Confronting An Opioid Crisis And Promoting Health From All Angles

Photograph by Shaun Ring

The University of Kentucky (UK) researchers were outsiders, so they brought food. They purchased a tent and a grill, set up in a gas station parking lot in the foothills of eastern Kentucky, and started cooking hot dogs.

They’d already tried posting fliers and then yard signs along the side of the road, with a phone number to call about a rural health study. “We were having a hard time breaking through,” says April Young, an associate professor in the Department of Epidemiology at the UK College of Public Health. “We thought it was worth a shot.”

On that 2017 day, they led with free food and a listening ear. They told anyone who stopped by that they were interested in learning more about how opioids had impacted them or their community in Appalachian Kentucky.

“That would start a conversation, and they would realize that we weren’t judgmental and that we cared,” Young says. “They would go back and spread the word that we weren’t so bad after all, and other people would come out of the woodwork.”

Opioids remain a seismic crisis for communities across the United States. In 2019 the National Safety Council reported that for the first time, Americans were more likely to die from an accidental opioid overdose than in a motor vehicle wreck.¹ Over the past decade the Bluegrass State has been among those particularly hard hit. Between 2009 and 2018 the number of patients treated at two of UK’s hospitals in Lexington for opioid use disorder and related medical issues, such as blood infections or hepatitis C, increased from about 1,500 patients to 8,782 patients by 2018, according to data that the university provided a local newspaper. The treatment bill for the two hospitals also swelled during that same stretch, from $7.6 million to $63.3 million.²

But statistics don’t even begin to capture the human costs, says Young, describing how a generational cycle of opioid and other substance abuse can develop. Children may grow up in households where drug use is the norm, or they may end up in the foster system because their parents have died or are in jail, she says. “For those folks, it’s very hard to be resilient when a lot of odds are stacked against them.”

Young’s research has since morphed into a broader federally funded study in eastern Kentucky with field offices, advisory boards involving active users, community coalitions with local leaders, and the collection of extensive survey and testing data. But that research initiative, conducted with Emory University co–principal investigator Hannah Cooper, is only one piece of a wide-ranging effort by UK clinicians and researchers through various programs and initiatives to help state residents kick their abuse of opioids—from pills to other forms, including heroin.

Photograph by Shaun Ring

In recent years the researchers have trained hundreds of Kentucky pharmacists about naloxone, after a 2015 change in state law enabled pharmacists to dispense the opioid reversal drug under a physician’s protocol. They’ve opened clinics and programs to assist those seeking recovery, including one for pregnant women and another for patients who have recently left the hospital after an opioid-related crisis. They’ve taken steps to reduce the amount of opioids that are prescribed after some common surgeries, such as gall bladder removal. And they’re getting out of their offices more to meet with people who are in recovery or struggling to get into treatment.

It’s a complex network of programs with equally complex, braided funding streams. Some elements have been funded largely or exclusively through grants. Other elements have relied on billing for treatment through Medicaid or other insurance payers, as well as some state resources and direct funding from UK. Other state-driven initiatives include a prescription drug monitoring program, first launched in 1999 to track controlled substance prescriptions, and various moves to expand access to medication-assisted treatment, including providing Medicaid coverage starting in 2015, according to a federal summary.³

Along with these ongoing efforts, Kentucky was one of four states tapped by the National Institute on Drug Abuse in 2019 to receive vast funding to combat the opioid crisis through the federal government’s HEALing (Helping to End Addiction Long-Term) Communities Study.⁴ The Lexington-based University of Kentucky, which was awarded more than $87 million, has committed to reducing opioid overdose deaths, with a project goal of achieving a 40 percent reduction in deaths.

