Reversing the Drug Trend
Dr. Carl Sullivan has been finding solutions to addiction for decades and developed a comprehensive opiate addiction treatment.
Dr. Carl Sullivan has been finding solutions to addiction for decades and developed a comprehensive opiate addiction treatment.
IT STARTED WITH A CAR ACCIDENT,
which resulted in a permanent metal plate in her side. Then highly addictive pain pills to numb the chronic pain. A childbirth, resulting in more pills — and a path of deeper addiction.
When the pills ran out, the cravings didn’t stop. Blair Crisson turned to heroin — a cheaper, easier-to-find alternative.
“Pain pills just became too expensive … so I had to move on to bigger and better things to feed the addiction,” said Crisson, who is 25 and lives in Morgantown, W.Va. Before long, navigating a needle down into the veins of her arm was routine to stave off the pain.
“Addiction is not something I can describe,” she said. “It’s unlike anything else you’ve ever experienced. It takes ahold of you, and it doesn’t let go.”
The national climate of prescription opioids changed some 15 years ago when outpatient doctors began overprescribing these highly addictive drugs to treat pain.
Between 1999 and 2014, sales of prescription opioids in the U.S. — medications like Vicodin, Percocet and OxyContin — quadrupled, according to the Centers for Disease Control and Prevention.
Why? Well, it was partly due to the marketing from pharmaceutical companies that sold the drugs and two small accounts published in medical journals that claimed most patients would not become addicted to these opiates. That — coupled with “pain clinics” popping up that found a gray area in which to operate to make a quick buck off patients who suffered from the desire to get their fix — the use of pain pills skyrocketed, according to West Virginia University Reed College of Media associate dean and associate professor John Temple’s new book “American Pain.”
"Doctors would make $75 a patient, and they could see a patient every four minutes."
“American Pain,” which critics have named an essential read in the nation’s painkiller saga, chronicles how a young felon in Florida and his ring of doctors helped to unleash America’s deadliest drug epidemic by operating the largest pain clinic in the nation. Temple shows how a collection of ex-convicts and construction workers exploited a vulnerability in oversight for these types of clinics that enabled them to hire doctors who prescribed massive amounts of pain pills — often without being seen. And with cash — lots of it — changing hands.
The story begins with a group of homebuilders who had a small steroid clinic side business with a doctor who wrote prescriptions for bodybuilders. When the housing market crashed and the men were no longer building homes, the doctor suggested looking into painkillers, because many more people wanted them — and would pay dearly for them.
“They had no idea,” Temple said. “But they opened a tiny hole-in-the-wall clinic with one doctor. And it exploded. They were young, aggressive businessmen, and it blew up. It became the biggest drugseeker destination in the country.”
People facing the same dilemma as Crisson started out seeking pain pills to make real pain subside, but as these highly addictive pills were being overprescribed, it created a gnawing addiction and a need to seek out these clinics.
“There was this veneer of no one talking about it,” Temple said. “The doctors acted like it was this legitimate business, even though all day long, they’re writing gigantic prescriptions for the same high doses — never referring anyone out to another place or doing any real examination of any kind.
“Doctors would make $75 a patient, and they could see a patient every four minutes. A patient would come in, say their back hurts, they’d get an MRI so there was something to put in the patient file, and the doctors would write a huge prescription for dangerous, addictive heroin-like pills. Even on the first visit.”
The Florida business grew to include lots of doctors, two pharmacies and multiple pain clinics. Carloads of people would travel down I-95 and I-75 to load up on pills and return home — most often to Kentucky. Or West Virginia.
Appalachia provided the perfect environment for addiction to take hold: poverty, lack of jobs, low education rates and a sense of desperation, said Clay Marsh, BS ’81, Biology, MD ’85, vice president and executive dean for WVU Health Sciences.
