Dreamland (40 page)

Beeghly was astonished. They dissected the numbers further. That’s when they realized that right then and there drug overdose deaths were about to surpass fatal auto crashes as Ohio’s top cause of injury death.

This was a stunning moment in the history of U.S. public health. Since the rise of the automobile in America, vehicle accidents sat unassailed atop the list of causes of injury death in every state, and in the United States as a whole. Now Ed Socie’s numbers showed that would soon no longer be true in Ohio. And by the end of 2007, it wasn’t.

“That was a really startling trend,” Beeghly said. “It took the pills to get us here. We’ve exposed a much greater population to these opiates than we had back in the 1970s with the heroin epidemic.”

Drug overdoses passed fatal vehicle accidents nationwide for the first time in 2008. But it happened first in Ohio, where two complementary opiate plagues met and gathered strength in the late 1990s: prescription painkillers, especially Purdue’s OxyContin, moving east to west; the Xalisco Boys’ black tar heroin moving west to east.

The effect showed up a decade later in the death numbers Ed Socie untangled.

Socie and Beeghly also found that quantities of prescription painkillers dispensed annually in Ohio followed the same upward line as overdose deaths. Both rose more than 300 percent between 1999 and 2008. But even that hid the truth. The use of some opiates actually declined: codeine, for example. The real story was in what skyrocketed. Oxycodone. Dispensed grams of oxycodone—the only drug in OxyContin—rose by almost 1,000 percent in Ohio during those years.

They wrote a report revealing once-camouflaged facts.

•  The number of Ohioans dead from drug overdoses between 2003 and 2008 was 50 percent higher than the number of U.S. soldiers who died in the entire Iraq War.

•  Three times as many people died of prescription pill overdoses between 1999 and 2008 as died in the eight peak years of the crack cocaine epidemic.

•  In 2005, Ohio’s overdose deaths exceeded those at the height of the state’s HIV/AIDS epidemic in the mid-1990s.

Down in Portsmouth, a doctor named Terry Johnson wasn’t surprised.

By 2008, Johnson had been Scioto County coroner for six years. He was a family doc and untrained in forensic medicine. But family doctors in small towns often take on the responsibilities of coroner. Johnson was elected to the job in 2002 just as pills were washing across his county in numbers sufficient to create an OxyContin economy. He was still trying to figure out what a small-county coroner did besides assigning cause and manner of death when a deputy called one night.

“We got what looks like a drug overdose, Doc,” the deputy said. “Don’t know what you want to do. You don’t have to come out if you don’t want.”

Previous coroners hadn’t.

“I thought I probably should go out,” Johnson said. At the scene, he found a man dead with a needle in his arm.

Fatal overdoses came regularly after that. The office had a small budget and dead junkies would have been easy not to autopsy. But Johnson sent the bodies to medical examiners in larger counties better prepared to do full autopsies and blood tests. These invariably turned up opiates, usually combined with benzodiazepines, the old Dr. Procter cocktail.

Johnson is a trained osteopath, a discipline focusing on a holistic approach to health. He had once convened a summit of Scioto County doctors, pharmacists, and elected officials to address the new and aggressive opiate prescribed for chronic pain. Nothing had come of that.

Now pill mills swept across his city. Fatal drug overdoses increased every year. He saw the lines outside the pill mills, and the junkies wandering down Highway 52 to Walmart. He watched capable young people get themselves declared “simple” to get SSI and the Medicaid card, and thus access to pills. Johnson began tabulating what he termed “drug-related deaths”—a death that probably had to do with the person’s addiction but that was officially deemed, say, a heart attack. When he did that, the numbers doubled.

By 2008, Scioto County had twenty-one fatal drug overdoses and twenty-three drug-related deaths—giving it the second-highest death rate in the state. Yet, in Columbus, the legislature had other concerns. The Ohio boards governing the licensing of doctors and pharmacists—believing their hands tied by the state’s intractable pain law—kept silent.