The Kentucky project, which will be completed by 2023, focuses on sixteen counties highly affected by the state’s opioid crisis, which have been randomized into two groups. Counties in both groups will get access to the same bevy of opioid treatment and prevention strategies, including expanding access to naloxone and medication-assisted treatment such as buprenorphine and reducing the local opioid supply by reducing prescribing and encouraging the safe disposing of unused opioids. But the two groups will start getting the community interventions at two different times, with group 2 beginning twenty-four months after group 1. That difference in timing will allow researchers to parse associations between the interventions and any potential improved outcomes. For example, to determine the reduction in opioid overdose death rates, the deaths from group 1’s second year of implementation will be compared with data from group 2 during the same time—a period when group 2 will not yet have started the interventions, study organizers say.⁵

Photograph by Pete Comparoni

According to Michelle Lofwall, a psychiatrist and addiction researcher who is part of UK’s HEALing Communities team, the overarching goal is to educate clinicians and residents in the participating counties that opioid use disorder can be treated just like diabetes or any other chronic medical condition. “So that they understand that opioid use disorder is a disease, and that it can go into remission,” she says. “That medication access greatly reduces the risk for death, there are no ‘ifs,’ ‘ands,’ or ‘buts’ about it.”

The disorder may begin with prescribed pills, but individuals may then transition to heroin, which is cheaper to obtain, Lofwall says. Once they’re injecting drugs, they risk developing serious infections, such as to the heart valves or the brain, she says.

“The heartbreaking thing is that it’s really sad when you’re seeing some of these patients and you know they’ve had many visits and many contacts with the medical system,” Lofwall says. “And it’s clear that they were injecting drugs. And no one has ever screened them or offered them treatment. And it’s now become a life-threatening illness. And sometimes we’re too late.”

‘The Beating Heart’

Deaths from substance use disorders have surged in recent years in Kentucky. An analysis of US counties published by JAMA in 2018 showed that eastern Kentucky along with adjacent West Virginia had among the highest rates of fatalities.⁶ Kentucky also ranks among those states with the highest rates of suicide, according to the same JAMA analysis. Smoking rates remain high, part of the explanation for why Kentuckians are more likely to die of cancer than residents of any other state, according to 2018 federal data.⁷

“If you look at a heat map of deaths of despair, Kentucky is the center,” says Alex Elswick, cofounder of Voices of Hope, a Lexington-based nonprofit organization that supports people seeking recovery. “Kentucky is like the beating heart of the heat map.”

The physical labor required for coal mining, farming, and other jobs resulted in the back pain and other injuries that played into the hands of pharmaceutical companies marketing the drugs in Kentucky and elsewhere, Young says. “People needed opioids to be able to get back to work.”

Meanwhile, nonopioid treatment options can sometimes be scarce, says Trish Freeman, a pharmacist at the UK College of Pharmacy, who also is part of the HEALing Communities team. Freeman has conducted extensive research related to the opioid crisis, including interviews with primary care providers in Kentucky about their opioid prescribing practices.

“Some of them would say to us, ‘Well, what choice do I have?’” Freeman says. “‘I have a person who has legitimate pain. I’m in this rural community, there is not a massage therapist here. There is not a physical therapist here. I don’t have nonpharmacologic options for pain the same way that you have in Lexington.’”

Young’s outreach in eastern Kentucky has made her a bit of a road warrior. The research initiative she helps lead, called CARE2HOPE (Kentucky Communities and Researchers Engaging to Halt the Opioid Epidemic), focuses on a twelve-county region that stretches from one to three hours southeast of her Lexington office.⁸ The project, which works closely with local residents, is striving to research and develop community-driven strategies to get more people into opioid treatment and reduce harms, such as overdoses. For instance, CARE2HOPE is working on getting people into opioid treatment who have just been released from jail.

Young and her colleagues have witnessed a lot of heartache along the way. From detailed surveys and periodic testing involving more than 300 residents—current opioid users or those in recovery—they know that about 60 percent already have hepatitis C. Roughly one-third were homeless as of earlier this year. Methamphetamine has reemerged in recent years—not the home-cooked version, but crystal meth sold through drug dealers, Young says. Users may alternate between methamphetamine and opioids, sometimes using the former to stay alert on the job and then switching to an opioid to come off the meth high, she says.

