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‘Hooked up’

Nation’s war on opioids hits home in Jessamine County

Last year, the overdose death rate in Kentucky decreased by almost 15 percent, marking the state’s first decline in five years.
While this decrease marks an improvement, many officials have stated there is still work to be done to combat the fight against heroin and methamphetamine in Kentucky. Most of the deaths reported were caused by fentanyl, an opioid that is reportedly 50 times more potent than its competitors.
“(The) announcement of a 15 percent decrease in the number overdose deaths in the Commonwealth is certainly positive news and a step in the right direction,” United States Attorney Robert M. Duncan, Jr said in a prepared statement. “However, we all recognize there is still work to be done. We remain committed to using all available tools to combat this crisis, including vigorously prosecuting unlawful opioid traffickers, partnering to conduct community outreach and education and encouraging those needing help to seek treatment.”
The Eastern and Western District United States Attorney’s Offices are reportedly pursuing the cartels supplying the majority of illegal synthetic opioids, like fentanyl, to residents in Kentucky. Opiates are naturally-occurring compounds derived from the opium plant. Opioids are synthetic compounds which bind to the same receptor sites in the brain the opiates do. Synthetic opioids are known to have opiate effects on users.
“The terms are often used interchangeably and medically interact with the same brain receptors,” Medical Director of the Jessamine County Health Department Dr. Steve Davis said.
The major difference, Davis said, is if the drug is derived naturally, such as opiates/opioid, which comes from the poppy plant, known commonly as morphine or codeine versus if the drug was derived synthetically such as opioids commonly known as oxycodone or fentanyl.
Fentanyl was discovered in the 60’s and used for surgery. In the 90’s, it was expanded on with an extended release skin patch for chronic pain treatment.
In 2016, synthetic opioids (primarily illegal fentanyl) were reported as the most common used drugs in overdose deaths in the United States. Unfortunately, those numbers are still rising.

By the numbers

The Kentucky Office of Drug Control reported 1,333 overdose deaths in the Commonwealth in 2018. This was 233 fewer than was recorded in 2017, a decline of 14.9 percent.
Of the 1,333 deaths, 93.6 percent were Kentucky residents. The highest rate of overdose deaths were reported in Boyd County, followed by Madison County, Kenton County, Clark County and Campbell County. The age group with the highest rate of overdose was 35 and 44 year olds, followed by 25 to 34 year olds and 45 to 54 year olds.
Of the 1,298 deaths listed in the toxicology reports available, 786 were fentanyl-related. This was near 61 percent of deaths. An increase from the reported 52 percent in 2017 and 47 percent in 2016.
An increase in deaths caused by methamphetamine was also reported in 428 cases last year. This showed an increase as well, from the 357 reported cases in 2017.
Still, some drug usage showed a decline instead of an increase, such as overdose deaths caused by heroin, alprazolam and gabapentin.
Heroin-related deaths dropped by 30 percent, from 270 in 2017 to 188 in 2018. Gabapentin showed the same decrease of 30 percent, from 363 cases in 2017 to 255 cases in 2018. Oxycodone deaths dropped as well, with 110 reported last year compared to 157 reported in 2017, a 30 percent decrease. Alprazolam deaths dropped 20 percent, from 269 in 2017 and 214 in 2018.
Jessamine County reported 18 overdose deaths in 2018 per 100,000 residents. This computes to a rate of 36.58 percent.
Looking back further, from 2006 to 2012, reportedly 16,899,450 prescription pain pills were supplied to Jessamine County residents.
That is enough for 51 pills per person per year.
Of these pills, 4,080,080 were distributed by McKesson Corporation, followed by Walmart, Walgreens, Kroger and Cardinal Health.
SpecGx, LLC, manufactured the largest amount of these pills during that time with 7,037,200 reported, followed by Actavis Pharma, Par Pharmaceutical, Purdue Pharma, LP and Amneal Pharmaceuticals, LLC.
Walmart pharmacy received the highest number of pills during this time with 2,815,820, followed by Drug Mart, Walgreens, Kroger and Kentucky CVS pharmacy.

