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Opioid Epidemic

Driving While Recovering: For Some Fighting Addiction, A Roadblock On The Path To Sobriety

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After decades of addiction to heroin and prescription opioids, Wendy Crites finally made a clean break.

“For the first time in my life I just wanted to be off of it,” she said from her home in Ranson, West Virginia. “I hit rock bottom.”

Last year the ReSource profiled Crites, a single mother getting by on low-wage jobs during her first year of sobriety. Crites has had success with a combination of counseling and a medication called Suboxone.

Crites cuts Suboxone film, which she uses along with regular counseling. Photo: Rebecca Kiger, Ohio Valley ReSource

“It’s been a huge part of my recovery,” she said. “I feel like the Suboxone has saved my life.”

Suboxone is a mixture of naloxone, the opioid-reversal medication, and a less potent opioid known as buprenorphine. It satisfies the brain’s craving for opioids without the body feeling the full effect of more powerful opioids.

Crites is among the thousands of people caught up in the Ohio Valley’s opioid crisis who find that treatment with medications such as Suboxone help them recover from addiction. But some face an obstacle on the road to recovery. Using the medication while driving can land them in trouble with the law. For Crites, that threatens the fragile gains she has made to better provide for her child and keep on the path to sobriety.

Maintaining Her Life

“When I met her she was renting a room that had no heat, during winter,” Rebecca Kiger recalled. Kiger, a photojournalist based in West Virginia, spent time with Crites documenting her struggle for sobriety, and the two have stayed in touch as Crites has improved her situation.

“She was working a minimum wage job at McDonald’s, she had no transportation but would ride a bike to work at all hours, including in the dark,” Kiger said.

“Since then I got my own place,” Crites said proudly in a recent interview with Kiger. “I got my license back, I got a car now.”

Kiger saw how important it was for Crites to have medication-assisted treatment.

Alexandra Kanik, Ohio Valley Resource

“What it does for her, Wendy who has kind of lived with an addiction disorder since she was 15 years old, it allows her to not have her whole life focused around drug use,” Kiger said.

“I have not used heroin one time since I started taking Suboxone,” Crites said.

Kiger has seen how sobriety has changed Crites’ life and the lives of those around her.

“She can help her son get to school, help him study, hold down a full-time job, maintain relationships with her friends and family,” she said. “You know, maintain her life.”

Crites has been clean now for two years. But an incident in August could be her biggest challenge yet. Ironically, it has to do with the very medication that has helped keep her sober.

“I saw lights”

Crites said that a friend, another person in addiction recovery, asked her for a ride.

“Thirty seconds after I got him in the car I saw lights, got pulled over,” she said. The officer told her she had rolled through a stop sign, something she does not dispute. But what came after is what has her upset and worried about her future.

“When the officer saw who I was, he knew me,” she said.

The officer recognized Crites as someone he had once arrested in the days when she was in active addiction. He asked if there were drugs in the car.

“I said no, officer, I’ve been in the Suboxone program for two years and I don’t do drugs anymore.”

She allowed officers to search the vehicle. They found nothing.

“Then he asked, ‘So you said you’re in the Suboxone program?’” Crites recalled. “‘You will have to pass a field sobriety test.’”

Driving Problems

Suboxone has the potential to impair some drivers at certain doses. The safety information from Suboxone’s maker includes this warning: “Do not drive, operate heavy machinery, or perform any other dangerous activities until you know how Suboxone Film affects you.”

The company advises that buprenorphine, the main drug in Suboxone, “can cause drowsiness and slow reaction times during dose-adjustment periods.”

A study published in 2013 found slight impairment, especially among those not yet accustomed to the medication.

Before getting her car, Crites bicycled to her job. Photo: Rebecca Kiger, Ohio Valley ReSource

“At least some opioid maintenance therapy patients are observed having only slight impairments of relevance to driving,” the authors concluded.

Crites said she had been on the same prescribed dose for more than a year and was not impaired when she was pulled over. But when asked to stand on one foot, or walk heel-to-toe, she failed the sobriety test.

