Connecticut takes on abuse of prescription painkillers

Connecticut is one of 17 states whose residents are more likely to die from unintentional drug overdoses than in motor vehicle accidents, with the majority of those deaths caused by common prescription opioid painkillers.

From 1998 to 2010, the latest year for which data are available, an average of 272 people, ages 20 to 64, died each year in Connecticut of unintentional overdoses, while the average number of motor vehicle deaths was 201, according to state Department of Public Health statistics.

Overall deaths from drug overdoses have tripled since 1990. Today, most of those deaths are caused not by street drugs like heroin, but by prescription painkillers like Vicodin, OxyContin and Percocet. The Centers for Disease Control and Prevention refers to this as a growing and deadly epidemic.

The Association of State and Territorial Health Officials (ASTHO) — a national nonprofit organization that represents state public health agencies — has been targeting the epidemic since last year. This summer, it chose Connecticut and three other states to take part in a national initiative to address the problem of abuse and misuse of prescription painkillers.

The national association will regularly convene health representatives from the four states –- Delaware, Arizona and Illinois, in addition to Connecticut — provide data and statistics on prescription drug abuse, and pay $5,000 to support cross-sector partnerships and collaboration.

By encouraging states to collaborate and begin addressing the issue in innovative ways, the association hopes to see what works and then encourage effective strategies across the country, said Dr. Paul Jarris, ASTHO’s executive director.

Dr. Daniel Tobin, assistant professor of medicine at Yale University, is one of six public health officials spearheading the issue in Connecticut, along with the team’s leader, Dr. Jewel Mullen, commissioner of the Department of Public Health.

Referring to prescription painkillers, Tobin said, “These are medications that can help a lot of people but can also cause a great deal of harm if they’re used inappropriately. There’s this big misunderstanding that because it’s a prescribed drug, it’s safer.”

Mullen said long-term solutions must be taken with a “public health approach,” including more treatment programs, increased education and the collection of real-time information so addiction and overdose can be prevented.

“But first,” the commissioner said, “We have to inform the public this problem exists.”

The scope of the problem

Tobin was working in the Yale Primary Care Center when he received a phone call from a pharmacy.

By any chance, the pharmacist asked, had Tobin prescribed a patient “mofine?” Also, was it possible that the doctor had misspelled his own name?

The pharmacist’s guess that the patient had stolen a prescription pad was correct. As a result of poor spelling and careful pharmaceutical practice, no morphine was prescribed that day, nearly 13 years ago.

But, so-called “prescription mischief” is not typically how those who misuse and abuse prescription painkillers obtain the drugs.

For those looking for them, prescription painkillers are found in others’ medicine cabinets or obtained through “doctor shopping” -– a problem that the state’s Prescription Drug Monitoring program often detects.

“Part of what I teach is that when your patient seems to have a stronger relationship with the drug than they do with you and the desire to actually get healthy, then that’s a real important clue that there could be prescription drug misuse,” Tobin said.

He added, there are frequent instances where – through urine testing – doctors find that patients will have painkillers in their systems that were not the ones prescribed to them, or there are no painkillers found in their systems at all, but meanwhile the patient is still filling their prescription every month, meaning the patient is hoarding the medicine or it’s going to someone else.

Not hard to believe, because from 2010 to 2011 nearly 55 percent of people said they obtained painkillers free from a friend or relative, with another 17 percent buying or taking them from a friend or relative, according to the National Survey on Drug Abuse and Health conducted by the Substance Abuse and Mental Health Services Administration.

Traci Green, who has spent much of her academic career studying opioid-related drug abuse in New England, recently received two grants from the Centers of Disease Control and Prevention to continue her progress. This time, Green has ventured into Connecticut and Rhode Island communities where the drugs are hitting hardest.

She has talked with residents, hearing their stories, which helps her make better sense of what’s happening. She is also learning that the ways people are getting painkillers illegally is hardly ever like the stereotypical drug deal.

