The opioid boom

The prevailing practice for treating addiction to painkillers led from the physician’s office to the worst man-made epidemic in modern medical history.

In 2002, something just didn’t make any sense: workers with routine back injuries were being prescribed whopping doses of opioids like Vicodin and OxyContin—and some were dying. Concerned officials in the state’s Department of Labor and Industries’ medical director’s office needed to get to the bottom of this situation.

The agency’s chief pharmacist, Jaymie Mai, a graduate of the UW School of Pharmacy, scoured the medical, prescription and physician records that accompanied the workers’ compensation claims. What she and Gary Franklin, a School of Public Health research professor and L&I’s medical director, uncovered was jaw-dropping: over just a few years, 44 people in Washington suffering from chronic pain had died of prescription opioid overdoses.

Something had to be done. So Mai, ’94, ’96, and Franklin became the first in the nation to sound the alarm about the link between the opioids physicians were prescribing for pain control and a high number of so-called “accidental poisoning” deaths. Ironically, in 1999, the year all those lives were lost, was also the same year Washington law was changed to say “No disciplinary action will be taken against a practitioner (physician) based solely on the quantity and/or frequency of opioids prescribed.”

The fact is, physicians in Washington and across the country were over-prescribing Vicodin and OxyContin to patients whose pain was not related to cancer. By simply following their physicians’ advice, patients were becoming increasingly dependent—and some became addicted, often unknowingly.

“It has been the worst man-made epidemic in modern medical history,” Franklin says. “It happened because of the false teaching in the medical community—that the addiction rate is less than 1 percent, that there is no ceiling on dose, and that the way to prevent tolerance is to increase dose.” You can imagine how the national medical community reacted to reports that opioid-poisoning deaths occurred so soon after efforts to make opioid prescribing more permissive. Franklin was shouted down at major meetings of pain specialists who felt strongly that treating non-cancer pain with opioids was the correct course. The view that opioids weren’t addictive and that physicians had an obligation to prescribe them for non-cancer pain had taken on the patina of gospel truth. And it was all wrong.

David J. Tauben, ’82, UW Medicine’s chief of Pain Medicine, may have said it best: “With the best of intentions and the worst of outcomes, physicians—in an effort to swim against a current of desperate patients, limited time and the rising mythology of how pain should be managed—were seduced by quite a number of people advocating for opioid pain treatment.” By 2006, more than 10,000 Washington residents were on very high opioid doses.

Art by Carlo Giambaressi

Powered by the University’s 50-year legacy of pain research and innovative patient care—the first chair of the UW Department of Anesthesiology and Pain Medicine, John Bonica, is known worldwide as the “father of pain medicine”—UW faculty were well prepared to join with Franklin and Mai. The outcome: The state of Washington published the nation’s first opioid-prescription guidelines in 2007. (Those guidelines were updated in 2010 and again in 2015.) In 2012, Washington also became the first state to legislate limits on the prescription of opioids. Clearly, Washington state has led the way on reversing the opioid epidemic.

Tauben, ’82, and Franklin were part of the group that introduced the idea of prescribing limits. UW faculty members Caleb Banta-Green, ’96, ’97, ’08, (from the School of Public Health) and Mark Sullivan and Joseph Merrill (both from UW Medicine) collaborated with researchers nationwide to be among the first, in 2010, to establish the clear relationship between the prescription of high doses of opioids and overdoses, as well as the high rates of addiction. In 2013, UW School of Pharmacy research showed that making naloxone readily available helped prevent overdose deaths.

It happened because of the false teaching in the medical community—that the addiction rate is less than 1 percent, that there is no ceiling on dose, and that the way to prevent tolerance is to increase dose.

Gary Franklin, Research Professor in the School of Public Health

But the UW’s impact in dealing with this crisis goes much deeper. For instance, at UW Medicine’s Harborview Medical Center, an innovative program was created to treat patients with heroin addiction the same way it would treat those suffering from a chronic disease, such as diabetes. Alumni serve on the front lines of addiction, providing people with counseling and medication in federally-licensed methadone clinics; faculty have developed programs in conjunction with Muckleshoot tribal leaders that keep people with opioid addictions on the path to successful treatment; and clinicians who practice in the region’s rural areas can use TelePain, the UW’s distance-consult service, whenever they need advice about caring for patients with pain and addictions.

