Opiate addiction nearly cost Zack Armbrust his life. Like millions of Americans, he got hooked on painkillers and heroin, a crippling combination that’s often deadly.
Now about 30 months clean, the Roseville resident considers himself one of the lucky ones.
In America’s war on opiate abuse, the problem of painkiller overuse has been as perplexing as it is pervasive.
As prescriptions for Oxycontin, Vicodin and other opiate painkillers soared in the last 15 years, so did addiction and overdose deaths. In 2014, nearly 18,900 Americans – a record peak – died from prescription painkiller overdoses, according to the Centers for Disease Control and Prevention.
On average, 78 Americans die every day from an opioid-related overdose, the CDC reports.
Efforts to knock down those alarming statistics are firing on multiple fronts, from Sacramento opiate-abuse clinics and UC Davis medical school classrooms to the California Legislature and the White House.
“There’s a lot we can do around treating pain that has nothing to do with opioids,” said Dr. Scott Fishman, a UC Davis School of Medicine professor and the director of its Center for Advancing Pain Relief. Those alternative approaches to opiates, he said, include acupuncture, physical therapy, mindful meditation and self-hypnosis.
Other efforts are underway. Last month, state lawmakers passed a bill requiring doctors to check their patients’ prescription drug history in the state’s controlled substance database before prescribing opiates. And last week, the Obama administration announced $53 million in grants to beef up prescription drug-monitoring programs, expand emergency responders’ access to overdose drug naloxone and fund other anti-opiate state programs.
In addition, pharmaceutical companies are rolling out alternate forms of buprenorphine, a widely used medication that relieves the physical cravings of opiate dependency. One company, Braeburn Pharmaceuticals, recently earned Food and Drug Administration approval for an under-the-arm implant of buprenorphine that lasts six months.
The prescription opiate epidemic has its roots in the 1990s when pharmaceutical companies began offering Oxycontin, Vicodin and other painkilling drugs for surgery, back injuries and dental procedures. While heralded as effective medications based on their use in cancer and end-of-life care, the long-term effects on chronic users were less understood. Ultimately, overprescribing led to dangerously high rates of addiction.
Fishman, a national pain expert and author of “The War on Pain,” said treating pain is challenging, especially when time is limited in a doctor’s exam room and physicians don’t always have adequate training. “When you don’t have time, it’s easier to go to the prescription pad,” he said. “We’re trying to teach doctors to not do that.”
In Sacramento, the UC Davis Pain Management program has been training new medical students and veteran doctors alike in how to use alternatives to opiates for treating chronic pain. It also hosts weekly “telementoring” video conferences for primary care clinicians in rural Northern California on pain management techniques. Later this month, Fishman and UC Davis colleagues will meet in Japan with worldwide pain experts to discuss new training guidelines for doctors, pharmacists and medical students.
78: Average number of Americans who die – daily – from opiate-related overdoses.
Every patient is different, said Fishman, noting that some people can learn how to manage their pain with mind-body techniques, similar to how athletes learn to push through pain using mental strategies. Physical therapy and other interventions also can help. For some patients with chronic back pain, for instance, UC Davis has seen positive results using spinal cord stimulation, sending electrical impulses via a catheter in the back to jam pain signals.
Certainly, not everyone whose doctor prescribes an opiate gets hooked.
When Diane Greenberg was sent home after her fourth spinal surgery, she was given prescriptions for two potent pain relievers, Percocet and Valium, three pills a day of each. Her surgeon advised her to taper off or risk getting dependent.
“They do tell you to taper off, but they don’t really tell you how or what the side effects will be,” Greenberg said. “They don’t sit down and have that conversation with you.”
A retired UC Davis nurse practitioner, Greenberg knew the effects of abrupt withdrawal, so she drew up a written schedule to slowly, carefully wean herself off the opiates. Over two months, she cut back her pills to twice, then once a day. Today, with screws and rods imbedded in her back, the Carmichael retiree is off opiates entirely. She still has chronic pain, but manages it with a non-opiate nerve medication and visualization techniques, such as imagining her pain as a fire and mentally dousing it with a firehose of cold water.
Others say they manage pain by keeping their prescription consumption to a minimum. Tom, a 72-year-old retired construction worker who doesn’t want to disclose his real name to protect his privacy, said he takes a Norco tablet twice a day for relief from a deteriorated disc.
“It gave me my life back,” said the Sacramento County resident, whose prescription helps him sleep at night and function during the day. “I can do things around the house and feel no pain in my back and down the leg.” Prescription opioids, he contends, can be a life-saver, if used responsibly.
For every patient like him and Greenberg, thousands of others become dangerously addicted. In 2012, an estimated 2.1 million Americans suffered from substance abuse related to prescription opioid pain relievers, according to the National Institute on Drug Abuse.