“West Virginia is this microcosm for what’s really happening nationally with opioid abuse,” Marsh said. “At the root of addiction here is the breakdown of communities and lack of purpose. Communities are failing because of economic pressures and educational pressures, and when drugs come into these communities, it breaks down that connection.”
With a shaky foundation and lack of financial stability in Appalachia, the addiction to pain pills took another turn.
Pain pills aren’t cheap. Oxycodone sells for about $1 per milligram, so a typical “oxy 30” sells for $30 on the street. When the crackdown on pain clinics began just a few years ago, pain pills became more expensive and more difficult to obtain, Temple said.
In Appalachia, where about 18 percent of the population lives below the poverty line, that meant people went searching for a cheaper fix.
“Heroin became easier to find,” Crisson said. “It was everywhere. It was cheaper. It was easier to get … So, I got it.”
Heroin feeds the same addiction. The only difference between pills and heroin, Temple said, is how people use it.
“People tend to think of heroin as being super scary, but it’s the same addiction,” he said. “There is no significant difference pharmaceutically between heroin and oxycodone. It’s the same basic drug.
“The main thing — to gauge how bad someone’s addiction is — is their method of ingestion,” he said. “Do they take pills at a party, which gives them a buzz? Do they snort a pill, which gets into their bloodstream faster? Or, do they inject it — including those using pills. Each is sort of a graduation to a more hardcore addiction. Heroin is a graduation because it’s illegal, but beyond that — the high is basically the same thing.”
As the addiction to pain pills and heroin that festered in West Virginia — feeding on struggling communities, workplace injuries and a lack of hope — began blanketing the country, it spiraled into a full-blown epidemic.
Drug overdose deaths have overtaken car crashes as the leading cause of accidental deaths in the United States. More than 47,000 people died from drug overdoses in 2014 — 1.5 times greater than the number killed in car crashes.
“The drug problem is a symptom of a bigger problem, and West Virginia is a place where you might see it more quickly and more clearly than other places. We know there’s a significant problem. We have to figure out what comes next, as a state — and ultimately as a country.”
West Virginia has the highest rate of prescription drug and heroin overdose deaths in the nation. In 2014, there were 35.5 drug overdose deaths per 100,000 people in West Virginia, according to the Centers for Disease Control and Prevention.
The epidemic hit West Virginia hard early on, leading doctors at WVU to develop a response first — one that other universities around the country have followed.
"Opioids alter the reward pathways in the brain, and the drug is engineered perfectly to fit those sensors — in an almost scary way."
The University started the Addictions Program in 1982 when 90 percent of patients
sought help for alcohol addiction, said Carl Sullivan, BA ’74, Biology, MD ’80,
director of the program at WVU Medicine.
“In the decade of the 1990s, I saw maybe just two or three people total using heroin,” Sullivan said. “I remember so distinctly sitting in this office and thinking if you have an opioid addiction, it’s hopeless. Just hopeless.
“From the late 1990s and carrying on through today, the treatment focus has switched remarkably from alcohol to opioids. Then, slowly, heroin started to come in. Now, it’s almost exclusively prescription opioids and heroin.”
Previously, heroin addiction was only really found at the extremes — in urban centers or among rock stars, Sullivan said.
“But now it’s so pervasive. It’s everybody. If you look at the clinic, these people look like everybody else — you or I,” he said. “They look like your typical cross-section of American society. These are not people who are down and out, living under a bridge and standing in alleys.
“They’re married, divorced, have kids, some have jobs, some don’t. Some are pregnant, some are living in a homeless shelter, an abandoned house, while others are working long hours in managerial positions. Others are nurses and doctors. It’s the whole spectrum. Opioids alter the reward pathways in the brain, and the drug is engineered perfectly to fit those sensors — in an almost scary way.”
An aspiring nurse. With one kid and another on the way. Someone with a desire to help others. That was Crisson.
“That’s the scariest part about this disease: Heroin doesn’t discriminate,” she said. “It doesn’t matter who you are, what you’re doing, what your dreams are. It takes hold, and nothing else matters.”
