Cure for pain: Preventing opioid-related deaths

Buncombe County, like many places across the country, is in the throes of an opioid epidemic, many local sources say. Despite law enforcement efforts and increased awareness of overprescribing, the last few years have seen a dramatic rise in opioid-related overdoses and deaths.

Between 2005 and 2014, the county had 110 homicides, according to the state Department of Health and Human Services. During the same period, 195 county residents died from opioid overdoses. And between 1999 and 2015, Buncombe ranked eighth among the state’s 100 counties, with 304 opiate deaths. Worse yet, those numbers are accelerating rapidly. During a 15-year stretch (1999-2013), Buncombe County recorded 17 deaths from heroin overdoses. In the next two years alone, the county had 27 heroin-related deaths. The number of overdose emergency calls has also soared, according to Asheville Police Department statistics. In 2015, city emergency personnel responded to 70 overdose calls. Last year, that number jumped 67 percent, to 117 calls.

Hope may be on the horizon, however, thanks to a sea change in how the problem is viewed. Increasingly, county officials, law enforcement personnel and health care providers are framing addiction as a public health issue rather than a crime. And a proposed diversion program could prevent deaths and ruined lives while creating a healthier community.

The vicious cycle

Buncombe County District Attorney Todd Williams wants to establish a program aimed at helping first-time users get treatment, avoid the judicial system and escape the stigma of a felony arrest that would follow them for the rest of their lives.

“The old way was to offer a deal, reduce it to a misdemeanor, give time served and put that notch on the belt,” the DA explains. “But there are so many collateral consequences to that misdemeanor. You’re going to be checking boxes on job applications, and it doesn’t get that person who has that issue out of the weeds.”

Addiction, continues Williams, “is a mental health and substance abuse disorder: It’s a medical condition.” And it often begins with a legitimate prescription for pain medication that eventually leads to illegal activity. “The folks who are transitioning from pills to street drugs … these people are at risk,” he says. And when they’re arrested, “The wheels of justice grind slowly. That person is going to get their continuance for their court date; that person might not come back for their court date: They might be dead.”

That, says the DA, is where the carrot comes into play. Having a remediation option available at the very first court date, he maintains, can immediately get people back on track, before they’ve fallen into the so-called vicious cycle.

Here’s how it would work: “Someone comes in with a felony charge; we have them do an assessment, they comply with the recommendations, they come back for their court dates,” Williams explains. “Once they’ve done that … we’re not breaking it down to a misdemeanor: Let’s dismiss it. Set them up so they can get that charge expunged, so they can have this completely behind them.”

The DA envisions a probation period of six to nine months before the case actually comes to trial; during that time, the offender would have to meet certain benchmarks in order for the conviction to be expunged. “There are different ways to enforce the law,” he points out. “By diverting cases, we’re not saying people can use heroin: You’re in the criminal justice system. If you don’t want to do the program, we’ll put you on probation, give you the criminal conviction. But we want to show people a light at the end of the tunnel.”

Slippery slope

Opioids are chemicals, either natural or synthetic, whose effects are similar to those produced by opium and its derivatives. And the problems associated with them aren’t limited to Buncombe County. Between 1999 and 2015, more than 183,000 people across the country died from overdoses of prescription opioids, according to the Centers for Disease Control and Prevention. Every day, notes the CDC, more than 1,000 people nationwide need medical help related to misusing these drugs.

Many of those who struggle with opioid addiction are veterans.

“Most of our veterans, their issues start with pills,” says Eric Howard, who coordinates the Buncombe County Veterans Treatment Court. About half of the vets coming through the court, he notes, have opioid problems. “You see it happen more and more frequently. That’s just the trend, because of the overprescription of opioid medication. The VA just happens to be the largest hospital system in the nation, so they contract for a lot of medication.”

But when patients can no longer get, or afford, the prescription meds, they sometimes turn to other drugs. “We have a gentlemen who was hit with an IED explosion; he got spacers put in his knee,” says Howard. “So two years after he gets back from Afghanistan he’s on pain management, doing well. Doctors start pulling him off the pain management, and heroin is cheaper and easier to get.”

It’s not just veterans, either, notes Buncombe County Sheriff Van Duncan. “There’s one case that I personally know of where a young man — good student, high school athlete — hurt his shoulder, got on prescription medication and eventually went to heroin, which killed him. We’re beginning to hear now a lot of older folks are switching [to heroin] because they can’t afford their meds, or maybe they sell their meds because of other hardships and buy the heroin and try to self-medicate, because it’s cheaper.”

Those street drugs also tend to produce more fatalities, because they’re cut with unknown, often dangerous fillers such as fentanyl, a powerful synthetic opioid. “We see more than one overdose death a month; some months we might have as many as five. And those are just the ones we respond to,” Duncan reports.