“What’s a dealer?” asks Green, assistant professor of emergency medicine and epidemiology at Brown University’s Warren Alpert Medical School. “What’s a dealer in a suburban town? Is it really like a dealer would be conceived of in an urban setting where you go and meet up in the parking lot, exchange the money and that’s that?”

Green heard that in one small town, elderly residents were exchanging painkillers for car rides into the city.

“When you live in a small town, public transportation is an issue,” she said. “[Painkillers] become a currency and especially in hard economic times, it actually does become a currency. If that’s what you have at your disposal, then this is survival.”

Who is abusing and misusing painkillers?

Painkiller overdose deaths in Connecticut, according to Green’s earlier studies, are found mostly in the 35- to 54-years-old age range, although the rates are climbing for 17- to 25-year-olds.

Younger users tend to use with other people, Green said, and are more likely to be checked on by parents or friends, increasing their chances of being found during the early stages of an overdose, unlike older users who tend to use in isolated settings.

Not restricted to inner cities either, the epidemic is wreaking most of its havoc in the states’ suburbs and rural areas.

Green suggested that because suburbs and rural settings tend to be such wide-open places, there could be longer response times from emergency service units, compared with response times in cities. She also noted that emergency service units outside of cities are often voluntary, and some emergency medical technicians may not all be trained in administering medications to counter the effects of overdose.

In other cases, the reasons people do not seek emergency help, or even treatment, when they know they have an addiction problem, could be due to fear or embarrassment. 

“When you have an emergency, something you’re ashamed of or trying to hide, when someone gets in trouble or they’re found out for something they shouldn’t be doing, the stakes can be high in small towns and suburban places where people talk and there are good reasons not to call for help,” Green said.

Why people die

Susan Wolfe, previously head of addiction services at Connecticut Valley Hospital and now part of the commissioner’s staff with the state Department of Mental Health and Addiction Services, said there are many reasons why people suffer overdoses when misusing prescription painkillers.

The most common overdose event is when people mix prescription drugs with other substances, like alcohol or tranquilizers, she said.

Wolfe also said the concept of drug tolerance tends to be misunderstood. When people build up their body to a certain dose and then stop taking the drugs before going back to them, even a few days later, their body is more likely to reject the substance. Other factors may consist of a taking the drugs with an already compromised immune system, or simply underestimating the drugs’ strength.

If reached within one to three hours, an opioid overdose can be reversed with Naloxone, a drug marketed as “Narcan.” Opioids fit into specific brain receptors that also affect the drive to breathe, so once the Naloxone is administered, it reverses an overdose by competing with those same receptor sites. A person usually revives within two to eight minutes feeling “dope sick,” not realizing he or she had overdosed.

The prescribing and administering of Naloxone became legal in Connecticut in 2012.

A gateway drug

“I always wonder about whether or not people think that there’s less stigma or harm associated with something when it’s legal rather than illegal,” Mullen said. “The mind set of, ‘Well, I’m doing Vicodin but at least I’m not shooting heroin’.”

Even then though, Mullen acknowledged, for some painkiller addicts, heroin is the next drug in line – an illicit painkiller with very similar effects and a much cheaper street value. Other states are seeing this phenomenon, she said, where people are seeking heroin when they can’t get prescription painkillers.

Green called this a “huge issue,” one she is tracking in Connecticut.

“In some ways [heroin use] becomes an economic equation despite the fact that it’s an illicit substance and that it has a very different connotation,” Green said. “Addiction does change the way we weigh some of these long- and short-term risk benefits.”

As for why there has been an increase in overdose deaths within the past two decades, Tobin had a hypothesis.

In the 1990s, doctors started to become more aware of their patients’ aches and pains. Pain even became known as the “fifth vital sign.” This was followed by more prescribing and an increased circulation of painkillers, possibly leading to more people getting them illegally.

Tobin’s hypothesis may be fact: The rise in overdose deaths parallels a 300 percent increase since 1999 of the sale of these painkillers, according to the Centers for Disease Control and Prevention.

“We allowed it to sneak up on us,” Jarris said. “I don’t think anyone had any idea this was going to kill more people than motor vehicle accidents. We let it sneak up on us. We have to take care of it.”