Why Is It So Hard To Reduce Drug Overdoses?

Jun 23, 2015

Note: I've added a point about the Good Samaritan law, thanks to comments from readers. It's up for consideration now at the Statehouse.

A group of state and federal leaders gathered yesterday for a roundtable discussion on Rhode Island's seemingly intractable drug overdose crisis. Present for that discussion: Sen. Jack Reed (D-RI), health dept. director Dr. Nicole Alexander-Scott, behavioral health dept. director Maria Montanaro, Gov. Gina Raimondo, and head of the state police, Col. Steven O'Donnell. Reporters were invited to listen in, then ask a few questions.

After the meeting, I couldn't help but wonder: how many more roundtables, public forums, legislative hearings, committee meetings, press conferences, and more will I attend before we see this crisis abate?

And when I say crisis, consider this: imagine for a moment that two of these Boeing 737s crashed last year in Rhode Island.

Most Boeing 737s can seat about 126 passengers.
Credit Boeing Commercial Airplanes

That's about the number of people who died from accidental drug overdoses in 2014. We're on track for a similar number of deaths in 2015, and the numbers have been climbing for a few years now. Overdoses have been killing more people than any other kind of accident, including car accidents, since about 2008, according to the Centers for Disease Control and Prevention.

More people might have died, had it not been for some of the efforts I've outlined below. But still: 239 people died from accidental overdoses last year. Two whole commercial airliners full of our neighbors, friends, family members, co-workers, colleagues, classmates.

That's despite more vigorous outreach efforts to overdose survivors and those at risk of overdosing, on the part of addiction treatment professionals, state agencies, health care providers, law enforcement, and community groups.

  • Recovery coaches are now on call at many emergency rooms around the state on weekends, thanks to The Providence Center, to speak with overdose survivors peer-to-peer about getting into treatment. Many ERs discharge survivors, who are at risk for another accidental overdose if they continue to use opioids like prescription painkillers or heroin, with an overdose antidote drug called Narcan.
  • There's a public awareness campaign, sponsored by community mental health and addiction treatment provider The Providence Center, the state health department, and others that proclaims, in billboards and online ads, "Addiction is a disease. Recovery is possible."
  • Many community groups have hosted public meetings and forums throughout the state to raise awareness about the dangers of prescription painkillers and other drugs like heroin, and how to recognize the signs of an overdose.

That's despite more widespread availability of the overdose antidote Narcan. The drug, which can be injected into the muscle or sprayed up both nostrils, can reverse an overdose in seconds.

  • It's available without a prescription from any Walgreens, from overdose prevention groups like the PONI program at the Miriam Hospital, and in some hospital ERs.
  • All state police, ambulances, and many municipal police officers carry it. Over the past couple of years, emergency responders have saved hundreds of lives.
  • Sen. Jack Reed (D-RI) has just introduced legislation that would boost funding for more community groups to be able to distribute it.
  • The VA is getting ready to distribute Narcan kits that talk you through how to use it to every patient who's on a high dose of opioids, like Vicodin or Percocet.

That's despite greater awareness among doctors and other prescribers of the dangers of prescription painkillers, alternatives for managing a patient's pain, and health-system-wide policies (such as Lifespan's) meant to curb over-prescribing in places like the emergency room.

That's despite the laudable efforts of law enforcement to arrest heroin dealers, whose product is increasingly often laced with fentanyl, an opioid 50, some say 80 times, more potent than morphine and the cause of many accidental overdoses in Rhode Island.

And it's despite better access to addiction treatment, now that more Rhode Islanders carry health insurance.

Despite all of these efforts and more, we're still in the midst of a public health emergency. And those aren't my words; those are the words many health care professionals, scholars, and state officials have used to describe the situation to me.

Why is it so tough to curb this crisis? I don't have all the answers, but here's a list of some of the factors, according to the many health care professionals, academics, recovering addicts, policy experts, and others I've interviewed over the past few years about this crisis.

