Need for painkillers and social support, shortage of treatment programs, feeds prescription drug abuse in Appalachian Ky.

By Ivy Brashear
Kentucky Health News

Taking opioids is still the best way to treat patients with pain, but the drugs are addictive because they do more than just alleviate physical suffering — they cause patients to feel good too. That’s causing big problems in Kentucky, the state with the highest rate of opioid use and overdose.

In Perry County, for example, prescription medicines are the drugs of choice, second only to marijuana, and users may get more of them from relatives than from doctors. And their drug use appears to be part of a social support system.

Those were the findings of three separate studies presented at the second annual Appalachian Health Summit in Lexington last week.

Prescription-drug abuse is “an epidemic” that “seems to have started in rural Appalachia,” Jennifer Havens, an associate professor in the University of Kentucky Department of Behavioral Science, said in presenting a study showing how disease spreads through the region.

Havens’ study of Hazard and Perry County found that prescription drug abuse in the county is second to marijuana use, and that painkiller abuse among high school seniors is at the same rate as in adults.

Though it’s not clear why prescription drug abuse is so rampant in the region, Havens speculated that lack of availability of other “hard” drugs, like heroin and cocaine, has led Appalachian drug users to turn to prescription medicine to get high. There are few drug-treatment options for users in the region, and many hospitals aren’t “financially viable” to care for drug abusers, she said.

An earlier study in which Havens was involved revealed that rural adults use more “alternate” methods to take drugs, including snorting and injecting. The study compared drug users in Perry County to those in Louisville and found that more than 40 percent of adults in the Hazard area were injecting prescription drugs to get high, and youth there were 25 percent more likely than those in Louisville to abuse such drugs.

The study found high rates of sharing drug-taking instruments, which increases risk for diseases such as hepatitis and HIV, Havens said. Almost 90 percent of participants said they shared snorting straws, and almost 1 in 3 said they shared syringes. No cases of HIV were found among the participants, but almost 43.7 percent of the 500 interviewed had hepatitis-C, and 11.5 percent had herpes-2.

Eighty percent were lifetime users, and about half first abused Oxycontin through injection. Havens said 28 percent of users had overdosed, and 58 percent had witnessed an overdose.

The study also found that a person’s likelihood of continuing drug use correlated with higher levels of social support, which Havens said contradicts long-held assumptions that drug users continue to abuse prescription pills because of low social support.

“Most people in the study depended on people also using drugs for social support,” Havens said. “As you can imagine, that’s not a good idea.”

No good alternative to prescribing painkillers

Despite widespread opioid abuse in Appalachia, such drugs are “still the best pain therapy,” UK physiology professor Karin Westlund High reported.

The purpose of her study was to determine what effect a high-fat and alcohol diet would have on “visceral pain” in the pancreas, and then what effect opioid gene therapy would have on the organ.

There are clusters of Appalachian counties at high risk for pancreatitis, which can lead to pancreatic cancer. Severe abdominal pain is associated with both, and morphine is typically used to treat it. However, High said, patients usually develop a tolerance to the drug over time.

She and other researchers used rats to test an opioid gene therapy involving herpes simplex-1, which 90 percent of Americans already have, to see if it would reduce pancreatitis pain without building tolerance in the rats. After 10 weeks of treatment, there was no tolerance present and the therapy seemed to be reversing damaged sections of the pancreas caused by the disease.

While opioids are effective in alleviating pain, “There are lots of different kinds of pain, but most opioids act as if they treat the same pain,” said Michelle Lofwall, a UK psychiatry and behavioral science assistant professor. Lofwall set out to discover how pain affects prescription drug abuse, since that is the main reason such drugs are prescribed or first used.

Her study participants, who were all drug users, placed one arm in a cooler of ice to elicit pain, and then were asked about pain levels. The test was repeated after a dose of painkiller.  Researchers were attempting to give the drug to treat patients’ pain only, and not to have the patient feel a high when the drug was in their system, but that failed.

“Unfortunately, in my patients I wanted to say, ‘Yes, let’s treat your pain and you won’t feel any good effects’,” Lofwall said. “I wasn’t able to say that to them.” She said they are now trying to help doctors better prescribe pain medication so that habits aren’t formed.

One of the biggest habit-forming painkillers is Oxycontin, which was introduced in 1996 but wasn’t abused on a large scale until doctors had to start documenting pain in 1999, Lofwall said. Sales of, treatment for, and death from prescription drug abuse have increased since then. She noted that Kentucky has the highest rates of opioid use and overdose.

The makers of Oxycontin have reformulated the drug to make it harder to crush, mix with water and snort, but a new drug has risen to take its place: Opana. Lofwall said researchers have been trying to study Opana use, but can’t get a study supply because it is in such high demand. She said she has seen more of a rise in heroin use by her patients because even heroin is easier to get than Opana.

Though legislators are grappling to curb the proliferation of “pill mills” in the state, Lofwall said “doctor shopping” may not be the problem it’s been billed to be. According to the National Household Survey on Drug Use and Health, 56 percent of users get their supply from a relative, of whom 85 percent have a prescription from one doctor. The drug abuser may get the drug from the relative as a gift, by paying for it or by stealing it.

Asked about the Kentucky All Schedule Prescription Electronic Reporting system, which allows doctors to search a database for “doctor shoppers” before prescribing pain pills, Lofwall said KASPER is limited because it only covers Kentucky, but “I think the state’s ready to make it better.”

Kentucky Health News is a service of the Institute for Rural Journalism and Community Issues, based in the School of Journalism and Telecommunications at the University of Kentucky, with support from the Foundation for a Healthy Kentucky.

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