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The opioid epidemic is one of Missouri’s most pressing health issues. To put it in perspective, roughly 64,000 Americans died from drug overdoses in 2016, with 49,900 of those deaths related to fentanyl, heroin, and prescription opioids. In Missouri, overall overdose deaths were up a shocking 28 percent from 2015. Rural communities are being hit particularly hard. We’re in crisis mode! But how have things become so dire that many police departments now carry the opioid overdose antidote Narcan? It’s essential for us to investigate the long-term factors that led to this epidemic, if we are going to respond to it in the most effective way possible.

The epidemic deserves sustained action and careful examination from multiple perspectives. The complex intersection of how we treat pain and the dynamics of addiction raises numerous health issues. The crisis is usefully viewed at the juncture of the societal and the personal. At a societal level, what are the conditions that allow addiction to flourish? At the personal level, how are those conditions experienced, thus contributing to addictive behavior?

The economic trends associated with the restructuring of the economy over the last several decades set the stage. Tellingly, the lag in purchasing power affected the vast majority of Americans, a precursor to the opioid epidemic’s widespread effects.

These long-term trends reflect a crucial blind spot in U.S. economic and social policy throughout this time period. The impact on a wide swath of Americans was neglected and steps to invest in a foundering segment of our workforce have been too small and too late. In short, we had an economic situation rife for what can be called “adverse adult experiences,” analogous to the well-known adverse childhood experiences. Being fired; getting evicted; having a car repossessed; losing health insurance; family trauma like divorce, serious illness, or death – due to economic trends, all these and other everyday obstacles have become more likely to occur for many Missourians. And these events accumulate over time, reinforcing their negative effects and leading people to lose hope, to doubt their self-worth, to despair at their inability to fulfill the basic family responsibilities.

Another crucial ingredient in the epidemic has been the health care system – drug companies, doctors, payment systems, and regulators – as they fundamentally changed pain management and fostered the widespread use of opioids. The particulars are documented in-depth in books such as Dreamland, but here I will note how unusual it is for an epidemic to have as one of its primary causes the behavior of the very systems and professionals who have the responsibility to heal our citizens. Doctors prescribed 240 million bottles of opioids in 2014.The aggressive treatment of pain and the downplaying of opioid addiction fueled a devastating and destructive “answer” to the despair generated by economic circumstances. This came at time when many vulnerable citizens were seeking relief from personal pain associated with loss of hope, respect, dignity, and a vision for a better future for themselves and their loved ones.

We need to work on multiple fronts to care for people currently addicted and to prevent others from becoming addicted. Government is rightly taking the lead by enlisting a broad base of Missourians to address this multi-faceted challenge, including private sector actors like Express Scripts. Tactics currently in place include chronic care for addicted patients, prevention, education, and multi-sector coordination among government agencies from courts to prisons, to clinics to public health departments. There is still so much left to be done to keep the crisis from getting worse. We also need to address the underlying conditions that foster addiction in the first place. These societal and economic factors were decades in the making; unfortunately widespread progress will likewise take decades, even with strong action starting now.

Source: Missouri Foundation for Health

Brent Swanson saw firsthand how an addiction to prescription painkillers can destroy a family.

His daughter was prescribed opioids at age 16 after having her wisdom teeth pulled. Her problems started then, Swanson said, and after she was again prescribed painkillers to deal with pain from a car crash, “it was over.”

“My wife and I have been married for 32 years. We taught our children all the morals, how to respect themselves, how to respect others,” he said. “And when this destruction overtakes them, all of that goes out the window.”

Swanson was among those who spoke Thursday morning at the White River Conference Center, leading off a series of nine community meetings across Missouri. Federal, state and local authorities had an audience of about 400 as they discussed how the opioid epidemic affects Springfield.

The drugs made his daughter feel like she belonged in the world, Swanson said, adding that he’s spoken to “hundreds of addicts” with similar stories. The spending money he sent his daughter while she was in college went to drugs.

“We didn’t know about the pills, I’m sorry to say,” Swanson said. “… We look back now, and there’s so many signs we could have seen. But after she started taking heroin, we did notice.”

