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Bitter pill

Arkansas is second in the nation when it comes to opioid prescription rates. Those numbers are edging down, but some say the worst of the epidemic may be yet to come.

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NOTE: There is a correction at the conclusion of this article.

Though Lane Huie was 27 years old when he died in a car crash on July 4, 2013, his mother, Darla Huie, never knew her son as a fully functional adult. She could see his potential, of course, as every parent can see the potential in their child. But from the time he was 17 years old, the man he might have been otherwise was always distorted by a crippling, seemingly unbreakable addiction to opioids.

When he was 17, Lane hurt his hand playing football, a fracture that would take, at most, a month or two to heal for a boy his age. He left the doctor's office with a prescription for the opioid pain reliever hydrocodone. Within a week, his mother said, she saw a change in him, from a happy-go-lucky boy to a person she almost didn't recognize. Within a month, she said, he was hopelessly addicted.

"We didn't have the skill set to deal with it," Huie said. "We didn't know what we were looking at, and didn't understand the physiology of the drug. Because we'd never been exposed to it, we didn't know. Lane was a happy kid who traveled and had a good time, a very friendly person, excited and exuberant about every day. He went from that to angry and screaming. We had no clue what happened."

He would remain an addict for the rest of his life, in and out of rehab and in trouble with the law as he tried to keep pace with his habit. Eventually, he turned to heroin.

Once, after he finished yet another rehab, Huie said she came into his room to find him loading a shotgun to kill himself. She wrestled the gun away. "He was like, 'Mom, I can't,' " Huie recalled. " 'I can't fight this. I don't know who I am. I've fucked up my life. Nobody in our family has ever been to jail. What am I doing? I don't know how to handle this. My brain, I fight it all day. I'll get up and I'll say, I'm not doing this. I'm not going to do it ... . I tell myself, I'm going to have a good day, a great day. I'm going to make them proud. By 3 o'clock, you know how you get a song stuck in your head? It starts playing, Just do it. You did good. Just do it. Do it again. Put yourself out of your misery and go to sleep. ' "

Lane was making one last, desperate attempt to wean himself off opioids cold turkey, Huie said, when he died. She believes he may have had a seizure behind the wheel, brought on by withdrawal. She uses a metaphor about the last 15 years of her life that would be heartbreakingly beautiful if it wasn't so tragic: that it was as if she spent a decade crawling along in the dust behind her son, begging him to get well, and has spent the five years since she lost him trying to stand.

"You can't sleep," she said. "You don't have healthy relationships. I would literally have friends wanting me to do things, and the whole time I was thinking, 'What about Lane? Is Lane OK? What's wrong with him? Asking for help. Trying to help him. Going to counseling. Sending him to rehab.' "

BETTER DAYS: Lane Huie with friend Aimee Stockton.
  • BETTER DAYS: Lane Huie with friend Aimee Stockton.

R.J. Looney also knows what it is to fear for an addicted loved one. His son, Zachary, now 29, has been in prison since 2016 on theft charges, which Looney said Zachary committed to support an opioid addiction. After becoming addicted to opioids purchased on the street when he was about 14, the younger Looney progressed from snorting crushed pills to injecting heroin when he was a junior in high school.

"It just led to the destruction of his teenage years," his father said. "Everything he lived for was just for getting high. ... He stole firearms, chainsaws, window air-conditioning units, debit cards, anything that wasn't nailed down." At one point, Looney said, his son blew through a $2,500 college fund in a single week. Finally, in 2015, after losing his job and unable to find money to feed his habit, he committed a robbery in the parking lot of Little Rock's White Water Tavern. Arrested, convicted and sentenced to five years of probation, he landed in prison last year after violating the terms of his probation.

With his son scheduled to be released at the end of April, Looney knows the feeling of being trapped between the devil and the deep blue sea: He wants Zach to be free, but knows that once he's released, he may return to his addiction. A wave of recent overdoses and deaths by heroin users in Little Rock is constantly on Looney's mind.

