Friday, October 24, 2014

Bad Medicine

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Even after high-profile tragedies, a silent epidemic of prescription drug overprescription, abuse and overdose continues to plague Arizona. 

It was a syringe full of medicine that plunged her down the rabbit hole, and medicine that kept her there, dragging her deeper into a hinterland of darkness, till she could barely remember the woman she once was – or, really, anything at all. 

 

While in high school, Gabrielle Ryan had been diagnosed with endometriosis, an often severely painful affliction in which uterus cells form satellite sites around the body. It necessitated four surgeries and nearly prevented her from entering the Air Force, but after her third attempt, she finally convinced the military recruiter to give her a chance. “When I set my mind to something, I’m determined to get it done,” she says.

After the fourth surgery, she was given three injections of the hormone-altering drug Lupron to treat the endometriosis. The third shot triggered the migraines: “At the very beginning I had them 24-7,” Ryan says. “I woke up with them, I went to bed with them, I had them all day long, they would wake me up at night.” Sometimes the throbbing brought her to tears. 

The military doctor was at a loss. He prescribed a series of painkillers, none of which worked. “So we came to this verbal agreement that when I would call him, I would go in for a shot of Demerol or Phenergan and he would send me back to my dorm room so I could sleep,” she says.

The pain persisted, and she was constantly falling asleep while she did military data entry work. “I remember one time, my ex-boss walked past me and he said, ‘Are you on drugs?’ And I said, ‘Yes, sir, I am.’”

When gas mask training sent her to the ER twice with debilitating migraines, Ryan was medically discharged from the Air Force. She left the New Mexico base, returned to her native Arizona, and sought help from the VA Health Care System. 

Thus began a decade-long “roller-coaster ride” driven erratically by prescription drugs. Vicodin, Percocet, Dilaudid, methadone, anti-depressants, anti-seizure meds, sleeping pills. In another fateful blow, she developed interstitial cystitis, an excruciating disease of the bladder. Her body was wracked with pain and wrecked by painkillers. The medicine fogged her brain and robbed her memory. It usurped her upbeat personality and replaced it with an angry, paranoid, reckless stranger. By the end of the 10 years, she had almost alienated her family and  lost her friends. She wasn’t showering, barely ate and rarely rolled out of bed. 

Then, in 2007, model and actress Anna Nicole Smith died of a prescription drug overdose. Ryan couldn’t keep her eyes off the TV coverage of the toxicology findings. “She was on half of the stuff that I was on,” Ryan says. “I just lay there and I thought to myself, ‘My God, I do not want to die like her.’ And I knew that if I did not get help that I was going to die.”   

Over the last several years, a coterie of celebrities has admitted to prescription drug abuse, including Rush Limbaugh, Matthew Perry, Eminem, and Gerard Butler. Others have died from prescription drugs, including Michael Jackson, Heath Ledger, and, many now suspect, Whitney Houston.

“Those are the ones that we hear about,” says Will Humble, director of the Arizona Department of Health Services (ADHS). “But there are hundreds in Arizona every year that no one ever hears about except for the families and the people who go to the funerals.”

In 2010, more than 1,100 Arizonans died from prescription drug poisoning – surpassing the number that die annually in car crashes, according to ADHS. It’s part of what the Centers for Disease Control and Prevention (CDC) calls a “silent epidemic” of overprescribing, abuse and misuse. Prescription drugs killed more than 20,000 people nationwide in 2008. Of those, nearly 15,000 deaths were caused by painkillers, more than cocaine and heroin combined. 

“If a thousand people were dying of some infectious disease every year, people would be running in the streets saying, ‘This is ridiculous. Stop this immediately,’” Humble says. “But there’s a thousand people dying of prescription drugs that are left over in their medicine cabinets, and they’re like, ‘Oh, well.’”

It’s as if the public has fallen under the soporific spell of these medications, seduced by their scientific pedigree, assured by doctors’ endorsements, lulled into security by the sight of their own names on the labels. Addiction to legal drugs also doesn’t carry the stigma embodied in illicit drugs – no need to slip over to Van Buren under cover of night to buy a bag of heroin from some twitchy-eyed thug with a switchblade when a Florence Nightingale-type will ring up your OxyContin at the local CVS in broad fluorescent light. And then there’s the fact that deaths from prescription drugs are so insidiously serene: Pop a few Xanax and some glasses of zinfandel, doze off, and you simply… don’t wake up.   

The trouble is, the death toll will continue to rise until everyone – from doctors to patients to the government – wakes up.

