End to painkiller epidemic requires change from doctors, patients, community

From 2007 to 2009, state records show, overdoses killed more people in Wilkes County than car wrecks.

Almost all of the overdoses were attributed to prescription painkillers.

Enter Fred Wells Brason, a hospice chaplain who began studying the county’s painkiller problems and eventually founded an overdose prevention group called Project Lazarus.

Armed with grim statistics, Brason began as a volunteer. He spread the word anywhere people would listen, to doctors, patients and police, in schools and churches and at public meetings.

The result: While the number of painkiller overdoses has continued to climb across the United States, it dropped in Wilkes County by 69 percent from 2009 to 2011.

“It was basically a community response, because nobody else had answers,” Brason said. “It’s essentially changing society’s perspective, but it has to be comprehensive.”

Yet the number of overdoses has continued to rise.

Brason’s approach was not as simple as banning painkillers, which experts say could lead to untreated pain and have its own devastating effects. In Wilkes County, 60 miles west of Winston-Salem in the North Carolina foothills, painkiller prescription levels actually remained higher than the state average.

But doctors and emergency departments were urged to be more cautious when prescribing painkillers, and patients and family members were warned about the risks of long-term use.

In 2011, not a single overdose in Wilkes County could be traced back to prescriptions there.

Fayetteville and other communities across North Carolina are working to copy Brason’s blueprint. It’s a strategy that must include changing the culture of pain treatment and providing better help to people who become addicted to legal drugs.

The state and the Kate B. Reynolds Charitable Trust have pledged $2.6million to expand Project Lazarus throughout North Carolina.

The test will be whether Brason’s approach can work on a much larger stage. Cumberland County has nearly five times as many people as Wilkes County and many other complicating factors.

The downside of successful local initiatives is that they push the problem to neighboring counties, said Dr. Mike Lancaster, leader of the statewide Project Lazarus program. When hospitals in Wilkes County tightened painkiller policies, for example, some patients began driving to hospitals outside the county, Lancaster said.

Karin Suess, a pharmacist and manager at Carolina Collaborative Community Care, is leading the Cumberland County effort.

One of the most important factors here will be trying to get a handle on the size and scope of the problems because local statistics often do not include information from Fort Bragg’s Womack Army Medical Center or the Veterans Affairs Medical Center on Ramsey Street.

Being able to accurately measure the problems will be key in determining whether Project Lazarus is working.

Suess said that as the Project Lazarus initiative takes shape, success will be measured by tracking overdose deaths, emergency room visits for painkillers, prescribers’ participation in the state prescription-tracking database and other factors.

“I know it’s bad, but I don’t know how bad,” Suess said. “We have a bigger problem in Cumberland County than we understand at the current time.”

Project Lazarus plans to hire someone who can analyze information from the county, Womack and the VA and work as a liaison with the two federal hospitals, Suess said.

The liaison will likely have a daunting task in getting the hospitals for soldiers and veterans to work smoothly with civilian health officials.

Evidence suggests that officials are working to close the gap between the military and VA health systems and the civilian one.

Since late 2008, Fort Bragg pain specialists have been working on a plan similar to what Brason employed in Wilkes County. The effort, dubbed Operation Opioidsafe, led to the first community pain conference in November. The conference included leaders from Fort Bragg, the VA and the Fayetteville medical community.

Finch, of the Governor’s Institute on Substance Abuse, said doctors and patients alike need to adjust their expectations when it comes to treatment with narcotic painkillers, often referred to in the medical community as opioids.

“We really have gotten into a cultural fix where people think if they have pain, they need opioids, and if they have pain, they need to get rid of their pain,” Finch said. “The goal is functional improvement and not obliterating pain.”

Finch urged doctors to try other forms of treatment before introducing painkillers. And, he said, when starting a patient on painkillers, doctors should refer to it as a temporary trial and make sure patients understand the risks. A little background work — asking about prior substance abuse, talking to family members and checking prescription histories — can help doctors determine whether patients are at risk for dependence or abuse, he said.

“Everybody needs to be more knowledgeable about how to prescribe in a way that you minimize the chance for abuse,” Finch said.

Painkillers can become a dead-end treatment that harms patients more than they help, Finch warned.

“We need to be very thoughtful about the idea that if you end up with someone on opioids for chronic pain, it’s going to be very difficult to get them off,” he said.

Finch and other pain specialists say the pain scale — patients being asked to assess the severity of their pain on a scale of 1 to 10 — is outdated.

Instead of relying on that self-evaluation, prescribers should judge the effectiveness of treatment by patients’ ability to function, Finch said.

Dr. David Kishbaugh, a Fayetteville pain specialist, said he asks patients how their life has changed for the better when they are taking painkillers. Have they been able to get off the couch, for example, or can they play with their children?

“If you don’t ask those questions and we only listen to that scale of 1 to 10, patients have it in their head that if they don’t tell you their pain is a 10, you’re going to take their medicine away,” Kishbaugh said.

Chronic pain is often accompanied by depression or other mental health problems, so it is usually a good idea to use counseling or therapy alongside any long-term pain treatment, he said. Without therapy, some patients end up using prescription painkillers to dull emotional pain.

