Healthy Choices

Activists see link between over-prescribing of opioid painkillers and increase in overdoses

Tammy and Tim Smick, center, join families of victims of drug abuse, physician overprescribing, and medical malpractice at a California Medical Association convention last year in Anaheim.
Tammy and Tim Smick, center, join families of victims of drug abuse, physician overprescribing, and medical malpractice at a California Medical Association convention last year in Anaheim. Los Angeles Times

Alex Smick’s agonizing, fateful slide toward death by prescription drugs began with a simple act of kindness: He tried to save a little dog from a big dog.

It was a sunny day in Southern California in 2010, and Alex was riding his skateboard, the family dog loping by his side. A tiny, yapping challenger charged at them, and Alex made a quick turn of his skateboard to block off the little David to his dog’s Goliath. Too quick, it turned out.

He hit the pavement hard. He severely injured his back, ending up with five bulging disks – though he would not learn this for months. The family’s health insurance company denied requests for diagnostic imaging of his spine. Instead, three different doctors over the next two years would put him on a regimen of opioid prescription painkillers that escalated in potency – from Vicodin to oxycodone to morphine. He was 18.

At 20, Alex had not yet been seen by a spinal cord injury specialist. There was no plan for treatment. But he was fed up with the drugs and checked into an Orange County hospital in 2012 to detoxify. There, a fourth doctor put him on a lethal combination of 11 drugs, including more opioids. Alex stopped breathing. Cause of death? Poly-acute drug intoxication.

It’s a wrenching story that his mother, Tammy Smick, a Downey schoolteacher, tells time and again. A parent-advocate fighting for more responsible use of prescription painkillers, Smick has joined a growing number of parents nationwide who’ve lost their children to the same scourge: over-prescribing of dangerously powerful and addictive opioid pain medications.

“Alex wasn’t a drug-seeking kid,” his mother said. “He was my big, beautiful, athletic, kind, handsome son. Alex thought going to the hospital was the safest, smartest way to get off the drugs. But they loaded him up with so many meds, they just put him to sleep. I didn’t know enough about excessive prescribing. I was naive.”

No longer. Smick retraced the steps of Alex’s care. She hit the website Epocrates, educating herself on the drugs Alex was given, including the risk of interaction with other medication. She hired a private pathologist. She sought sanctions against the hospital, doctor and nurses. She speaks out about medical negligence, and how it’s the third-leading preventable cause of death.

In rallies on Capitol Mall in Washington and across the nation, in testimony before legislators, in community meetings and online, parent-activists are trying to make their voices heard. They are armed with statistics such as this shocker from the Centers for Disease Control and Prevention: In 2012, health care providers wrote 259 million prescriptions for painkillers, enough for every adult in the United States to have a bottle of pills.

Their message is spurring action on several fronts. States tallying the highest numbers of prescription drug overdoses are cracking down on the most prolific prescription drug providers – and those who obtain drugs for illegal sale. Elected officials from the U.S. Congress on down are taking notice of a federal research finding that 50 percent of deaths by drug overdose involved prescription drugs; and that 75 percent of those deaths involved legal opioid painkillers.

Law enforcement agencies are deploying narcotics agents to curb street sales of opioids. States are reining in so-called “pill mills,” or pain management clinics that prescribe large quantities of the painkillers. Attorneys general of 29 states signed a letter to the U.S. Federal Drug Administration recommending that the FDA reverse its 2013 approval of a new, highly potent narcotic called Zohydro that can by given at doses as much as 10 times higher than what’s typically prescribed.

A coalition of addiction specialists, doctors and parent-activists called Fed Up! recently demanded the removal of FDA commissioner Margaret Hamburg, noting that it’s been under her watch that the overdoses have escalated to roughly 15,000 a year nationwide.

Some citizen-petitioners are even demanding that the FDA take opioid narcotics off the legal market altogether, stirring up a hornet’s nest of objections from pain management doctors who, for decades now, have argued they have an obligation to ease their patients’ suffering.

FDA chief Hamburg stands with them: “We must meet the very real medical needs of the estimated 100 million Americans living with severe chronic pain or coping with pain at the end of life.”

On Monday, the federal Drug Enforcement Agency tightened restrictions on a class of opioid analgesics called hydrocodone combination products, moving them into a more restrictive controlled substances category called Schedule II, from Schedule III. This means that drugs such as Vicodin or Norco are now classified as having the greatest potential for harm, abuse and dependency.