“Had [the boards] been the slightest bit creative they could have put a stop to this. They could have put [the pill mills] out of business,” Johnson said. “I was trying to bend our prescribing habits down. What I was fighting was a multimillion-dollar ad campaign to liberalize prescribing. Then the epidemiologist showed I was right. But no one was looking at it until the state Department of Health realized our numbers exceeded [fatal] traffic accidents.”

Not long after the report she wrote with Socie, Christy Beeghly called Portsmouth city nurse Lisa Roberts for a meeting with women from around the state to talk about the problem.

Lisa called a friend and public health colleague. This was finally a chance to talk about pills along the Ohio River. They drove to Columbus. It was quickly apparent, however, that the other women in the room would have no conception of what had hit Portsmouth.

“We’re setting there and they’re telling stories about how wonderful their daughters are. Each one is, like, ‘My daughter’s in college; my daughter has a Ph.D.,’” Roberts remembered. “I pass a note to my friend: ‘What are we going to do?’ She passes one back to me: ‘I’ll tell the truth if you will. These women need a wake-up call.’”

When it was her turn, Roberts told the gathering that her daughter was a pill addict who had stolen from her blind. Lisa had forced her daughter out of the house. “My daughter,” her colleague said, “is in jail accused of executing three people for their pills.” Half of their coworkers’ kids were addicted. They followed with a description of the pill mills, of the OxyContin barter economy, of the constant overdose deaths.

The room was silent.

“I remember coming home and being real mad,” Roberts said. “It’s not right that our kids are having their futures and freedom taken from them because they’ve fallen prey to this horrible chemical that steals their soul. Our kids shouldn’t be going to the grave. We sent our kids into the military. After she got clean, my daughter had a better chance of surviving a war than she did of surviving the pill epidemic.”

Beeghly put together a presentation on overdoses. The PowerPoint showed a red stain of overdoses spreading north out of southern Ohio. Portsmouth held three town hall meetings with Terry Johnson, people from the medical and pharmacy boards, and the DEA. Then-governor Ted Strickland used an emergency executive order to form a state opiate task force to recommend policy changes.

In Athens County, Ohio, meanwhile, Dr. Joe Gay got hold of the figures that Ed Socie and Christy Beeghly had prepared. A garrulous transplanted Texan, Gay directs a rehabilitation clinic serving four Appalachian counties in Ohio. He also has a passion for statistics.

The Department of Health’s graph of overdose deaths looked almost identical to the graph of dispensed prescription painkillers. Gay crunched the numbers to see how exactly they correlated. Then he called a friend and colleague, Orman Hall.

Orman Hall directed a drug rehab clinic in Fairfield County, near Columbus. That afternoon, he was hiking with his son, who was headed to medical school and who, like his father, had a strong interest in statistics. Returning from the hike, Hall checked his phone messages. His eyebrows arched.

“That was Joe Gay,” he said, chuckling and shaking his head after he clicked off the phone. “He says he’s found a 0.979 correlation between prescription pain pills dispensed and the number of overdose deaths from opiates.”

This was preposterous. Never in thirty years of statistical mechanics had Orman Hall heard of a correlation that close to 1.0, which was almost as if the charts were saying that dispensing prescription painkillers was the same thing as people dying.

Gay couldn’t believe it either. He ran the DOH numbers again. Each time, 0.979 appeared on his computer screen.

Every statistician knows correlation does not mean causation. But to Gay the correlations did mean that Ohio could all but predict one overdose death for roughly every two months’ worth of prescription opiates dispensed.

A Pro Wrestler's Legacy

Seattle, Washington

In 2007, Alex Cahana opened the door to what had been John Bonica's Center for Pain Relief at the University of Washington and found a cobwebbed relic.

