Funerals For Friends: How Public Health In Colorado Handles Growing Prescription Drug Misuse

A health leader from Colorado's stunningly beautiful but economically challenged San Luis Valley sobered an afternoon crowd by declaring that his rural community was "flirting with an epidemic" of opioid overdoses and deaths.

Hours later, statewide experts called that assessment of substance use in the West too optimistic. "It's more like a shotgun wedding with an epidemic," pronounced Robert Valuck, an epidemiologist, professor at the University of Colorado Denver Skaggs School of Pharmacy and Pharmaceutical Sciences, and coordinator of the Colorado Consortium for Prescription Drug Abuse Prevention.

The opioid painkiller epidemic, leading directly to use of cheaper and even more dangerous heroin, is all too real in every state of the union, Valuck warned his evening audience on the opening night of the Colorado Health Symposium 2016. Valuck elicited audible gasps from the crowd when he offered a math lesson in modern opioid prescribing—enough scripts are now written in the United States each year to give every adult a Vicodin every four hours for an entire month.

In Colorado's rural southern counties, where overdose death rates are climbing at an alarming rate, the destruction is all the more visible, said Freddie Jacquez, executive director of the San Luis Valley Area Health Education Center. "We know these people," Jacquez said. "We're going to a lot of funerals."

Intense and often emotional discussions of substance use were purposely programmed into the Colorado Health Foundation's 2016 forum in Keystone, Colorado. Substance use and other behavioral health issues were among the top community concerns at nearly every stop on a six-month listening tour of every county in the state undertaken by foundation president and CEO Karen McNeil-Miller. Unprompted, national health leaders invited to the conference also painted vivid portraits of substance use problems from their own work, including Baltimore Health Commissioner Leana Wen's battles to save a teenage patient in the emergency department (ED) who was addicted to pain pills.

Moderators at the symposium framed the talks this way: Colorado is in the midst of a unique experiment with its residents' capacity to handle a flood of mind-altering substances.

• Overdose deaths from opioid abuse have tripled or quadrupled in many counties, reflecting a national epidemic that has pushed prescription drug deaths above even car accidents and guns in causing injury-related deaths.
• Colorado is on pace to sell well more than $1 billion of legal marijuana in 2016, and while teenage use appears flat so far, the culture of drug acceptance worries many in the addiction treatment community.
• More and more babies are being born with marijuana or opioids in their systems in cities ranging from Denver to Aurora to Pueblo—thus, taxing hospital and community health services.
• Tourism and economic development officials celebrate Colorado's growing status as a pioneer in craft beer, yet binge drinking and alcoholism rates combine with other substance use to spotlight the state as a multidrug threat for abuse in federal statistics.

Valuck noted that state government officials and public health leaders are working to slow the flow of prescription opioids by improving the state prescription monitoring database and training doctors on the importance of checking it. But only seven states—not including Colorado—actually require doctors to check the database for abuse before issuing a new prescription, Valuck added.

Physicians can be hard pressed to use a complex database to track prescriptions and fully educate patients about the dangers of drug misuse and addiction when they practice in health systems often designed around twenty-minute appointment blocks, said Ingrid Binswanger, a practicing physician and senior investigator at Kaiser Permanente's Institute for Health Research. Patients arrive suffering real pain, and physicians must balance the risk of addiction with their professional obligation to offer help, she said.

Many people recovering from addictions would like the chance to sit down with prescribing providers and help them understand the reality of opioid use, said Austin Eubanks, a program director at The Foundry treatment center, in Steamboat Springs. Eubanks brought his personal story to the symposium, where he explained how his injuries from being a shooting victim in the 1999 Columbine High School massacre, and the psychological trauma of seeing a friend murdered in the school's library, led him to addiction.

Doctors and counselors need to help patients work through their mental health issues before prescribing mind-numbing opioids for pain that will delay holistic recovery and risk addiction, Eubanks said.

Back in Colorado's San Luis Valley, a growing network of community activists and agencies are trying to focus on what substance use issues they can control first. Jacquez worried that funding for the substance use fight in the San Luis Valley will end just as they are knitting together the right coalition. "We didn't get here overnight, and we're not going to get out of here overnight," he told his audience.

Jacquez said the concept of slowing the supply of opioids can seem daunting, and what he and his colleagues need to do right now is keep people alive.

Health leaders are trying to spread the highly effective anti-overdose drug Naloxone—which anyone can administer through a nasal spray —to as many community sites as they can. They have already saved lives by getting this opiate-countering drug as close to at-risk addicts as possible, Jacquez said.

Save people first, and they can live to fight their addiction for another day, as Jacquez put it. Both Jacquez and Wen dismissed recent worries that Naloxone is merely an enabler, giving addicts a false sense that they can overdose without consequence.

If a girl with a peanut allergy walks into her Baltimore ED in reactive shock, no one says, "We're not going to give you the Epi-Pen because you might eat peanuts again," Wen said. That would be absurd.

Jacquez said that spotlighting a community crisis is not popular in small towns, and yet the magnitude of the opioid epidemic has thickened his skin.

"Let's save some lives," he said. "I'll take the heat."

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