“Simply curbing prescriptions will not, in my opinion, solve the issue,” said Cecil Yount, an addiction counselor in Waynesville. “It has to be part of a much larger plan. This is going to be hard in a financial atmosphere where the available funds are being cut.”
North Carolina passed the STOP Act to limit the amount of opioids prescribed to people without chronic pain. U.S. Rep. Mark Meadows, R-Asheville, recently introduced legislation to put similar restrictions in place at the federal level. As Meadows has said, it’s not the end-all-be-all of solutions, but it’s the first step toward addressing a problem that’s been the cause of 12,000 deaths in North Carolina alone since 1999.
There’s plenty of blame to go around for how the opioid epidemic reached this point — big pharmaceuticals pushing physicians to prescribe them, legislators exacerbating the problem by cutting mental health funding, and a lack of resources in rural areas like Western North Carolina. Several systemic issues need to be studied and addressed if the U.S. wants to get a handle on the root cause of addiction.
Who’s at risk?
Opiates can be extremely addictive, but not everyone who is prescribed opiates will develop an addiction. According to the National Survey on Drug Use and Heath, only one in 130 prescriptions for an opiate results in an addiction. So what makes one person more susceptible to forming an addiction than another?
Yount said there’s no simple answer to the complicated, multi-faceted issue.
“People become addicted for a myriad of reasons. A family history of addiction certainly increases the likelihood or potential of addiction, but people who do not have such a history do become addicted and people with family histories may never become addicted,” he said. “My experience with the consumers that I see, which by the way are young adult or older, has been that the addiction came about as a result of injury treatment.”
Yount added that many of the people he sees also have other substance use issues — such as an alcohol use disorder — in addition to the opiate addiction.
“This is one of the aspects of treatment of any substance use disorder and one reason why I don't believe we can talk about ‘just the opioid epidemic’ because of the incidence of multi-substance use disorders,” he said.
There’s also a belief that addiction — in many forms — is simply a symptom of a larger problem someone is not coping with and instead is turning to whatever vice is soothing their pain, however temporary. While there are certainly cases of people with mental health issues “self-medicating” with prescription painkillers, Yount said it’s not the majority.
“There are people who develop addiction without any underlying behavioral issues and there are people who have underlying or co-occurring mental health disorders and they become addicted,” he said. “Certainly the mental health issues of depression, anxiety, and bipolar disorder have significant rates of co-occurring substance use disorder because they find, through their own efforts of medicating, that the substances reduce the unpleasant symptoms — for a while — of the behavioral issues.”
It’s those efforts to self-medicate, he said, that can lead to issues like DWI, physical withdrawal and more. Subsequently, these people often end up needing treatment for both substance abuse and mental health disorders.
Drug of choice
Just like prohibition didn’t keep people from consuming alcohol, placing a cap on opioid prescriptions won’t stop addicts from getting their hands on them. It could also have unintended consequences since addicts will go to great lengths to maintain the sense of euphoria they feel while taking opiates. If the cost of pills increases to a certain point, addicts could then turn to using heroin, a cheaper and more dangerous opiate option.
“Will curbing prescriptions without providing options for treatment lead to more heroin use? Probably,” Yount said. “I think we are already seeing it, and along with that comes the dangers of fentanyl laced heroin and uncontrolled qualities of street heroin. This is something that we, as a nation, are already seeing.”
In his 40-plus years working in the substance abuse/addiction field, Yount has seen waves of substance misuse disorders as the drug of choice changes and another comes to the forefront. In 1976, when he started with one of the first DWI prevention programs in North Carolina, he said the substance of misuse was alcohol and the clientele were largely white males nearing the end of their diseases. In the ‘80s, cocaine and crack were in the spotlight of misuse followed by methamphetamine in the early ‘90s edging into the earliest stages of the current opioid circumstances with Oxycontin — also referred to as “hillbilly heroin.”
“Each cycle brought new issues in treatment and new costs to society. Along with all of that came new research and new ways of treating consumers,” Yount said. “Does big pharma play a role in this current issue? Absolutely. Any time you have profits by corporations involved, somebody is going to find a way to maximize their bottom line.”
He said the same is true for the alcohol and tobacco industries as well. Even the Mexican cartels work to maximize profits lost with the legalization of marijuana in the U.S. by flooding the streets with cheap heroin.
International case studies
The U.S. isn’t the first to deal with an opioid epidemic. Johann Hari, author of Chasing The Scream: The First and Last Days of the War on Drugs, recently pointed out in an L.A. Times op-ed that Switzerland experienced a serious opiate epidemic in the ‘80s and ‘90s.