“I can’t do it. I am flat-footed and uncoordinated,” she said with a laugh. She also had recently recovered from a broken ankle in the past year, something Kiger documented during their time together.

Crites suspects there is another reason she was made to take a sobriety test.

A Catch-22

Crites said she thinks she was targeted because of her past and because of a stigma associated with Suboxone and other medication-assisted treatments for addiction.

“That’s how I messed up, I told him I take Suboxone,” Crites said of her encounter with the police.

Crites is not the only one who suspects law enforcement officers frequently take a dim view of Suboxone.

Public health experts call medication-assisted treatment, including use of Suboxone, the gold standard of addiction care. But outside of the clinical setting, Suboxone can also be abused and is sometimes diverted into the black market drug trade. That appears to color how police consider Suboxone users.

In her new book “Dopesick” author Beth Macy writes, “If you were drawing a Venn diagram comparing Suboxone attitudes among public health experts and criminal justice officials in Appalachian Bible-belt communities where the painkiller epidemic initially took root, the spheres would just barely touch.”

That disconnect between police and physicians is playing out on the region’s roads.

Dr. Jana Burson is a specialist in the treatment of opioid addiction working in North Carolina, where she also maintains a blog on issues that arise in treatment programs. In August Dr. Burson posted what she called “A Letter to Law Enforcement” about medication-assisted treatments and the number of her clients who were being pulled over on the highways.

Wendy Crites has had success in recovery thanks to medication-assisted treatment. Photo: Rebecca Kiger, Ohio Valley ReSource

“Dear Officer Zealous,” she began. “Please stop arresting my patients for whom I’ve prescribed methadone and buprenorphine …You mistakenly think all people taking these medications have no right to be driving, and you are wrong.”

Past Isn’t Dead

“I just wish people would get educated on Suboxone, that’s all,” Crites said with a sigh of exasperation, noting that her treatment is paid in part by the government.

“It’s like the state says ‘Okay, we need to help these people.’ But then the state penalizes you for it!” she said.

And in a small town where reputations matter, she feels she is still being punished for her past.

“It makes me angry that people can’t let you live down your past,” she said. “I’ve got so many people behind me who can say how much I changed my life, but there are people who can’t see past that.”

Crites is angry. She is also worried that she could lose her license, something that could jeopardize much of what she worked for in the past year. As Kiger learned in her time with Crites, she and her son live on a very thin margin.

“She faces paying a lot of fines, which can be crippling to someone who is in the economic category she’s in, which is basically working poor,” Kiger said.

Without transportation in a rural setting Crites would face difficulties getting her son to school and herself to work.

“I stand to lose everything, really,” Crites said. “My job, my home.”

And Kiger worries that Crites’ hard-won sobriety could also be at risk.

“It would be a real setback,” Kiger said. “After years of drug abuse, I would hate this to become a stress that has her turning to drugs to cope.”

Crites faces a preliminary court hearing in December. She said she will refuse a plea deal. But she does not yet have an attorney to offer her legal advice.

Crites applied for representation from the public defender’s office but found that with the slight raise she received from her new food service job the state considers her too wealthy for a court-appointed attorney.

This article was originally published by Ohio Valley Resource

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Opioid Epidemic

Fentanyl-related Deaths Are the Highest in W.Va. This Is What They’re Doing about It.

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An addict injects heroin, even as a fentanyl test strip registered a positive result for contamination, Wednesday Aug. 22, 2018. Photo: Bebeto Matthews/ AP Photo

West Virginia has the highest per-capita drug-overdose death rate in the country. And while the Centers for Disease Control and Prevention has reported a recent decline in overall drug overdose deaths nationwide, deaths involving fentanyl, a synthetic opioid, are on the rise. West Virginia leads the nation in that rate as well.

According to the CDC, fentanyl can be up to 100 times more potent than morphine, many times stronger than heroin, but drug users are often unaware that the heroin they’ve purchased has been laced with the drug.

Health care professionals are understandably alarmed at the rising prevalence of fentanyl, and in West Virginia they’re acting on several fronts.