Lawmakers and major health plans are attacking prescription abuse on multiple fronts.
Last month, state lawmakers passed Senate Bill 482, by State Sen. Ricardo Lara, D-Bell Gardens, requiring doctors to check a patient’s prescription drug history before issuing opiate medications. The bill, which still requires the governor’s signature, is designed to make it harder for patients who “doctor shop” to obtain multiple prescriptions or dangerously high levels of opiates.
In March, the CDC issued new guidelines for prescribing opiates, advising physicians to “start low and go slow” by offering the lowest dosage for the shortest duration. Those guidelines also urge doctors to initiate pain-management alternatives, such as physical therapy and cognitive behaviorial treatment. (The guidelines are not directed at prescription opiates used for cancer, palliative and end-of-life care.)
Health systems are also changing how their doctors prescribe, dispense and treat pain, in some cases cutting prescription painkiller rates by up to 50 percent or more, according to a recent study by the California Health Care Foundation.
Kaiser Permanente Southern California, for instance, has cut Oxycontin prescriptions by 85 percent since 2010 and also reduced the number of patients on high-dosage opioids. It’s done so by educating and involving its entire medical community, including physicians, pharmacists and patients.
Among Kaiser’s tools: When a doctor tries to electronically issue a new prescription for Oxycontin or other high-dose opioids, a yellow warning pops up on the online screen. Unless an exception is made, only doctors in pain management, oncology or palliative care are allowed to write new prescriptions for those high-dose drugs. Opioids can be prescribed for only 30 days and cannot be renewed any earlier. In the emergency room, painkiller prescriptions are issued for just a three-day supply. Pharmacists are allowed to question doctors who prescribe high-quantity, high-dose prescriptions, greater than 200 tablets or more than 120 morphine milligram equivalents a day. Doctors deemed “outliers” – with high rates of opiate prescriptions – are offered peer advice on pain management alternatives and how to taper patients to lower dosages.
It’s not an overnight solution, noted the California Health Care Foundation study. Converting to a system that “sustains a new culture and practice of safe and effective opioid use was not easy, and is an ongoing process.”
For those who’ve become addicted, the path to recovery is never easy.
“The people who do best are people who have lives and got involved in chronic pain, overused opiates and got addicted. They have a strong motivation to get off the pain meds and they have a strong support system,” said Dr. Claude Arnett, a Sacramento psychiatrist who treats opiate addiction.
For the last 10 years, Arnett has been prescribing buprenorphine, calling it “a nearly miracle medicine” for opiate dependency because, unlike methadone, addicts can’t get high and rarely overdose on it. It allows the body’s natural endorphin system, which helps alleviate stress and pain, to begin repairing itself. Ideally, it makes patients stable enough to concentrate on other aspects of their recovery, such as counseling and stress management.
Armbrust, one of a handful of recovering addicts interviewed for this story, took a familiar route to addiction. As a senior in high school, he and friends started “having fun,” experimenting with alcohol and weed. Eventually, that led to Oxycontin and heroin. “It was just another thing to do for the first time,” he said.
An only child who credits his parents with being 100 percent supportive, Armbrust said he wasn’t trying to escape a troubled childhood or numb unhappy memories. Instead, he simply liked the feeling of being high. “No worries, no pain. It made you feel perfect; everything was good,” he said.
And then it became not so good.
By 19, Armbrust was stealing from his family to support his drug habit. He was arrested for a DUI after police found him with weed, alcohol and prescription pills – stolen from his grandfather – in his car. The then-teenager was ordered to attend Alcoholics Anonymous meetings three times a week for 18 months, but didn’t take it seriously. Instead, he and a friend tried heroin. To support what became a $100-a-day habit, Armbrust started selling heroin on the streets of downtown Roseville. His turning point came in October 2013, when he was arrested for selling half an ounce. While awaiting court appearances, his family forced an intervention and he was sent to a live-in rehab program in Natomas, where he underwent counseling and treatment for three months.
Facing a possible prison sentence and ashamed of the financial and emotional toll he’d subjected his parents and family to, Armbrust knew he needed a major turnaround. After finishing his 90-day rehab, he moved, changed friends, got a full-time job at an auto parts store and says he’s now been clean for 2 1/2 years. He takes buprenorphine twice a day but has cut the dosage in half over the last two years.
“Fear of the consequences definitely kept me clean and sober long enough to fully give (rehab) a shot,” said the 25-year-old, sipping an after-work vanilla latte last week at a Roseville Starbucks. “Once I put my heart into it, it kept me sober. There’s no greater feeling.”
Despite the nation’s war on opiates, prescription opioids still have a place, say pain experts. “They’re really essential drugs in medicine,” said UC Davis professor Fishman. “There’s no benefit without risk, particularly with painkillers. We just want to avoid treatments that are worse than the disease.”