But despite the challenges, and the damage that the drugs have already inflicted, there are some inherent sources of resilience that can be tapped in these rural eastern Kentucky communities, says Young, who grew up in rural Georgia.

“The social connectedness can be a real strength,” she says. “Often these families have lived in these communities for generations, and so there’s a strong connection to place. That can be a strength and a real sense of pride. Those are all, I think, really important forces for potentially shaping better health outcomes.”

‘Too Much…Too Long’

Elswick, now age 29 and more than six years in recovery, traces his own slide into first oxycodone use and later heroin to wisdom teeth surgery at age 18. Initially he was prescribed about five days of oxycodone. “Then I got dry sockets in all four of the wounds in my mouth, so I went back,” he recounts.

He was prescribed ten more days. “I would much rather have just taken the pain in retrospect, though,” he says. When that prescription ran out, Elswick felt a bit sick, and his struggles with anxiety really ramped up. “On a cellular level, I knew if I could get some more of the medication, I would feel OK,” he says. “So I started buying them on the street.”

Another patient, Lydia, who asked that her last name not be used, has been in opioid treatment since 2015 with the help of several UK programs. She blames the start of her disorder on a brutally painful tonsillectomy surgery at age 19. “I would rather go through four more births of children vaginally than have a tonsillectomy again,” she says.

The doctor initially prescribed what she describes as a “giant bottle” of Percocet, which got her through most of her painful recovery. But Lydia admits that when she asked her doctor for another prescription, it wasn’t so much for pain anymore.

“It had started making me feel like Superwoman,” says the 30-year-old. “It made me feel like I could conquer the world. It gave me energy.”

UK HealthCare, a sprawling institution that includes three acute care hospitals and an array of medical, public health, nursing, and other health colleges, joins other academic medical institutions in the US that have taken a hard look at their prescribing practices as the opioid crisis worsened. “Basically, if we don’t have to use these drugs for somebody, then we don’t,” says Douglas Oyler, a pharmacist who directs UK’s Office of Opioid Safety.

Oyler was part of one of the first efforts at UK HealthCare to reduce opioid prescribing, focusing on trauma patients coming through the emergency department. To minimize opioid use, the patients were offered alternatives, including nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen; acetaminophen; some types of muscle relaxants; and drugs that can ease nerve pain, such as gabapentin.

The approach reduced the total dosage of opioids that trauma patients were discharged with by roughly half compared with those who were treated before the opioid reduction strategy was implemented, according to the findings, published 2018 in the American Journal of Health-System Pharmacy.⁹

Since then, efforts have been made to eliminate opioid prescribing after some operations, such as thyroid surgery. In other common surgeries, such as gall bladder or appendix removal, the goal is to send patients home with just three pills of either oxycodone or another opioid, tramadol, Oyler says.

In years past it wasn’t uncommon for patients undergoing one of these general surgeries to be prescribed thirty opioid pills afterward, which poses several risks, Oyler says. “They are probably taking too much on a given day, or they’re taking it for too long,” he explains. “We know that the longer that you expose an individual, the higher their risk for developing problems associated with opioid use.”

Plus, he adds, what if the patient stops after a few days and leaves the extra in a medicine cabinet for someone else to find? He points to an analysis, published in 2019 in JAMA Internal Medicine, which showed that the risk of an opioid overdose was nearly three times higher if someone in the household had been previously prescribed the drug.¹⁰

By 2019 the three hospitals that are part of UK HealthCare were dispensing the equivalent of 280,000 fewer opioid pills annually to hospitalized patients—based on an average hydrocodone 5 mg dose—compared with what was dispensed in 2016, according to data from the Office of Opioid Safety. Also in 2019 only 5.8 percent who weren’t taking an opioid immediately prior to hospitalization or surgery—often described as opioid naïve—were sent home with an opioid prescription. Just three years before, in 2016, 16 percent were.