Impacting youth and families

Rob Revelette with Pediatric Associates-KY One Health in Nicholasville said most individuals start abusing opioids in adolescence, and he has seen children as young as 13 shoot up.
“Although the national opioid crisis affects all age groups, the steepest rise in unintentional opioid overdose fatalities has been in young adults aged 18 to 25 years,” Revelette said.
Although heroin epidemics are not a new thing, there is a difference to the one the nation is currently facing.
“(Years ago) the pharmaceutical companies began reassuring both patients and prescribers that opioids were not addictive,” Revelette said. “We know now that this is not the case and the results of this campaign have been disastrous. About 80 percent of people who use heroin first misused prescription opioids.”
Davis said Kentucky has been a national center for opioid-addicted individuals for years. As the supply has decreased, the opioid-addicted individual has since turned to less expensive, easily available counterparts – such as heroin. Opioids, Davis said, know no group boundaries.
“Individuals with sudden acute pain can quickly become addicted to opioid medication,” Davis said. “Chronic pain sufferers can become addicted to opioid medication. Risk taking individuals can become addicted to opioid medication.
Emotionally distraught individuals can become addicted to opioid medication. ‘Drug dealing crooks’ can and will seek out people to become both users and sellers of opioids with the false hope of an improved lifestyle.”
Davis said there are ways in which a doctor can identify a person for being at risk of transitioning from an opioid to heroin, such as screening tools.
“There are several educational screening tools that have been shown to be very beneficial,” Davis said. “Screening, Brief Intervention and Referral to Treatment (SBIRT) is one that has evidence-based practice to identity, reduce and prevent problematic use, abuse and dependence on illicit drugs.”
Revelette agrees with Davis and said misuse of prescription opioid medications are associated with 19 times greater risk of transitioning to heroin compared to no misuse by patients and individuals. Psychiatric risk factors, Revelette said, also play a part, as do depression and increased impulsivity.
However, debate still circulates around if addiction is a disease. When asked how he could clarify, Revelette pointed out the need to look at the definition of both the term disease and addiction.
“A disease is defined as a problem that a person, group, organization, or society has and cannot stop,” Revelette said. “The American Psychiatric Association defines addiction as, ‘a complex condition, a brain disease that is manifested by compulsive substance use despite harmful consequence.’ People with addiction (severe substance use disorder) have an intense focus on using a certain substance(s), such as alcohol or drugs, to the point that it takes over their life. They keep using alcohol or a drug even when they know it will cause problems. In many cases, addiction is even strong enough to break the bond between a mother and her child as many mothers have their children placed in state custody due to opioid use.”
An individual’s brain, Davis said, has receptor sites that, when hooked up to a certain substance, causes the body to become addicted.
“When occupied, ‘hooked up,’ to certain substances, this causes the body to become addicted to the need for these substances,” Davis said. “This physiologic process then takes away the body’s ability to electively ‘use or not use’ the substance, thus creating a bodily disease.”
Davis believes that if a known prescription can help with any bodily disease, it should be instituted. Known prescription methods for dealing with opioid addiction include methadone, buprenorphine and Suboxone.
“Methadone binds fully to the opioid receptors in the brain while buprenorphine binds partially and is generally considered safer,” Revelette said. “This means that, like opioids, methadone produces effects such as euphoria or respiratory depression. With buprenorphine, however, these effects are weaker than those of full drugs such as heroin and methadone. Suboxone is a mediation in which buprenorphine is combined with naloxone (Narcan). The naloxone helps with withdrawal and in the event that pills are crushed and injected the Narcan effect dominates and is protective.”
Narcan, Revelette said, also saves lives. However, Davis suggests the argument is undecided of whether or not making Narcan easily available might encourage drug users to keep using.
“There have been studies that show an increase in opioid usage when Narcan is available to opioid-addicted patients,” Davis said. “Additionally, there are studies showing that the usage of Narcan has enabled patients with opioid addiction to state they have hit rock bottom thus leading to more rehabilitation… I personally favor its widespread availability.”