"Really early, before I go to work, is when the black dog wakes me up and I start thinking about things," he said. "It's always in the back of my mind: the recidivism rates that I've read about. ... I've always said, 'If you love an addict, you'll get to a point where it's about self-preservation, so they don't take you down with them.' They will. You can give up on trust. There's no way I'd ever trust him again, unless it's after years of being clean. But the two emotions you can't give up on are love and hope. That's about all you've got left for them. You always love them. You always hope they'll get better."

Stories like these are the tip of a looming iceberg the state and nation are only starting to comprehend. America consumes over 80 percent of the global output of prescription opioids, and 99 percent of the world's hydrocodone. According to the Centers for Disease Control and Prevention, Arkansas has the second highest legal opioid prescription rate in the nation: 114.6 prescriptions for every 100 people in the state. Only doctors in Alabama prescribe more opioids. Greene County in Northeast Arkansas has the highest prescription rate in the state, with 122 prescriptions per 100 people. In counties on the other end of the spectrum, the rates are half that. Troublingly, nobody — not addiction specialists at the University of Arkansas for Medical Sciences, nor the state Department of Health, nor the state drug director — can definitively say why there is a difference in prescription rates from county to county.

What is known, according to the health department's Prescription Drug Monitoring Program, is that doctors and pharmacists in Arkansas legally prescribed and distributed a staggering 235.9 million opioid pills in 2016 alone. Forty-six percent of Arkansans over the age of 18 filled at least one prescription for an opioid drug that year.

With all those pills floating around, opioid theft for illicit use — what police and policymakers call "diversion" — is rampant. The CDC ranks Arkansas first in the nation when it comes to children aged 12 to 17 who have misused opioids. While opioid-related deaths seem to be edging downward since the introduction of prescription monitoring, opioid overdoses in Arkansas have tripled since 2000.

Meanwhile, a study released last March of 1.2 million UAMS patient records collected between 2006 and 2015 found that the likelihood of becoming dependent on opioids long term increases by leaps and bounds with every day beyond three that a patient takes the drugs for pain. The study found that patients who were prescribed an 11-day supply of opioid drugs had a 1 in 4 chance of still being on opioids a year later.

In short, it's clear we have a problem that isn't going to be resolved with thoughts and prayers. Just how to go about solving it, how it got so bad in the first place, and how to pay for a fix is still being debated, but things are moving quickly now. Recent months have seen the Arkansas State Medical Board working on new guidelines to try to rein in prescription rates and problem prescribers, the Attorney General's office announcing it intends to investigate drug manufacturers and bring charges if warranted, and the Association of Arkansas Counties filing a federal lawsuit — and planning to soon file a series of further suits in state courts — against some of the nation's most prominent drug companies and distributors.

Meanwhile, many chronic pain patients with debilitating injuries are terrified that a crackdown will take away the painkillers they say allow them to lead something approaching a normal life. While efforts such as the state's Prescription Drug Monitoring Program have led to an overall decrease in the amount of "doctor shopping" — hopping from one doctor to another while trying to get opioid prescriptions — and a historic drop in the number of opioid overdoses in the state, state Drug Director Kirk Lane and others the Times spoke with say they believe the worst days of the epidemic are still ahead, as regulatory efforts and stricter prescription guidelines make pharmaceutical drugs like hydrocodone and oxycodone harder to get from doctors and more expensive when diverted to the streets and as prescription opioid abusers turn to much cheaper heroin — some of it laced with the brutally potent synthetic opioid fentanyl.

Whether those efforts succeed in moving the ball on opioids in a positive direction or not long term, it's clear that the issue is much more complicated than old-fashioned pill mills.

