THE OPIOID EPIDEMIC: Prevention to Treatment— the Physician Role
Tom James, MD
I
’ d seen her as the mother of one of my pediatric patients; but now I was seeing her as the patient. She told me she had moved to Louisville from Eastern Kentucky because she wanted to live. Too many of her friends at home were dying from overdoses of opioids. That is not the way it was in her county when she was a child. That is when coal started to decline in favor of more environmentally friendly, cheaper power sources. Tobacco became the new substitute for coal money. Tobacco subsidies were paid to people not to grow tobacco. That was easy money— until under pressure from the tobacco cessation lobby, the support for any kind of tobacco forced the end of subsidies. The people in her county then turned to the then new cash crop— marijuana. That is, of course, until Kentucky began using defoliants from helicopters flying over the small fields. Forced by the loss of now two cash crops, enterprising people in her county drove to the pill mills of Florida. There, with a few urgent care and physician office stops, they could come back to Kentucky with large supplies of prescribed opioids that had a ready market in the struggling counties of the Appalachian parts of our state, as well as in West Virginia, and parts of Ohio and Pennsylvania. But then cheaper heroin drifted in, and began to displace the prescription pills. Heroin, just like other opioids, can kill. And that is exactly what happened. My patient related this to me non-emotionally. She just wanted to go to the relative safety of a larger city. She didn’ t want to die.
Nationally, the picture of overdose deaths has been shifting from the West where in 1999 drug-related mortality was strongest in California, Washington state, and the Southwest. By 2005, the highest rates were seen around southern tier states such as Arizona, New Mexico, Oklahoma, Louisiana and Florida. But Kentucky and Tennessee were also in this high overdose mortality region. A decade later most of those states were improving. But the range of states with the highest drug overdose mortality statistics was sweeping along a northeasterly diagonal from Tennessee, Kentucky and West Virginia through Pennsylvania and into New England. In 2005, the worst death rate was in New Mexico with 15 deaths per 100,000 population. By 2015, the highest mortality was in West Virginia with 41.5 deaths for every 100,000 citizens. That year, Kentucky was tied with Ohio for third worst rate at 29.9. The New York Times( Oct. 26, 2017) called“ overdoses fueled by opioids, the leading cause of death for Americans under 50 years old— killing roughly 64,000 people last year, more than guns or car accidents, and doing so at a pace faster than the HIV epidemic did at its peak.” President Trump declared the opioid crisis a public health emergency in October, but did not provide funding.
The cause of this opioid crisis cannot be linked to the socioeconomic strata of the users. Many lay the cause of the epidemic at the feet of physicians and pharmaceutical companies. Certainly, there was the unintended consequence of higher prescribing with resulting addiction coming from the well-intended efforts to free patients from pain. The efforts in the 1990s to make pain moni-
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