Kill Pill
A few decades ago, physicians were reluctant to prescribe opioid painkillers unless patients were on hospice or had a terminal disease, says Dr. Tory McJunkin of Arizona Pain Specialists in Scottsdale. It’s easy to see why. Opioids are natural or synthetic derivatives of opium or morphine; they include OxyContin, Vicodin and Percocet, and they can be as potent as another famous opioid: heroin. 

“They’re derivatives of the same medicine, so they would be just as strong and just as dangerous,” McJunkin says.

In fact, many prescription opioids are stronger than their heroin cousin. Take Fentanyl, which was prescribed 4.7 million times in 2010, mostly in patch form for chronic pain, and about which the U.S. Drug Enforcement Administration (DEA) has this to say: “The biological effects of the fentanyls are indistinguishable from those of heroin, with the exception that the fentanyls may be hundreds of times more potent.”

But around the 1980s and ’90s, McJunkin says, “There were a couple studies that said, ‘Look at these people. We’ve had them on high-dose narcotics and they’re doing really well and we’re not having a whole lot of bad effects from this treatment.’ So there was a swing.”

That swing got a big push from Purdue Pharma, makers of OxyContin. In the 1990s, they began promoting what was then a little-used cancer pain drug as a broad-use analgesic for everyday muscle and joint pain. They eased physicians’ apprehension with videos assuring them that doctor-supervised opioid use yielded addiction rates “much less than 1 percent.” Sales for OxyContin, which reached $45 million in 1996, skyrocketed to almost $3 billion by 2009. 

However, it turned out that Purdue Pharma had grossly misrepresented OxyContin’s risks for addiction. In 2007, the company pleaded guilty of criminal misbranding in federal court and paid more than $600 million in fines. But the damage had already been done: OxyContin had left a scourge of addiction and death across the country, most infamously in Appalachia, where it became known as “hillbilly heroin.” 

During the same time period, a shift began taking place in hospitals: Pain management became a requirement for medical treatment, and hospitals and providers began to get sued for not treating pain, McJunkin says. 

“If you under-treat the pain, as a provider you’re actually setting yourself up for a malpractice suit,” says Dr. Ravi Chandiramani, corporate medical director for Sundance rehab center in Scottsdale. “So there’s a lot of that fear in the marketplace.”

These and other factors have led to a deluge of prescription drugs in the medical field. The number of prescription painkillers sold to pharmacies, hospitals and doctors quadrupled from 1999 to 2010. According to Wall Street analysts Cowen & Co., in 2010, 254 million opioid prescriptions were filled in the U.S. – enough to “medicate every American adult around the clock for a month,” reports the CDC. In turn, the number of opioid overdoses tripled from 1999 to 2008. 

“It’s getting worse every year,” Humble says of the overdoses.?

Part of the onus is on the health care system and doctors, who often fail to warn their patients of prescription drugs’ potentially addictive and deadly nature. “With the current insurance-based system, where [doctors] have three to five minutes to see a patient, how much education is it possible to provide on medication interaction, side effects, etc.?” Chandiramani asks. “What they opt to do instead is either rely on the pharmacy staff to provide that basic education or give [patients] a handout that allows them to say they’ve fulfilled their requirement of providing that information. Now how many people are going to read that handout? I think that number is relatively small.” 

The current hurry-’em-in-hurry-’em-out health care system may also be impacting the number of pills physicians are prescribing, Humble says. “Instead of a physician writing a script for six [pills] and [saying], ‘Come back in three days if it doesn’t work,’ they’re like, ‘You know what, I’ve got a full patient load, I can’t see this patient.’” So to save time, Humble speculates, the doctor writes the script for more pills. “If people do what’s directed on the label, they’d be fine. And maybe they do only take six of the 30, and then they sit there for two years.” 

Sitting in the medicine cabinet for a few months or years, the pills become a ticking time bomb, Humble says. That’s partially because they’re a temptation to teens. Nearly one in 12 high school seniors report non-medical use of Vicodin, while one in 10 report abuse of OxyContin, according to the National Institute on Drug Abuse. And most of those teens get the pills from friends or the family medicine cabinet. 

However, it’s much more likely that the pills will be a temptation to you, Humble says. “When you hear about the [epidemic of prescription drug overdose], my gut reaction is to think, ‘Well, of course, it’s teens that are experimenting.’ But if you look at the data, it’s not [teens]. It’s people my age. It’s people between 40 and 60 mostly.

“To me it looks like these are mostly accidental overdoses where it’s an old prescription and they’re not quite sure what they’re supposed to do,” Humble continues. “They’re not doing it under medical direction, so they take one [pill] and they say, ‘My back still doesn’t feel good.’ So then they take another one. Well, the time release part of the pill might not have taken effect yet, so now you’ve got a double or a triple dose in your bloodstream. And you throw back a glass of Chianti and bam, you don’t wake up.”