A plague in a bottle

Though doctors have known the addictive and often deadly consequences of using opioid drugs since the days when snake oil containing opium and heroin was readily available on drugstore shelves, the last two decades of the 20th century saw a wholesale rethinking of opioids and their addictive properties in the medical community, including the idea that the powerful drugs could be safely prescribed for temporary "acute" pain and chronic pain without fear of addiction. As seen in a number of lawsuits filed across the country over the last 10 years, including the one filed in late 2017 by the counties association, a case can and has been made that much of that rethinking by physicians, and the attendant explosion in opioid prescription rates, corresponds with a decades-long, multimillion-dollar marketing push by pharmaceutical companies beginning in the 1990s, the goal of which appears to have been to convince physicians that no patient need ever be in pain, that opioid painkillers are neither as dangerous or addictive as previous generations believed, and that those drugs could therefore be safely prescribed for pain other than that experienced by late-stage cancer or hospice patients.

The counties association filed suit last December in federal court against several of the biggest makers and distributors of opioid painkillers, including Purdue Pharma, Janssen Pharmaceuticals, McKesson Corp. and others. The lawsuit calls the effort to sell physicians on the idea that opioid medications were safe and nonaddictive a "marketing scheme designed to persuade doctors and patients that opioids can and should be used for chronic pain." It reads like the bleak color commentary on a slow-motion train wreck, laying out the history of how opioids came to be so widely prescribed in Arkansas and America, including claims that drug companies spent millions to downplay the risks of opioid addiction and dependency by using paid "opinion leaders," employing "front groups" masquerading as impartial patient advocates, spending tens of millions of dollars to advertise in medical journals and using drug reps to make the case for shaky concepts such as "pseudoaddiction," the idea that if patients taking opioids were found to be engaging in behaviors indicating addiction, that meant their pain was not well managed and their dosage should be increased. Citing what she called "staggering" statistics, Arkansas Attorney General Leslie Rutledge announced Jan. 24 that her office would bring in extra legal help to investigate several yet-to-be-named opioid manufacturers and will potentially bring lawsuits or charges against those firms if warranted.

FILED SUIT: Chris Villines (left) and Colin Jorgensen with the Association of Arkansas Counties. - BRIAN CHILSON
  • Brian Chilson
  • FILED SUIT: Chris Villines (left) and Colin Jorgensen with the Association of Arkansas Counties.

The counties association lawsuit points out several of what seem to be damning facts: The named defendants spent over $14 million to advertise their products in medical journals in 2011, triple what they'd spent in 2001, and spent $168 million in 2014 alone to market opioid drugs to doctors through "detailers" — friendly drug company sales reps who visit physicians in their offices — double what they'd spent on opioid detailing in 2000.

"Manufacturer defendants also identified doctors to serve, for payment, on their speakers' bureaus," the lawsuit goes on to say, "and to attend programs with speakers and meals paid for by Manufacturer defendants." Among other damages, the lawsuit calls for funds specifically to pay for opioid addiction treatment costs in Arkansas in coming years.

Colin Jorgensen is litigation counsel for the Association of Arkansas Counties Risk Management Services. He said there are obvious parallels between the lawsuits filed against opioid manufacturers and those filed in the past against Big Tobacco, but also significant differences.

"The parallels are mostly in the legal theory and the misrepresentation in the marketing by the companies," Jorgensen said. "That's what's similar between tobacco and the opioids — the deliberate deceit about the addictive nature of these products, knowing full well the truth. The damages are not exactly the same. We've got a lot more local-level impact this time with the opioid epidemic than with tobacco. ... We need education, prevention and treatment, and all three of those things are extremely expensive, and they're best deployed at the local level." The price tag for that intervention could easily run into the billions of dollars nationwide, Jorgensen said.

Jorgensen said he believes physicians have been duped about opioids just like patients, but are quickly working to turn things around. "The awareness in the medical profession is shifting dramatically," he said. "I think you're probably going to see a pretty substantial drop-off in the prescription rates and things moving forward. The doctors are in a tough position because they don't necessarily have effective alternative treatment, but they're learning now that [opioid] treatment is ineffective, too."

Association of Arkansas Counties Executive Director Chris Villines said the financial and social impact on counties and cities in the state is shaping up to be much more costly than that posed by tobacco addiction in the past. "We didn't fill our jails with people using tobacco," he said. "We didn't have to go out and police the street for tobacco users. [Tobacco] really had more of a direct impact on health care than anything. This plague has had an impact all over: the court system, the county hospital, the county jail, policing, law enforcement, coroners, everybody."