But it is oxycodone, used in OxyContin – already a Schedule II drug – that the DEA has identified as the most-abused medicine in America. Hydrocodones rank second.

Dr. Timothy Albertson is the UC Davis Medical Center’s chairman of internal medicine for pharmacology, toxicology, anesthesiology and emergency departments. He also serves as the medical director of the Sacramento division of the California Poison Control System.

He applauded the DEA’s action, which no longer allows automatic refills, or faxing or phoning of prescriptions to pharmacies.

“The use of high-dose, chronic opioid treatment creates the environment for drug diversion and drug misadventure for the patients,” Albertson said. “We continue to see the numbers of prescription opioid overdoses increasing in our emergency departments.”

California has set up an electronic database for pharmacists and doctors to check if a new patient has already obtained controlled-substance medications and is simply seeking more drugs, or “doctor-shopping.”

On Sept. 29, the Medical Board of California made a formal recommendation that all California pain-medication prescribers use the database, known as CURES.

Even drug companies have responded to the crisis – in their own way. Purdue Pharma, which manufactures the blockbuster drug OxyContin, came up with a way to add an opioid receptor blocker to a new high-dose oxycodone painkiller, called Targiniq ER.

If the pill is crushed for injection or snorting, the opioid blocker naloxone prevents the enhanced effect abusers seek. But when swallowed, naloxone has no effect.

CDC Director Dr. Thomas Frieden has issued a call for reform of prescribing practices. For anything other than cancer pain or end-of-life suffering, the risks of prescribing opioids outweigh the benefits, he said.

He draws a direct line between over-prescribing and the decadelong pattern of steady increases of drug overdose deaths – now officially the No. 1 cause of accidental deaths nationwide, surpassing fatal car accidents.

“Prescription drug overdose is epidemic in the United States,” Frieden said.

California has already heeded Friedan’s call for a “good Samaritan” law that allows people to dial 911 to report an overdose without getting themselves in trouble.

Recently, the state took a significant step toward helping families or people close to opioid users. Gov. Jerry Brown signed into law a provision allowing people to buy the antidote to opioid overdoses without a prescription to have on hand in case of emergency. When injected or used as a nasal spray, naloxone reverses an opiod overdose. It’s been used in ambulances and emergency rooms for decades.

California is one of the lowest-prescribing states. Still, public health officials are worried about prescription painkillers leading users to heroin, a cheaper option than the pricey oxycodone.

State tallies of death-by-poisoning show California saw a 60 percent increase in drug deaths from 2000 to 2012, largely driven by the opioid overdoses.

Opioids are chemically similar to opium, derived from the seeds of poppies grown largely in Afghanistan. For centuries, opium has been used as a mind-altering substance in certain cultures. Modern versions include the prescription drugs, heroin, morphine, methadone and codeine.

Prescription painkillers work by binding to receptors in the brain to decrease its perception of pain and introduce a feeling of euphoric well-being. In the process of sedation, the user’s breathing slows and, in cases of overuse, stops altogether.

In Sacramento County, about 2,500 residents were hospitalized for opioid overdoses from 2006 and 2012. Of the state’s 15 largest counties, none had a higher rate of the hospitalizations, according to data from the Office of Statewide Health Planning and Development.

David Sheff is the author of “Clean,” an exhaustive look at addiction as a disease, and “Beautiful Boy,” a best-seller that laid bare his family’s chaotic and emotionally painful home life during his son Nic’s years of addiction.

In an interview, Sheff, who lives in the Bay Area, said not enough is being accomplished to fight addiction disease.

“We are way behind where we should be,” he said. “With more funding, we’d have a renaissance in terms of scientific understanding of addiction and how to treat it. We could be so much further.”

That’s a goal that Alex Smick’s mother pushes for as she repeats her story over and over to different audiences.

The night Alex died, he was left unmonitored for seven hours, even though the nurses’ station was right around the corner from his room, Tammy Smick said. By the time a nurse did check on him, Alex’s body was in full rigor mortis.

“All we want to do is bring about change,” Smick said. “This is about the small percentage of negligent and over-prescribing doctors. Change is not moving quickly enough and many people have died.”

Phillip Reese contributed to this story. Call The Bee’s Cynthia H. Craft, (916) 321-1270.

  Comments