The deadly cocktail of alcohol and prescription drugs is one that’s increasingly showing up on postmortem toxicology reports. Though the results of Whitney Houston’s toxicology test were not released as of press time, many people speculate that the culprits were anti-anxiety med Xanax and its anti-anxiety partner in crime – alcohol.

“Xanax and alcohol for people that are in their addiction is like peanut butter and jelly,” says Jaime Vinck, corporate clinical director of Sundance rehab center. “People drink and take Xanax all the time. So let’s imagine that a woman is going through menopause. [She] goes to her doc, says, ‘I’m having all this anxiety, panic attacks and so on.’ The doctor may prescribe Xanax. Well, in addition to that, he may not tell her  [to] knock off the three glasses of wine every night. The Xanax exacerbates the effects of the alcohol. And we could easily have situations like Whitney Houston where people just don’t wake up.” 

The drugs themselves hinder people’s ability to make smart decisions about the drugs. Xanax, for example, impairs judgment, memory and self-control, which can make people lose track of how many pills they’ve taken and forget they’re not supposed to take it with alcohol. This is also the case with the ubiquitous and seemingly innocent insomnia medication Ambien, Vinck says. “We see people who are prescribed Ambien and other prescription drugs. I’ve seen a couple people pass away, because Ambien is a short-term amnesiac, and they just don’t remember what they took. They get befuddled.”

Breaking the Habit
The Sundance center for drug and alcohol rehab is an oasis in the northeast Scotts-dale desert. A trickling fountain is the only sound on the serene residential street, and inside the Santa Fe-style converted house, a group therapy session is calmly conducted, while a gourmet chef sautés a nutritious meal. 

When Gabrielle Ryan came here five years ago, a staff member greeted her with, “Welcome home, Gabrielle.” She broke down crying. 

It took her a week before she could say in the group sessions, “Hi, I’m Gabrielle. I’m an addict.” She didn’t feel like one of ‘those people.’  She had never taken illegal drugs and rarely drinks.

“I had friends and family for years telling me that I was taking too much medicine,” Ryan says. “They told me that I needed to get help, and I told them, ‘You’re the one that needs to get help. You don’t understand the pain I’m going through. I’m just taking this stuff to get rid of the pain. I’m not taking this stuff to get high.’”

But as she progressed through Sundance’s several-week series of holistic treatments – the 12-step program, group and individual therapy, yoga, meditation, art therapy and equine therapy – she realized the truth about herself and prescription drug addiction: “Addiction does not discriminate,” she says. “I know now that your brain doesn’t know the difference whether you’re taking it to get high or taking it for pain.”

As she was weaned off opioids, she also noticed that she felt better and her migraines became less frequent. “The biggest thing that I realized after going off of the narcotics was how much pain they were actually causing me,” Ryan says.

It’s one of the biggest misconceptions about painkillers, says Arizona Pain Specialists’ McJunkin. “You don’t get much more pain relief on high doses than you would moderate doses, because your body just adapts and makes new pain receptors, and you have about the same amount of pain relief as you had on the moderate or the low doses.”

Ryan also realized she had become dependent on a crutch that had destroyed her life: “I always thought that I couldn’t live without the medication, but what I came to realize was that I couldn’t live with it.” 

Contrary to Purdue Pharma’s “less than 1 percent” addiction statistic, more than 25 percent of opioid users could be classified as addicted, according to Physicians for Responsible Opioid Prescribing. According to the CDC, about 6.2 million Americans said they abused prescription drugs in the past month in 2010 – and those are just the ones who know and admit they’re doing it. 

“A lot of them find their way to prescription drugs through an injury and then they progress up the chain from milder narcotics all the way up to the strongest things we have available to us, at which point they find that that’s an expensive habit to maintain,” Sundance’s Dr. Chandiramani says. “And what inevitably ends up happening is that they turn to heroin, which is a cheaper alternative and readily available on the streets. 

“People start out taking them orally as intended by the prescriber,” he explains. “And then a subpopulation of those individuals will end up crushing them and snorting them. And a smaller percentage will end up crushing them, melting them and shooting them.” 

“I believe Vicodin generally gets people hooked. Vicodin and Percocet,” Vinck says. “Doctors often prescribe those, and people fall in love, and then it begins.

“Our area high schools are just flooded with prescription pills,” she adds. “It’s very easy to get them out of mom and dad’s medicine cabinet, stashed away from an old surgery. What I see from a lot of my younger clients is that they’ll start out taking a pain pill with friends at a party, or even, with our young athletes, for a sports-related injury, and then they start crushing them, then they progress very quickly to heroin.”

