The opioid epidemic is fueled both by the abuse of street drugs such as heroin and the addiction to prescription painkillers. The Centers for Disease Control and Prevention says prescription opioids contribute to 40 percent of all opioid overdose deaths in the United States.
BY AMBER SMITH
Solving the opioid crisis is a team effort. Many Upstate people are involved, in multiple ways.
Some are caregivers, helping those impacted by substance abuse. Some teach how to alleviate pain without using opioids. Some work to prevent addiction. Some are family members, touched in personal ways by the epidemic.
Here’s how they contribute.
How did we reach the point where deaths from opioid overdoses (more than 42,249 in 2016) surpassed deaths from gun violence (38,658 in 2016)?
Willie Eggleston blames over-prescribing of opioid pain medications such as oxycodone and aggressive ad campaigns from drug manufacturers.
The use of opioids began increasing in the late 1990s when medical experts began putting more importance on pain control. Nurses started asking patients to assess their level of pain as “the fifth vital” when they recorded their four vital signs: pulse, respiratory rate, temperature and blood pressure.
Eggleston is a doctor of pharmacy who works in the Upstate New York Poison Center, specializing in opioid addiction and harm reduction. He leads the Opioid Research Center for Central New York, a group whose mission is to reduce the impact of the opioid crisis by making the best use of existing resources and expanding access to treatment.
After prescription painkiller abuse was recognized as a problem, the number of opioid prescriptions began to decline in 2010. Today, doctors in New York are limited to prescribing seven days’ worth of opioids. Eggleston says the crisis is like a sinkhole that suddenly opened.
“We covered the sinkhole, but we didn’t bother helping those who had already fallen in.”
Without their prescription opioids, many people turned to heroin or synthetic opioids such as fentanyl. Such street drugs are dangerous because buyers don’t know what they’re getting, or the concentration.
Brett Cherrington, MD, a doctor of emergency medicine with a specialization in toxicology, says, “All of our heroin is now laced with fentanyl, and a lot of times when people purchase what they think is heroin, they get fentanyl.”
Fentanyl is a drug that is used in hospitals for pain control. It’s more potent than heroin, so the overdose risk is greater. A similar drug called carfentanil is used in veterinary medicine to tranquilize elephants. It’s 100 times more potent than fentanyl — and responsible in 2017 for strings of overdose deaths including in Central New York.
Also that year, the Upstate New York Poison Center handled 59 cases of people who abused or overdosed on anti-diarrhea medication containing loperamide, an opioid. At least four of those people died.
In an effort to minimize the side effects of opioids, which include constipation and drowsiness, some people mix an opioid along with an “upper,” such as cocaine. Cherrington points out that’s also dangerous.
Too big of a dose of opioids can cause a person to stop breathing. Emergency responders are equipped with a drug called naloxone that can reverse opioid effects. Regular people have also been trained in how to administer the rescue medication, which can be purchased at pharmacies throughout New York state. Eggleston says the availability of naloxone throughout CNY is helping save lives.
Still, officials from the Drug Enforcement Administration say that more people report using controlled prescription drugs than cocaine, heroin and methamphetamine combined.
The emergency doctors
Doctors working in the emergency departments at Upstate’s downtown and community campuses combined saw more than 1,000 patients in 2017 who were overdosing or struggling with addiction, reports Jay Brenner, MD. As with smoking cessation, he points out, “Catching people when they’re at their sickest, for counseling, is sometimes when you can catch people most willing to reconsider their lifestyle choices.”
But the emergency department is where lives are saved and patients are stabilized. It’s not designed for more involved drug interventions. Typically, emergency doctors would send those patients home with referrals to addiction treatment programs.
Ross Sullivan, MD, said that wasn’t working. Often it took days or weeks to get an appointment, and in the interim, many patients continued using opioids to stave off withdrawal.
“There had to be a different way to help these people, to make them safer, to make them healthier,” he says. Sullivan is one of fewer than 1 percent of emergency physicians who are also certified in addiction medicine. In 2016 — the year 142 people died in Onondaga County from opioid overdoses — Sullivan established what he calls the bridge clinic.
It’s a service that bridges that gap between the patients’ trip to the emergency department and their entry into addiction recovery.
How it works today is, patients at the emergency department who want help getting off opioids receive a dose of buprenorphine, a tablet that melts beneath their tongue, and can help decrease drug cravings and suppress the symptoms of withdrawal for up to three days. They also receive a follow-up appointment a few days later at Upstate.