However, despite the University’s best efforts, the crisis remains an uphill battle with no end in sight. For example, in 2016, someone in Washington died of an opioid overdose every three days. In early September, The New York Times reported that the first count of fentanyl deaths in 2016 showed a 540 percent increase in three years, driven by potent illicit fentanyl-type drugs. While much of the recent increase in deaths nationally has been caused by fentanyl or carfentanil (a drug that is sometimes cut into heroin), many of these people started with opioids. Not long after that report, The Times and ProPublica reported that almost every insurance plan covered the prescription of common opioids, and very few required prior approval. However, less addictive or non-opioid pain killers were often not covered.

The sad truth is that opioid-overdose deaths are now the leading cause of accidental deaths in nearly every part of the state and nation, surpassing the number of deaths from motor-vehicle accidents and firearms. In 2015, 718 people died from opioid overdoses in Washington, including those from heroin and illicit fentanyl. Even more discouraging is the prediction that overdoses are expected to remain the leading cause of death for Americans under age 50.

While deaths specifically from prescription-opioid drugs have declined, heroin-overdose deaths are on the rise, particularly among young people. It’s no mystery why: for around $10 a bag, users can stay high all day on heroin. OxyContin can cost $80 per pill.

Banta-Green, principal research scientist at the UW Alcohol and Drug Abuse Institute, explains that more than 50,000 people in Washington suffer from opioid use disorder (opioid addiction)—and the barriers to treatment are myriad. “Less than half of those who would benefit from methadone or buprenorphine are able to access them in Washington,” he says.

Opioid-overdose deaths are the leading cause of accidental deaths in nearly every part of the state and nation.

Banta-Green continues to work with pharmacists—many of whom are graduates of the UW School of Pharmacy—to increase the availability of naloxone, the drug that can revive someone on the brink of death from an opioid overdose. While naloxone can bring back a person from overdose, it isn’t the only medication that plays a critical role in a patient’s recovery. Without such medication-assisted treatment using drugs like buprenorphine, Richard Ries, UW Medicine physician and professor who heads UW Medicine’s addiction division in the Department of Psychiatry and Behavioral Medicine, says it’s extremely difficult for patients to turn away from using. “Medications form the floor of treatment. Without medications, people will not get stabilized. You really need to have medication before anything else happens,” he says.

There’s a problem, however: methadone, which prevents withdrawal symptoms and stabilizes opioid addiction, can only be dispensed at federally-regulated clinics, and there aren’t enough community-based physicians to prescribe buprenorphine (the brand name is Suboxone), a drug that is used to reduce cravings for opioids. Nurse practitioners and physician’s assistants can now prescribe this drug but only if they have received special training. Then there is the reality that many primary care physicians don’t feel up to facing these often complex cases.

“Sitting through a class is not enough; it’s learning from a book,” says Tauben, who is director of pain education for medical students at the UW School of Medicine. “You can’t book-learn the practice of medicine. You have to be mentored.” Fortunately, that occurs at Harborview, where attending physicians and internal-medicine residents participate in buprenorphine prescribing through a nurse care manager program that has seen 220 patients since January 2016.  A multidisciplinary team supports the program, advising on challenging cases and crafting clinic policies. Moreover, students at the UW School of Pharmacy can take a “curriculum enhancement pathway” in chemical dependency, and all second-year pharmacy students take a course on chemical-dependence concepts. The school offers practicums as well.

This fall, the UW Neighborhood Clinics that specialize in primary care are rolling out a pilot buprenorphine program at multiple sites. Pam Sheffield, a physician and associate medical director of UW Neighborhood Clinics, explains that until recently, the UW Neighborhood Northgate Clinic was the only UW Neighborhood Clinic where physicians could prescribe buprenorphine. True to its public mission and commitment to innovation, UW Medicine’s neighborhood clinics will integrate teams of behavioral- and mental-health specialists into the system of caring for patients with opioid addiction. “We hope to roll out to all the other neighborhood clinics quickly, when we have the tools—good patient information, good charting tools to guide providers,” says Sheffield. These services are available to Neighborhood Clinic patients and those referred from UW Medical Center.

