Community leaders striking at the roots of Dane County’s heroin and opiate crisis

Bill Reay thinks he has a handle on the origins of Dane County’s current heroin crisis – and it has a lot to do with his own profession. Reay, the former chief pharmacy officer and senior director for Physicians Plus Insurance Corp., is convinced that the startling rise in heroin use both here and across the country stems from a marked increase in opioid use in general since the 1990s.

“What happens to people sometimes is they get exposed to one of these opiates, and because of their genetic makeup, sometimes they’re prone to addiction with that particular compound, and they need more and more drug,” said Reay, a doctor of pharmacy who holds a master’s in health care administration. “Well, the drugs are expensive, and eventually doctors won’t write their prescription for them, so they buy street drugs. And what we know in the community is that heroin is much less expensive than these opiates.

“A good example would be, there’s probably a couple products out there that are $1 per milligram, so if you buy it on the street, it’s a 10-milligram tablet – it costs $10 on the street. Well, heroin on the street costs about $5 a hit, so heroin is much cheaper, and that’s how people evolve into this.”

“The answer is, prescribe less; if you need the medicines, lock them up; and when you’re done with them, throw them out. Very, very simple.” – Bill Reay, former chief pharmacy office and senior director for Physicians Plus Insurance Corp.

Of course, while heroin is a much more effective headline-grabber than Vicodin or OxyContin, the problem, says Reay, is really opioid use as a whole, and that includes prescription painkillers, whose use has become increasingly widespread in the last decade and a half.

It’s a problem, says Reay, for the whole community, and it’s taken a comprehensive approach from community leaders representing law enforcement, drug treatment and health care providers, judges and attorneys, public health professionals, policymakers, and parents to start to get a handle on it.

That effort has been led by Safe Communities, for which Reay volunteers, and it involves six distinct areas of focus: reducing access to drugs; reducing inappropriate prescription use; improving overdose intervention; providing early intervention, drug treatment, and recovery; integrating mental health care; and preventing substance abuse.

Launched in the fall of 2011 and supported by the city of Madison and Dane County, Safe Communities’ Drug Poisoning Initiative has been recognized as a national model in overdose prevention. In fact, Safe Communities recently received a $10,000 award from the U.S. Conference of Mayors for its leadership on the issue. In April, the group convened a Drug Poisoning Summit Reunion, where it gave updates on the local drug overdose problem.

That there is a problem is incontrovertible. Reay points to both an increase in the number of deaths from opioids (including heroin) locally and an alarming increase in the number of pharmacy robberies, including two in Dane County just last month.

Indeed, from 2009 to 2012, the number of heroin-related deaths in Dane County soared from nine to 21 (though it’s begun to level off in the past two years), and as Cheryl Wittke, executive director of Safe Communities, notes, the number of opioid-related deaths in Dane County has tripled in the last decade. In fact, despite the widespread angst that a street drug like heroin can engender among the public, the bigger problem remains prescription drug abuse.

“If you look at the numbers locally and nationally, there are more deaths from prescription drugs than heroin, by far,” said Wittke.

New perspectives on pain

The problem locally mirrors an alarming increase in overdose deaths nationwide, which parallels an increase in the availability of prescription opioids.

According to the Centers for Disease Control, opioid pain relievers are involved in more overdose deaths than cocaine and heroin combined, and in 2009, prescription painkiller abuse was responsible for more than 475,000 emergency room visits, a number that nearly doubled over the span of five years. The CDC also reports that more than 12 million people reported using prescription painkillers non-medically in 2010, and that the quantity of prescription painkillers sold to pharmacies, hospitals, and doctors’ offices was four times larger in 2010 than in 1999.

Furthermore, the deaths owing to prescription painkillers are simply the most visible and tragic part of a broader problem. According to the CDC, there were 14,800 prescription painkiller deaths in 2008, and for every one death there were 10 treatment admissions for abuse, 32 emergency department visits for misuse or abuse, 130 people who abused the drugs or were dependent, and 825 non-medical prescription painkiller users.

Much of the increase in both prescription painkiller use and abuse, say Reay and Wittke, can be linked to a shift in attitudes toward pain management.

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“I’ve been around a lot of years, and when I first came out of school, we had cancer patients who were suffering in pain, so there was a great debate in the ’70s about whether you should liberalize narcotics in cancer patients, and clearly we needed to and we did that,” said Reay. “England kind of led the way with that thought. It came to the states, and the liberalization of narcotics over the ’80s and ’90s in oncology was pretty well understood and done.

