/ 8 January 2013

Pain of getting hooked on ‘hillbilly heroin’ crushes developed world

For almost two decades Geni Swartzwelder has played an elaborate game of hide-and-seek with her daughter Heather. Every day, Geni (52) takes a bottle of little white pills and sneaks it away to a secret location. Every day, 32-year-old Heather goes on a hunt for the bottle. Many days she succeeds in finding it. Geni knows because when she counts the pills at the end of the day she often finds their numbers depleted.

The game began when Heather was 14. Geni noticed, uncertainly at first but with growing alarm, that her husband's opioid painkillers, prescribed after he was injured in a motorbike accident, were coming up short. "Heather tried to convince us that we'd lost them, but there was no other way, and in the end we concluded she had to be taking them. So I started hiding them, every day, some place different."

Geni was forced to confront the fact that her only child was stealing her husband's pills and had become hopelessly addicted to them. When her efforts to hide the drugs failed, the Swartzwelders bought a metal safe and locked them up. That put a stop to the game, but not for long. Heather used the family video camera to film her mother opening the safe and studied the footage to extract the combination.

Heather's father died three years ago, but the game of hide-and-seek goes on. Now Geni hides her own little white pills – she has end-stage cancer and takes opiate derivatives – medically prescribed synthetic heroin – to ease the agony in her back and chest. Geni desperately wants to increase the strength of the medicines she is taking, because she is in excruciating and intensifying pain. But she knows that, if she does, the consequences for her daughter could be devastating: "I'm in pain, very much so, more and more each day," she said. "But I know that if I move to stronger drugs I could make her problems so much worse."

Geni's dilemma captures in microcosm one of the great unfolding tragedies of our time. Over the past 20 years, societies in the developed world have made it a priority to eradicate pain, encouraging hospitals and doctors to combat it as aggressively as they might a life-threatening virus. A public expectation has taken hold that we should all be entitled to lead pain-free lives, in rather the same way as we have come to expect to be able to own a car or to holiday abroad. But the pursuit of painlessness has come at a high price. The level of prescription of opioid painkillers – Percocet in Geni's case – has soared and with it the incidence of addiction and addiction's grim best friend: fatal overdoses.

The same escalating use and abuse of powerful painkillers can be found in rich societies from the United Kingdom and across Europe to the antipodes. But the country that really knows all about prescription pill excess and the human toll it claims is the United States. Americans make up less than 5% of the global population, but consume 80% of the world's supply of opioid prescription pills. Sales of the drugs have increased more than fourfold in the past 10 years, grossing $11-billion a year. To express that figure more personally, enough of Geni's pills, or their brand-name equivalents, were handed out in 2010 by doctors to medicate every American adult with a typical dose of hydrocodone, a pure opioid as powerful as morphine, every four hours for a month.

The more pills handed out, the more cases of addiction; the more cases of addiction, the more illegal street trafficking of the drugs; the more illegal street trafficking, the more snorting and injecting of the crushed pills; the more snorting and injecting, the more overdoses; the more overdoses, the more deaths. The result is that about 15000 Americans die every year from prescription pill overdoses – triple the rate of a decade ago, according to the US government body the Centres for Disease Control, which has declared the problem an epidemic. The death toll exceeds that caused by heroin and cocaine combined and in 17 states has become the number one  killer, surpassing even car crashes.

A rationale to treating pain
Apart from the sheer scale of the crisis, the profile of victims is striking. Unlike the crack cocaine epidemic of the 1980s and early 1990s that wrought havoc particularly among younger African-Americans, those who succumb to a prescription pill overdose are likely to be white, male and middle-aged.

The other factor that sets this disaster apart is its source. Track the supply of opioid painkillers involved in overdoses and you will eventually arrive not at a Mexican or Colombian drug cartel or an international smuggling ring, as might be the case with heroin or cocaine, but at the doctor.

"It started as a genuine attempt by doctors to help those who needed it," said Dr David Caraway, Geni's physician. "There was a rationale to treating pain with opioids. But 10 years down the line we have come to understand the consequences."

Caraway said that, in the late 1990s, the Joint Commission on Accreditation of Healthcare Organisations, a private body that provides guidelines for hospitals, launched an initiative that encouraged doctors to wage war on pain wherever they found it. It focused on opiate derivatives – drugs that work by modulating pain messages as they pass up the spine to the brain. For years opioids had been regarded as a drug of last resort, suitable only for the most severe cases. Now the emphasis began to shift towards prescribing them for chronic pain.

At around the same time, drug companies, led by Purdue Pharma, the manufacturer of the leading opioid painkiller OxyContin, embarked on a massive marketing push. In 2001 Purdue Pharma spent $200-million promoting OxyContin. Primary care physicians, in particular, were targeted and their patients induced to try out the drug with 30-day free trial periods.

Concerns about potential addiction were assuaged in promotional videos that claimed the incidence of addiction was less than 1%. Sales grew and grew, to about $3-billion for OxyContin in 2010.

Caraway knows intimately the outcome of what he describes as this "perfect brew" of official encouragement and big pharma marketing. He is a specialist in pain management and vice-president of the professional body that represents such experts, the American Society of Interventional Pain Physicians. He also works at a pain management centre, the Centre for Pain Relief Tristate, right at the heart of the painkiller epidemic in the small town of Huntington, which sits at the intersection of three states straddling the Appalachian mountains – West Virginia, Kentucky and Ohio.