Now Oyler has teamed up with surgical oncologist Emily Marcinkowski to apply for a federal grant to study opioid-free mastectomy surgery. Under the protocol, patients would instead follow a scheduled regimen of acetaminophen and ibuprofen, Marcinkowski says. “It’s not that we’re not giving them pain medicine—it’s just not narcotic pain medicine.”

Since 2018 the breast surgeons have already adopted a more limited pain management approach following mastectomy, only prescribing either twenty pills of oxycodone 5 mg/acetaminophen 325mg (Percocet) or twenty pills of oxycodone 5 mg, Marcinkowski says. Other changes have been made. Patients are given the prescription before surgery so they can fill it in advance and are told that it’s their only one.

Just as crucially, the surgeons educate patients about what’s considered pain control, Marcinkowski says.

“Patients have a perception that their pain should be at 0 after surgery,” she says. “That’s not realistic. We are making an incision on your body.”

‘No Cookie-Cutter Mold’

Drug crises have surged and waned over the years, but what has distinguished opioid use disorder is the lethal risk it poses, says Roger Humphries, who chairs the Department of Emergency Medicine at the UK College of Medicine. Since the drug can suppress the respiratory system, it can result in brain damage or a cardiac arrest, he says. “Over the last several years as we’ve seen more and more overdoses, it was clear that it was a crisis,” Humphries says.

Moreover, those overdose patients remain vulnerable, even if they survive, Humphries says. He cites a study, published in 2019 in the Annals of Emergency Medicine, which found that 5.5 percent of overdose patients who were treated in the emergency department died within the subsequent twelve months.¹¹

In 2018 UK established the First Bridge Clinic for opioid users who have been recently hospitalized, to help them gain quicker access to buprenorphine and other medication-assisted treatment.¹² These prescribed medications block the drugs’ euphoric effects and help ease opioid cravings.

But convincing patients to come to the outpatient clinic after they’ve been admitted to the hospital has been easier than reaching those who only got care in the emergency department. That is because the hospitalized patients are started on medication-assisted treatment, such as buprenorphine, before discharge, says Lofwall, the First Bridge Clinic’s medical director.

Patients who have been treated in the emergency department with naloxone are thrown into the misery of acute withdrawal as a result, Humphries says. “It feels like a severe flu. They are going to have nausea, vomiting, abdominal pain, severe body aches. And that’s what they wake up with.”

Some of those patients leave against medical advice, sometimes even within the first hour after being resuscitated, likely to obtain more opioids so they don’t feel so dismal, Humphries says. “They’re dope sick, and they are trying to figure out how to make those symptoms go away,” he says. “So they are not the best candidates to try to impact at that moment.”

Earlier this year, UK started buprenorphine training for physicians and residents, with the goal of making the medication treatment available in the emergency department to overdose patients by fall, Humphries says.

The First Bridge Clinic is one of several programs that UK has launched in recent years to provide a stairway toward recovery.

The First Bridge Clinic is one of several programs that UK has launched in recent years to provide a stairway toward recovery, often with the help of medication treatment. Lydia—whose opioid use disorder took root after that initial posttonsillectomy prescription—reached the point of injecting Percocet before she started her recovery in 2015. She credits several UK programs, including one for pregnant women with opioid and other substance use disorders, called the Perinatal Assessment and Treatment Home (PATHways).

Lydia had been taking Suboxone, a buprenorphine/naloxone medication, for several months when she realized that she was pregnant. When she went to the obstetrician/gynecologist for her first ultrasound, Lydia was exhilarated to find out that she was carrying twins. But her soaring excitement quickly soured after the physician realized that Lydia was taking Suboxone, as she recalls it.