In a recently released paper, researchers at the West Virginia University School of Public Health report on a joint effort of the WVU schools of public health and pharmacy and the state’s chief medical examiner to monitor drug-related deaths in order to more accurately pinpoint life-saving initiatives.

They’re mining a forensic drug database maintained at the WVU Health Sciences Center that includes every drug-related death in the state. It documents cause of death and demographic information and other medical conditions, with the objective of detecting trends in drug-related deaths.

The researchers also advocate for wider distribution of naloxone, a drug that reverses the effects of opioid overdose, an effort in which the school of public health has taken an active role.

“Naloxone really is the miracle drug,” said Gordon Smith, an epidemiologist in the School of Public Health. “We have this very, very effective reversal agent that can keep people alive.”

“While in the long-term, effective treatment and getting people off drugs is the answer,” Smith said, “you have to be alive to be able to get you off the drugs and get you into long-term treatment.”

The School of Public Health is also actively involved in addressing that longer-term objective, with a model program that uses peer recovery specialists to engage overdose victims and others with opioid-use disorder and helps get them into treatment and recovery.

Leveraging Data

With his WVU colleagues Marie Abate and Zheng Dai, Smith coauthored “Fentanyl and fentanyl-analog involvement in drug-related deaths,” funded by the National Institutes of Health and just published in the journal Drug and Alcohol Dependence.

The research team found that deaths from fentanyl in West Virginia continue to rise, with 368 in 2016 and 553 in 2017. One factor, they write, is a surge in illegal fentanyl imports from China.

The CDC reports that of the more than 70,200 drug overdose deaths estimated in the country in 2017, the sharpest increase was in deaths related to fentanyl and fentanyl analogs, with more than 28,400 deaths.

Smith believes detailed data can help curb this trend.

“We’ve been working for a while now here at WVU in collaboration with the medical examiner’s office to develop what’s really a very unique database,” he said. It’s aimed to provide health care providers and law-enforcement officers with insight into trends as they unfold.

The data can, for example, help decipher the chemical makeup of a fentanyl analog that just hit the streets or the combination of drugs involved in an overdose.

“West Virginia is one of a very limited number of states that has a very complete death investigation system,” Smith said, “and as a result, we have very, very good statistics.”

Statistics from the National Center for Health Statistics, Smith said, generally simply state that someone died of a drug overdose, “and it’s often very difficult to know the multiple drugs that are involved.”

This research was launched, he said, when medical examiners began noticing an increase in the number overdoses in which the level of each individual drug wasn’t sufficiently high enough that you would expect a person to die. It was, rather, a mixture of drugs.

“One of our significant findings is that it’s not just fentanyl,” Smith said. “It’s a whole mixture of different drugs that people are taking.”

“What we think is the most important part of our research is the ability that we have to monitor the changes in drug use over time,” he said.

What “really frightens us,” Smith said, are the fentanyl analogs. “There’s a particular drug called carfentanil that’s 100 times stronger than fentanyl. This was never used in humans; it was developed for anesthetizing elephants.”

“We’re absolutely terrified,” he stressed, of not only this drug but others that have never been tested. “An important part of our program of research is to be able to monitor, ‘What are the current drugs that people are dying from? And how do we need to modify our strategy?’”

Breaking the Cycle

The Health Sciences Center database can also suggest where greater access to naloxone is most urgently needed. Naloxone, Smith asserted, is “an important part of this multifaceted prevention program to stop people from dying of drug overdoses.”

Herb Linn, the WVU Health Research Center’s program director for collaboration and communication, helped launch the West Virginia Rapid Response Program when he was with the WVU Injury Control Research Center and has continued this work at the research center.

The Rapid Response Program was a partnership of the state Department of Health and Human Resources and the Injury Control Research Center that received funding from the federal Substance Abuse and Mental Health Services Administration to purchase and distribute naloxone kits throughout the state.

Linn believes hundreds of West Virginians have been saved through the administration of naloxone. But, he added, “we’ve got to think more systematically about how to … take these opportunities to engage people to try to help them break out of the cycle of addiction.”