At that appointment, the patient meets with Sullivan, specialists in social work and case management, plus a “peer,” someone who is years into recovery. The patient may need help obtaining health insurance, food stamps, housing or other important services, things that need to be stabilized “before we can even think about them doing all the work they need to do to try to conquer their drug addiction,” Sullivan explains.
He sees about 60 patients per month, some for up to three to four visits as they prepare to enter treatment. Sullivan says 75 to 80 percent go on to enter addiction treatment, the majority in outpatient programs in the Syracuse area. “The most rewarding thing about this work really is when a patient thanks you, and they can look you in the eyes and tell you how their life has changed,” he says.
The number of opioid deaths in Onondaga County dropped to 91 in 2017 from 142 the year before. Sullivan says that doesn’t mean fewer people are using opioids. As hopeful is he is that patients will stop using, he wants them to be safe if they don’t. He provides prescriptions for naloxone, the rescue medicine that can reverse an overdose, and instructions about using clean needles.
“You don’t cure addiction,” Sullivan explains. “You learn to live with it and manage it.”
The infectious disease specialist
Overdose is not the only risk in abusing opioids. Deaths are just the tip of the iceberg, says Timothy Endy, MD, professor and chair of Upstate’s microbiology and immunology department and an expert in infectious diseases.
He’s concerned about two sets of people: those who share needles and spread infections such as hepatitis C and the AIDS virus, and those who introduce bacteria into their bloodstream when they inject a needle through skin that is not sterile.
“That’s really the problem we’re seeing related to IV drug use,” Endy says before detailing the skin abscesses, muscle and bone infections that lead to paralysis or bacterial endocarditis, an infection of the heart valves.
In 2011, five patients were treated for bacterial endocarditis at Upstate University Hospital; the number climbed to 37 in 2017, Endy says. “This is the underbelly that we don’t really talk about, and that the public should be aware of.”
Such serious infections can require lengthy hospital stays and lifelong medical care, depending on how far the infection has progressed.
If caught early, bacterial endocarditis can be treated with a six- to eight-week course of intravenous antibiotics. “The problem is, we do it through a special intravenous line called a PICC line that can stay in place for several months. With addicts and opioid users, they’re not capable of going home with PICC lines because of the potential for misuse. So they end up staying in the hospital for eight weeks,” he says.
Drug addicts also are likely to have nutritional deficiencies, and their immune system is likely to be depressed because of poor nutrition and opioid use.
They may also require heart valve replacements, he says, recalling a 20-year-old who recently had to have two valves replaced. “These are serious medical problems.”
Endy speaks from experience not only as a medical provider — but also as a parent.
Endy’s son, Justin, started misusing drugs in high school and had developed a serious heroin addiction by the age of 24. He overdosed twice. Both times he was saved with a dose of naloxone and wound up in the emergency department of Upstate University Hospital.
Justin Endy spent time in jail. He failed two outpatient rehabilitation programs. Three times he tried to stop using cold turkey.
“Watching him, we realized he was slowly dying,” Timothy Endy recalls of that time in 2016. “My wife and I felt like he would die in the next couple of weeks. Our son was just exhausted. We knew we had to get him into a program.”
With help from a recovery specialist, they enrolled him in a 30-day residential detoxification program called Sierra Tucson in Arizona, followed by a structured yearlong 12-step program called Bringing Real Change in Austin, Texas. “The transformation in Justin was dramatic,” Endy says. “He says he has finally found peace and serenity.”
The Endys’ health insurance plan did not cover the recovery programs, so the Endys paid for the treatment on their own. Subsequently, they helped sponsor 10 other people who were struggling with addiction and recovery through a charitable foundation they created at road2recoverycny.com
The addiction specialists
Some people require inpatient treatment. Others succeed through outpatient detoxification programs.
“We have not cured one person of addiction, but we have gotten people into recovery,” says psychiatrist Brian Johnson, MD, director of addiction medicine.
Upstate Addiction Medicine is a holistic medical practice that offers detoxification and treats chronic pain. Walk-in appointments (if you call ahead, at 315-464-3130) are available weekdays, and patients are asked to bring a non-addicted support person with them.
“If there’s a loved one involved, the chances that people are going to remain sober greatly increase,” explains psychiatrist Sunny Aslam, MD. That first appointment is lengthy. Some patients will make daily visits until they stabilize, and then they may come in weekly.
Johnson says he’s seen more than 17,000 patients successfully detox from opioids, alcohol and other substances. He prescribes buprenorphine, plus other medications that help with gut cramps and anxiety. “They go home with their support person,” he says. “A week later, they’re off opioids, and it was no big deal.”
