Second of a two-part series
By Ed Runyan
It’s been a challenge to explain why Trumbull County’s problem with drug-overdose deaths has risen at such an alarming rate in recent years, but one factor is the amount of prescription drugs in the marketplace.
It’s a problem Jeff Orr, a longtime drug-enforcement commander, has mentioned several times over the years – too many legally prescribed opiates in the community.
“We overprescribe here for opiates,” Orr said in March 2015. “We way overprescribe.”
The state has taken several steps over the years to slow the rate of opiate scriptwriting, such as keeping closer track of how many opiate prescriptions are filled at Ohio pharmacies and putting that information into a database that law enforcement can access.
In January 2016, the state issued guidelines requiring doctors to use the database before writing certain opiate prescriptions, to know whether the patient also is getting them elsewhere.
And on March 31, Gov. John Kasich announced that doctors can no longer write a prescription for more than seven days of opiates for an adult and five days for a minor, with some exceptions, to further curb overprescribing. The specific rules for physicians will be written later.
Ohio is first
Ohio ranked No. 1 in the nation in 2015 for overdose deaths, surpassing states with much more population, according to the Kaiser Family Foundation.
Ohio was fourth in the nation in 2015 for overdose deaths per 100,000 of population, according to the U.S. Centers for Disease Control and Prevention. Neighboring states West Virginia and Kentucky were first and third, with New Hampshire second.
The reason for limiting the quantity of opiates a patient gets is so that excess drugs in the medicine cabinet don’t end up in the wrong hands, Orr said.
Some people fill a prescription for pain medication and “leave them sitting around,” Orr said. “The more [opiates] that are available, that means the abuse is going to be up,” Orr said.
If you talk to addicts, many will tell you their craving for opiates such as heroin began with a pain pill such as oxycodone, Orr said.
Orr, who was with the Trumbull County Sheriff’s Office and was commander of the Trumbull Ashtabula Group Law Enforcement Task Force for decades, said the Ohio Board of Pharmacy plans to roll out additional measures in the future to use its database of opiate prescriptions to target individual drug abusers.
“They are going to recognize that [a person] has a problem and [the person] needs to get help. Rather than coming out and putting you in prison, they recognize that you have an addiction problem and the board of pharmacy is going to help get you resources to help you get off of that, get you into a system where there’s a contract to get you some help,” he said.
Orr says local physicians have reduced the amount of opiates they prescribe in the past year or so especially.
“We are coming down. We are still seeing more opiates prescribed in Trumbull County than the rest of the state,” he said. “We still have work to do to bring it down a little lower through educating doctors and patients.”
According to the Ohio Department of Health, Trumbull County had the 12th highest overdose-death rate per 100,000 people in the state from 2010 to 2015. Mahoning County was 19th.
Patients in Trumbull County also got among the largest amounts of opiate prescriptions per person in the state from 2010 to 2015, ranking tied for ninth out of the 88 counties. Mahoning and Columbiana counties are well down the list.
Most of the Ohio counties with high rates of overdose deaths and opiate prescribing have been in southern Ohio, where “pill mills” took root a decade ago.
The state closed down southern Ohio’s pill mills in 2010 and 2011. One of those counties, Scioto, still has a serious problem with overdose deaths, and doctors there still write prescriptions at a high rate.
Scioto County, however, saw a reduction in opiate doses per year between 2010 and 2015 of almost 24.6 percent. In Trumbull, the drop was 1.1 percent.
Mahoning County saw a 9 percent drop, Ashtabula County 19.5 percent, Columbiana County 4.3 percent, Jefferson County 12 percent and Cuyahoga County 9.8 percent.
Statewide, the number of opiate prescriptions written by doctors peaked in 2012 and steadily dropped 9.9 percent between 2010 and 2015, the most recent year for which complete-year data are available.
Dr. Daniel Brown, chief medical officer with Meridian Healthcare, sometimes writes prescriptions for opiates but is best known for helping people overcome drug addiction.
Dr. Brown said the most recent guidelines for Ohio doctors are intended to continue to reduce the amount of opiates in the community.
