For Immediate Release
Date: Oct 16th, 2017
Contact: Dr. Beverly A. Largent
The Opioid Epidemic in Kentucky
The opioid epidemic in Kentucky has been well-publicized, and has become a part of the current lexicon. What was in the 1960s considered to be the problem of the flower child, has now become a disease/addiction that affects the entire population. Every Kentuckian is touched in some way. Few cannot claim a friend or relative who is an opioid user, and everyone suffers the drain on the community through the cost of first responders, law enforcement and treatment centers. Everyone knows the problem, but the terms opiates, opioids, Methadone, Suboxone can cause confusion in the most educated who do not deal with the problem on a daily basis.
In June 2017, the Kentucky Office of Drug Control Policy released its report on fatal overdoses in Kentucky for the year 2016. There was a 7.4% increase from the prior year. In 2016, 1,404 Kentuckians lost their lives to a drug overdose. The drug Fentanyl was associated with more than half of all the fatalities, as it was in 2015. Louisville, Lexington and Northern Kentucky suffered the most fatalities, but almost every county in Kentucky had at least one fatality due to a drug overdose. (1) Leslie County had the highest number of deaths on a per capita basis, followed by Bell, Powell, Gallatin and Campbell counties. (1) In far Western Kentucky, an older population continue to be prescribed opioids. Also impacting the western part of the State is the proximity of Missouri, the only state in the U.S. without a reporting system like KASPER, making doctor shopping relatively easy. (10)
Fentanyl is a Schedule II narcotic, and as a street drug, is manufactured outside the U.S. and smuggled through Mexico. It is approximately 50 times more powerful than heroin, alone, and is manufactured in such a way that users don’t know that it is present, or how much is present. Even in very small amounts it can be lethal. (3)
The American Society of Addiction Medicine (ASAM) defines addiction: “Addiction is a primary, chronic disease of brain reward, motivation, memory and related circuitry. Dysfunction in these circuits leads to characteristic biological, psychological, social and spiritual manifestations. This is reflected in an individual pathologically pursuing reward and/or relief by substance use and other behaviors.
Addiction is characterized by inability to consistently abstain, impairment in behavioral control, craving, diminished recognition of significant problems with one’s behaviors and interpersonal relationships. Without treatment or engagement in recovery activities, addiction is progressive and can result in disability or premature death.” (2)
Specifically, the impact of opioids on physical health includes drowsiness, constipation, depression of the Central Nervous System, liver and kidney disease, damage to vital organs, HIV, Hepatitis C, and hyperalgesia, or an increase in pain. (4)
What are the differences between opioids and opiates? An opiate is a drug that is natural and is derived from the opium poppy. The drugs morphine and codeine are opiates, as well as the lesser known Thebaine. Another class of opiates are the semi-synthetics such as Morphine-heroin, known as MS Contin; Codeine, under the names Vicodin, Lortab, Oxycodone, Percocet, Tylox and OxyContin, and Thebaine, which is not used therapeutically, but is converted into Naloxone, Naltrexone and Buprenorphine. The fully synthetic drugs are opioids. They include Methadone, Fentanyl and Darvon. Heroin is an opioid. (4)(5) “Heroin—known by nicknames such as Black Tar, Big H, Dog, Horse and Puppy Chow, is a highly addictive drug derived from morphine, which is obtained from the opium poppy. Heroin can be injected, smoked in a water pipe, inhaled as smoke through a straw or snorted as a powder through the nose. Heroin is especially deadly because it is both highly addictive and unpredictable. It is also dangerous because there is no way to know exactly what you‘re buying. A key driver behind the uptick in heroin abuse was the reformulation of two widely abused prescription pain drugs, making them harder to crush and snort. Drug manufacturers reformulated Oxycontin in 2010 and Opana in 2011. (9)
Opioids are successfully used in end-of-life care and for post-surgical pain. Unfortunately, most of the prescriptions for opioids in the United States are for common conditions, where the use of opioids could potentially cause more harm than good. (5) The American Association of Oral and Maxillofacial Surgeons (AAOMS) published a White Paper this year titled, “Opioid Prescribing: Acute and Postoperative Pain Management.” The recommendation from AAOMS is that Non-steroidal anti-inflammatory drugs be used as first line analgesic therapy. This White Paper can be accessed through the AAOMS website, and includes several considerations and recommendations for pain management, as well as support for the patient-practitioner relationship, allowing for the practitioner to make the judgement for appropriate pain control.