“But that same philosophy of liberalizing narcotic analgesics to people suffering more general pain has now come, I believe, from the oncology area, and the idea now is to treat all the pain you can with whatever you have to make sure you have no pain, and then not really realizing all the other ramifications that come with it.”

“If you look at the numbers locally and nationally, there are more deaths from prescription drugs than heroin, by far.” – Cheryl Wittke, executive director, Safe Communities

In fact, the trend toward prescribing more painkillers has become part of medical protocol, according to Wittke.

“If you look at the treatment of chronic pain and the attitudes about that and the regulation that [medical professionals] face, it’s swung in the direction of treating pain,” said Wittke. “If you go to the emergency room now, they’ve got the faces that ask ‘what sort of pain are you in?’ There’s a reason for that. It’s because that’s the way physicians are evaluated. It’s a new standard. So they check your blood pressure, they check your pulse, they ask you if you’re in pain, and they can be evaluated negatively if they’re not treating your pain.”

While such attitudes have been a godsend to many chronically ill patients, the consequences have been devastating to others, say Reay and Wittke.

Reay points to a recent Wall Street Journal story about Russell Portenoy, a prominent figure in the successful movement for liberalizing the use of prescription opioids. Once a strong advocate for treating chronic, non-cancer pain with opioids, Portenoy has since had a change of heart.

“Did I teach about pain management, specifically about opioid therapy, in a way that reflects misinformation? Well, against the standards of 2012, I guess I did,” Portenoy told the Wall Street Journal. “We didn’t know then what we know now.”

Use and abuse

One eye-opening statistic that might shock local parents is the fact that 70% of people who abuse prescription painkillers get them from friends or relatives, while only 5% get them from drug dealers or through the Internet.

To help address that problem, Safe Communities is aggressively promoting its MedDrop program, which allows Dane County residents to safely dispose of their prescription medicines at various drop boxes throughout the area. According to Safe Communities, drug poisoning is now Dane County’s number one cause of injury-related death, but area residents remain relatively blasé about the dangers posed by medicine cabinets full of unused prescription pills.

In fact, Reay points to the danger of so-called Skittles parties, an alarming new fad in which young people share prescription medicines they find around the house.

“They take medicines and get together as a group and decide to have a party,” said Reay. “They take all the pills and they throw them in a bowl and everybody takes a handful, and they have no idea what they’re taking, and they’re probably taking alcohol with it, and it’s just a mess. And that kind of thing exists. It’s a national issue and it’s seen here in the community, and I don’t think anybody’s aware of that.”

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To help raise awareness of some of the issues parents now face, Safe Communities is also promoting its Parent Addiction Network, an online resource center that’s touted as a one-stop shop of treatment and recovery resources.

“How do parents recognize that their kid might have a problem?” said Wittke. “If you have an adult child that has an addiction problem and they’re mixed in with the criminal justice system now, how do you negotiate that? So it’s really a one-stop resource center for families that are dealing with addiction.”

Employer involvement

According to Reay, prescription painkiller abuse is an issue that should also be of interest to employers, who need to be mindful of safety concerns and are often plagued by “presenteeism” among drug-affected employees who may be clocked in but mentally absent. He suggests making sure that HR departments are well aware of the issue and that companies that offer a pharmacy benefit have the right kinds of checks and balances in place to monitor prescription painkiller abuse.

More than anything, though, businesses can help by raising awareness of the problem – and health care professionals can be more wary about overprescribing medications.

“The answer is, prescribe less; if you need the medicines, lock them up; and when you’re done with them, throw them out,” said Reay. “Very, very simple. And as far as employers helping with this, those kinds of reminders could be given through every HR department for every business.”

For Wittke’s part, she’s eager to receive any help she can get – whether that comes from the business community, the health care community, or the community at large.

“Basically, we’ve pulled together a strategy that’s based on what we know works in terms of addressing these issues, and you can sort of think of this as a supply-and-demand approach,” said Wittke. “These two pieces – reducing access to drugs through the MedDrop program, for example, to make sure there aren’t excess drugs lying around, and working with prescribers to address some of the issues Bill talked about. For example, do we need to prescribe 30 tabs of OxyContin or Vicodin when a kid has a wisdom tooth extracted?

“And the health care providers are very engaged in this. All the health care systems, the Dane County Dental Society, the Dane County Medical Society, are part of this effort. So there’s a really good understanding of the role that they can play in doing something about it.”

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