Eventually, Swanson said, he threw his daughter in his car and drove to a rehab clinic in Minnesota after three Missouri programs couldn’t help her. After going through withdrawal, and months of counseling treatment, she pulled through.

Now, she works in a recovery program, Swanson said, “and she’s one of the neatest people I’ve ever met.”

Swanson acknowledges that he was able to pay for the care his daughter needed. He counts himself among the lucky ones.

“The help is out there,” he said. “Unfortunately, it’s incredibly expensive, and we were fortunate enough to be able to afford that. So what we’ve gotta do now is go back and get the rest of them.”

More stories of addiction

Following Swanson was Chris Gaul, a local peer support specialist and a recovering opioid addict, and David Stoecker, who has turned a history of family abuse and struggles with alcohol, methamphetamine and opioids into a career of advocacy.

Both men say their personal experience with drugs informed their view that addiction is a mental illness, not a moral failure, and should be treated like other diseases.

Gaul advocated for making medication-assisted treatment more available to people who don’t have access to inpatient therapies, and Stoecker, in particular, spoke at length about how drugs changed his mind.

“I never abused drugs,” Stoecker said. “I cared about them.”

Gov. Eric Greitens relayed a similar story about his cousin, who he said was in and out of prison after starting with prescription medication, graduating to heroin and eventually succumbing to addiction.

After the legislature again did not pass a prescription drug monitoring program bill, Greitens on Monday issued an executive order to give the state access to drug-tracking data.

In Springfield, the Republican governor praised this new tool as a way to generate analytical evidence about prescription drug abuse.

Seated in the front of the room were numerous members of his cabinet, whom Greitens has instructed to develop ways for their different departments to respond to the opioid crisis.

For example, the Department of Labor and Industrial Relations might look at how opioids are being prescribed to people on workers’ compensation, Director Anna Hui said. And the Department of Social Services hopes to give its caseworkers better access to the opiate-blocker Narcan, Acting Director Steve Corsi said.

Greitens also praised recent developments: 50,000 new drug disposal kits from Mallinckrodt Pharmaceuticals to get rid of extra pills; a new “Generation Rx” program that might resemble D.A.R.E. but focus on prescription drugs; and a bill taking effect in late August that Greitens said will allow anybody to purchase Narcan, an opiate blocker used to treat overdose victims.

“I’m really inspired to see the tremendous, tremendous efforts of people who are working on the front lines, who are joining us in this fantastic effort to make sure that we can save lives,” Greitens told reporters.

Greitens also touted federal funding the state had secured to combat opioid abuse, such as a $5.5 million grant to go toward purchasing Narcan.

On the possibility that Missouri might receive some of the $45 billion in funding to combat the opioid crisis recently considered by Senate Republicans who want to reform the Affordable Care Act, Greitens said, “we’re obviously monitoring the back-and-forth in Washington, D.C., and once they have a bill, we’ll be happy to take a look at it.”

Greitens did not answer directly when the News-Leader asked if he would consider a special legislative session for a prescription drug monitoring program bill.

His press secretary, Parker Briden, told the News-Leader later that the governor would not call a special session on this topic and continued to support repealing and replacing Obamacare.

The Senate plan with the $45 billion in opioid funding is on hold while GOP leaders scramble for votes. State officials told the News-Leader after the press conference it seemed too early for them to speculate on how much money Missouri might receive to deter prescription drug abuse — if funding even materializes.

However, the repeal of Obamacare is not expected to have a “tremendous” impact on Missouri’s anti-opioid efforts, said Mark Stringer, director of the Department of Mental Health.

Randall Williams, director of the Department of Health and Senior Services, said Missouri is not going to wait for the Senate GOP bill to pass.

“The governor has made it really clear to all of us in the cabinet that we were to act,” Williams said. “That we’re not going to let what we can’t do keep us from what we can do.”

PDMP furor

Greitens’ executive order to create a drug-monitoring system is big news for many in Missouri, the last state to enact any such measure.