  • The nature of addiction. Addiction rewires the brain and hijacks the body. Telling an addict to stop, cutting off a prescription, or hauling them to jail usually don't work. Recovering addicts tell me they would have done almost anything for the next fix to avoid withdrawal, which is like the flu times a thousand, one said.
  • The availability of opioids. Prescribers doled out nearly three million doses of prescription painkillers in Rhode Island in May. Just in May. If you've ever had dental work, or gone to the emergency room, or injured yourself playing sports, you probably know how easy it is to obtain a prescription for painkillers. Taking them for long periods, or when you don't really need them, can put you at risk of getting hooked. And every once in a while, an unscrupulous prescriber hands out many more prescriptions than are necessary, or doesn't take precautions to ensure a patient isn't seeking more than necessary - and showing symptoms of addiction.
  • The cost of heroin. When filling another prescription for Vicodin isn't an option, addicts find ways to buy the pills on the street. But a single pill can run you $80 dollars or more. For an addict taking many pills a day, that quickly becomes too much. So many addicts have shared the same story with me: the pills got too expensive, then someone told them about heroin. It's the same high, they're told, but much cheaper - $60, $70 dollars cheaper, they tell me.
  • The unpredictability of heroin content. Many of the confirmed accidental overdose deaths in Rhode Island involve fentanyl-laced heroin. Fentanyl, as I wrote, is many times more potent than heroin. And addicts don't always know when it's been added - there's no good way to tell. So they buy a bag of heroin thinking it's the same dose they're used to, but actually they're taking 50, maybe 80 times that dose.
  • The culture of pain avoidance. No one wants to be in pain. Doctors don't want their patients to be in pain. Opioids are really effective for easing acute pain; but they haven't been found to be as effective for chronic pain (plus they're addictive). They're a great tool we might have learned to use a bit more sparingly. But several years ago pain became another vital sign. Hospitals' performance was measured based on how well patients said their pain was managed. And no one was talking about the risks of opioid painkillers. Least of all the maker of OxyContin, Purdue Pharma, whose executives were convicted of lying about the drug's addiction risk and fined $600 million dollars.
  • Lack of treatment. Addiction is a treatable disease. The kind of treatment needed depends on the individual, the stage of his or her addiction, and the type of drug involved. For opioid addicts, many doctors, including addiction psychiatrists, tell me one of the best options is an opioid maintenance medication, like Suboxone. It helps keep a tightly monitored amount of opioid in an addict's system to avoid withdrawal, and can be used to help them taper off. But a doctor recently told me that there are too many barriers standing between doctors and patients who could benefit from the treatment. You need to be certified to prescribe it, the number of patients you can treat is limited, and it can be complicated to manage a patient with addiction.
  • Stigma. Addiction is a disease recognized by nearly every major medical association. But it still carries the scent of shame. And not everyone understands how this disease works. Some addicts have told me that stigma prevented them from seeking treatment, and sent them deeper into the shadows.
  • Fear of arrest. There's the fear of calling 911 for a friend who's overdosing, if you're worried about getting arrested. People who are violating their parole, for example, could still be arrested, even if they're calling 911 to get help. Rhode Island has a Good Samaritan law, however, that extends legal immunity to people from drug possession charges. The law will expire July 1st unless lawmakers vote to extend it. Many health care professionals and recovery advocates hope they'll extend protection for parole violations, too.
  • Lack of coordinated prevention efforts. There's no law that says every grade schooler, every middle schooler, every high schooler should be educated about the disease of addiction or the risks of prescription painkillers. There's no universal health care system that tells every doctor, every prescriber to warn patients about the dangers of prescription drugs. There's no single statewide or nationwide public awareness campaign. There are some great drug abuse prevention programs, of course. And there are some great individual health care systems, hospitals, and doctors focused on reducing the risk of addiction. There are efforts to reach people leaving prison, who are greater risk of overdose, with Narcan kits and education about those risks. But not everyone is getting the message, not like they did when the nation made a concerted effort to raise awareness about some other public health risks, like not wearing a seatbelt, or smoking.

What did I miss? There are surely other factors compounding the crisis of accidental overdoses and opioid addiction. Please weigh in if you think I've left out some big ones. Also, it bears saying that alcohol is still the most widely used and widely available addictive substance. It's responsible for more deaths and more illness, by far.

There's hope. Lots of people are working on this crisis. Awareness is growing. Efforts are being made at all levels of government, from towns and cities, to the state, to the federal government and agencies. Health care providers are often doing their best. Law enforcement and emergency response teams are saving lives. And addicts are recovering. There is hope. But clearly, more must be done.