Since the prescription pill tragedy began some 10 years ago, Appalachia has been in the thick of it. This beautiful area of rolling wooded hills hides levels of poverty and poor education on which drug addiction breeds. Appalachia has long been accustomed to high levels of addiction to tobacco, alcohol and meths and in the past decade it has similarly embraced "hillbilly heroin", as opioid painkillers have come to be known locally.

Mild complaints
Caraway has watched the epidemic take hold. He remembers his astonishment when he first started seeing patients coming in with signs of addiction to massively powerful opiate painkillers, having been put on them for comparatively mild complaints. "That was stunning to me – that a primary care doctor would write large doses of potent opioids for relatively benign pain conditions was extraordinary," he said.

He also remembers the moment the penny dropped – the realisation that the US was falling into a crisis of epic proportions. It was when a patient came to see him who had been complaining of muscle aches and pains of the sort you might feel after a long run, or if you had a light case of flu. His doctor had put him on 540mg a day of the most commonly prescribed opioid painkiller, OxyContin.

"Let me give you a little understanding about that," Caraway said. "OxyContin is up to two times more potent than morphine. So this is the equivalent of about 1000mg of oral morphine. That's a whopping dose that is every bit as potent as heroin, every bit as addictive. I was stunned that someone would prescribe this level of medicine to someone who wasn't suffering from end-of-life cancer."

After that experience, Caraway watched as similar cases became more and more common. And he watched as the problem fanned out from the medical world into the realm of illicit drug dealing as addicted patients, desperate for money to pay for their habit, began to sell the prescription pills on the street. "I've seen it tear apart families and lead to loss of life. The most horrifying thing I've seen is that this is causing hopelessness, leading to suicide and murder," Caraway said.

He treats patients who have severe pain and genuinely need treatment with powerful opioids. He does not treat active abusers. But several of his patients have had experiences relating to the epidemic of painkiller addiction. Take John Brumfield (61), who ruptured a disc in his spine and has been on painkillers for many years. After friends heard that he was on them, Brumfield started noticing something strange.

"If we had people over to the Super Bowl or a holiday season party, I'd notice that my medicines would come up short, no matter how good friends they were."

Twice people broke into his house to get to the drugs. Like Geni, he ended up installing a safe to secure the drugs. And he stopped having parties. "You don't know how sad that is to know the lengths even your friends will go to to get these drugs."

Not so lucky
A few years ago Brumfield went one better – he implanted what is essentially a mobile safe into his body. Under Caraway's supervision, he had a box embedded under the skin of his stomach into which opiate derivatives can be injected and then pumped in micro amounts through a tube directly into his spine: "No one can get at my drugs now. I no longer have to worry about people I thought of as my friends trying to take it from me," Brumfield said.

Mark Maynard (37) knows what addiction to prescription pills does to you. In 2006 he was working on a metal roof when he slipped and fell nine metres, smashing seven vertebrae. He was put on OxyContin and rapidly became addicted. He had to take ever larger doses to ease the pain and suffered cravings when he went without. At the peak of his addiction, he was taking 250mg of OxyContin, three 800mg Ibuprofen tablets, three doses of Neurontin, two of Lyrica, plus Diazepam and Ativan each day. His nadir came a few years ago on Christmas Eve. He had taken his two children to his mother's house and stayed up to wrap the presents. He took too much OxyContin and passed out; when he woke up eight hours later he was in the living room. "I'd wet myself, the kids had gone and I was on my own with wet pants, not remembering anything that had happened."

After that, Maynard pulled himself together. Under Caraway's care he gradually reduced his intake and is now on a much lower dose of painkiller and doing well. But many friends have not been so lucky. He knows 10 or so people who are in prison or have overdosed and died as a result of opioids.

Black-market drugs are freely available in the area, much of it trafficked through the so-called OxyContin Express: people travel down to Florida, home to many unscrupulous doctors and their "pill mills" where prescriptions for painkillers can be bought with no questions asked, and bring the spoils back to Appalachia to be sold on the street for up to $100 a pill. "It's hard to find people round here who don't take pain medicine," Maynard said.

Finally, and very belatedly, the US authorities have begun to grapple with the problem. The Centres for Disease Control has named painkiller abuse a number one priority, police have begun closing down pill mills in Florida and physicians are being educated about the dangers of overprescribing. And in Appalachia new rules have been introduced that require doctors who treat more than half of their patients for chronic pain to be registered. Purdue Pharma has also reformulated OxyContin so that if the pills are crushed they turn into a gloop that cannot be injected or snorted.

But now that the genie is out of the pill bottle, it is very hard to put back: pill mills closed in Florida pop up again in Georgia or Maine; addicts who were using OxyContin switch to Opana or another brand name. The insatiable desire for hillbilly heroin continues unabated.

"This is still getting worse," said Caraway. "In our pursuit of 'pain-free', that elusive modern goal, we have created a monumental problem of drug addiction, abuse, lost productivity, crime and death." – ©  Guardian News & Media 2012