Similar to the U.S.’s Reagan-era War on Drugs, the Swiss attempted to squash the problem by instituting harsher penalties and punishment for drug dealers, but the rate of overdoses and HIV transmission continued to rise. Switzerland was even home to the infamous “needle park” in Zurich where people could openly buy and inject heroin, but that created more chaos.
Then the Swiss tried a new method in the early 2000s that has proved successful, and according to Hari, should serve as a model for the rest of the world. Addicted people were assigned to clinics where they continued to take opiates while being medically supervised. At the same time, addicts also underwent therapy and received help turning their lives around, whether it was finding a job or a place to live.
“They gave you the drug, and at the same time, they dealt with the underlying pain that made you feel you needed the drug in the first place,” Hari wrote in her article. “Patients can stay on that program for as long as they like, there's no pressure to cut back, but almost everyone chooses to stop after a few years. Since the program began, there have been zero overdose deaths on legal opiates in Switzerland. None.”
The U.S.’s drug policies are obviously much different than Switzerland’s — the U.S.’s policies are more focused on criminalization while the Swiss focus on keeping people with addiction safe. However, the supervised opioid substitution program coupled with therapy and assistance was successful in reducing overdoses and getting many people off drugs.
Portugal used a similar approach with the goal of reducing harm while keeping drug-use illegal. Drug use and possessing small quantities is considered a public health issue instead of a criminal offense, which encourages more people to seek help without fear of going to jail. The result has been a 50-percent reduction in drug-related deaths and HIV transmission.
While public policies can take a while to catch up, one thing is clear — the best chance someone has at kicking an addiction is by undergoing a multi-pronged treatment approach. Yount said the best treatment for opioid addiction starts with a full assessment following American Society of Addiction Medicine (ASAM) Patient Placement criteria guidelines, which is a service he provides through his private practice.
“This makes it highly individualized, as it should be,” he said.
That assessment will determine what level of treatment someone needs. Yount provides Level 1 outpatient services — services that typically do not exceed more than two times per week with one time per week or less being most common. For comparison, Meridian Behavioral Health Services’ Substance Abuse Intensive Outpatient program would be considered Level 2 services; Appalachian Community Services’ Balsam Center inpatient services would likely be a Level 3; and Haywood Regional Medical Center’s ICU would be a Level 4.
“Some consumers may fall out at an ASAM Level I placement while others need a much higher level. I don't know of any single approach for everyone,” Yount said. “The greater the withdrawal need and the less secure the living environment, the higher the level of care will be needed.”
He said a lack of available treatment at all levels for the multiple demands of addiction, whether opioid, other, or combination, is one of the driving factors in how well a person does in seeking and maintaining recovery. Based on his experience and observations, the most successful treatment for opioids is suboxone in conjunction with counseling after the successful management of detoxification and withdrawals.
“The difficulty with suboxone is finding sufficient numbers of physicians that prescribe it. The demand far outweighs the current resources,” he said.
Community support through churches, family, friends, and self-support groups also play a key role in a comprehensive recovery program. Yount said Haywood County was fortunate to have many active self-support groups.
As legislators, pharmaceutical companies, physicians and law enforcement sort out the many pieces of the opioid epidemic and hold responsible parties accountable, Yount said it’s important for consumers to educate themselves about the potential risks.
“The bottom line is that we, as consumers, are responsible for what we put into our bodies. With all of the education now going on about the long-term effects of opioids, the consumer base should become more knowledgeable about their own treatment,” he said. “It is all of these aspects that will have a positive impact on the current cycle of substance misuse and will hopefully lead to generalized learning that will help when the next cycle, whatever it may be, comes around.”
• While opioid addiction tends to impact every demographic and socioeconomic group, it is more prevalent in some parts of the county than others. Using health data from nearly a million people who use employer-based health insurance, a 2017 report from Castlight Health mapped out the top 25 worst cities for opioid abuse.
• The data placed four North Carolina cities in the top 20 for opioid abuse among the local workforce — Hickory landed at No. 5, Jacksonville No. 12, Fayetteville No. 18 and Wilmington at No. 1.
• Other surprising finds were that baby boomers are four times more likely to abuse opioids than millennials, those with behavioral health issues are three times more likely to abuse opioids, and abusers are more likely to live in the South.
• The top states for opioid abuse are Oklahoma, Alabama, North Carolina, Louisiana and Tennessee.