His version involves contracting with companies such as ExpressScripts to work with investigators to identify doctors and pharmacies that inappropriately prescribe Schedule II-IV controlled substances, including opioids. “Bad actors” would then be referred to law enforcement or professional boards.

Williams said the program is expected to cost about $450,000 annually.

But a push continues for a more traditional drug database that allows medical professionals to track patient prescription patterns. Several speakers at Thursday’s event said noted that Greitens’ executive order was a good step but wouldn’t solve the problem.

Gil Mobley, a Springfield doctor and political activist, was more critical. He attended the opioid summit wearing his scrubs with a message prominently written across his back: “Greitens’ PDMP is a joke.”

The governor’s version aims to crack down on “pill mills” that repeatedly over-prescribe. Critics of Greitens’ plan, including the Missouri Democratic Party, questioned whether it would actually come between the addict and the supply.

Williams, whom Greitens appointed in February, also said there was still a need for a traditional prescription drug program such as the one supported by Rep. Holly Rehder, who told the News-Leader on Thursday she was still pushing for her version.

“We think that the benefit of a ‘traditional PDMP,’ as you put it, is it gives clinicians the ability, if they choose, to look in real-time at the patient in front of them and look at their prescription history,” Williams told reporters. “… I’ve used a PDMP. So we fully support that and don’t see our efforts in any way to be contradictory to that, and (they) are in fact complementary.”

The view from the DEA

Numerous panels followed the governor’s address, including a presentation from James Shroba, a DEA agent based in St. Louis.

The U.S. has 5 percent of the world’s population but demands 95 percent of its hydrocodone, Shroba said of the country’s challenges with prescription and illicit opioids.

“We have an insatiable appetite for it, and that is the springboard for our heroin and fentanyl crisis,” he said.

Shroba’s information identified St. Louis as the epicenter of Missouri’s westward heroin epidemic. On the rise are fentanyl, a cheaply made and powerful synthetic opioid contributing to skyrocketing overdose deaths, and carfentanil, which is essentially an elephant tranquilizer people take to get high.

People search for and crave these intensely powerful synthetic drugs out of the belief that “there has to be something better,” Shroba said. And as the highs get higher, it takes more and more doses of Narcan to bring people back from the brink of overdose.

While Shroba said much of the activity is focused in St. Louis, Kansas City and Cape Girardeau, he noted that fentanyl trafficking there affects Springfield, St. Joseph and Jefferson City.

Based on Shroba’s presentation, Springfield is becoming less of a rest stop for opioid-trafficking cartels and more of a destination.

“They may not manufacture a product like GM or Ford,” Shroba said of foreign cartels based south of the U.S. border, but “they do manufacture grief and misery … and they’re very calculating about the marketplaces they saturate.”

The local impact

Also speaking Thursday were numerous Springfield-based officials who emphasized the local impact of opioids and discussed ways to address the crisis.

Doctors from CoxHealth, Mercy and Jordan Valley Community Health Center noted that their treatment of patients for opioid-related conditions has been on the rise.

“In the EMS side, because of this epidemic, we’ve increased our Narcan by five times on every truck, because we can’t control this,” said Tom Lewis, an emergency physician with Mercy.

Lewis added that while Greitens’ prescription drug monitoring program and his signing of a bill to increase the availability of Narcan were laudable, “realistically, that’s not going to fix this.”

Greene County Presiding Commissioner Bob Cirtin noted Springfield’s continued efforts to pass its own version of a drug monitoring program, Greitens’ version notwithstanding, and pledged that the county would take similar action soon.

Matt Morrow, president of the Springfield Area Chamber of Commerce, and Denise Silvey, human resources manager for Paul Mueller, both said the opioid crisis affects businesses. Morrow said companies should “act in their own self-interest” with regard to opioid addiction by taking care of their employees and forming wellness programs.

Judge Peggy Davis, commissioner of the Greene County Drug Court, noted that the opioid epidemic “pays the rent at my house, unfortunately” and said interagency coordination was necessary to solve the problem.

“My hope is you put me out of business,” she said.

Source: Springfield News Leader