Among the initiatives in which Linn’s involved is a CDC-funded project through the West Virginia Bureau for Public Health to engage overdose survivors in emergency departments, connecting them with peer recovery coaches, treating them with buprenorphine for their withdrawal symptoms and helping them get into long-term treatment.

“We’ve got to keep getting [naloxone] out there,” Linn said, “and then we have to build up a systematic approach to helping people break that cycle.”

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Opioid Epidemic

Purdue Pharma Taps a Gilded Age History of Pharmaceutical Fraud

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Classified advertisement for Leslie Keeley’s Gold Cure. Courtesy: ProQuest Historical Newspapers: Chicago Tribune, July 21, 1884

Newly unsealed documents from a lawsuit by the state of Massachusetts allege that Purdue Pharma, maker of OxyContin and other addictive opioids, actively sniffed out new, sinister ways to cash in on the opioid crisis.

Despite years of negative press coverage, unwanted attention from regulators, multi-million dollar fines and several major lawsuits, Purdue staff and owners sought to expand the company’s sights beyond its usual array of opioid painkillers. Purdue planned to become an “end-to-end pain provider,” by branching into the market for opioid addiction and overdose medicines, looking to peddle these medicines even while the company continued to aggressively market its addictive opioids. Internal research materials coldly explained the rationale behind this plan: “Pain treatment and addiction are naturally linked.”

As thousands of Americans continue to overdose on opioids annually, Purdue’s secret marketing research predicted that sales of naloxone, the overdose reversal drug, and buprenorphine, a medicine used to treat opioid addiction, would increase exponentially. Addiction to Purdue’s opioids would thus drive the sale of the company’s opioid addiction and overdose medicines. Purdue even planned to target as customers patients already taking the company’s opioids and doctors who prescribed opioids excessively, according to the Massachusetts lawsuit filing. To keep the plan quiet, Purdue staff dubbed the scheme “Project Tango.”

According to the Massachusetts lawsuit, Purdue used this graphic in its internal strategy materials to illustrate Project Tango. Photo: State of Massachusetts, CC BY-SA

The audacity of Project Tango enraged many observers. But considered in historical context, the news that Purdue sought to peddle opioid addiction medicines while continuing to sell opioids seems less surprising. In fact, there is clear historical precedent for Purdue’s business plan. Over a century ago, “patent medicine” sellers pioneered this strategy during the U.S.’s Gilded Age opiate addiction epidemic.

Opiate addiction in the Gilded Age

Opiates were some of the most commonly prescribed medicines in American history until the 20th century. Pills containing opium, hypodermic morphine injections and laudanum, a drinkable liquid concoction of opium and alcohol, constituted half or more of all medicines prescribed in American hospitals during most of the 19th century, according to research by the historian John Harley Warner. Opiates were also present in countless “patent medicines,” over-the-counter panaceas made of secret ingredients, often sold under catchy brand names like Mrs. Winslow’s Soothing Syrup. Americans could choose from 5,000 brands of patent medicines marketed for all manner of ailments by the 1880s. In 1904, just before federal oversight began, patent medicines had matured into an astonishingly profitable industry, with estimated sales at US$74 million dollars annually – equivalent to about $2.1 billion dollars today.

Opiate-laced prescriptions and patent medicines often caused addiction. The historian David T. Courtwright estimates that opiate addiction rates in the U.S. skyrocketed to 4.59 per thousand Americans by the 1890s – a high rate, although lower than the rate of fatal opioid overdoses in recent years. Most individuals developed addictions through medicines, rather than the infamous smoking variety of opium. Victims of “the habit” cut across demographic lines, encompassing middle-class housewives suffering from menstrual pain, Civil War veterans reeling from amputations and many others in between.

Yet even for those who became addicted to prescription opiates, the condition was socially stigmatized and physically dangerous. Like today, addiction to opiates often led to fatal overdose, condemnation and sometimes even involuntary commitment to mental asylums. As one doctor reported to the Iowa Board of Health in 1885, addicted people lived “truly in a veritable hell.”

