We know that more Americans are dying annually from drug overdoses than car accidents and gun homicides combined. Opioids have been behind a majority of these fatalities, and nowhere is the problem more prevalent than the Appalachian area, especially in regions in Kentucky. We’ve traced the journey of opioids from the historical usage of the opium poppy for medicinal purposes to the modern day pharmaceutical cash cows of OxyContin and OxyCodone. To understand how the Appalachian region became so particularly devastated by the opioid crisis requires a more detailed examination of the regional economy and the pharmaceutical industry’s efforts to push the drug.
Drug manufacturers have been mass producing painkillers since the 1800’s, starting with German pharmaceutical giant Bayer, famous for distilling opium into morphine. In the 1980’s, pain specialists and doctors, funded by large drug manufacturers, formed an organization dedicated to calling attention to the millions of Americans who suffered from “untreated pain.” The American Pain Society began a national campaign to label pain as the “fifth vital sign” that doctors should look for.
The plan worked. The Federation of State Medical Boards began recommending that doctors not face punishment for prescribing large quantities of opioids to patients and even outlined penalties for doctors who under prescribed for pain. In the 1990’s, one class action lawsuit also awarded $16 million to families and patients that did not receive adequate amounts of opioids, calling the doctors guilty of negligence. The Joint Commission began to require that hospitals assess their patients using one to ten pain scales to measure patient suffering. Many believe that this lead to even more prescriptions.
In 1987, Purdue Pharma began selling the time release opioid drug MS Contin. This derivative of morphine would net the company more than $88 million over the next decade. However, they had another drug on the horizon that they believed would make even more. The drug, a time released version of Oxycodone called OxyContin, was going to be targeted at the over 25 million Americans suffering from chronic pain. By 2001, the company would be spending more than $200 million on promotion and marketing for their product.
Opioids Flood Kentucky
In the Appalachian region, sales reps from Purdue flooded hospitals and clinics with promotional materials. Doctors were overwhelmed by the opioid crisis. Many were unversed in pain treatment, and sales reps did everything they could to keep it that way. OxyContin became touted as a revolutionary painkiller that had a lower risk for addiction than any other painkiller before. These claims were of course stolen from small clinical trials and generally filtered through the marketing machine before arriving at the feet of doctors.
If there was one thing the pharmacy giants were truthful about, it was the boatloads of money they stood to make. OxyContin went on sale and netted more than 7 million prescriptions and $3 billion in revenue. However, there was a dark underside that Purdue sales reps neglected to include in their marketing materials. Persons admitting to abusing OxyContin rose to 3 million by 2003, yet prescription rates and sales continued to increase.
The evidence slowly began to pile up. Instead of the dubious claims that only 1% of patients were at risk of developing an addiction, studies found that nearly 1 in 4 patients prescribed the drug would struggle with addiction. It wasn’t until 2007 that Purdue’s holding company would plead guilty to falsely misrepresenting OxyContin as a safe, less addictive opioid painkiller. The company paid a $600 million fine, and multiple executives plead guilty to misbranding.
Healers Become Dealers
Dr. Anna Lembke, an associate professor at the Stanford University School of Medicine, believes that the flaw in our system stems from the assembly line transfiguration that took place within the medical community. When medicine becomes an industry, it can help with things like artificial limb replacements and surgeries, but when it comes to addiction, it’s ultimately counterproductive. Doctors can make more money by talking to a patient for five minutes and prescribing a pill as opposed to spending an hour doing psychotherapy with them.
Heroin Enters the Market
With the current opioid crisis and America’s rising rates of prescription opioid abuse, Mexican cartels discovered a perfect market opportunity to traffic in a cheaper opiate alternative, heroin. In 2016, overdoses from heroin topped 15,000, nearly ten times the amount 15 years earlier. To make smuggling easier and increase profits, Mexican cartels began lacing heroin with the powerful synthetic opioid fentanyl which is 50 times more potent than morphine. Says Dr. Anna Lembe: “Karl Marx said religion is the opium of the masses, we are at a point in history where opium is the religion of the masses.”
The Appalachian region has suffered much from the negative impacts of opioid abuse and addiction during the opioid crisis. The area initially attracted residents who worked in coal mining, but with nation’s transition to other energy sources, the once prominent area quickly went boom and bust. The result was residents either leaving for better opportunities and education or staying behind to weather the bad economy. The region, which includes Tennessee, Kentucky, North Carolina, the Virginias, Ohio, and Pennsylvania, has seen average rates of deaths spike from 1999 to 2013. Kentucky and West Virginia mainly have been the hardest hit. Ohio has also seen the rate of death from overdose spike from 2009 to 2013. The Ohio Department of Alcohol and Drug Addiction Services claims that 4 Ohioans die every day from a drug overdose.
A detailed look at the particular countries with the highest overdose and addictions rates during the opioid crisis shows some critical demographic similarities. Areas with a lower than the national average median household income and higher than the national average number of people living below poverty see the most addiction and overdoses. The areas where college education rates are drastically lower are also some of the most affected counties. The socioeconomic and education levels of the Appalachian region leave residents extremely susceptible to opioid addiction. In fact, states that make up the Appalachian region account for 22% of the nation’s opiate-related deaths.
