THE OPIOID EPIDEMIC : Prevention to Treatment — the Physician Role
Tom James , MD
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’ 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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