Unintended consequences

The current trend of opioid users transitioning to heroin, says the sheriff, is an unintended consequence of a crackdown on pills. “If you go back three years ago, the big focus was on prescription pills. What happened is we got way better at dealing with the issue of diversion of prescribed medication to people who are not supposed to have it. … You don’t have the amount of prescription narcotics out there that you used to have,” he says, noting the success of the prescription drug take-back program his department started about five years ago. “Not that you can’t still get them, but it’s driven up the cost of prescription pills on the illegal market. So what we’ve seen is that, in trying to do the right thing, it just opened the door for heroin.”

It isn’t just the primary user who’s affected, adds Duncan: The impact is felt by families, schools, workplaces and more. Even infants aren’t safe. Of the 4,898 babies born in Mission Health System’s six hospitals last year, 399 (more than 8 percent) were born with opioids in their bloodstream. Many of those babies (154) were born in Buncombe County.

Doctors’ dilemma

Doctors, stresses Duncan, are also in a difficult position. “They don’t want to get in trouble for underprescribing and letting someone suffer in pain. At the same time, they want to thread the needle of not giving too much medication.” Striking the right balance isn’t easy.

“There are patients who are appropriate for prescribing, and there are tools we can use to help us determine that. People who abuse opioids make it more difficult for people who really need them to get them,” says Dr. MaryShell Zaffino, medical director of the Blue Ridge Health Center in Hendersonville. “It’s also important to have serious conversations with patients who are appropriate for opioid pain medication to discuss the risks of taking them.”

Sometimes, notes Dr. Michael Dowling of Appalachian Mountain Community Health Centers, patients being treated for acute pain “find that they either like the feeling of the pills or feel poorly when they stop, either because of withdrawal symptoms or because it is difficult to enjoy previously pleasurable activities. The pain pills can give a sense of well-being, euphoria or relaxation, which can be addictive.” Addiction, he continues, “is not a moral weakness. There is complex interplay between the drug, the individual’s genetics, and their situation and environment. Stress and mental illness are important co-factors.”

Meanwhile, protracted use of pills actually changes the brain, says Dowling. “It gets used to being bathed in opiates, and the person can have unpleasant withdrawal symptoms if they suddenly stop the medication.”

That, in turn, makes it very hard to kick the habit, says Zaffino. “Withdrawal symptoms — fever, nausea, vomiting, diarrhea, dysphoria, anxiety, muscle cramps and jitteriness — are quite uncomfortable, and a long-term user will often go to great lengths to avoid them.”

Cross-currents

Changing these patterns is hard, due in part to larger social issues, says Kevin Mahoney, a state-certified peer counselor with 11 years of sobriety under his belt. “Pain medication is being overprescribed, and the medical community is trying to reel it in a little bit, but then you have Big Pharma giving out free samples,” notes Mahoney, who’s executive director of the Sunrise Community. The Asheville-based nonprofit provides peer support to people recovering from mental health and substance abuse challenges.

Dowling, too, sees some signs of change in the way physicians prescribe these drugs. “It has changed, especially in the last two years,” he says, “with more publicity about the risks and opioid deaths and the CDC getting involved, publishing recommendations. Some would also say because it has hit the more politically connected and Caucasian communities as well.”

But while that awareness is spreading, overprescribing remains a significant problem, stresses Dowling. “Recently I had a person given 90 pills for what the CDC would have recommended no more than 21, with follow-up.” Nonetheless, he hopes that new long-term studies will shine a light on the issue. In the meantime, says Dowling, resources for those grappling with addiction are becoming more accessible (see “Resources for Substance Abusers”).

Technology is also helping physicians make better decisions, says Zaffino. “Having the controlled substance database — in which we, as prescribers, can assess the controlled substances being filled by anyone in North Carolina prior to prescribing — has been very helpful in identifying abusers and people who are trying to get prescriptions from multiple providers,” she maintains. But it’s not a silver bullet, in part because the database “does not include prescriptions filled in other states. We still have a long way to go.”

Changing the conversation

Often, notes Mahoney, the people who overdose on opioids are those who’ve gained some traction with sobriety, perhaps through a program such as Narcotics Anonymous, but then slip up. “Some folks who have had some recovery time lapse: They go back to using at the level they did before they got clean, and it’s too much for their system to handle.”

Mahoney supports the diversion program, which the Sunrise Community will partner with. But he’s also adamant that the community needs to change the way it views and talks about addiction.

Peggy Weil of The Steady Collective agrees. “If we call someone an ‘addict,’ it makes them less than. If we use the word ‘clean’ vs. ‘dirty,’ there are connotations there.”