To avoid these frightful outcomes, desperate, opiate-addicted Americans frequently sought out medical treatment for their condition.

Gilded Age Americans could choose from a range of therapies for opiate addiction. Wealthy patients frequented plush private clinics, where they could receive inpatient treatment for opiate addiction. The most popular were the Keeley Institutes, which offered patients injections of the “Bichloride of Gold” remedy, invented by the doctor Leslie Keeley.

Scores of Keeley Institutes sprang up around the country in the late 19th century, a testament to the popularity of Keeley’s “Gold Cure,” which he marketed for alcoholism and drug addiction. No up-and-coming Gilded Age city was complete without a Keeley Institute. At the height of the Gold Cure craze, there were 118 institutes serving 500,000 Americans between 1880 and 1920. Even the federal government had a contract with Keeley to provide the Gold Cure to addicted veterans. Although injections of the Gold Cure had little intrinsic medical value, historians believe that socializing with other like-minded patients in the Keeley Institutes may have helped some patients recover from addiction.

Advertisement for the main Keeley Center, in Dwight, Illinois, 1908.

Keeley faced stiff competition, however. Other popular therapies for opiate addiction included patent medicine “cures” and “antidotes,” which were cheaper than inpatient care. These could be ordered by mail without a prescription, and consumed in the privacy of one’s home, away from prying eyes.

Fueled by high demand, during its heyday at the turn of the 20th century, addiction cures bloomed into a multimillion-dollar sector of the patent medicine industry. Dozens of pharmaceutical companies peddled their “cures” to willing, opiate-addicted customers, which they marketed through pamphlets, postcards, and newspaper and magazine classifieds.

Ironically, these “cures” for opiate addiction almost universally contained opiates, unbeknownst to hopeful customers, who received little therapeutic benefit by today’s standards. But in an era before federal regulation of medicines and narcotics, there were no effective safeguards to protect addiction patients from medical fraud.

Pharmaceutical fraud

Much like Purdue Pharma, which famously marketed Oxycontin as non-addictive precipitating the opioid crisis, Gilded Age patent medicine companies also fraudulently marketed their addiction treatments as non-addictive, targeting and intentionally deceiving addicted customers. For their part, Gilded Age doctors were deeply skeptical of such products, and they often accused proprietors of fraud in medical journals and newspapers.

Samuel B. Collins of La Porte, Indiana, inventor of the “Painless Opium Antidote,” one of the era’s most popular brands, insisted that his product was not addictive. Collins was proven a fraud, however, by a skeptical Maine doctor, who in 1876 sent off a sample of Collins’ product to several chemists for analysis. Their tests indicated that the Painless Opium Antidote contained enough morphine to perpetuate opiate addiction, actually fueling demand for Collins’s product, rather than curing the underlying addiction.

Despite the overwhelming evidence, however, without any effective medical regulation or oversight, Collins maintained his fraud for decades. His business strategy presaged Purdue’s Project Tango by targeting vulnerable opiate-addicted individuals.

Advertisement for Theriaki, a painless cure for the opium habit. Exterior view of Dr. Collins’ Opium Antidote Laboratory, LaPorte, Indiana. National Library of Medicine

After decades of exposés by doctors and journalists, however, the opiate addiction cure trade collapsed during the Progressive Era under mounting public pressure and new federal legislation. One famous “muckraking” exposé, The Great American Fraud by the journalist Samuel Hopkins Adams, pulled back the curtain on the industry of opiate addiction cures for millions of appalled readers.

Collier’s ad, Dec., 1905, after the publication of articles on patent medicine fraud. Wikimedia Commons

Hopkins painted such a scathing portrait of opiate addiction cures, whose proprietors the writer dismissed as “scavengers,” that the American Medical Association paid to disseminate Adams’s reporting as part of a lobbying campaign for the regulation of patent medicines. This strategy paid off. Although far from perfect solutions, the Pure Food and Drug Act of 1906 and the Harrison Narcotics Tax Act of 1914 regulated the ingredients and sale of patent medicines and narcotics, including opiate addiction medicines. These measures ultimately ensured that Collins, Keeley and other patent medicine sellers could no longer prey upon opiate-addicted customers.

