What’s destroying the young men of southern Ohio? Their death march often begins with an injury, and ends with a drug cocktail meant only to stop pain and give peace. But it ends life instead. So how do we save the men at risk? That is, how can we save ourselves?
By Melody Petersen
On the night after his 29th birthday, Brett Lute went out drinking with friends. A big man who had worked as a carpenter, Brett was trying to pull his life back together. He had just moved out of his girlfriend’s house after the two quarreled bitterly about their future. He was the father of two young children and he had no job. Times were tough in Portsmouth, Ohio. Yet he had plans. He had told his family that he wanted to enroll at the local university.
Brett had hugged his mother before he left that July night. She urged him to be careful. “I’m going to party just one more time,” he told her.
After a night of drinking, he arrived at his sister Lynnsi’s apartment. Morning had already dawned.
Brett planned to sleep and later to play with his two nieces. Five-year-old Marilyn and 3-year-old Emma loved their uncle. Brett would toss them into the air as they shrieked with delight. Marilyn said no one could throw her higher.
Before he went to sleep, Brett took half of a 40-milligram tablet of a new narcotic pain pill called Opana. The drug’s active ingredient, oxymorphone, was used mostly in hospitals by injection until its manufacturer, Endo Pharmaceuticals, began offering it in tablet form in 2006.
Opana, even when taken as prescribed, has such high potential for abuse and dependence that the Drug Enforcement Administration puts it in the same category as cocaine. But that hasn’t stopped Endo from promoting the drug directly to consumers through its website. “Hello, my name is Bill and I am a 40 year old construction worker who developed low back pain,” it says next to a photo of a heavyset man in jeans and work boots. “Are you like Bill? Talk to your doctor…”
The same promotional website warns patients not to drink alcohol while taking Opana because doing so can result in a fatal overdose. This is not an idle warning: In the first 6 months of 2010, medical examiners in Florida found, oxymorphone caused the deaths of 52 people.
Lynnsi let Brett sleep. But as the afternoon turned into night, she went to check on her brother. She entered the room and nudged him; he didn’t move. “He felt a little cold,” Lynnsi remembers. She decided to let him sleep some more. “I covered him up and left the window open.”
An hour later, she went back into the bedroom. She tried to roll Brett over.
“My girls were playing in the front room,” she says. “They heard me scream.”
A few days later, a woman called from the morgue: The autopsy revealed that the cause of death was an accidental drug overdose. Brett had died in the morning, tests showed, soon after going to sleep. Combined with alcohol, the 20 milligrams of Opana had been enough to kill him.
“He was a good father with a big heart,” says Lynnsi. “Emma says, ‘Uncle Brett flew away.’ ”
She pauses. “A lot of people around here have died that way.”
America has a new drug problem. It’s being facilitated by white-coated pharmacists in neighborhood drugstores, and delivered by letter carriers in convenient mail-order envelopes. Sometimes drugs are pushed across counters in cash-only pain clinics, or passed among addicts who sell part of their stashes to buy more drugs. Whatever the delivery method, the fatal overdoses that result have increased by almost fivefold since 1990. Most of the increase is due to prescription medications. In 18 states, the number of deaths caused by drugs now exceeds the number of motor-vehicle deaths.
The majority of those victims are men.
Heath Ledger was one, and the collection of drug bottles found in his apartment are evidence of what any one of us could be up against if life circumstances conspired against us. Mix anxiety, sleeplessness, and pain, add a desperate search for relief, and you might suffer the ultimate side effect: death, in pill form. Tallies of death certificates reveal that men, especially middle-aged men, make up roughly two-thirds of accidental drug overdose deaths. But few men realize that just about anyone taking one or more of a host of medications is at risk.
Why do men have twice the risk of women of dying from prescription drugs?
The story of Ryan Dickerson, a hardworking 22-year-old from northern Kentucky, offers some clues. Ryan died of an overdose of oxycodone on a late June night in 2009. His roommate found his body in the bathroom.