The Asheville-based collective, a peer-to-peer support group, also provides access to naloxone (a drug that can treat opioid overdoses), syringes, harm-reduction education, treatment options and more. In addition, says Weil, the nonprofit tries to give recipients a sense of dignity. “If we continue to look at these people as criminals, we’ll never get the community support we need for these programs.”

But it’s not just about changing language, either, she maintains. “There are a lot of families that are suffering quietly, in shame, because they feel they can’t tell their friends, their church members, about what they’re dealing with,” Weil points out. “If you have a family member that dies of cancer, people bring you a casserole. If you have a family member die of an overdose, nobody calls: Nobody knows what to say. The community, even family members, don’t know how to address the issue. It’s often looked at as a moral failing.”

Courthouse clemency

Judge Calvin Hill is well aware of the impact of opioid abuse on the criminal justice system. “We certainly deal with a large volume of these cases and would be able to use those resources elsewhere if we didn’t have to use them in this area,” says Hill, chief judge of Buncombe County’s 28th Judicial District.

Hill says he likes the idea of the proposed diversion program, at least in some cases. “With regard to first-time offenders, I think people that come to the courts with genuine addiction issues are well-served to have a treatment option rather than prison. I view sellers of these drugs in our community differently,” he continues. “I cannot stress enough, however, that I believe there should be judicial oversight of these programs and processes at every stage, to ensure they’re administered in a fair and nonprejudicial manner, open and available to people regardless of socio-economic status.”

Sam Snead, a Buncombe County public defender, has represented a number of people facing legal troubles stemming from opioid use. “Preventing overdoses is something that’s in everyone’s best interest,” says Snead, who also supports the idea of steering some indictments away from the courts. “It’s good that all the stakeholders in the criminal justice system seem to realize it’s primarily a public health concern: As a criminal defense lawyer, that’s very comforting to me. That’s the first place to address the problem.”

But Snead also sees a need for legal reform. The active ingredient in pain pills, he points out, constitute only a tiny fraction of the pill’s overall weight, but the law doesn’t take that into consideration. “If I have 10 pills, I have over 4 grams, but in essence what I have is 50 milligrams of an opiate. Yet an officer has the authority to charge that person with trafficking, and case law — which is derived mostly from possessing cocaine, heroin — supports it.” District attorneys, says Snead, “recognize these arguments. You have to continually advocate that the public policy behind the criminalization of some of these circumstances is ludicrous. You keep doing it and hope they agree with you.”

Paradigm shift

Local policymakers are also cognizant of the issue. Brownie Newman, the new chair of the Buncombe County Board of Commissioners, says, “One of my best friends works at Mission Hospital and relays that it would be hard to overstate the scope of the problem. … When I first heard the term ‘heroin use,’ you think of some kind of really rough, biker gang element. … But it is so pervasive throughout society.” For these reasons, Newman supports the DA’s proposed program, calling it “an excellent idea.”

For Williams, that’s yet another hopeful sign that the opioid diversion program will soon become a reality. “I don’t think we’re going to have much resistance,” he observes. “I think there’s broad consensus that the community needs this program.”

Although the DA doesn’t need anyone’s permission to implement the diversion program, he’s been talking with judges, defense attorneys and other stakeholders so it’s not a surprise when he starts rolling it out. Williams is also working on defining benchmarks such as drug testing, attendance at meetings hosted by groups such as Narcotics Anonymous or the Sunrise Community, and not being charged with any additional crimes. And though he wants to set the bar high for getting charges dismissed, the DA also wants to build in some flexibility, so the rules can be considered on a case-by-case basis. Funding is not an issue, as there are no additional costs connected with the program, and Williams hopes to have it up and running within the next few months.

For his part, Sheriff Duncan is convinced that it’s time for law enforcement to pivot in order to combat the problem. “What we’re doing now is not working,” he notes. “Shooting heroin is truly playing Russian roulette. And the threat of dying doesn’t dissuade someone from using. So, really, the threat of incarceration is not something that stops people.”

Like Judge Hill, Duncan believes “We have to have some good, accountable law enforcement for people who are trafficking and making a profit off the devastation this causes.” For the end user, however, he favors “looking at that more from an epidemiology standpoint — as a chronic disease, as opposed to a crime.”

Eric Howard of the Veterans Treatment Court couldn’t agree more. “Going to jail is just stupid,” he says bluntly. “Treatment is your better route, because we’ve got people getting back into college, getting engineering degrees. If they just sit in jail, you’re paying for it, and they still end up out there in that vicious cycle.”

But to prevent opioid deaths and heal the physical, emotional and social wounds caused by drug abuse, he maintains, will require a deeper kind of change. “We need to get over our American idea of drug use,” says Howard. “The general public needs to understand that the cost is in this cycle. We have to make a concerted effort to change. There’s a lot of opportunity in Buncombe County: We’ve just got to start directing people through those routes.”