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SF Special: Fighting Back in Rural America’s Opioid Crisis

Operating a Christmas tree farm for 20 years took a toll on Kathi Albertson’s shoulder, so last January the Cambridge, Ohio, farmer enlisted a surgeon to restore it. Beyond giving Albertson much-needed relief, the surgery sparked a new Farm Bureau program in Guernsey County, where Albertson is a volunteer, to help prevent unused prescription opioid pills from circulating in area communities. The rural, east-central Ohio county is about 60 miles west of Wheeling, West Virginia.

“One of my finest workers died of a heroin overdose,” says Albertson, her voice cracking as she describes the high schooler who had enjoyed driving four-wheelers and helping families pick out holiday trees at Albertson’s farm.

Although Albertson isn’t familiar with how the young worker eventually became addicted to drugs, she knew prescription pain medications were often an entry point. She was horrified when her orthopedic surgeon gave her a prescription for Percocet as she was leaving the hospital. “I didn’t want the pills sitting around my house,” she says.

Experts say opioids – including Percocet and other pain medications you might take following surgery or for a toothache, plus illegal heroin, and even more powerful synthetic opioids, including fentanyl and carfentanil – are driving the nation’s burgeoning addiction and overdose statistics. Consider:

  • Opioids claim the lives of 91 Americans each day and prescription opioids are involved in more overdose deaths than any other drug, according to the Centers for Disease Control and Prevention (CDC).
  • Since 1999, the number of overdose deaths involving opioids has quadrupuled.
  • A June forecast by the medical news website STAT projected that opioids could kill 500,000 Americans over the next decade.

But if the words opioids, heroin, or addiction bring to mind homeless people living on the streets in large metropolitan cities, think again. While the nation’s drug crisis has spread throughout the U.S., some experts say the impact is hitting small, rural communities the hardest.

According to the CDC, overdose death rates are rising fastest in states with large rural populations like West Virginia, Kentucky, and New Hampshire. Over the past 10 years, the rate of babies born with opioid withdrawal, or neonatal abstinence syndrome, has risen twice as fast in rural areas compared with metropolitan areas, according to a recent study led by the University of Michigan and Vanderbilt University. Drug-related complications like Hepatitis C are also on the rise faster in rural areas.

The CDC goes so far as to say that the combination of living in a rural area and having a low income is proven to increase your risk of prescription opioid abuse and overdose. Other risk factors include shopping for overlapping prescriptions, taking high daily doses of prescription opioid pain relievers, and having a mental illness or history of substance abuse.

Last week, the opioid crisis was declared a nationwide public health emergency by Acting Health and Human Services Secretary Eric D. Hargan as directed by President Donald Trump. USDA Secretary Sonny Perdue also weighs in on the epidemic and a directive from President Trump to use all appropriate resources to combat the opioid epidemic.

Complex problem that cuts a wide path

The magnitude of this epidemic is frightening and sobering, and undoubtedly there are no easy answers for solving the national crisis. But what’s perhaps even more frightening is that opioid use disorder (OUD), the medical term for addiction to opioid pain medications, doesn’t discriminate based on age, job, income, or social status. It bulldozes a wide, destructive path.

“School teachers, farmers, bankers, and many other people have become addicted to opiates through prescriptions. It is not just homeless people in downtown Denver, or Chicago, or the Quad Cities,” says Dr. Jack Westfall, a family medicine doctor in Fort Morgan, Colorado, and professor at the University of Colorado School of Medicine.

Westfall says rural communities need to guard themselves, particularly if there is economic hardship. “When rural communities suffer, it raises the general stress of everybody, and some people are using opiates as an anxiety reducer and stress reducer to relieve pain,” he says.

How addiction starts

Addiction, Westfall says, often begins innocently after an injury or surgery when a patient uses pain medication carelessly or improperly. In rural areas, where patients may live long distances from providers, or perhaps do not have access to alternatives such as massage or physical therapy, pain medications have been a quick fix to help patients return to normal activity, particularly those with physically demanding jobs such as farming.

"As doctors, we thought opioid pain medications were safe, and they are safe, to a degree, but one big problem is that are physically addictive,” says Westfall. Even a single prescription of certain opioids can be dangerous, he cautions.  

“A 100-tablet bottle of Percocet, for example, is about the number it takes to become addicted,” he says. What begins with taking a pain pill for relief for physical pain can quickly lead to needing more pills to avoid the discomfort of opiate withdrawal, and spiral into seekingless expensive, but more dangerous means to get high.

“One day the person selling you Percocet or Oxycontin at $30 per pill says, ‘I’ve got heroin at $15 for the same dose,’” says Westfall. A person may soon find themselves smoking or injecting heroin to get high. “But with heroin, it is so short-acting, that in six to eight hours, you are starting withdrawal and that means fever, shakes, abdominal pain, nausea, vomiting, and diarrhea. So, you get more (drugs) to avoid withdrawal,” Westfall says.  Opioid addiction “hijacks your brain” and finding the next fix becomes an obsession, according to Westfall.

Even if you don’t abuse opioids, unused prescription medications stored in your medicine cabinet can trigger or perpetuate addiction. “Your teenage kids might find them and put them in a candy bowl at a party where kids take stuff. Or it could be a neighbor who says, ‘I ran out of pain medicine. Can I borrow yours?’” says Westfall.

Training doctors to treat addiction

Last year, Westfall and his colleagues at the High Plains Research Network (HPRN), a group of medical researchers, care providers, and community leaders aimed at improving health in 24 rural counties in eastern Colorado, obtained a $3 million federal grant to train primary care physicians, nurse practitioners, physician assistants, and medical office staff about OUD and medication assisted treatment (MAT).