The death shocked his family. A quiet giant at 6-foot-4, Ryan had never been in trouble. He went to church. He was the kind of guy who would hug his aunt as soon as he saw her. His family didn’t even know he had begun taking oxycodone and then abusing it just weeks before he died.
Ryan had injured his ankle, according to his father, Rick, and a doctor had given him a prescription for the narcotic painkiller Vicodin. Ryan then sought more painkillers, either from a doctor or a friend, or both. His father believes Ryan swiftly became dependent on the drugs, in part because he didn’t want to miss a day of work at his new job, where he installed heating and air-conditioning systems. He didn’t know how dangerous the drug was, his father says. “He went a little too far.”
Ryan gambled by abusing the painkiller, and paid for it with his life.
“Unfortunately, this behavior is just in the character of men,” says Jennifer Sabel, Ph.D., an epidemiologist with the state of Washington’s injury and violence prevention program. “They tend to be risk takers.”
The number of overdose deaths from prescription pain drugs has skyrocketed in Washington, just as it has across the United States. Based on evidence from death certificates in the state, Sabel says, men are more likely than women to combine a pain medication with an illicit drug such as cocaine—a sign of their willingness to experiment.
Leonard Paulozzi, M.D., M.P.H., an epidemiologist at the Centers for Disease Control and Prevention, has spent years analyzing deaths from overdoses of prescription medications. In an interview, he pointed out that men are more likely to die in accidents of all kinds, from car crashes to drownings to firearms. Many men who die due to prescription drugs, he says, were using them in a nonmedical way or to get high. Men may just be more likely to engage in what Dr. Paulozzi calls “socially deviant behavior,” like injecting prescription drugs.
A study of Maine residents published in the American Journal of Managed Care found that while women were slightly more likely to obtain prescriptions for opioid painkillers like oxycodone or hydrocodone, men were more likely to abuse these drugs. (“Opioid” refers to all opium-like drugs, which include prescription narcotics as well as heroin.) And in Massachusetts, medical records from recent years show that men made up more than 60 percent of people discharged from hospitals or emergency rooms for opioid abuse, dependence, or poisoning.
Medical examiners say the highest death rates were among 35- to 54-year-old men. Terry Johnson, D.O., the former coroner in Scioto County, Ohio—where Portsmouth is located, and where accidental overdoses are up 360 percent since 1999—explains that many of the middle-aged men who died had medical conditions that made them more susceptible to a drug’s toxic effects. They were longtime smokers, he says, and had heart and lung problems. It is also clear that researchers can be too quick to blame those men for their own deaths. In fact, a multitude of outside forces are involved.
David P. Phillips, Ph.D., a professor of sociology at the University of California at San Diego, analyzed all death certificates filed in the United States between 1983 and 2004. He noted that in many ways the world had become a safer place. Over two decades, deaths due to traffic accidents, drownings, fires, and firearms had all decreased. But the rate of deaths from prescription and over-the- counter drugs was “not only increasing steeply, but at an accelerating rate,” he wrote in the study, which was published in 2008.
By 2004, prescription and over-the-counter drugs were responsible for far more years of lost potential life than all accidents from falls, firearms, drownings, fires, and nonmedication poisonings combined.
Phillips calls these deaths “fatal medication errors,” while other researchers often refer to them as accidental overdoses, which implies that the patient mistakenly took too much of the drug. Phillips said it is impossible to know from the information on a death certificate who is to blame for the death. Some blame, he says, might lie with the doctor, the nurse, or the pharmacist. “Someone is at fault,” he says, “but it’s unclear who.”
It’s more obvious who the victims are. For men, the rate of fatal medication errors rose nearly 400 percent in the two decades Phillips studied. And according to his analysis, the sharpest rise—more than 3,000 percent—was among people who died at home after mixing medications with alcohol and/or street drugs. These drug samplers are far beyond the help of a label warning.
