Rife on the range: Opioids affecting rural communities
November 20, 2018
Ryanne's parents never realized how bad her opioid addiction was.
They knew she was addicted, but didn't know the severity.
And when they tried to have an intervention for her, she packed her bags and left.
She worked five jobs, trying to make enough money to support her habit.
“There’s a lot of normal people you would not think are drug addicts.” Doug Austin, CEO of Addiction Recovery Centers of the Black Hills
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But there was never enough money, and there were never enough drugs for the young woman.
When she was 16, Ryanne had her wisdom teeth pulled by a dentist who prescribed 12 Vicodin for the pain. At the time, she and her parents didn't know that a dozen was too much. The pharmacist who filled the prescription mentioned that it was a lot, but the prescription was filled.
Ryanne (not her real name to conceal her identity), who grew up and lives in North Dakota, was a good kid. She knew drugs were bad. But the Vicodin from the dentist's office gave her a happy feeling. "Oh, this is fun," she thought.
She worked at a grocery store, with a supervisor who was an ex-heroin addict. The boss showed her what the next level of drugs looked like. Soon, she and other co-workers were shooting up in the back of the restaurant, one of her other jobs.
Then it escalated into meth.
Ryanne's addiction was more than a dozen years ago, and since then, the drugs have become stronger and more easily available. Fentanyl wasn't on the scene back then, heroin is cheaper, and opioids like oxycodone and hydrocodone weren't common.
Now they are easily accessible and spreading like wildfire across the nation, especially in rural areas.
Overdoses due to opioid use killed more than 72,000 people in 2017, more than were killed by guns, car crashes or HIV/AIDS in a single year.
And opioid use isn't limited to big cities. Only about twenty percent of Americans live in rural areas but a disproportionate number of rural-dwellers are prescription opioid and illegal drug abusers. In non-metro counties in the U.S., the rate of opioid-related overdose deaths is 45 percent higher than in metro counties.
The addiction often starts like this: a doctor prescribes a painkiller, due to a medical procedure. The painkiller feels good: it kills the pain. The patient goes back for refills, and pretty soon they're hooked. When the doctor refuses to refill the prescription, but the patient still needs the drug, he or she goes to the streets to get it. That's when the addiction sometimes gives way to heroin. Heroin is cheap and easy to get.
When the drugs are illicit, off the streets, their contents might be uncertain. Prescriptions are monitored by the FDA and their contents are sure. Drug dealers might use ingredients that aren't what they're supposed to be, and the dealer buys whatever he can get. Their "recipe" isn't controlled by the FDA; the mix may not contain what the user thinks he's buying, and it may be more powerful and deadly.
Liquid fentanyl came into southwestern South Dakota with the Sturgis Rally, says Doug Austin, CEO of Addiction Recovery Centers of the Black Hills, in Rapid City. Users mix heroin with liquid fentanyl, and "they don't know how much to cut the heroin with, and an unknowing person will grab hold of a needle, inject it, and it's overloaded with fentanyl. Their heart quits, and they OD."
Heroin has been around for a long time, Austin said, but it's less expensive than it used to be. "It's a cheaper high," he said.
Common prescription opioid painkillers include fentanyl (brand names are Actiq, Duragesic, Fentora, and others), hydrocodone (brand names are Vicodin, Hysingla and others), meperidine (brand name Demerol), oxycodone (brand name Oxycontin),and methadone (brand names Dolophine and Methadose).
On Oct. 24, President Donald Trump signed legislation called the Support for Patients and Communities Act, a package of bills designed to fight the opioid epidemic through a variety of avenues.
It offers about $500 million a year towards the opioid crisis, and gives states more flexibility in using the funding; lifts restrictions on medications for opioid addiction, making it possible for more health care practitioners to prescribe the drugs that fight addiction; makes changes to Medicare and Medicaid to attempt to limit the over-prescription of opioid painkillers; expands an existing program to get more first responders to carry and use naloxone, a medicine that reverses opioid overdoses, and allows federal agencies to research addiction and pain.
One of the treatment options that will be expanded through the SUPPORT Act is MAT training: medication assisted treatment. Through a doctor, medications can be prescribed to help opioid abusers. Methadone, buprenorphine and naltrexone are used to treat opioid dependence, and subauxon is used for heroin addiction. The medications help with withdrawal and lessen the cravings for the opioid or heroin.
MAT for the patient is two-fold: a doctor prescribes the medication while the patient receives assessments for behavioral health, or gambling or alcohol addiction. Federal law requires patients getting opioid treatment to get medical, vocational, counseling and educational assessment and treatment.
One of the provisions in the SUPPORT Act allows medical experts other than doctors to be able to prescribe the opioid addiction medications. Right now, doctors, nurse practitioners and physician assistants can prescribe certain drugs, with a federal waiver. Few get the waiver; it requires more training and means more patients added to their workload, when there are fewer doctors and the number of hospitals in rural areas is decreasing.
Another provision in the SUPPORT Act allows for telemedicine to serve those in rural or remote areas. With the telemedicine component, rural health clinics can partner with an addiction specialist in the state to provide remote telemedicine services for addiction treatment. The local nurse practitioner examines the patient, determines that treatment for opioid addiction is needed, and connects the patient with the specialist via a telecommunications system. The addiction specialist visits with the patient remotely and issues a prescription.