Villines noted that while there is a clear need to curb the prescription opioid rate in the state, slowing the supply does nothing to stop the demand from those addicted to opioids. Like several the Times talked to, Villines fears that attempting to restrict the number of legal prescriptions without a corresponding increase in funding for drug treatment — money that is going to be very hard to find in a cash-strapped state like Arkansas — may well result in a new scourge.

"Between 2005 and 2009, Mexican heroin [production] increased from 8 metric tons to 50 metric tons," he said. "Almost all of that increase is going straight to those who are getting off of opioids. So if we talk about the solution being, 'Let's cut back the flow of opioids,' we're not helping. We're actually driving addicts more quickly into illegal heroin than we would be if we had a good plan in place to help get them off of opioids."

Jorgensen said the association plans to file lawsuits somewhat similar to its federal action in state courts this spring. He said the fact that the vast majority of the counties in Arkansas — 70 out of 75 as of this writing — quickly signed on to the forthcoming state lawsuits shows the extent of the problem in both cities and rural areas, and officials' frustration with the issue. The association will also be partnering with the Arkansas Municipal League on the state lawsuits; the municipal league has signed up over 100 cities across the state, including the largest cities, Jorgensen said.

He and Villines said that in talking to groups around the state, they're seeing that police and leaders understand that it's impossible to arrest their way out of the opioid crisis, and are willing to view opioid addicts as victims of a scheme rather than criminals.

Though Jorgensen said it's his belief, based on the available evidence, that drug companies set out to get people hooked on dangerous opioid painkillers, he said the lawsuit need only prove the companies knew their drugs were dangerous and addictive and deceptively marketed to prevail. The lawsuit is not about trying to tell doctors how to practice medicine, he said.

"Ending the deceptive marketing scheme and hopefully enjoining and compelling the companies that produce these pills and the companies that distribute these pills to market them truthfully, that may change the culture among doctors," he said.

The candyman

Retired for the past three years, Benton physician Dr. Sam Taggart has long been something of a Paul Revere on the subject of opioids. Both a medical historian (he'll soon publish his second book on the history of the profession in Arkansas) and an early proponent of the idea of "wellness" — the idea that if you eat right, get exercise, stay near an ideal weight, don't smoke and follow other healthy guidelines, the body doesn't need much medicine — he said that the idea of "a pill for everything" has been pushed by the pharmaceutical industry since the turn of the 20th century, starting with vitamins. The result, he said, is that America is a drug culture that has been training its population to look for health in pill form for over 100 years. The problem with that, according to Taggart, is that the pharmaceutical industry is in the market to create customers, not to produce cures.

Since the opioid boom, Taggart believes, the result of that century-long training of American consumers has come home to roost in nearly every Arkansas city and town. "A lot of towns have a candyman," he said. "They have a guy that everybody in town knows: If you need something, you go to this guy. I honestly didn't want to be that person under any circumstances. So I began very early thinking about those kinds of issues and saying, 'How do you keep that from happening?' "

While it was starting to change by the time he left his practice, thanks in part to the state's Prescription Drug Monitoring Program and other efforts, Taggart said the local "candyman" would often persist for years because those physicians flirt with the edges of the law and Medical Board regulations. "I don't want you to misunderstand me, and please don't misrepresent this: I'm not being judgmental of my fellow physicians, except to say that, in every community, and I believe this is still true ... if you go into the drug-seeking community, there is a network and they know who prescribes drugs," Taggart said. "They know who will do it, they know where they can get it, they know how much they can get."

NO 'CANDY MAN': Dr. Sam Taggart. - BRIAN CHILSON
  • Brian Chilson
  • NO 'CANDY MAN': Dr. Sam Taggart.

