Program State Medical Director Elinore McCance-Katz talked about contributing causes of addiction, its treatment and current prevention measures. Education is key, she said, since anyone can become addicted to these legal drugs, many people without the intention of doing so.
McCance-Katz’s presentations and Q&A sessions addressed what she referred to as the escalating opioid addiction epidemic sweeping the nation. Locally, said ATF member and Presiding Inyo County Superior Court Judge Dean Stout, there are “tragically increasing numbers of overdoses, deaths and incarcerations related to abuse of prescription narcotics.”
McCance-Katz said, “We want to de-stigmatize and medicalize” prescription pain medication (opioids), addiction and that means “addressing a vast array of subjects.” McCance-Katz, noting that this was her first time speaking with community members rather than healthcare professionals, stressed that education is the solution – educating the children and schools as early as middle school level, the parents and the patients as well as the healthcare practitioners.
BY THE NUMBERS
The statistics of non-medical use of opioids is staggering, said McCance-Katz: The U.S. is 4.6 percent of the world’s population but uses 80 percent of the world’s opiate supplies with California the biggest user. In the last six years, prescription drug-related deaths, accidental and otherwise, ER visits and addiction have risen to the top of statistic lists. More than five million people, 12 years and older, admit to prescription drug misuse.
Numbers are actually higher, said McCance-Katz, but doctors don’t always know how to ask the right questions. And opioids are now the leading first recreational drug for 12-year-olds and up – 56 percent say they get opioids for free from relatives and friends – whether these relatives and friends know it or not. Opioids like Oxycontin, Vicodin and Percocet and benzodiazapines like Valium, Adivan and Xanax are very popular among drug abusers, she said.
McCance-Katz added that opioid addiction is a top priority with Centers for Disease Control and similar agencies.
At the ATF meeting, she discussed the CURES program, “an important program to help prescribers know who else might be prescribing controlled medications and which drugs are being prescribed … This is an important safety issue.” CURES can help reduce doctor shopping, the overuse/misuse of drugs and the possibility of drugs being diverted to people without prescriptions, said McCance-Katz.
Unfortunately, only seven percent of prescribers are using CURES, she told ATF members. “I use it every single time,” McCance-Katz recommended that prescribers use CURES even before prescribing meds. Filled prescriptions should also be entered promptly by pharmacists. It’s “a form of prevention which only takes one or two minutes to do,” she said.
Few prescribers are adequately trained to properly diagnose and treat addiction, she added. Medical school curriculum is very set and isn’t yet required to teach prevention and treatment, said McCance-Katz. However, there are currently three pieces of legislation in Congress that require prescribers to have ongoing education in this area, she said. These bills “will regulate us big time” if we don’t act, she said at the ATF meeting.
“Doctors need to be trained to know when and how to prescribe in medical and dental school.” They have a lot to accomplish in the average 15-minute patient visit, added McCance-Katz. “We need reasonable ways to ascertain each person’s real need. We need to get evidence before we put people on these drugs,” said McCance-Katz. And giving patients only a few pain pills, instead of a month’s worth, in ER would require them to seek immediate follow up treatment.
Diagnosing the subtle nuances of addiction correctly can be very difficult; there are many factors to consider. For example, “People with mental health issues often have substance abuse problems and people with substance abuse problems often develop mental illness.”
AN OLD STORY
Neither inadequately trained providers nor rapidly accelerating narcotic medication addiction are a new phenomenon. The Harrison Act put the clamp on rampant opioid prescribing; doctors became reluctant to prescribe narcotics even to patients riddled with cancer, McCance-Katz explained. In 2000, the pendulum swung again when pain was declared a fifth vital sign and prescribers were required to offer pain meds – if not, they could be prosecuted. As a result, “doctors seem not to know what they can and cannot do,” she said.
One symposium audience member related his experience after a surgery. “I resent the doctors who told me I had to take morphine” to heal better. After three days, he quit them. “I didn’t like them,” he said. After his second surgery, he “only took Tylenol and recovered just as well without all the side effects.” McCance-Katz said, “This is a story I’ve heard a number of times.”