Rural areas have a bit of catching up to do, however. Holly Andrilla, a biostatistician at the WWAMI Rural Health Research Center, surveyed rural physicians across the U.S. and found that more than 60 percent of rural counties lack a physician with the special training necessary to prescribe buprenorphine. But even those physicians who have taken the special training “are not using it to its full extent or at all,” Andrilla explained in a 2017 research paper.

UW Medicine provides a solution specially designed for those outside urban centers: the TelePain program, a videoconference-based weekly session in which clinicians across the Pacific Northwest can connect with UW Medicine pain experts for guidance on how to treat patients with complex pain problems, including opioid addiction. TelePain, which started in 2011 under Tauben’s leadership, recently conducted its 300th session. An average of 30 providers from Nome to North Bend and Colville to Casper participate in each weekly session. The service is also linked to a Pain and Opioid Hotline that is funded by the state of Washington. In yet another effort to reach providers across the state, addiction psychiatry specialists Mark Duncan and Richard Ries lead UW Psychiatry and Addictions Case Conference series, a weekly web-based conference that supports providers caring for patients with addictions and psychiatric problems.

The number of opioid-overdose deaths in the state of Washington in 2015: 718.

One physician who sees patients in a lightly populated area of Washington explains how valuable the UW outreach efforts are. “We inherit these patients who are already at a higher dose [of opioids], so we’re kind of stuck,” says Ron Bergman, a Port Angeles physician. “How do we turn it around and get opioid-dependent or addicted folks back to more appropriate dosing? The UW faculty gave me the tools to be firm and establish that opioid levels need to come down. They talk about alternatives to opioids like acupuncture, exercise, massage and chiropractic—because if you’re telling patients that they will receive less medication, you want to give them something else.”

Beyond the prescription opioid problem, Washington’s heroin situation extends to all socioeconomic levels, and Marie M. is a classic example. Raised in a middle-class home in Renton, she dabbled in drugs for decades. Her life was in ruins because of opioid addiction and other drugs. You name it—liquid cocaine, glue, heroin, diet pills—if it was a drug, she smoked it, shot it, swallowed it or snorted it. And yet, despite years of addiction broken by spells of recovery, she was a productive member of society most of the time. She always worked. She earned a degree from The Evergreen State College. She was a parent of two children, although she lost custody of her daughter at one point. If you sat next to her on a bus, you probably wouldn’t guess she was addicted to heroin.

Finally, she developed an abscess in her leg from shooting heroin; her legs are scarred from years of injections. She bounced in and out of the Harborview emergency room until one day, she met Hugh Foy, ’83, UW professor of surgery. He told her that if she stayed clean for two months, her body would be healed enough so he could perform surgery to clean up the abscess.

After she recovered from surgery, Foy told her about Joe Merrill, the UW Medicine addiction specialist. “He was doing a study on buprenorphine and that’s how my recovery began,” Marie says. “He’s the kindest man in the world. He treated me like an equal. He cared about me and treated me like a person.”

With medication and previous 12-step work in Narcotics Anonymous, she stayed in recovery and has weathered tough economic times, even losing her house in the Great Recession of 2008. Today, she is a loving grandmother, a devoted partner and mother to her children.

Brian Lundquist, ’11, has worked as a counselor at Therapeutic Health Services in Everett for 13 years. It’s the city’s sole methadone clinic and it has a waiting list of 150 people. (After that, the clinic stopped taking names.) A graduate of UW Bothell, Lundquist carries a caseload of more than 150 people. “We’re still in the ‘Just Say No to Drugs’ era,” he says. “The fundamental problem is, until society looks at these people as human beings instead of garbage to be thrown away, we are not going to solve this problem.”