The pathbreaking clinic was now in a windowless basement. No signs announced it. Calendars were out of date, piles of papers sat near unread charts and stacks of still-unpacked boxes that sagged like old wedding cakes. As Cahana walked its corridors, the clinic's fifth interim director told him how much he wanted out.

This was what remained of the world's first pain clinic. The concept of pain as a disease, a topic worth study, originated here. So, too, did the idea that chronic pain had many causes and thus needed not just drugs but occupational, physical, and psychological therapy, too; even social workers had a role.

Bonica, the anesthesiologist and former pro wrestler, had founded the clinic. He wrote a classic pain-management textbook from what he learned. He retired in 1977 and died in 1994. Later, his disciple, Dr. John Loeser, expanded Bonica's clinic. Hundreds of clinics followed across the country. But insurance companies gradually stopped paying for the services that made the clinics multidisciplinary. Prescription pills were easier and cheaper, and at least for a while they worked well. In 1998, Loeser resigned as the multidisciplinary clinic was marginalized at the school that had invented the idea.

A decade later, Cahana said, “it was as if [the clinic] didn't exist. It was a metaphor for what happened to multidisciplinary pain management.”

The staff called it the Dungeon. Stepping through this wreckage was a bittersweet moment: Alex Cahana had long been inspired by John Loeser. Cahana began his pain specialty in the Israeli army in the late 1980s, with battlefield experience. He attended a conference in Paris in 1993, where he met Loeser, who was then president of the International Association for the Study of Pain.

Cahana remembered Loeser's message: “That pain is the essence of what we do as doctors, that relieving pain is basic medicine. He spoke about Bonica being a military physician who, after witnessing the suffering of his wife during childbirth, decided to create modern pain medicine. And to do that, you had to be multidisciplinary.”

That inspired Cahana. Years later, when the University of Washington asked him to resurrect the clinic, Alex Cahana knew its importance in the history of pain management. Succeeding Bonica and Loeser was a dream come true. But he saw why the school went abroad to find someone to take the job.

“It was a completely broken system that no one would touch,” he said.

Cahana wrote a forty-three-page contract committing the school to a new aboveground clinic. He wanted windows and the walls made of natural materials and painted with soft colors. He wanted a “bullpen”—an open area where doctors had desks but not offices, so they could better share information. He wanted the best imaging machines to help locate body pain. He wanted a nurse-manager overseeing it all.

The school agreed. On April Fools' Day 2008, Cahana started his new job.

He was immediately shocked at the patients in the UW clinic.

“These were people on tons of opioids for a long time, completely broken and abused. We're talking hundreds of milligrams of morphine-equivalent doses. Doses I'd never seen in my life: four hundred, five hundred, six hundred milligrams a day.”

What's more, no one tracked the effects of opiates on a patient's pain, function, depression, sleep. He called colleagues elsewhere and found this to be true across the United States.

“Not one center had measurements-based pain care. This is 2008,” he said. “It would all be subjective: They're doing fine or not doing fine. There was a pain rating scale: one to ten. It was insane. A multibillion-dollar industry was based on no measurements whatsoever.”

Cahana began resurrecting what Loeser and Bonica had built. He and his staff came up with a computerized questionnaire, and shorter follow-ups, for each time a patient visited. If a patient said his pain was less but things were going poorly, maybe there was another issue.

There Alex Cahana ran into the problem John Loeser faced. An insurance company would reimburse thousands of dollars for a procedure. But Cahana couldn't get them to reimburse seventy-five dollars for a social worker, even if it was likely that some part of a patient's pain was rooted in unemployment or marital strife.

“Nobody thinks those things are of value. Talk therapy is reimbursed at fifteen dollars an hour,” Cahana said. “But for me to stick a needle in you I can get eight hundred to five thousand dollars. The system values things that aren't only not helpful but sometimes hurtful to patients. Science has shown things to have worked and the insurance companies won't pay for them.”

 

Great Time to Be a Heroin Dealer

Nashville, Tennessee