Part of being the change he hoped to see in the world was insisting on something that has grown much more common among doctors in recent years: that chronic pain patients in his care be evaluated by a chronic pain management specialist. "If it looked like they had a problem," Taggart said, "something like a severe back problem and there was nothing that could be done, or a severe hip or leg problem and nothing could be done about it, what I would do is start warning them after about three weeks, 'This is not long term. We're not going to do this long term.' I wouldn't write big, long-term prescriptions. I'd say, 'If we decide that this is what you're going to need, I'm going to send you to a chronic pain management specialist,' but with a caveat: 'OK, we'll let them evaluate you. If they think you need this medicine, I'll continue writing the prescription.' "

During his years in practice, Taggart refused to hear the pharmaceutical companies' sales pitch on opioids. As early as 1983, Taggart said, he stopped seeing "detailers" who asked to come to his office to market drugs. Once, Taggart said, most drug company sales reps were former pharmacists who were informed about medicine and patient care. But during the early 1980s, that changed. "They'd send out pretty young girls, pretty young guys, and they'll send them out with a study that might have six people in it, which is no study at all," Taggart said. "They have direct access. They come right into the doctor's office. They bring food for the whole office staff. They're salesmen. It's sales, is all it is." The sales pitch often worked, Taggart said, because doctors are just suceptable to a friendly face offering direct marketing as anyone else.

"For a long time, they provided all kinds of freebies," Taggart said. "They would hire physicians to be speakers at meetings: 'We want you to be part of our staff.' That part was ultimately outlawed, I think. I was never part of that. I was never interested in it. I had way too much to do and I wasn't interested in what they had to say. I'd rather get my information from a reasonably objective source."

Denise Robertson has served as administrator of the health department's Prescription Drug Monitoring Program since it started in 2012. The job has given her a daily view of the flowering of the opioid crisis in Arkansas. Established by Act 304 of 2011, the program collects daily reports from pharmacies, allowing doctors and pharmacists to see with just a few keystrokes whether a patient is engaging in "doctor-shopping" behavior to get more pills from multiple physicians.

Act 820, passed in the last legislative session, made it mandatory for doctors to consult the drug-monitoring program before writing opioid prescriptions, and for pharmacists to update the registry whenever they fill a prescription. The change from voluntary to mandatory has been controversial, Robertson said, but it is helping to slow the spiraling opioid prescription rate in Arkansas. She noted that since the program was instituted, there has been a 20 percent decrease in prescription opioid overdose deaths in the state. That's the fourth largest decrease nationwide, according to the CDC.

Robertson said one issue that drives opioid abuse in Arkansas is the fact that Missouri is the only state in the nation without some form of prescription drug monitoring system. The Missouri legislature has made attempts to establishing a system for tracking opioids in their last three sessions, but has failed each time (lacking guidance from the state, St. Louis County and bordering counties finally started their own system, which has helped). Looking at Arkansas county-by-county maps of overdose rates, Robertson said, you can actually see the deadly results of addicts hopping the border into Missouri to doctor shop. "You'll see a lot of that concentrated up there on the border of Missouri," she said. "We have no idea, really, what's going on across that border."

Drug Director Lane agrees that Missouri's lack of a drug-monitoring program is contributing to the problem in Arkansas. He said the impact of prescription monitoring can be seen in the two states' opioid overdose death rates. "Before we started our program, we ranged about 12 deaths for every 100,000 people," he said. "Missouri tracked right along with us. We were side by side, Missouri and Arkansas. We kicked into our PDMP, and our death rate remains the same today. Based on the current figures, we have around 12.5 people per 100,000. Missouri is at 20 [deaths per 100,000] now. So they have grown. We've maintained."

ON THE FRONT LINES: State Drug Director Kirk Lane. - BRIAN CHILSON
  • Brian Chilson
  • ON THE FRONT LINES: State Drug Director Kirk Lane.

Formerly the chief of police in Benton, Lane has seen firsthand the impact of the opioid crisis in the state. He said that prescription opioids go for about a dollar per milligram on the street. "If you have a 10- to 15-pill-a-day habit, you can add up the money there," he said. "It comes from taking from medicine cabinets, stealing or other criminal activity to raise the money and feed the substance abuse disorder. Eventually, you move to heroin because it's cheaper. The supply of heroin is coming into the state very rapidly now."