Medicine cabinet-raiding is common in the prescription drug addiction world, as is so-called doctor shopping, McJunkin says. “There are a subset of people who become addicted and go around and see multiple physicians and get lots of prescriptions because of addiction but also because there’s a lot of street value in narcotic medicines… We’ve certainly seen patients in their 70s and 80s who were on really high doses, like 1200 milligrams of morphine a day… and you’re just like, ‘How are these people standing? That would knock over a horse.’ And we will test their urine and nothing’s there at all. So those people are probably diverting… That could bring on $40-, $50-, $60,000 a year, so it’s like a full-time job…. And we’ve had some older people come in and say, ‘My son is stealing my Duragesic patch’ (which releases the powerful opioid Fentanyl). So they have children who are stealing from them.”

Shot in the Dark

“There’s no single silver bullet that’s gonna take care of this issue,” Humble says. “You’ve got to hit it from all these different angles to make a dent in it.” 

Rather, it will take a combination of public awareness and doctor proactivity.

Patients must realize the potential hazards of prescription drugs. “It’s amazing to me that people have so much trust,” Vinck says. “If they haven’t had addiction in their family and they’re not familiar with the process and the progression of an addiction, they come in and they’re totally in shock that they’re going through physical withdrawals.”

Patients must also have realistic expectations about painkillers, McJunkin says. “I think many patients think, ‘I’m on this narcotic, I’m not going to be able to feel anything.’ It’s important for patients to realize that the medicine is not going to take away all their pain. At best, long-term, it looks like narcotics reduce pain about 30 percent. So they’re certainly helpful for patients, but it’s not going to be the end-all cure-all for them.”

Most importantly, Humble says, “When you get your prescription, talk to your doctor about it at the time. Do what they say. Follow the directions and then get rid of it. Don’t keep it around for your teen to be tempted or for you later to be tempted.” He says the DEA holds occasional National Prescription Drug Take-Back Days, when people can dispose of their drugs safely. The next event is scheduled for April 28. Check the ADHS website (azdhs.gov) for more information.

To prevent doctor shopping, physicians can communicate more with a patient’s other docs and check the Arizona Board of Pharmacy’s Prescription Monitoring Program (azpharmacy.gov/CS-Rx_Monitoring) to find out what drugs their patient has recently been prescribed. 

They can also develop a protocol for painkiller prescriptions. “Our stance and what’s becoming more common in medicine in general is to always use moderate or lower doses,” McJunkin says. He says Arizona Pain Specialists has a “strict 12-step opioid compliance program. We feel that that’s industry-leading. We developed it ourselves based on the DEA recommendations and the recommendations in journals. We so far have not had any patient deaths in our practice.” 

McJunkin also advises targeting the source of the pain rather than covering it up, as well as using a multifaceted strategy for relieving pain. “It’s like a stool,” he says. “If you just have one leg, and it’s just standing on opioids, the stool’s gonna fall over.” The other legs? Arizona Pain Specialists utilizes a combination of non-opioid meds such as anti-inflammatories or muscle relaxants, plus complementary care like chiropractic care, active release techniques, acupuncture, nutrition, behavioral feedback and psychological counseling.

Out of the Dark

Gabrielle Ryan, now 38, has finally climbed out of the dark hole of prescription drug addiction and dependence. A hysterectomy reduced the pain of endometriosis, but she still has interstitial cystitis and migraines, for which she takes a non-addictive medication, plus an anti-depressant. 

She is, she says, “a totally different person now.” Gone are the storms of anger and paranoia, and the fog of bewilderment and memory loss, though she often loses her train of thought. Her personality strikes one as ‘mostly sunny with a chance of rain,’ for she still bears the scars of her journey: “It feels like I lost 10 years. I lost most of my 20s. And that’s very hard.” 

Last year she injured her foot in a fall and had to undergo three surgeries. The Percocet was there at her bedside, but she took it for only a few days and felt no desire to go back down that path. “I trust myself now,” she says. “Do I have days that I have cravings? Absolutely I do. Do I have circumstances in my life where I just would love to be numb?... Yeah. But would I risk almost five years of being clean? Absolutely not.” 

Today, she has an understanding of both the benefits and hazards of prescription drugs that she didn’t have when she innocently began her roller-coaster ride 15 years ago. When she entered rehab, the Sundance staff member who welcomed her home told her, “Your kind is the hardest to treat.” 

“Why?” she asked. 

“Because it’s prescription drugs, so you think it’s OK.”

 

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