“She said, ‘I’m sorry. But I cannot take care of you for your pregnancy.’” The physician handed Lydia a list of several options, one of which was the PATHways program. Lydia, who now has three girls under the age of 5, credits the group therapy and parenting education meetings through PATHways with her ongoing recovery. Also crucial, she stresses, is the Suboxone; her dose hasn’t changed since 2015.

“I wholeheartedly believe that there is no cookie-cutter mold for everybody with substance use disorder to recover,” Lydia says, noting that abstinence is a better path for some.

“I’ve got three small children, and it has worked for me,” she says. “I don’t know if I will ever come off of it. From the very beginning, I look at it just like I look at my blood pressure medicine that I take in the morning.”

‘Hearts And Minds’

Convincing providers outside Lexington and other large cities to more frequently prescribe and dispense the opioid reversal drug naloxone and treatment drugs like Suboxone has been one of the forces that’s driven Freeman, Young, and other UK researchers and clinicians.

After state legislation passed in 2015 permitting pharmacists to dispense naloxone, Freeman was part of a massive effort to train Kentucky pharmacists, reaching 1,254 pharmacists and 348 student pharmacists in the first eleven months, according to published data. Of those who completed the requisite ninety-minute training, half immediately applied to the state board to become certified to dispense the drug.¹³

Opioid users might not have a regular doctor, Freeman points out. But they may walk into a pharmacy to buy a magazine or over-the-counter medicine and notice a sign posted about naloxone’s availability. “It may be just the sort of nudge that someone who is at risk needs,” she says.

Still, some physicians and pharmacists have proved to be a tough sell, Freeman and Young say. They find it hard to get over the notion “that you’re trading one addiction for another,” Freeman says. “You were using heroin but now you are using buprenorphine. You really should not be on anything.”

In a series of interviews conducted from February 2018 to January 2019 with pharmacies in twelve rural Appalachian Kentucky counties, they found that twelve of the fifteen pharmacies provided some type of limit: either not dispensing buprenorphine to new patients, limiting quantities dispensed, or refusing outright.¹⁴ That can pose a significant barrier for patients living in rural communities where there isn’t another pharmacy just down the road, Freeman says.

Patients desperate for treatment can sit on waiting lists 200 names long to see a physician willing to prescribe, Young says. In meeting with doctors in some of these rural communities, she finds that they agree that the medication can be effective. But they are afraid.

“They’re afraid that they’ll become known as a pill mill doc,” Young says. “Or that their kids will be ostracized at school if everybody finds out that their dad is treating people who use drugs. Or they’re afraid that their staff will all quit and walk out if they start treating people who use drugs.”

To counteract those perceptions, Young recounts how she and her colleagues have handed out educational materials and attended numerous community meetings to boost awareness about buprenorphine’s effectiveness, including telling stories about people whose lives have benefited from it. “To change hearts and minds, but it is a process,” she says.

‘Resilience’

Before the emergence of coronavirus disease 2019 (COVID-19), Kentucky appeared to be easing itself out of the worst of its opioid crisis, with federal data showing that overdoses were declining, says Elswick, the Voices of Hope cofounder.¹⁵ Elswick is one of those success stories. He has not only launched a recovery organization, but earlier this year earned his PhD from UK.

He worries that economic, mental health, and other stressors from the pandemic will reignite deaths of despair. “I can tell you from seeing on the ground that there’s no question that there has been a spike in overdoses,” he says.

Those on the team for the massive federal HEALing grant haven’t wavered in their commitment to push as hard as they can to reduce deaths by 40 percent.

But those on the team for the massive federal HEALing grant haven’t wavered in their commitment to push as hard as they can to reduce deaths by 40 percent. Again and again, as Young reflects on those eastern Kentucky communities where she has spent time, she talks not about the gaps, but about how to leverage those long-standing strengths—from deep roots to strong kinship networks.

“Resilience—my goodness, the things that these communities have faced,” Young says. “The shutdown of factories, the decimation of coal mines. They have overcome so much. And so I think that can be leveraged to overcome the opioid crisis.”

NOTES

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