Because smugglers have upped supply to meet demand, an amount of injectable heroin to satisfy an opioid habit that would cost thousands of dollars a day goes for about $10 in Arkansas, Lane said.

Much of the heroin seized in Arkansas in recent years, he said, tests positive for fentanyl, a synthetic opioid that's 50 to 100 times more potent than morphine and that — unlike heroin — can be absorbed through the skin. The drug, normally only used in patch form by late-stage cancer patients, is now being synthesized in cartel labs in Mexico and smuggled into the U.S. in tonnage quantities, sold either alone or mixed into heroin. Because of fentanyl's potency, the fact that it looks identical to heroin and has the ability to pass through the skin, Lane said, the drug has been linked to overdoses across the nation in not only opioid users, but cops, drug dogs and family members who stumbled upon a loved ones' stash.

"Where heroin will be fatal slowly by slowly depressing the respiratory system," Lane said, "fentanyl acts very quickly. And carfentanil, which we haven't seen in the state yet to my knowledge, is 100 times more potent than fentanyl." Carfentanil, which has popped up in some opioid hotspots around the country, is normally used by veterinarians as a surgical anesthetic for very large animals, including elephants.

The risk of addicts turning to heroin, the danger of fentanyl and the attendant overdose deaths and needle-related diseases that will result, are why Lane believes the worst days of the crisis in Arkansas are still ahead. It's part of the reason he helped lead the state's effort to make the lifesaving drug Narcan, which can temporarily reverse an opioid overdose and give first responders time to rush a patient to the hospital, available over the counter in the state. First responders have used Narcan to save over 30 overdose victims in Little Rock alone so far this year, including a 17-year-old who overdosed in a bathroom at Little Rock Central High School. Lane said the state has received $3.5 million in grants to provide Narcan to first responders in the state over the next five years. The state's drug takeback program — online at artakeback.org — has 194 secure boxes in the state where patients can dispose of their unused narcotic drugs 24 hours a day. Lane said that between the boxes and statewide takeback events — the next one is Saturday, April 28 — the state has collected and destroyed 131 tons of prescription drugs — enough to fully load over three tractor trailer rigs. About a third of the surrendered drugs, Lane said, have been opioids.

Lane couldn't give a definitive answer as to why the prescribing rates are so high in certain counties. The issue of prescription rates, he said, is multifaceted and the reasons may vary from county to county. "Some Arkansas counties have a lot of retired folks who move here from other states," he said. "Older people have more medical problems than younger people and because of that, they have more medications than younger people. So that may be part of the issue on the prescribing rates. Some of it could be the physicians themselves. ... Some of the problem [may be due to] the older prescribers, who are set in their ways and were trained that opioids were OK in the past. Basically, trying to retrain them and reprogram them to the latest techniques to deal with the opioid epidemic is a big push, not only in Arkansas, but in the U.S."

One issue as the state moves forward, Lane said, is that Arkansas is in the bottom 10 percent in the nation when it comes to the availability of drug treatment, a problem especially acute in rural areas.

"Good medically assisted treatment isn't just giving somebody Suboxone or methadone [drugs that mimic opioids but don't cause a high] and letting him walk out the door with a prescription," he said. "Good medical-assisted treatment is the constant monitoring of somebody, urinalysis, and also a piece with peer recovery — not only getting that person clean but maintaining that sobriety and giving them tools." There is also, Lane said, the issue of breaking the stigma of addiction so people can come for help without shame. For a lot of opioid addicts, he said, using is not about getting high; it's just about feeling normal and not getting sick. While that drive can cause addicts to engage in criminal behavior, Lane said that people who have been punished need to have a way back to the community and a sense of worth.

"We as a society have to understand that and give these people a second chance," Lane said. "It's kind of hard for a longtime cop to say that, but it's a realization of the problem we have and what pushes people into these behaviors. It really takes all of us working together to understand the problem. We created the problem. We can fix it. ... You can't turn addiction off like a light switch. You just can't do it. It takes hard work and support, and it takes a community to solve the problem."