“They can’t just give you a month of medication anymore, which makes a lot of sense, to reassess that pain on a weekly basis,” he said. “They are just demanding that physicians monitor it more closely and see the patients more frequently and stop the medication if there are any signs of abuse or signs that the medication is no longer needed.”
Dr. Brown said he thinks the majority of physicians are responsible in how they prescribe and know how to do it the right way.
“Unfortunately we’ve seen some bad actors in the area. This will allow the board of pharmacy and others the ability to monitor and crack down on those so-called pill mills,” he said.
“Patients who are coming in for addiction treatment are reporting that there really is very, very limited amounts of prescription drugs on the street right now,” Brown said. That causes addicts to switch to cheaper heroin and fentanyl.
Dr. Brown notes that the current heroin crisis was aided by a change in the attitude of the national medical community in the 1990s about opiates such as OxyContin.
“A lot of that was fabricated by pharmaceutical industries that were selling long-acting pain medications like OxyContin,” he said. “There was this general trend toward more prescribing that started in the ’90s and it’s just self-correcting at this point.
“Looking back historically in the 1990s, a lot of physicians were trained that we were undertreating pain and that the risk of creating addiction was a lot lower than what we all had been taught,” Dr. Brown said.
“Historically in this country there have been epidemics of opiates and heroin many many times over many, many different years that have been caused by different prescribing habits,” Brown said.
He said heroin was first released in 1898 by the Bayer Corp. as a cough medication. It caused an epidemic of addiction and death in places such as New York City. “It’s a lesson that seems to keep repeating itself,” Brown said.
Dr. James Enyeart, a Girard physician and the Trumbull County Combined Health District medical director, was asked whether he thinks Trumbull County physicians are too quick to prescribe a pain pill when something over the counter would be sufficient.
“Honestly, it’s hard for me to think of that,” he said. “Why would you give something to somebody that they didn’t need?”
With some patients, surgery isn’t the answer, he said.
Dr. Enyeart, who specializes in geriatrics, said that as a person ages, the “harsh effects, the side effects, of medications increase.” And over-the-counter pain relievers are “fraught with long-term use problems, primarily hypertension, heart attacks, strokes, kidney disease and things like that.”
When asked whether patients sometimes manipulate a doctor to prescribe opiates, he said: “If you have a problem and go to the doctor, do you want him to solve it? You would want some help, I would guess. Well, it doesn’t matter if it’s shortness of breath or pain or whatever. I would assume any professional person would do whatever was in the best interest of the patient.”
When asked why Trumbull County patients receive more opiates, on average, than people in many other counties, he said the age of the people is probably one.
“What I see is an aging population,” he said.
Tracy Plouck, director of the Ohio Department of Mental Health and Addiction Services and a Trumbull County native, said during a recent visit to Warren that the “oversupply of pills” in a community is always a “driver” for drug abuse.
The Ohio Board of Pharmacy and Ohio State Medical Board are interested in hearing allegations about inappropriate prescribing by doctors, she said.
The second “driver” is the high availability of heroin coming into Ohio from Mexican cartels. The Mahoning Valley is among communities that are more exposed to the influx of cheap heroin because it has one of the major highway arteries (Interstate 80) running through it, she said.
Ohio Attorney General Mike DeWine filed a lawsuit May 31 in Ross County Common Pleas Court in southern Ohio, one of the hardest-hit counties for overprescribing opiates.
The suit seeks damages against five pharmaceutical companies, alleging that they engaged in fraudulent marketing regarding the risks and benefits of prescription opioids.
Among the allegations in the suit is that the companies led doctors to believe opioids were not addictive and that addiction was easy to overcome.
It says the companies identified doctors to serve “for payment, on their speakers’ bureaus” and deliver scripted, misleading information that influenced their colleagues to view opioids as safe.
The suit cited New York physician Russell Portenoy, who was paid by two of the companies while speaking on ABC’s “Good Morning America” in 2010 and influencing policies in 1997 and 2009 for a national committee that encouraged the regular use of opioids to treat chronic pain.
Portenoy later admitted that he gave “innumerable” lectures in the 1980s and 1990s about addiction that “weren’t true,” the lawsuit says.