Phillips says that since the 1980s, the manner in which drugs are being dispensed has shifted significantly. Doctors once rarely prescribed dangerous medicines like narcotic painkillers outside of a hospital setting, he explains, but they now routinely prescribe one or more of these drugs. “Maybe they shouldn’t be sending patients home unsupervised with these powerful medicines.”
Brett Lute’s hometown of Portsmouth, an economically struggling industrial city built on the banks of the Ohio River, provides a window into what is happening in communities across the country. The drug-death trend is in hyperdrive. Scioto County’s fatality rate from opioid pain drugs is twice the state average and rising. Residents open the Portsmouth Daily Times straight to page 2, where the obituaries are printed next to the daily Bible verse. They say too many of the deaths seem to be young adults, who are dying in their 20s, 30s, and 40s. The paper doesn’t list causes of death; it says simply that many passed away at home.
Dr. Johnson, who was the coroner in Scioto County as drug overdoses spiked, blames a mix of prescription drugs for the deaths. At the top of the list are painkillers like oxycodone, the generic name for a drug also sold under brand names such as OxyContin. Many of the dead were also taking benzodiazepines, a class of depressants that includes Xanax, Valium, and Klonopin. Other medicines involved in the deaths are muscle relaxants, sleeping pills, and antidepressants. Another fatal combination: mixing alcohol with medications.
The deaths have horrified local residents. They say the lax prescribing practices of county doctors are transforming their community—hurting its economy, destroying families, and filling jails. They say certain doctors have become white-coated pill peddlers, handing out prescriptions and pocketing profits with little thought to consequences for their patients.
“This is like legal drug dealing,” says Andy Albrecht, 32, who became addicted to oxycodone and then recovered; he now works as a drug counselor in Portsmouth. “The primary reason doctors are operating like this is greed.”
In January 2010, R. Aaron Adams, D.O., the Scioto County health commissioner, took the unprecedented step of declaring a public-health emergency. Dr. Adams explains to me that this is the same move he would have made if a tornado had destroyed a quarter of the city. But this public-health emergency was caused not by a natural disaster or a disease pandemic but by the healthcare system—the same system that Dr. Adams, who is also a practicing family physician, is part of.
He points to a study by state officials that found that doctors in southern Ohio were writing far more prescriptions for painkillers than physicians in similar-size counties in the northwestern part of the state. And those higher rates of prescriptions, the researchers found, corresponded directly with sharply higher death rates.
“I’ve grown up here and I’ve watched this thing evolve,” says Dr. Adams, looking over his reading glasses as we sit in his medical office discussing the prescription problem. “The numbers don’t lie. We’re dispensing too many of these drugs.”
Written reports from Porter Township’s emergency squad first raised fears in Bob Walton Jr., an elected trustee.
Walton had moved back to his hometown of Wheelersburg, Ohio, after living and working near Cincinnati as a sales representative for the drugmaker GlaxoSmithKline. He and his wife wanted to raise their two young boys in a quieter place like Scioto County, where almost everyone knows everyone else and watches out for one another.
Walton had been elected to the board of trustees at age 38; he monitored the budget, which included data on how many runs the ambulance squad made. After a year on the job, he noticed that the numerical code for “respiratory distress” started appearing on many of the daily reports.
Walton learned that many of the victims—people in their 20s and 30s—had taken a cocktail of prescription drugs: often a painkiller, a benzodiazepine like Xanax, and a sleeping pill. These medicines have a similar effect on the body: They depress the central nervous system and slow breathing. Taking more than one enhances that effect, as does adding alcohol.
“Respiratory distress,” says Walton. “That’s how this cocktail kills.”
Walton also noticed that sheriff deputies were reporting more break-ins and robberies. One or two break-ins at a time had increased to eight or more, Walton says. Law-enforcement officials were blaming the increase on the rising number of local residents who had become addicted to their medications and were stealing cash to buy more.
The escalating crime rate and ambulance runs, Walton says, corresponded with the opening of several new medical clinics in the area that specialized in treating pain. “We’re in a county of 80,000 people and we have nine pain clinics,” he says. “We’re not in that much pain.”