Like its Gilded Age predecessors, today’s Big Pharma actively schemes to profit off of vulnerable, addicted customers, even while taking steps to ensure that opioid addiction persists. I believe that only sustained, vigilant oversight can prevent the reemergence of a medical Gilded Age, one in which companies like Purdue Pharma can manufacture an addiction crisis and charge customers for “curing” it.

Jonathan S. Jones, PhD Candidate in History, Binghamton University, State University of New York

This article is republished from The Conversation under a Creative Commons license. Read the original article.

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Opioid Epidemic

HIV Cluster Found in West Virginia County with High Rate of Opioid Use

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Dr. Michael Kilkenny, physician director of the Cabell-Huntington Health Department, discusses the recent HIV cluster in Cabell County on Monday, March 4, 2019, in Huntington.Photo: Lori Wolfe/The Herald-Dispatch

An active HIV cluster of 28 known cases has been confirmed in Cabell County, West Virginia, primarily among the area’s population of intravenous drug users, according to the state’s Bureau for Public Health.

The cluster, tracked from January 2018 to the present, represents a sharp uptick from the baseline average of eight cases annually over the past five years. This is the first notable HIV cluster in West Virginia where intravenous drug use is identified as the main risk factor, said Dr. Michael Kilkenny, physician director of the Cabell-Huntington Health Department.

In Appalachia, HIV is typically a rare diagnosis compared with coastal cities. This latest cluster represents a continuing shift in how HIV is most often spread, from men having risky sexual contact with other men to intravenous drug users, Kilkenny said.

Other areas in the region are likewise experiencing HIV clusters, including the Cincinnati metro area and smaller pockets scattered around West Virginia.

More than 20 of the 28 known HIV cases are Cabell County residents, Kilkenny said, while the remainder live elsewhere but may have been diagnosed at one of the county’s medical facilities.

The West Virginia Bureau for Public Health characterizes a cluster as being confined to a certain population – in this case, IV drug users – where it may be able to be controlled with minimal risk to the general public. An outbreak would indicate the disease is spreading beyond that initial group.

Kilkenny said there is no model to predict how much Cabell County’s cluster could grow, and declined to speculate.

A true-life worst case scenario was lived out around 250 miles down the Ohio River in 2015, when rural Scott County, Indiana, suffered an HIV outbreak infecting 181 people among a close network of residents sharing needles to inject opioids.

Cabell County is estimated to have more than 1,800 active IV drug users, so introducing HIV into that population is a point of major concern, Kilkenny said.

However, he continued, Huntington is well-equipped with the systems already in place to treat substance use disorder and that at-risk population, meaning it’s better prepared to face the spread of HIV than a community starting from scratch.

“We know how many people we have and we have outreach already into that population,” Kilkenny said.

“So while on the one hand that sounds like a scary number, on the other hand I don’t think that another community, that I could name, has that information going into the intervention.

“So I think we’ll be able to intervene quicker and more effectively than a community who doesn’t know what their population is or doesn’t have programs in place that touch those people.”

The main push of the plan to treat HIV in Cabell County – which has been in the works for about six weeks between the county and state – is to identify every case and refer individuals to treatment, Kilkenny explained.

Even though HIV isn’t curable, medication can now drive down the viral load in a person’s blood to the point where it can no longer be spread.

The plan also includes an ongoing public awareness campaign to encourage those at risk to get tested, and to reduce stigma surrounding the disease in the general public.

The health department hosted a public forum on HIV on Feb. 19 to offer information on the disease. It featured state and local experts.

“It’s important for people to know that HIV is not the death sentence it was 30 years ago, and that it’s not spread by social contact like hugging or shaking hands,” Kilkenny said.

“Those people should have no concerns at all about HIV,” referencing those who don’t engage in known risky behaviors.

This article was originally published by the Herald-Dispatch.

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