Dr. Rick Smith chairs the UAMS Department of Psychiatry and serves as director of the hospital's Psychiatric Research Center. He works with patients to break the cycle of opioid addiction every day. "You've got a situation where there are a lot of pills out there. A huge number. Too many pills are out there that are not taken," he said. "There's this diversion phenomena, so the adolescents and young adults get hold of them, and then they end up graduating from pharmaceutical grade opioids to heroin. There used to not be a market in Arkansas for heroin. Heroin would pass through Arkansas on the way to Chicago and other cities up north, but there wasn't enough market to stop here. Now there's plenty of market to stop here because [addicts] can't afford the prescription-grade opioids."

While it's impossible to determine who will become addicted to opioids and who won't, Smith said there is clearly a genetic susceptibility to opioids in some people linked to their body's activation of opioid receptors in the brain — the golf-tee-like sockets that opioid molecules plug into.

Educating or reeducating doctors about the danger of the drugs is key, Smith said. In the past, doctors were often misinformed about opioids during their initial training. "The pharmaceutical reps were saying: These drugs aren't dangerous and folks aren't going to get addicted to it if they're having post-surgery or post trauma [pain], which is just not true," Smith said. "I was taught that in my fellowship. I did my fellowship in 1981, and we were taught that if somebody was given a pain medicine after surgery or after trauma, they would almost never get addicted to it."

EDUCATING DOCTORS ON THE RISKS OF OPIOIDS IS KEY: UAMS' Rick Smith. - BRIAN CHILSON
  • Brian Chilson
  • EDUCATING DOCTORS ON THE RISKS OF OPIOIDS IS KEY: UAMS' Rick Smith.

Smith said there is a common euphemism for the four categories of doctors who prescribe too many painkillers: those who are dated in their knowledge, those who are duped by their patients into overprescribing, those who are disabled by an addiction to medication themselves, and, the last category, which Smith said is much more rare — doctors who are dishonest and overprescribing for personal gain. "The Prescription Drug Monitoring Program helps sort those out, especially the last group," Smith said, "which is really the responsibility of the DEA and the Medical Board. Reports are sent from the PDMP to the board."

Helping patients get off long-term opioids must be done slowly and carefully, Smith said. The approach that works best right now is what's called medication-assisted treatment. "The one that we're hoping works and gets widespread use in Arkansas is treatment with Suboxone," he said. "That can be done in a primary care physician's office. They have to have counseling as well as this drug in tapering doses, tapered over a number of weeks. If they're on really high doses of opioids, you have to lower the doses of opioids first, and then get them on Suboxone."

Asked whether prescribing medical cannabis instead of opioids for pain might help in solving the opioid crisis in the state, Smith said he doesn't believe so. "We know from research that it's a gateway drug," he said. "Adolescents especially will start with marijuana because our society believes that marijuana is harmless or even helpful. So they start using marijuana and they oftentimes graduate to other drugs. It's not always, but it's statistically significant."

Smith believes the state is moving in the right direction to combat the opioid crisis, taking very aggressive action and instituting programs, like the PDMP, which help stem the tide. "The health department has taken a strong lead, the Arkansas State Medical Board is, the Medical Society is," he said. "Everybody is concerned about the problem, and I don't see anybody really holding back. It's just a very complex problem. We shouldn't and can't blame this on the patients. The patients are suffering. We have to put the patients' best interest first. We can't just ban the drugs. When I had a leg injury, I needed the medicine for a day or two ... There's a battle about: Is this a moral flaw? That's the stigma. No it's not. This is physiological. This is brain physiology — brain and body physiology."