Womack and the Fayetteville VA are not just talking about pain. They are working to make pain treatment safer. Later this year, leaders at Womack plan to open a clinic called the interdisciplinary pain management center.

That center will use acupuncture, yoga and other alternative treatments alongside traditional medicine. Doctors at the center will train primary care providers on Fort Bragg on how to manage pain most effectively.

“We’re going to have a lot of education on chronic pain and how to ease your pain without medications,” Algeo said.

About 1,500 soldiers a year at Fort Bragg receive painkillers as treatment for chronic pain, Algeo said.

He said his office is trying to steer wounded soldiers considered at high risk toward treatment on Fort Bragg instead of from civilian doctors, partly so their medications can be better tracked and partly because he thinks pain treatment in Fayetteville is often substandard.

The Fayetteville VA is turning to alternative pain treatments. The medical center uses tai chi and yoga and plans to begin offering acupuncture soon.

Fayetteville State University is collaborating with the VA through a $1 million federal grant to offer free acupuncture and massage to veterans and their families.

Oren Miller, a 58-year-old veteran, worried about becoming addicted to painkillers after tearing his Achilles’ tendon. He took oxycodone after an operation and felt like he was hallucinating because the pills were so strong. Now, he gets free acupuncture through the FSU program, which he says helps him regulate his pain.

“I was just out of it,” Miller said of his experience with painkillers. “That was the reason I didn’t want any more of that stuff.”

Afua O. Arhin, chairwoman of the FSU nursing program where the clinic is based, said the idea for it came when she noticed wounded soldiers and veterans flocking to spas in town for massages.

“I think it’s our responsibility to do more,” Arhin said. “We have a young 22-year-old who’s been through God knows what in Afghanistan. It’s not right for him to come home and die from an overdose.”

But many insurance plans for civilians do not cover alternative treatments, and even covered treatments — which typically require a co-payment for every visit — are more expensive than prescription painkillers. Lancaster said insurance providers, including Medicaid, push people toward pills and procedures.

As prescribers and patients become more aware of the risks of long-term use of painkillers, officials hope that fewer people become dependent or addicted.

But that will not help the people who are already hooked.

Doug Webster, director of behavioral health services for Cape Fear Valley Health System, said the hospital plans to expand the county’s lone detoxification center later this year. The move will double the number of beds at the Roxie Avenue Center to 16 and allow potential patients to go directly there for help instead of having to be placed through the hospital’s emergency department or the Mental Health Center.

Webster said the community needs more preventive services and more outpatient treatment options that may help people before they need costly inpatient treatment.

He said drug and alcohol abuse centers are difficult to open because they are expensive to operate and public funding often does not cover the costs.

“These are not highly funded areas; never have been,” Webster said. “The old thing is, ‘Why do I want to spend money to treat these drug addicts?’”

But painkiller patients are not so easily categorized. Addiction experts say it is not like there is a population of people in pain taking painkillers and a population of drug addicts faking pain.

Brason often says the painkiller epidemic is a complex problem that requires a complex solution.

It’s not a matter of arresting abusers or getting doctors to stop prescribing, since painkillers have valid uses in many instances.

Progress will depend on the community making many difficult changes, and failure at any one of them could prolong the painkiller epidemic.

Among the challenges ahead:

* Cumberland County must get more doctors to use the state’s prescription tracking program. Only 16 percent are signed up, the worst rate in the state. 

Further complicating the ability to track legal drugs here is the disconnect between the state’s tracking system and the federal ones used at Womack Army Medical Center and the Fayetteville VA Medical Center.

“The military has been willing to work with us, but in some ways their hands are tied,” Lancaster said. “Let’s break down the federal barriers and enter people into the system so we can do a better job of identifying who needs help.”

* People who need help must have a place to receive it. Painkiller addicts in Cumberland County are often left out in the cold because of a severe lack of treatment options. If more services are not made available to them, some will continue to forge prescriptions or break into homes to steal painkillers. Some will become hooked on heroin, a cheaper substitute for painkillers on the black market.

* Although the Army and the VA are making improvements, one in three Fort Bragg soldiers and one in four patients of the Fayetteville VA receive prescriptions for opiate painkillers. A 2011 VA study found that veterans were twice as likely as civilians to die of a painkiller overdose.

To some extent, society created the problems with painkillers that Fayetteville now faces. We sent soldiers to war, created a culture that says no one should suffer pain and decided that treatment centers are not worth the cost.

Now, doctors and addiction specialists agree, society must work to fix the problems.

Algeo, the Womack pain chief, is among several experts who say the only way to truly solve the painkiller epidemic will be to change the way people think about the drugs.

Many people would not hesitate to give a family member or friend their leftover Percocet to help with pain. Surveys show that is the most common way people misuse them.

Patients and doctors alike need a better understanding of the risks associated with narcotic painkillers, Algeo said.

“Unless we can get out there in the culture to start pushing a different message,” Algeo said, “things will keep going the way they’re going.”