Taking away the pain
By Diane Smith
Seven heroin users walked into Fort Worth’s Recovery Resource Council on the Monday after Thanksgiving looking for help.
They wanted to stop injecting.
Case workers know when to expect spikes in traffic by people who don’t want to take pills or heroin anymore. They show up after holidays, when celebrities overdose or after police bust a “pill mill.” Family gatherings often include urgent pleas from fathers, mothers and siblings.
“‘Either you get treatment or you are not going to live here,’” said case manager Paula Shockey, imagining such family confrontations. “‘We don’t want to lose you.’”
The United States is grappling with a national crisis described by experts as a triple-wave opioid epidemic. The first wave began with over-prescription of addictive painkillers in the 1990s, followed by a second wave in which users of prescription opiates switched to heroin. By 2015, increased use of illicit fentanyl signaled a third and final wave.
In 2017, more than 70,000 people died of drug overdoses in the United States and about 75 percent were opioid-related, according to the National Center for Drug Abuse Statistics. That year, for the first time ever, more people died of opiate overdoses than car crashes.
“This is a national epidemic,” Dr. Michael Williams, President of UNT Health Science Center at Fort Worth, told community leaders in January. “It’s taking lives each day – tearing families apart.”
The Health Science Center is committed to fighting the epidemic and saving lives.
Students are learning about the opiate reversal drug naloxone. Experts are trying to find ways to decrease opioid-related overdose deaths and better monitor prescriptions. Some are using DNA research to fight chronic lower-back pain and help patients understand when opioids won’t work for them.
“It’s not a simple problem. There’s not going to be a simple solution,” said Scott Walters, PhD, Regents Professor of Health Behavior and Health Systems at the School of Public Health. “Solutions are going to have to be implemented on many different levels.”
One approach is guided by U.S. Surgeon General Dr. Jerome M. Adams’ recommendation that people who live or work with someone at risk of an overdose carry naloxone, an opioid overdose antidote. Naloxone comes in various forms, including a nasal spray called Narcan.
The Health Science Center is training students to administer Narcan. In January, it launched an effort that included the distribution of 9,000 doses of Narcan to students, employees and community members so they can administer the medicine if needed.
Ellias Hishmeh, a third-year pharmacy student, said naloxone can prevent deaths.
“Ideally, everybody would be able to be trained,” said Hishmeh after one campus talk on naloxone. “Just like CPR, even non-health professionals can have it on them or use it. I think that should be the attitude people take. It’s not a health-professional thing, it should be an everybody thing.”
A public health problem
Shockey, who has helped people struggling with drugs and alcohol for more than 20 years, works to save lives in Tarrant County – a calling that deepened when the opioid epidemic touched her personally.
Shockey’s niece died at age 37 after overdosing from opiate pills that belonged to a friend.
“It was really rough on the family, really rough on me,” Shockey said.
The ongoing opioid crisis grew out of prescribing practices of the 1990s.
“Pharmaceutical companies developed a new class of opioid medications that were long-acting,” Dr. Walters said. “These medications had traditionally been used for short-term pain relief or end-of-life care. Now, they were being used to manage chronic pain.”
The drugs were supposed to be safe.
“Companies cited evidence that only about 5 percent of people who took opioids became addicted,” Dr. Walters said. “In retrospect, that turned out to be flimsy evidence, and it probably is far higher than that.”
This first wave in the crisis was characterized by pill-related deaths that peaked in 2005. Then, as prescribing practices changed, some people who couldn’t get pills switched to heroin.
Historically, heroin came to United States from Asia, but users found a cheaper product – Mexican black-tar heroin. Drug traffickers used new supply-chain practices to deliver heroin into communities already flooded with prescription opiates, Dr. Walters said.
Previously, heroin traffickers also tended to be users of the drug. Each person in the supply chain would dilute the product to make money. That meant the product that end-users received tended to be relatively weak.
However, black-tar heroin was trafficked and sold by non-users – a practice that resulted in a more potent drug.
Cellphones helped drug traffickers enter new markets.