The current opioid epidemic can be traced to the 1990s with the introduction of OxyContin. The pharmaceutical company marketing the drug messaged to the medical community that people were being allowed to suffer needlessly. (5) In 1999, the Veterans Health Administration launched the initiative “Pain as the 5th Vital Sign”, requiring a pain intensity rating from 0-10 for all clinical encounters. (6) Although the 5th vital sign has been abandoned, these two factors have led to greater prescribing of pain medication. The increase of prescriptions for pain medications parallel increases in overdose deaths. There has been a 900 percent increase in opioid addiction in the U.S. since the 1990s. (7)(5)
In almost all populations of drug users, prescription pain medications were the starting point. When users are unable to get refills of their pain medications, they typically start to buy the drugs on the black market. Because of the high cost of the drugs, users who could, switched to heroin, a much cheaper drug. Heroin reacts with the brain in the same way as prescription drugs, so it is an easy switch. Some young adults have become addicted to heroin through recreational use. Heroin is available in most areas of Kentucky and the United States. Since 2015, there has been a marked increase in the mixture of black market Fentanyl with the heroin, which is thought to be the major cause of the increase in overdose deaths. (3) Some communities have reported several deaths in one night due to a bad batch of drugs. (3)
Kentucky has been on the forefront with policy to address the opioid epidemic. House Bill 1 was passed in a special session of the General Assembly in 2012. As described in “State Strategies for Combatting Heroin and Illicit Fentanyl”, HB 1 required the use of KASPER, required CEUs on addiction, changed requirements for ownership and operation of pain clinics, required coordination between licensing boards and law enforcement, and required licensing boards to promulgate regulations for the prescribing of controlled substances. House Bill 217 was passed in the 2013 Regular Session, which placed some of the items in HB1 into regulation and out of statute. Senate Bill 192 passed in Regular Session in 2015, and included a Good Samaritan clause for persons possessing a small amount of drugs who called 911 and stayed with an overdose victim. “The bill allows for local option syringe exchange and expanded access to Naloxone”, provides tougher penalties for drug traffickers, expands avenues for treatment over incarceration, and allocated $10 million for eight different programs. (8)
In addition to legislative efforts, there have been several efforts to educate practitioners and the public, create community grants for prevention efforts, and provide Naloxone kits. (8)
Naloxone is used in an emergency situation to reverse the effects of an opioid overdose. It is sold as Evzio and Narcan. Kentucky has provided Naloxone kits to emergency rooms in larger hospitals in the state, and is routinely carried by first responders and law enforcement.
There are three FDA-approved drugs used for the medical-assisted treatment of opioid use, to alleviate the withdrawal syndrome. They are Methadone, Buprenorphine and Naltrexone. The following descriptions are taken from the presentation “Medication Assisted Treatment for Opioid Addiction” by Mark Fisher, State Opioid Treatment Administrator.
Methadone is a Schedule II narcotic and was developed in Germany during World War II for pain relief. It is a long-acting analgesic and provides a blocking effect in the receptors in the brain. It is always delivered as a liquid. Methadone relieves the cravings, and helps the user return to “normal”, improving employment status and family life. Its safety is well-established, although there are cardiac concerns with initial use. (4)(11)
Buprenorphine is a Schedule III narcotic. Two forms were FDA-approved in 2002, Subutex and Suboxone. Both are delivered as a sublingual tablet. Buprenorphine blocks the receptors in the brain that generate the high from opioid use. Subutex is primarily used in the U.S. for pregnant women, and contains Buprenorphine, only. (Methadone is the Gold Standard when treating pregnant women.) Suboxone is Buprenorphine with Naloxone added as a means to decrease diversion. Buprenorphine can be expensive, and requires counseling. It decreases cravings and allows the user to return to a more “normal” lifestyle.
Naltrexone is not an opiate, but an opioid antagonist. It is primarily used to treat alcohol dependence. As with Buprenorphine, medication is only one component, and counseling is required. Treatment time is approximately three months, and it works best with highly-motivated patients. It can be prescribed by any physician, and is relatively inexpensive when compared to the other drugs. The stigma of visiting treatment centers is relieved with the use of Suboxone. (4)
In September 2017, CVS Pharmacy chain announced new guidelines for its pharmacists, expected to take effect in February 2018. The guidelines call for expanded customer education, for pharmacists to discuss the dangers of opioid addiction to both adolescents and their parents, a $2 million donation to federal treatment centers, new medication disposal kiosk, and holding pharmacist accountable to follow federal guidelines when prescribing opioids. (12)
All authorities agree that a successful war on the opioid epidemic must be two-pronged. Measures to stop trafficking, and measures to heal the addict are necessary. Senate Bill 192 has marked a change in Kentucky policy, treating the addict rather than incarceration. This bill also raised the risk to the trafficker, allowing up to 20 years of imprisonment. Public sentiment must change as well, and the realization that pain is not a disease is the first step.