That was where she found herself. Heroin had become the priority in her life, and she learned she was 13 weeks pregnant. She knew she needed help.
WVU, one of the first medical schools in the nation to have a formalized addiction program, was also one of the first to create a specific opioid addiction treatment plan, which Crisson enrolled in just about a year ago.
Sullivan and his team developed WVU’s Comprehensive Opioid Addiction Treatment program. It incorporates successful portions of other types of addiction treatment programs to create a comprehensive plan to battle opioid use disorder — the disease of opioid addiction.
One important piece was the availability of Suboxone, one brand of a buprenorphine-based medication that treats opioid addiction.
“Suboxone … if you give them the right dose, allows addicts to just feel normal for 24 hours,” Sullivan said. They’re not high. They’re not going through withdrawal. They just feel normal.
“And, it would be hard to overstate how important that is — how good that is — to an addict to just feel normal,” said Sullivan, who saw 30 patients on this particular spring morning — anywhere from zero days clean, up to more than 10 years clean.
But Suboxone by itself wasn’t enough.
"For the first time in my life, I feel like this life is too good to throw away."
“Initially, we used Suboxone to just detoxify, which worked fantastically,” Sullivan said. “Then, with mind-numbing regularity, they relapsed over and over again. Nobody was getting better. It was terrible. They were detoxed but not getting treatment.”
That’s when Sullivan combined the use of Suboxone with education about opioid addiction, individual and group therapy, and 12-step meetings — which had shown previous success in the now mostly defunct 28-day programs for addiction used in the 1980s.
“When we put this in place in 2004, nobody else in the country was doing this,” Sullivan said. “And, it has since been refined, but what it allows us to do is to treat patients both efficiently, effectively and in a cost-effective manner they can afford.”
Sullivan noted that Suboxone, when used correctly, is the most useful thing that has ever happened to the opioid addict. However, the skyrocketing need for the treatment combined with doctors who have no training with the medication has led to many pill mills across the state.
“Too many doctors just hand out the medication with virtually no therapy for the patients’ addiction … and often the doctor only takes cash,” Sullivan said. “While there is nothing inherently wrong with accepting cash, a legitimate clinic must provide the ‘assisted’ part of ‘medication-assisted treatment’ when using a medication like Suboxone. It’s really unfortunate that too often appropriate treatment is not provided. These patients are sick and desperate, and we have to find ways to help them get better.”
Sullivan’s clinic now sees about 450 patients, including Crisson, with another 538 on the waiting list. Almost 50 group therapy sessions per week are held, including telepsychiatry groups for southern West Virginia counties, pregnancy groups and men’s groups.
Clinics around the country are modeling their programs after WVU’s in hopes of seeing similar results.
“It’s all of it together that has really helped me get clean for a year and counting,” Crisson said. “It’s not just the medicine. It’s not just the meetings. It’s not just the therapy. It’s the combination of it all together that’s different from other places and other times I’ve tried to get clean. It’s connecting with other people and doing my part to help the next person.”
WVU is partnering with other institutions to help expand these efforts.
“We want to collaborate with everybody to do the right thing for the state,” said Marsh, who has named the opioid epidemic a University healthcare priority. “Our role as a land-grant university is to work with others to help solve these big problems. Each person can bring knowledge to the table, and we can help each other to help bring about better opportunities and communities.”
This treatment program has helped to change how Sullivan sees the future of opioid addiction.
“Things have changed,” he said. “People are getting better. I thought opioid addiction was a hopeless disease 15 years ago. I don’t feel like that anymore. I feel like there is hope now.”
Crisson has been clean now for about a year. She received her certification as a medical assistant and has begun working with preschoolers — getting back to her passion, helping people.
“I feel like I have the tools now to cope when something goes wrong,” Crisson said. “I don’t just look to go use. I have people I can rely on, and this life is too good.
“For the first time in my life, I feel like this life is too good to throw away.”