“There were these delivery boys that could bring you a reliable, fixed-price product, right to your door,” Dr. Walters said. “It was like ordering a pizza.”
The crisis’ second phase – the heroin phase – peaked about 2010, Dr. Walters said, leading to the emergence of the final phase, the rise of illicitly produced fentanyl from China and Mexico in 2015.
Illicit fentanyl is different from the synthetic drug approved by the U.S. Food and Drug Administration, which is used in small doses for pain management, surgery and end-of-life care.
Users of the illegal drug, also called Apache and China Town, believe it has a “super charge” effect when added to heroin, Dr. Walters said.
“People overdose because they get way more than they expected,” he said.
Controlling of an epidemic
Understanding chronic pain could help doctors confront the crisis by finding treatments that don’t pose risk of addiction.
John Licciardone, DO, MS, MBA, Regents Professor of Family Medicine and Executive Director of the Pain Registry for Epidemiological, Clinical, and Interventional Studies and Innovation (PRECISION), said a worldwide study by the Bill and Melinda Gates Foundation indicates that 632 million people suffer from lower-back pain.
At the PRECISION Pain Research Registry, investigators are using pharmacogenetics to find out how Americans metabolize opioids. They are looking for information that could help doctors better treat chronic pain.
“We know that people metabolize opioids differently based on their genetic makeup,” Dr. Licciardone said. “There are some people who are very sensitive to opioids, and there are others who are essentially non-responsive to opioids.”
Chronic pain coupled with social ills such as unemployment or lack of housing contributed to the opioid problem in states like Ohio and Kentucky, said Dr. Walters, who is the Steering Committee Chair for the HEALing Communities Study, a federally funded three-year effort to reduce opioid deaths by at least 40 percent in 67 communities hit heavily by opioid-use disorder.
The opioid crisis “hit middle America very hard,” Dr. Walters said. Some people became addicted to pain killers prescribed for chronic pain at the same time they were dealing with the impact of the 2008 recession. Evidence shows that when factories close, increased drug use occurs in those communities, he said.
Once hooked, some started seeking prescriptions from multiple doctors.
Dr. Marc Fleming, PhD, RPh, UNT System College of Pharmacy’s Chair of Pharmacotherapy, said pharmacists can play an important role by counseling patients about drug safety, safe storage of pain killers and effective disposal of prescription opioids.
Second-year pharmacy student Aicha Fokar said pharmacists can have a large impact in preventing opioid-related deaths.
“We are the most accessible health care provider,” she said.
Practices that save lives
Nationally, the rate of opiate overdose deaths is about 15 per 100,000 people. Dr. Walters said. In Texas, the rate is about five per 100,000.
In Tarrant County, there were 973 overdose deaths during 2013-2017. About 23 percent of those overdose deaths involved heroin, according to data from Tarrant County Public Health.
A number of efforts are underway to stem the epidemic.
The Texas Pharmacy Association has a standing order for naloxone to prevent opioid-related overdose deaths from pills and heroin.
“It means that anybody can walk into a pharmacy without a prescription and get naloxone with their normal insurance co-pay,” Dr. Walters said.
Dr. Fleming is working with the Texas Health and Human Services Commission on two grants totaling about $3 million to address prescription drug abuse in Texas and disposal of unused opioids. Those grants were funded by the Substance Abuse and Mental Health Services Administration.
State funding also has supported educating pharmacists about naloxone and the Texas Prescription Monitoring Program. The latter is a database that collects data on all prescriptions that ultimately are dispensed from pharmacies. Much of the focus is on opioids.
Dr. Walters said the federal effort, the HEALing Communities Study, will fund various efforts, including media campaigns to reduce the stigma of opioid addiction.
More than $350 million in funds from the National Institutes of Health are targeted for Kentucky, Ohio, Massachusetts and New York where experts will create a national model for fighting overdose deaths.
Solutions include connecting people to recovery programs – especially those who are coming out of prison or jail.
And in Fort Worth, Resource Recovery Council case workers distribute products aimed at destroying unused opioids.
“It’s all the same map, but these are different roads on that map,” Dr. Fleming said. “They are all linked and we have to figure them all out.”
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