North Carolina is one of the few states in the area to curb the rising death rate from overdose successfully. An initiative known as Project Lazarus was rolled out in 2008 that helped change the way clinicians and residents were educated about opioid addiction. The program also gave out free Naloxone, the opioid reversal agent that helps save addicts from the effects of an overdose.
Project Lazarus is a community-based initiative in North Carolina that was started to help reduce the amount of opioid-related overdoses and cases of abuse caused by the opioid crisis. Project Lazarus was introduced in Wilkes County in 2008, and within two years the Medical Care Provider Toolkit included within Project Lazarus was being used by every medical care provider in the county. This toolkit was prepared through cooperation between Project Lazarus and the Northwest Community Care Network, which would later become the Community Care of North Carolina’s Chronic Pain Initiative. In 2011, the mortality rate from opioid pain medications had been reduced by 69% in Wilkes’ County. The main strategies of the initiative include:
- Public awareness of the problem
- Gathering assistance from local community leaders to organize a response
- Collecting data and evaluation to measure effective strategy
- Community education to improve understanding of the opioid crisis
- Provider education to support better screening and pain management
- Extra pain treatment options and support
- Harm reduction through the dispersal of naloxone
- Funding treatment centers
Since its implementation in 2008, the project has achieved significant reductions in the number of opioid overdose deaths in each county. Based in Moravian Falls, North Carolina, the organization is headed by Chief Executive Officer Fred Wells Brason II. Brason is infamous for having also brought the fir4st opioid treatment rehab to Wilkes County, North Carolina. Similar to a methadone or buprenorphine clinic, the facility provides medication assisted treatment for those seeking help with opiate addiction. Brason had trouble getting the county to accept an opioid treatment center because the local community was anti-methadone. This lead to treatment options for opioid addicts being severely limited in the area.
The first step was setting up Mountain Health Solutions, an opioid treatment program owned by CRC Health Group. This location first distributed buprenorphine because it was an easier sell than other forms of medication-assisted treatment. It took two years of further campaigning to educate the public about methadone. Community leaders were especially vocal about keeping addicts out of their communities and doctors offices. Many saw the buprenorphine clinic as merely substituting one addicting substance for another.
Brason provided education to Wilkes County about the importance of medication-assisted treatment for helping recovering addicts. He helped to dispel myths about neonatal abstinence syndrome and the importance of safely withdrawing from opioids following a pregnancy. Nowadays, churches in Wilkes County can financially support their members to attend treatment and pay for medications. Brason is given a degree of credibility not for his medical education, but for this status as a chaplain, something that weighs heavily for conservatives in the South.
Through a grant from Purdue Pharma, the Lazarus Project was able to start providing kits of Naloxone for free to opioid treatment programs. The treatment programs write prescriptions for the naloxone kits for their patients and even send employees to pick up the medicine at local pharmacies. Patients are then given the medication while in the treatment program. This helps to reduce the number of drop-offs that occur between patient discharge and picking up their medication-assisted treatment. Brason also sends naloxone kits to other organizations like police departments across the county. The naloxone kits include nasal spray so that it’s easier for first time users to administer.
Across the state of North Carolina, local municipalities are working with various organizations and groups within the community to combat the growing opioid crisis. Over 200 police departments, including those in Chapel Hill and Carrboro, are becoming fully equipped to carry Naloxone. LEAD, Law Enforcement Assisted Diversion, is a program aiming to help people addicted to prescription opioids avoid criminal prosecution and get the help they need. Jail shouldn’t be the largest mental health institution a community has.
The program was created in response to a prominent negligent homicide case. A man overdosing on opioids passed out while driving and killed a 2-year-old boy in 2016. The man in question had been brought back to life reportedly five times using Narcan, the brand name Naloxone given out through harm reduction plans. In response, the community outline a process for opioid reversal procedures. If an individual refuses treatment following their opioid reversal episode, they are assigned a substance abuse counselor and checked up on again within 48 hours. If they refuse yet again, then the process continues until they either accept treatment, die from an overdose, or end up prosecuted. It seems counterintuitive, but the program helps educate addicts about the treatment services available and what insurance may help cover and it has worked elsewhere.
Another group working on reforming the way North Carolina views and handles addiction is the South East Area Health Education Center in Wilmington. This center has multiple locations throughout the state and provides CDC prescription guideline training to health providers. It also gives training seminars on alternative methods of treating pain. SEAHEC also offers educational talks and researches the spread of opioid addiction within the state to help inform preventative measures.
The Strengthen Opioid Misuse Prevention Act was passed by the governor of North Carolina Roy Cooper in June of 2017. This act mandates for clinicians to use a controlled substance registry similar to a PDMP, Prescription Drug Monitoring Program. The record is used by prescribers to check a patient’s history with opioid prescriptions and also limits the number of pills a patient can get from clinics.
Opioid addiction is one of the most destructive forces at work in the nation currently. The healing process for addicts and families starts with recognizing the danger surrounding these drugs, spreading public awareness, and expanding access to evidence-based treatment models. At Landmark Recovery, we believe in creating a supportive network of love and access to resources that can help you break free from the chains of addiction. Learn more about our drug and alcohol recovery program in Louisville, Kentucky today.