Drug abuse changed during the 13 years that Adam McIssac has been working as a drug and alcohol counselor in Asheville.
At the beginning, McIssac mostly saw clients who were addicted to methamphetamine. But over time “pills,” including opioids like oxycodone (OxyContin) and hydrocodone (Vicodin), became the main drugs that his clients abused.
Opioid abuse is still widespread today, McIssac says, but the drugs have continued to change. “The folks I work with now with opiates, it’s mostly fentanyl that they’re using — illegal fentanyl they bought off the street,” he explains.
Fentanyl is a synthetic opioid that can be up to 100 times more powerful than morphine, according to the National Institute of Health’s National Institute on Drug Abuse. To many people, using this potent drug may seem like an entirely different matter than taking Percocets after a knee surgery. But when McIssac asks his clients how they came to abuse fentanyl, he says, they usually tell a story of turning to the substance after getting addicted to prescription opioids.
An opioid epidemic has gripped the U.S. since the 1990s, according to the federal Centers for Disease Control and Prevention. Although the epidemic is a nationwide problem, it is particularly pronounced in North Carolina, in large part due to the state’s high rates of opioid prescriptions.
According to a 2012 audit by health care research company IMS Health, North Carolina doctors had issued 97 opioid prescriptions per 100 residents, a rate in the top quarter of U.S. states. And in 2019, the office of Gov. Roy Cooper noted that 1-of-20 residents in the state are living with an opioid use disorder.
For the past decade, a bold plan has been underway to address one of the root causes of OUDs: Educate the medical community to prescribe opioids less frequently and in smaller amounts. The goal, explains Dr. Blake Fagan, is to prevent patients from becoming addicted to legal opioids in the first place.
“It’s literally like turning the Titanic,” says Fagan, the chief education officer at Asheville’s Mountain Area Health Education Center. But unlike the Titanic, the response to this emergency is working.
Western North Carolina is one of the state’s hardest-hit areas, topping lists for emergency room visits and deaths due to opioid overdoses. The N.C. Department of Health and Human Services reports that Buncombe County’s rate of unintentional opioid overdose deaths in 2019 was 32.5 per 100,000 people, placing it in the highest fifth of counties statewide. And in April 2021, the latest month for which data is available, neighboring McDowell County had 24 opioid overdose ED visits per 100,000 residents, the state’s highest rate.
Fagan, who is also the co-medical director of MAHEC’s office-based opioid treatment services, says he witnessed the overprescription of opioids mounting throughout the 1990s and 2000s. “In Western North Carolina, if your 16-year-old got their wisdom teeth removed, they got 60 Percocet,” he says, noting that his own daughters received such prescriptions when they had oral surgery five years ago.
Before the 1990s, Fagan explains, providers primarily prescribed opioids for two reasons: acute severe trauma (such as a bone piercing the skin) or end-of-life care. But pharmaceutical companies then began encouraging doctors to prescribe opioids for chronic pain — and were at times deceptive about the drugs’ impact. As McIssac puts it, “I don’t think the pharmaceutical companies were transparent about how addictive this medication was going to be.”
Doctors had more opportunities to prescribe opioids if chronic pain and other health issues were deemed appropriate reasons, Fagan says, in turn generating billions of dollars in sales for drugmakers. But those uses, he continues, weren’t supported by scientific data. Subsequent research found that the use of opiates for chronic pain does more harm than good.
In November 2017, Buncombe became the first county in the state to file a federal lawsuit against pharmaceutical companies for their role in the opioid epidemic. (On June 1, Buncombe’s Board of Commissioners signed a memorandum of agreement regarding a settlement of that litigation, from which county officials expect to receive over $21 million.)
But by that point, a generation of medical professionals had already been trained to prescribe opioids — and millions of people were already addicted. Or, as McIssac puts it, “We created this monster and now we have to feed it, and it’s kind of gotten out of hand.”
In 2016, the CDC strengthened its guidelines for opioid prescriptions, and the N.C. Medical Board followed suit in 2017. The state General Assembly also passed the Strengthen Opioid Misuse Prevention Act in 2017, which limited the length of initial opioid prescriptions for acute injuries. As of 2021, the STOP Act also mandates use of the Controlled Substance Reporting System, an online database that providers must reference prior to writing a patient a prescription for most opioids.
Buncombe County began to address the opioid overprescription issue sooner than that. Around 2014, MAHEC began to offer a class for health care providers who can prescribe controlled substances called Treating Pain Safely. The course shares ways to treat pain with nonopioid alternatives, such as a combination of over-the-counter acetaminophen (Tylenol) and ibuprofen (Advil), as well as how to screen patients for OUD.
Consistent throughout these classes — which are now required by the state as part of continuing education for medical professionals — is the message that opioids are not the only option for pain relief. And if patients are to be prescribed opioids, they can comfortably be prescribed less.
“We actually have to teach [health care providers] how to use the medications correctly, which might be one to three days of opioids in certain surgeries — or none at all,” Fagan says. “But then also we have to take the next step and get them to believe they’ll get less phone calls in the evening.”
The classes also encourage health care providers to post flyers or notices in their waiting rooms that explain patients might not receive opioids. “I think that that education over the last several years has really helped,” Fagan said. “I know anecdotally in our clinic now, patients aren’t even asking for it.”
Power to the patient
Just the knowledge that health care providers are limiting prescriptions of opioids is a boon for people with an OUD, McIssac says. It means they won’t acquire more opioids than needed for pain relief, which can lead to a relapse.
“In that moment [where a] doctor says, ‘I’m going to give you 20 Percocets,’ they don’t have to sit there and think, ‘Should I take it or should I not?’” McIssac says. “The decision’s already been made. For folks with addiction, that’s helpful, definitely.”
McIssac recalls his experience working at a methadone clinic a decade ago where clients had developed an OUD from legal prescriptions. “I would see folks come in that had never any history of opioid use, or really any kind of drug use whatsoever,” he says. Clients were often in their 50s to 70s and had been prescribed opioid painkillers by a doctor. But by the time their opioid prescriptions ran out, McIssac said, they had become addicted.
“Doctors have a lot of power, and I think that’s what got abused during that period with the overprescription of these medications,” says McIssac. He points out that many people are raised to “always trust the doctor” and did not question the pills they were prescribed.
The adoption of new opioid prescribing practices is encouraging, Fagan says. “We’re getting education out there, and some providers are changing their practice and realizing patients are getting pain control with Tylenol and ibuprofen,” he explains. “Then hopefully what’s happening is we’re getting less opioids into people’s cabinets; we’re getting less people starting into their opiate use disorder.”
If you or someone you know is concerned about opioid use, you can find resources for treatment referral from the Substance Abuse and Mental Health Services Administration website. If you are in crisis, you can reach the 24/7 RHA Mobile Crisis Team at 888-573-1006.