The fall

The state Medical Board met Feb. 1 to hear comments on a proposed regulation that would give the board the power to revoke or suspend the medical license of any doctor found to have prescribed "excessive amounts of controlled substances to a patient, including the writing of an excessive number of prescriptions for an addicting or potentially harmful drug." As defined in the proposed rule, "excessive" wouldn't include medications given to patients in hospice, being treated for active cancer, emergency inpatient care or end-of-life care. For the treatment of acute, temporary pain from surgery or an injury, the regulation would define "excessive" as any pain medication prescription written for more than seven days "without detailed, documented medical justification." The board will hold another public comment session on the proposed regulation in April.

As the audience for the meeting filed into the chamber in the Victory Building in downtown Little Rock, it was easy to see which people were there to speak against the proposal — the half-dozen or so, many of them older, who hobbled in on walkers or canes. One man was girdled with an extensive black back brace. One woman in a surgical mask groaned as she lowered herself gingerly into a chair.

Along with Drug Director Lane — who, citing the UAMS study of addiction rates, advocated for the board to go further and limit opioid prescriptions for acute pain to five days — and Smith and other experts, several patients spoke before the board, saying that opioids had curbed their pain enough that they were able to live fuller lives following a crippling injury. Nearly every patient who spoke said their doctors, fearing repercussions from the Medical Board, had cut back on the amount of opioid medication they would prescribe. Some said they had been cut back to a point where they could no longer function. One patient, on opioids for a back injury for over 20 years, related that without the drugs, he feared he would have to go on permanent disability, close his small business and put his employees out of work. Board members, saying they wouldn't revoke the license of a doctor prescribing long-term opioids for legitimate chronic pain cases, repeatedly encouraged patients who spoke of skittish physicians to have their doctors call the board for reassurance and education about the regulations concerning opioid prescriptions for chronic pain.

Kelly Jones sat and listened as long as she could bear it, then left the room in tears, saying that the board would do nothing for a person like her. In the hallway, she leaned on a walker and cried as she related her story of living two decades in constant pain. In 1998, while hiding her children's Christmas presents, Jones said, she fell 10 feet from an attic to a concrete carport, rupturing nine disks in her back and neck and crushing an ankle so badly it had to be pieced back together with screws. Since then, bounced from surgeon to specialist, she has been in constant pain that turns to agony without high doses of opioid medication. Bent and wan, an oxygen hose threaded around her head to her nose, Jones said she spends most of her life in bed, the windows of her room heavily curtained because squinting in sunlight gives her headaches, thanks to the neck injury. Like several who spoke, Jones said her doctor has recently cut back her opioid medications, fearing his medical license might be in jeopardy if he continued to prescribe high doses. Dabbing her eyes with a tissue, Jones said she and other chronic pain patients are being punished for the crimes of others.

DESPERATE: Chronic pain sufferer Kelly Jones, who says her medication has been tapered off by her skittish doctor. - BRIAN CHILSON
  • Brian Chilson
  • DESPERATE: Chronic pain sufferer Kelly Jones, who says her medication has been tapered off by her skittish doctor.

"It's like I'm paying for the sins of what other people have done with their medicines," she said. "I can't be there to control what other people do with their medicines. But because they can't control themselves, I'm paying for it. I can't sit in there any longer. I kept asking them, 'Can I please talk? I have to go home and go to bed.' They keep bringing up people from the governor's office to talk. They won't let people talk."

She knows through being in pain management, she said, that she will never be pain free, but opioids allow her to at least control her pain. She prays for cancer, Jones said, so that at least she can get her medicine and be pain-free again for a little while before she dies. She said the members of the Medical Board will never understand pain like that.

"I pray to die," she said. "I pray every night to die. My husband actually took the guns out of the house because he was tired of listening to me threaten to do it. ... I'm on scraps of medicine. I can't live my life like this. They don't understand, because unless you have chronic pain, you will not understand what people with chronic pain are talking about. I can't talk anymore. I have to go."

At that, Jones turned and hobbled away, shuffling, pushing her walker along the carpeted hallway until she rounded the corner and disappeared from view, back to her darkened bedroom somewhere in Arkansas.


CORRECTION: Dr. Rick Smith is a psychiatrist at UAMS' Psychiatric Research Institute and the former chairman of UAMS Department of Psychiatry.

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