One month out, he says 60 percent of those who stopped taking opioids remain sober. He says some people relapse and go through additional rounds of detox.
He explains that drugs change the brain permanently. That’s why people continue to attend Alcoholics Anonymous even if they stopped drinking years ago.
“Once you reintroduce the drug into the brain, it turns on ferocious cravings that have been dormant,” Johnson says. “If you’re addicted to tobacco, you can’t go back to cigarettes once in a while. If you’re addicted to alcohol, it’s the same. If you’re addicted to opioids, it’s the same.”
The pain specialist
Withdrawal from opioids can feel 100 times worse than the flu, with severe vomiting, diarrhea and stomach cramps. Many people who are addicted to pain killers “are not looking to get high. They just do not want to go through withdrawal,” explains nurse practitioner Theresa Baxter. “They’re just so desperate to feel normal. They did not wake up saying, ‘I want to be a heroin addict’ today.’”
She explains that opioids are “very effective in treating that immediate, acute pain, after a surgery or after a terrible injury. The problem is when we continue them long term. They’re a lot more addictive than we thought.”
Also, with long-term use, opioids increase a person’s sensitivity to pain, she says. It’s called opioid-induced hyperalgesia.
Opioids are not the only way to treat acute pain. Baxter advocates for the use of acetaminophen, ibuprofen and muscle relaxants. Nerve blocks can also be helpful, depending on the type of pain.
She cares for patients with chronic pain, too, many of whom get relief from massage, chiropractic care, weight loss, muscle and core strengthening, cognitive behavioral therapy and/or medical marijuana.
Not everyone can expect his or her pain to disappear. Baxter’s goal is to restore functionality, so people can go on with their lives.
Opioids act on opioid receptors located on nerve cells throughout the brain and nervous system, producing an analgesic effect.
Until recently, scientists assumed that all opioids — those produced by the body, and those ingested as drugs – interacted in the same way with opioid receptors. Recent research has shown differences that may help guide the design of new non-addictive pain relievers.
Not only that. Recent research has also shown the potential for impacting the effect of opioids on the brain by inducing an anti-opioid immune response.
An experimental heroin vaccine induced an immune response that prevented heroin from traveling into the brain through the bloodstreams of laboratory animals, according to a study published in the Journal of Medicinal Chemistry.
“By eliciting antibodies that bind with heroin in the blood, the vaccine aims to block the euphoria and addictive effects,” Gary Matyas, MD, told Science Daily. He is from the U.S. Military Research Program at the Walter Reed Army Institute of Research. “We hope to give people a window, so they can overcome their addiction.”
Stephen Thomas, MD, professor of medicine and microbiology and immunology at Upstate, is excited by the prospect. “A heroin vaccine could play an important role in a comprehensive approach to treating people who are suffering from substance abuse disorders,” he says.
Upstate and Walter Reed researchers have been awarded a grant to advance the development of an experimental heroin vaccine. If successful in early development, a second grant award will support testing the vaccine in human volunteers. The clinical trial would be performed by Upstate in Syracuse.
Upstate Addiction Medicine, 315-464-3130; Road2RecoveryCNY.com
Buprenorphine — an opioid medication used to help decrease drug cravings and suppress the symptoms of withdrawal.
Methadone — an opioid medication used to help taper people off an opioid addiction.
Naloxone — a medication that rapidly reverses the effects of opioids and can save a person from overdose.
Opioids — a class of drugs that includes the prescription opiate medications codeine and morphine; plus semi-synthetics and synthetic drugs hydrocodone, oxycodone, fentanyl and others; and the illegal drug heroin.
Be aware: Emerging opioid substitute
A drug used in other countries to treat depression — and
also anxiety, asthma and irritable bowel syndrome — has the potential for abuse and addiction. Tianeptine is sold under the trade names Stablon and Coaxil in Asia and Latin America and obtained through Internet channels in the United States.
Poison centers in New York state handled nine cases of tianeptine overdose between 2000 and 2017, according to research by Upstate doctors of pharmacy Jeanna Marraffa and Christine Stork. One case involved a child who accidentally ingested the drug. Then there were five people who meant to abuse the medication, and three who had problems while taking a therapeutic dose of the medication.
Marraffa and Stork note that five patients described symptoms of opioid withdrawal, and, in two cases, patients received naloxone, a medication that can save people from opioid overdose.
This article appears in the fall 2018 issue of Upstate Health magazine