At the clinic: receiving treatment

Aaron Smallwood with Stepworks, a residential addiction treatment facility with a location in Nicholasville, said there are several options for addiction treatment when coming to their facility, which include residential treatment, intensive outpatient treatment and medication assisted treatment programs. Medications used to treat addiction depend on what the client is detoxing off of, the addict’s drug of choice and what the medical provider deems appropriate. Smallwood said the facility’s MAT Program (Medication Assisted Therapy), gives addicts a respite from the continuous cycle of addiction.
“Addiction is not just substance use – it’s a lifestyle,” Smallwood said. “It helps take them out of the world where they must engage in all of the behaviors required to feed the habit. It also helps remove them from the very harmful social environment that comes with an addicted life.”
MAT addresses the lifestyle of addiction and the fact that addiction is a brain disease, Smallwood said. It also can help to prevent the onset of withdrawal. Treatment varies for every individual. It can be a short taper or a lifelong treatment and depends on personal circumstances, or other issues such as PTSD.
“Dosage is determined by the amount of medication needed to control withdrawal symptoms and reduce craving to a manageable level,” Smallwood said. “Withdrawal symptoms can be controlled very effectively by MAT. Once MAT therapy is discontinued, some client’s do experience withdrawal, but this can be minimized by slowly tapering them down before discontinuation.”
“MAT is not a very effective means of therapy if it does not accompany other recovery resources,” Vice President of Residential Operations for Stepworks Melissa Koncar said. “This includes counseling, self-help group. and lifestyle changes like employment and housing.”
Counseling is offered at both residential and outpatient programs, Koncar said. Residential clients meet in a group for four hours a day and also meet with a therapist for an individual session once a week and for a family session during their 30 days.
“Our clients also use Recovering(me), which is out online based program where they can work on recovery lessons on their own time in between sessions,” Koncar said.
A sponsor is also a helpful tool for an addict, she said.
“Addiction is a brain disease, and eventually it controls their thinking and how they make choices,” Koncar said. “A sponsor is someone who helps addicts on their journey of traveling the road to recovery. They offer suggestions, experience, strength and hope. A sponsor also provides the element of accountability by having expectations and holding the addict to a certain standard. Accountability for addicts is an important part of getting better.”
Koncar said she believes a heroin addict entering a rehab facility presents as severe a case as a would-be suicide entering a psych ward.
“The level of lethality we are seeing with substances on the street today is the highest it’s ever been,” Koncar said. “Addicts become trapped in a cycle of repetitive behavior that could kill them on any given day. Unfortunately, the fear of death is not enough for addicts to stop using. Many people believe that relapse is an event that happens on a single day in an addict’s life. This is not the case. Recovery requires consistent and vigilant effort. The journey lasts a lifetime.”
Koncar said among the addicts she has encountered, they always have the same story of how they relapsed and are lucky enough to make it back to treatments since they stopped doing the things making it possible to be drug free.
“Substantive recovery permeates an addict’s entire life,” Koncar said. “It affects all of the roles they occupy as a human being. It shows up at their job, in their parenting, in their relationships, in their hobbies and in their perception of the world. The moment they stop working towards applying recovery to these areas, they are moving towards relapse.”
To those who say, neither Suboxone nor methadone are a miracle cure and only buy addicts time to fix their lives, seek counseling and allow their brains to heal, Koncar said she also agrees.
“MAT is not a miracle cure,” Koncar said. “It can only be part of the miracle but is not this miracle itself. The miracle is that an addict can trade in an old life of pain, suffering, and disconnection for a new life of freedom, peace, and connectedness. MAT can simply be a part of this process.”

Looking ahead

Federal waivers are required in Kentucky for doctors to prescribe buprenorphine products like Suboxone. The Commonwealth currently has 518 doctors with waivers who are clustered around Louisville and Lexington.
“In order to be certified physicians must take a course,” Revelette said. “There is also additional recordkeeping required in order to dispense the medication… There is a great need for more people to prescribe the medications in order to get patients off opioids.”
Steps are also being made in the medical profession to help reverse the epidemic.
“Physician education programs are in place to steer prescribers to non-opioid alternatives in treating chronic pain,” Revelette said. “Emergency rooms are limited in the total quantity of opioids they prescribe, and all controlled substances are monitored on the statewide Kentucky All Substance Prescription Enrollment Program (KASPER) network.”
Drugs which can be prescribed for chronic pain besides opioids include gabapentin and tramadol, Revelette said.
“Several studies have shown an equally effectiveness in the use of appropriately dosed non-narcotic medications,” Davis said. “The health care practitioner can and should provide recommendations on the various options.”
Reversing the epidemic can be done first and foremost by showing kindness and sincerity to the person in need, Davis said.
“Most always, drug addiction is a result of many associated contributors to include physical, social and/or illegal conditions,” Davis said. “The more that the health care practitioners can get to the root cause for the opioid usage the better the treatment plan can be designed.”
Davis said these treatment plans include medication-assisted programs, outpatient and inpatient rehabilitation programs, peer support recovery groups, individual mentors and faith-based commitments.
Davis also said numerous studies have shown consistently that needle exchange programs result in less secondary disease associated with needle injections, improved education about opioid addiction, increased acceptance of rehabilitation programs, safer community grounds and no increase in injectable drug usage.
Prescription drug monitoring programs are also in place to help health practitioners, pharmacists and law enforcement obtain data on prescribing, dispensing and drug usage.
“KASPER is a model for our nation’s prescribing programs,” Davis said. “This information is then utilized to identify ‘outliers’ in any and all of these groups so that appropriate record review and interview can occur to assure appropriateness of opioid prescribing, dispensing and usage.”
Davis said several projects are currently being worked on with a multi-faceted approach which would help bring the epidemic under control and help as many people as possible.
“(The Jessamine County Health Department) is joining with other community partners to establish local plans for prevention and prescription,” Davis said. “The Area Health Education Centers are likewise working in the same manner. The University of Kentucky has recently been awarded one of the few multi-million-dollar federal grants to address our epidemic head on. The challenge is great; however, failure should not be an option as our people are dying and our families are suffering.”