Many of these clinics accept only cash. No private insurance. No Medicare. No Medicaid, the health program for the poor. A visit costs $200 or more. Some clinics even sell and dispense the drugs that their own physicians scribble on their prescription pads, significantly boosting clinic income. These in-house pharmacies create a troublesome conflict of interest for even the most ethical of doctors. The more prescriptions they write, the more money they and their clinics make.
All of this is legal in Ohio.
Once a patient becomes addicted to opioids, the health-care bills spiral upward. A study in the Journal of Managed Care Pharmacy estimates that the medical expenses of a person who is abusing opioids are eight times those of a non-addict. Perhaps this is why the medical industry is booming in Scioto County even as other businesses die.
Downtown, the big department stores that once attracted thousands of shoppers are vacant. The green street signs are so faded that I’m sometimes left wondering where I am. In a neighborhood near downtown, paint peels from some of the wood-frame houses. I see couches on front porches and residents sitting on them in the middle of the day.
Yet several pharmacies downtown, including a new CVS, are busy. Staker’s Drugs and the Kroger supermarket, with its in-house pharmacy, are right next door to each other. As I follow a Baxter pharmaceutical supply truck on 11th Street, I can’t help but wonder how much money the health-care industry is making from this one sparsely populated county.
In fact, the easy availability of prescription pills has created an illegal subeconomy here. Several people tell me that the going price on the street for one 80-milligram tablet of OxyContin is $80, or $1 per milligram. It’s well known in Portsmouth that some residents who have become addicted are selling half their pills to pay for more. Inside the Kroger, I walk past the Starbucks counter and checkout stands to the pharmacy. Out front is a 3 1/2-foot sign featuring a photo of a middle-aged woman who is clearly stressed. Her to-do list is written on little notes that are stuck to her cheeks and forehead. “Take dog to vet,” says one. “3:00 meeting,” says another. Underneath her photo is the tagline, “You may have good reasons for not taking your medication. There are better reasons why you should.” In smaller type is the name Novartis, a drug company that has placed the placard here to remind people to stay compliant with their pharmaceutical regimens.
When experts at Ohio’s department of health, in Columbus, searched for the causes of what they call the state’s “unprecedented” rise in drug deaths, they found contributing factors other than the illegitimate pain clinics that have set up shop in places like Portsmouth.
In public talks, Christy Beeghly, M.P.H., the administrator of the state’s injury-prevention program, and her colleagues have attributed the death epidemic in part to the pharmaceutical industry’s aggressive promotion of its drugs. “You can’t turn on the television these days without bumping into a prescription-drug commercial,” Beeghly tells me. “Pharmaceutical companies have figured out that it’s very effective to market directly to the public.”
The ads seem to be working. In a 2007 survey by Consumer Reports magazine, 67 percent of primary-care physicians conceded they sometimes gave patients prescriptions for drugs they saw advertised on TV. Beeghly points out that most of the overdose deaths were patients taking multiple medications. A CDC survey found that during one-third of patient visits, doctors prescribe three or more medications. “Sometimes physicians may not even know all the drugs a patient is taking,” she says.
Beeghly also thinks doctors who prescribe painkillers could do a better job giving patients an exit strategy. After some time, patients taking a narcotic pain medicine will begin to develop a tolerance. When they abruptly stop taking the drug, they experience physical symptoms, such as nausea and sweating. In the worst cases, the patients’ pain can worsen and they’ll feel like they’ve been hit with a severe case of the flu. Beeghly says some doctors aren’t helping to wean their patients off the drug in a safe way. “They’re left to deal with it on their own.”
All this leads to one question: Who, exactly, is teaching physicians about these drugs? Answer: the drug industry. Not only do pharmaceutical companies send legions of sales representatives to physicians’ offices, but they also pay for at least 50 percent of the continuing medical-education classes doctors need in order to maintain their licenses. It doesn’t appear that patients are benefiting much from their doctors’ extra class work. In an FDA survey, 63 percent of patients reported that their doctors did not tell them about the dangers of the medicines they were prescribed.