1. 2016 Overdose Report Shows Fentanyl Driving Up Opioid Deaths, June 28, 2017, Http://kentuckky.gov/Pages/Activity-stream.aspx?n=Corrections&prld=71 ; accessed 9-20-17.
2. American Society of Addiction Medicine, asam.org/resources/definition-of-addiction; Entered site 9-21-17.
3. Opioid Death Reach Record High in Kentucky, Kelly Burch, 2-29-17, https://www.thefix.com/opioid-deaths-reach-record-high-kentucky; accessed 9-20-17.
4. Medication Assisted Treatment for Opioid Addiction, Mark Fisher, Program Administrator, State Opioid Treatment Administrator, Kentucky Division of Behavioral Health, https://dbhdid.ky.gov/dbh/documents.ksaods/2015/AckerFisherKeen3.pdf; accessed 9-15-17.
5. Our Evolving Profession and the Kentucky Lawyer; Spotlight CLE: The Opioid Epidemic in Kentucky; Inside Opioid Addiction: 10 questions with Dr. Andrew Kolodny, by Justin Allen; reprinted from https;//www.ket.org/opioids/inside-opioid-addiction-10-questions-with-dr-andrew-kolodny/99/9/16; http;//www.kybar.org/resource/resmgr/2017_conventionnnnnnn/pdfs/Opioid_Epidemic.pdf; accessed 9-19-2017.
6. J.Gen Intern Med. 2006 Jun;21(6);607-612.dio: 10.1111/;1525-1497.2006.00415.x
7. Kentucky has most opioid-dependent patients with private insurance, Terry DeMio, June 19, 2017, http;//www.cincinnati.com/story/news/2017/06/19/Kentucky-has-most-opioid-dependent-patients-private-insurance/395458001/; accessed 9-15-17.
8. Our Evolving Profession and the Kentucky Lawyer, 2017 annual convention, June 21-23, 2017; Spotlight CLE: The Opioid Epidemic in Kentucky; State Strategies for Combatting Heroin and Illicit Fentanyl; NGA Center for Pest Practices Learning Lab; http;//www.kybar.org/resource/resmgr/2017_convention/pdfs/Opioid-Epidemic.pdf; accessed 9-19-2017.
9. Our Evolving Profession and the Kentucky Lawyer; Spotlight CLE: The Opioid Epidemic in Kentucky; The Heroin Epidemic-There’s a New Drug of Choice in Kentucky: Heroin, Fentanyl; Reprinted from http;//odcp.ky.gov/Pages/The-Heroin-Epidemic.aspx; http;//www.kybar.org/resource/resmgr/2017_convention/pdfs/Opioid-Epedemic.pdf; accessed 9-19-2017.
10. Our Evolving Profession and the Kentucky Lawyer; Spotlight CLE: The Opioid Epidemic in Kentucky; Creating a Region-Wide Response to the Opioid Crisis in Western Kentucky, Patrick Reed; Reprinted from httpsl//www.ket.org/opioids/creating-a-region-wide-response-to-the-opioid-crisis-in-western-kentucky/(3/15/17); http;//www.kybar.org/resource/resmgr/2017_convention/pdfs/Opioid-Epidemic.pdf; accessed 9-19-2017.
Our Evolving Profession and the Kentucky Lawyer, 2017 annual convention, June 21-23, 2017; Spotlight CLE: The Opioid Epidemic in Kentucky; Maintenance Medication for the Opiate Addiction: The Foundation of Recovery; Gavin Bart, MD, FACP, FASAM; (2012) Journal of Addictive Diseases, 31:3, 207-225, DOI:10.1080/10550887.2012.694598
11. , reprinted by permission of Taylor & Francis, LLC (http;/www.tandfoline.com). http;//www.kybar.org/resource/resmgr/2017_convention/pdfs/Opioid-Epidemic.pdf; accessed 9-19-2017.
12. CVS to Follow Federal Guidelines for Opioid Prescriptions; Laura Kelly, The Washington Times; 9-21-12, www.washingtontimes.com; accessed 9-21-17.