Westfall says that MAT, combined with behavioral treatments, offers the best promise for recovery from opiates. Patients attend addiction therapy and counseling while taking a daily dose of the medication buprenorphine to abate addiction cravings.  “While individual response to buprenorphine may vary, the vast majority of patients report they have eliminated withdrawal symptoms and are able to successfully manage family, job, and community life,” says Westfall.

Prevention education

Ohio is often called the epicenter of the opioid epidemic due to a history of pill mills in southern Ohio where addicts flocked to obtain prescriptions without questions.  State lawmakers cracked down a few years ago, but the state has been hard hit and consistently ranks at the top of overdose death statistics. The Columbus Dispatch recently reported Ohio saw over 4,100 deaths from unintentional drug overdose in 2016, a 36% leap from 2015.

Michele Specht, organization director for the Ohio Farm Bureau in Carroll, Harrison, Jefferson, and Tuscarawas counties, became concerned about the impact of opioid addiction in rural communities where she works. “Everybody knows somebody who has been affected by this epidemic,” Specht says.

Last spring Specht met with representatives of the state Farm Bureau, as well as Ohio State University 4-H and Youth Development, FFA, Prevention Action Alliance, and the Ohio attorney general’s office. Specht says she quickly realized she and volunteers in her county could make the most impact in helping youth avoid the trap of addiction. “We can’t cure it, but if we can prevent our kids from going in that direction, that’s what we’ve got to do,” Specht says.

Specht and local Farm Bureau volunteers came up with several ideas to promote prevention. They organized a breakfast meeting with educators and through an FFA grant purchased photo booth equipment for use at county fairs and other events where 4-H, FFA, and Farm Bureau youth members gathered.  “We took pictures with kids with their 4-H advisors, FFA teachers, friends, parents, anybody who has got their back,” she explained. The kids were encouraged to tape the pictures to their dresser or bathroom mirror as a reminder of who to turn to instead of drugs.

Dr. Teresa Ferrari, associate professor and Extension specialist for 4-H and Youth Development at The Ohio State University, has also been working on addiction awareness and helped Ohio 4-H youth leaders obtain a national 4-H grant earlier this year to organize an educational booth. They enlisted Home Depot to donate a medicine cabinet and worked with the university’s College of Pharmacy to design replicas of pill bottles to depict facts about opioid addiction. Ferrari and the 4-H youth displayed the exhibit at the state and various county fairs, and it was featured at the Ohio Farm Science Review.

The unique medicine cabinet display is designed to remind people that opioid addiction often starts in a person’s home. “Looking into a bathroom mirror is a powerful image because this issue can affect anyone,” says Ferrari. “No one wakes up in the morning and says, ‘I think I’ll become a heroin addict,’ but it often starts with a person standing over their bathroom sink.”

Ferrari and Specht serve on the planning committee for an upcoming statewide teen forum on the opioid crisis called “Hope for Ohio” to take place on December 2, 2017, at the Nationwide and Ohio Farm Bureau 4-H Center in Columbus. The forum will promote drug prevention and awareness among 4-H, FFA, and Farm Bureau youth members plus adults who work with them.

In June 2018, the USDA launched an interactive map of opioid epidemic resources. The map shows the actions rural leaders are taking in small towns across the country to address the opioid epidemic through prevention, treatment, and recovery options. 

Pill disposal bags

Ultimately, Kathi Albertson agreed to a prescription for pain pills after her surgery last January but told the pharmacist her concerns about leftover pills. “He gave us a small plastic pouch and told us to add water and shake it up. A charcoal material deactivated the drug so we could safely throw the pills away,” she explains.  

The bags, called the Deterra Drug Deactivation System, neutralize about 98% of the contained medication so bags can be disposed of safely without the risk of the drugs entering the water supply or landfill.

The simple solution gave Albertson an idea to help prevent volumes of pills from circulating in her county. She worked with her local Farm Bureau to purchase 200 Deterra bags and they also obtained 1,000 more bags through a grant program by Mallinckrodt pharmaceutical company. They enlisted a local anti-addiction organization called CHOICES to help get the word out they had bags available.

The Farm Bureau program also provided bags at a local senior citizen center that organized a dinner and urged guests to bring unwanted medications. “They got rid of 3,000 pills that night,” says Albertson, who contacted other area organizations and businesses, including area funeral homes, to encourage them to distribute bags to loved ones of deceased persons in order to safely dispose of their medication.

“Our goal is to get unused opiates and other controlled substances out of the medicine cabinet and off the kitchen tables,” she explained.

That sounds like a good place to start the battle.

3 Ideas for Helping a Family or Community Cope from Dr. Jack Westfall 

  1. Emphasize social connections made through involvement with activities such as 4-H or Farm Bureau. “The opposite of addiction is connection,” says Westfall. “People need connection, employment, and purpose.”
  2. Set aside the stigma of drug abuse. Opioid addiction can strike any family or community. “Most all of your readers will know someone who’s been impacted,” Westfall says.  
  3. Encourage medical providers, social services, and others who can help to expand access to treatment, including primary care providers equipped to identify and treat for addiction, plus programs such as addiction counseling or 12-step programs.

5 Signs of Opioid Addiction

Suspect someone you know may be wrestling with opioid addiction? Here are five warning signs. 

  1. Still using prescription pain medicines two to three months after an acute injury or surgery.
  2. Runs out of prescription pain medicines earlier than expected.
  3. Borrows or buys pain medicines from a friend or stranger.
  4. Irritability or anger when asked about the use of prescription pain medicine.
  5. Free time spent trying to find opioid pain medicines.
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