Right now, two facilities in South Dakota offer MAT: Addiction Recovery Center of the Black Hills, in Rapid City, with Stephen Tamang, M.D. as its director, and a second location in Sioux Falls. With the extra funding by the Support Act, Austin hopes more will have the MAT program.
Opioid use in rural America is prevalent, Austin said. "There's a lot of normal people you would not think are drug addicts," Austin said. He gives the example of a rancher who breaks a leg and the doctor gives him pain pills. "And the doc says, when you're done with them, give me a call and I'll refill it. The pills make you feel better, so you give him a call and he refills it. Now you're wanting more, but he won't refill it. But you say, it's really hurting, so the doc gives him another fifteen, and on and on it goes."
There are people who say MAT is giving addicts another drug to get them off the drug they're on. But Austin disagrees. "Opioid addiction is a brain disease. The difference is the drug you're giving them is to get them off the drug that is causing death and overdoses. I look at it as no different than if you tell me I have diabetes. There are medicines I have to take to help control it. There's a lot of old philosophy out there. People think you're just substituting one drug for another drug. But this is the way of the future."
And getting users on MAT not only saves lives, but also saves resources.
"There are fewer ER visits, less involvement with the legal system, law enforcement, jail and detox. The main goal is saving lives but saving money, too," said Julie Birner, director of the Addiction Recover Centers of the Black Hills.
Being self-reliant and tough is typical of rural people, who don't usually want to admit they need help, Austin said.
"A symptom of this disease is you have this idea that you have to do it all by yourself. 'I'm a big, strong man, I can do it by myself, I don't need your help,'" Austin said. "They say that right into the grave."
The goal for opioid users at the Addiction Recovery Center is to get them clean, Austin said. "Clean, sober, and that means being off drugs. We teach them in treatment how to live your life that way, clean and sober." They also advise them to seek fellow addicts after treatment. "We encourage people to go to AA (Alcoholics Anonymous) or NA (Narcotics Anonymous)."
People who come to MAT are not court ordered; they come of their own free will. "They call us themselves. They know they have a problem and they want to fix it," Austin said.
Opioid addicts are often "normal" people. Ryanne grew up in a two-parent family with a strong Catholic background and was president of her high school FFA chapter her senior year, while she was addicted.
Her dad, a retired police officer, and her mom, knew about her drug habit but didn't realize the extent of it. They never turned her into the police, for which she is glad. "My dad knew if I was incarcerated, my chances of getting out of drugs and getting my life back were slim." Convicted felons can't own a gun, vote or get student loans.
Substance addictions, whether it's opioids, other drugs or alcohol, never leave solitary victims. It's estimated that the addiction affects at least seven other people within the addict's family.
That was the case in Ryanne's situation, but her family never gave up on her. "I was never disowned by my family. I would be working two or three jobs to support my habit. And they would bring a Thanksgiving meal to me. It would destroy them, it would break their hearts to see that I was so out of it."
She knew it hurt them. "It crushed my parents. When I look back on it now, my family went through such more hell than I did. But when you're that far advanced into an addiction, you don't care. You get to the point where you don't care about anything. The only thing you worry about doing is making yourself feel good to survive to the next day."
Ryanne didn't go through treatment to kick the addiction; she did it herself. She knew she had to change her habits or she would die. "There was a point when I saw this was not going to work. I'm either going to die or I'm going to fix it." A tragedy with her younger sister also motivated her. She saw her parents suffering with her sister, and she said, "wait a minute, I can only put my family through so much."
She stopped cold turkey. The withdrawals were terrible. The first three days were the worst. "You're nauseous, hot and cold, you can't sleep, you don't want to eat, and you're sick all of the time. Your body physically hates you, you have no motivation, and you're depressed because you have failed this monster."
Ryanne suffered some relapses, but she has been clean for over 15 years.
She doesn't tell many people she was an addict. "There's such a stigma with the shame, that you did drugs. I don't want to announce it because I could lose a future job." Winning her battle over her addiction is more of an accomplishment than having the addiction.
She fights it every day. "Narcotics (opioids) are available everywhere," she said. "If I know somebody that has Vicodin, I want it. I know I can't have it or be around it." She also will argue with a doctor or dentist if he prescribes a narcotic. "I have to have a conversation with the doctor. I know I need (the drug)," but she asks him to prescribe a minimum of pills. If a friend goes to the doctor and has a pain pill, she doesn't want to know about it. "Don't tell me," she said. "I'm confident I won't take it but I don't want to hear about it."
She's also had to change her thinking. "I had to train myself that if I ever did drugs again, I would die."
Drug users are recluses, Ryanne said. "They become ashamed, and then they are depressed, and the drug is even more their friend. And the more depressed you get, the more you don't care if you're loaded. And at that point, do you care if you overdose? You say, I just want to end it, I just want to be done."
Ryanne has advice for those who are addicted and their families and friends. "Don't give up. You're certainly stronger than you think, and your will is what will drive you towards the end. There is an end in sight."
And for families, "stick with them. Let them know (the addict) is human and makes mistakes, but don't support the habit. Tell them, 'I will help you, through love and support, and buy what you need, but I will not financially support your drug habit.' But let them know that you are family, and keep the love in it."