Clearly, not everyone gets addicted to opioid though it can happen to anyone, especially when these drugs are misused, said McCance-Katz. And 10 percent of humans are predisposed to addiction; it’s a brain thing. Simply put, these folks have a euphoric response to narcotics because their prefrontal cortex, which determines how much a person likes a drug, tells them they like these drugs a lot, she explained.
One audience member asked what’s to be done for addictive types with severe ongoing pain. They need a doctor who can do the right assessment and diagnosis, replied McCance-Katz. Sometimes, patients can experience hyperalgesia, where long-term opiate use actually causes heightened sensitivity to pain. Over the last 10-15 years, one in four Americans suffered from recurrent pain, one in 10 for at least a year. Liberal and long-term prescribing on the part of caregivers can lead to addiction. Treating pain with opioids is common, said McCance-Katz.
When doctors stop prescribing a drug due to patient addiction, patients often go to the street, she said, where prescription drugs are so expensive, they often turn to heroin. To make matters worse, West Coast black tar heroin must be injected.
“Where are we going with this … since it’s a relapsable disease?” asked an audience member. The Affordable Care Act includes an essential benefits package with a mental health component, said McCance-Katz. “Each state can decide how to use it.” When an audience member suggested targeted education for the public so they
can advocate for
themselves, McCance-Katz said, “Knowledge is power. People should not be passive participants in their own medical care. They have to step up to the plate.”
People often believe that if it’s prescription, it’s safe but the drug is not always used as prescribed, said the addiction psychiatrist. During the ATF meeting, an example was cited. On a sleep-over, a child complained of headache. In an effort to help, she was given an opioid and died. And these stories abound.
Another ATF member said, “We incentivize the return of Coke and water bottles” but patients don’t know how to return unused drugs – or even that they should do it. “We are placing our families at risk when we keep unused drugs” which happens, for example, after a family member with many medications passes.
Preventively speaking, there are many ways to treat pain “other than with opiates,” said McCance-Katz, and there’s no evidence that opioids work for long-term chronic pain for everyone. Alternatives include: trigger point injection, diet and exercise, physical therapy, surgery, chiropractic care, anticonvulsants, yoga, massage, acupuncture and cognitive behavioral therapy. “I have seen patients recover, sometimes altogether, from pain after the proper psychological treatment.”
Also, treatment agreements are now considered standard practice, said McCance-Katz. These agreements specify, for the patient and the doctor, the conditions under which prescriptions are given, what other therapy will be used to deal with underlying issues and so on.
However, once addicted, McCance-Katz stresses the need for professional help. She recommends medical treatment – detox, in slang parlance – which uses various drugs to detoxify the addict, prevent relapse by blocking the effects of the opiates and prevent impulsive use. “It buys you time to get to recovery.”
In her experience, the relapse rate with withdrawal treatment (which uses no meds) is higher, McCance-Katz said. Responding to an audience question, she said withdrawal treatment is used 80 percent more often than medical treatment because “it’s easy, it’s fast.”
Medical withdrawal is “not a substitution of one addiction for another,” was McCance-Katz’ response an audience member’s concern about treating drug addiction with other drugs. “It’s a once-a-day drug so people can go on with their lives.” But recovering addicts also need coping skills as well. “You get sick if your body doesn’t have (the medication you’re now used to) and … people have to unlearn behaviors and thought patterns.” McCance-Katz advocates psychotherapeutic approaches and 12-step work because “once the drug is out of the patient’s system, they are still left with their problems.”
“Addiction doesn’t happen in a day and recovery doesn’t happen in a day,” said McCance-Katz. And that’s a tough reality to accept for people who are used to the instant gratification of drug abuse. Many addicts may require multiple treatments to get long-term recovery, said McCance-Katz.
There are powerful lobbying forces at play and it’s going to take advocacy group efforts, like the Addiction Task Force, to change the situation, said McCance-Katz, in addition to education of healthcare professionals and self-advocacy through education on the part of the public.
“Twenty-eight thousand people die a year (from opioid addiction). Where is the public outrage? It would be there if 28,000 people a year were dying of any other disease,” said McCance-Katz.