But the coroners, scientists, and others who have studied the rising number of prescription-drug deaths raise the same point again and again: They blame the dead patients for misusing or abusing the drugs their doctors prescribed. Of course, it’s easy to think the worst of a now-dead patient, to dismiss him (or her) as “just another addict.” But if doctors never warned that patient that the drug could be addictive, that the drug could take control of and change his personality, that he might quickly feel as if he could not function or even live without the drug, then whose fault is his death?
“These are decent people,” says Frank Thompson, a retired high school English teacher who has decided to call attention to the county’s prescription death epidemic by starting a Facebook page; it has attracted more than 3,700 people. “Many of these kids who died are coming from rich families. They’re athletic kids, scholastic kids.
“It’s the drug, man. It’s the all-consuming drug that is tearing them apart.”
The signs taped to the door of Portsmouth Medical Solutions, a clinic on 11th Street, are not what you would expect to find when you visit a physician’s office.
EFFECTIVE IMEDIATLY
If you are a patient here, you are only to have one person with you.
They are to stay in the vehicle.
If these rules are not followed you will not be seen…
No exceptions! Please READ!!
Sorry NO Children
Notice: No Guns
There is an “open” sign in the window, but a woman inside says no one is available to talk to me. A few weeks before my visit to Portsmouth, federal agents had raided this pain clinic, surrounding it with yellow caution tape, questioning employees, and carrying out boxes of records.
That day, the DEA and FBI agents also raided a nearby clinic, Southern Ohio Complete Pain Management, at 1219 Findlay Street. Lisa Roberts, R.N., a nurse working for the Portsmouth health department, says she rushed over to the clinic to see the raid in progress. She and dozens of other residents stood across the street and cheered. Others drove by in their cars, honking as they passed. Roberts says people hoped law enforcement officials had finally gathered enough evidence to close the clinics. But the next day, both clinics were open once again for business.
Residents first noticed pain clinics opening in the county in the late 1990s, not long after Ohio legislators passed a new law. The measure states that doctors can’t be prosecuted for prescribing painkillers as long as they examine the patient and document that the patient has intractable pain and needs the medication. Patient advocates had lobbied to pass the law in Ohio as well as similar versions in dozens of other states. The advocates complained that many doctors were undertreating pain because they feared they might attract attention from the DEA if they wrote prescriptions for federally controlled narcotics.
But these laws had other supporters, who largely kept quiet behind the scenes even though they were the ones supplying most of the lobbying funds. The painkiller manufacturers, including Purdue Pharma, maker of OxyContin, paid millions of dollars to support campaigns for those patient advocates. Many drug companies continue to fund the efforts of these groups today.
No doubt many of the advocates involved never knew they were part of one of the most successful prescription-drug promotion campaigns in U.S. history. After these laws were passed, sales of opiate painkillers exploded. According to the DEA, 37 million grams of oxycodone were sold in the United States in 2006—an eightfold increase from its 1997 sales of just under 4.5 million grams.
But now the science seems to be running contrary to the sales figures. Researchers have discovered that these drugs don’t always work well to treat chronic pain, like lower-back pain, and with long-term use they can actually make pain worse. Some patients actually become more sensitive to pain.
In one study, researchers at Stanford University school of medicine tested six patients’ sensitivity to pain before the patients began taking morphine for chronic lower-back pain, and then again after they had been taking the drug for a month. They found that all the patients became more intolerant of pain while taking the morphine.
As patients become more sensitive to pain, they ask for ever higher doses of the drug, potentially touching off a cycle without end.
“This is a very real phenomenon that is seen particularly with very high opioid dosing,” said Jane C. Ballantyne, M.D., a professor of anesthesiology and critical care at the hospital of the University of Pennsylvania.
So while researchers debate whether or not patients are benefiting from the new laws, the consequences to society—as seen in Scioto County and other places across the country—are clear.
“In essence, what we’ve done,” says Beeghly, of Ohio’s health department, “is expose a much larger proportion of the population to heroin.”
