A drug problem in rural Georgia

Meet Johnathan, a 34-year-old male from rural Georgia we recently treated for back pain as a result of some extra contractor work he took on over the holidays.  We see patients like him every 11 minutes, which doesn’t leave much time to get beyond Johnathan’s chief complaint.  He leaves with his first prescription for opioids.

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Of the 91 Americans taken each day, Georgia now claims four, or more than twice our share.  Deaths from prescription opioid overdoses increased tenfold between 1999 and 2015, compared to fourfold nationally, putting us among the nation’s top 10 states with the most deaths from opioid overdose. It’s safe to say our national epidemic has particularly devastated our state during the past two decades.

As medical best practices spread quicker in today’s digital age, medicine has become increasingly standardized with less variability; according to recent data from the Centers for Disease Control (CDC), however, opioid prescribing can vary by a factor of six across counties.  Opioid prescribing is an anomaly in modern medicine, with some areas lagging far behind others, and our state, unfortunately, is the picture of that anomaly.

When we examine the areas of highest prevalence to learn why, we see higher prescriptions tied to areas with higher unemployment or populations with diabetes, arthritis, or disability.  We have plenty of those areas.

Shortly after his initial injury Johnathan went on disability leave and returned the next month for more help to control his pain.  When taking his medications, his pain subsided, and he was willing to tolerate a necessary consequence of his medication, constipation.  We talked about this side effect for all 11 minutes. 

We have just as many Georgians as opioid prescriptions just in 2017, and approximately 10 percent of those prescribed opioids develop an opioid use disorder. At the moment, we’re being pillaged for our opiates statewide.

Johnathan came back for months to ask for higher doses as the previous ones lost effect after a while.  Around this time, our hospital started an opioid academic detailing initiative, with pharmacists offering fellow providers the data behind high dose opioids and prompting conversations about risks to the patient as well as de-escalation techniques.  It wasn’t easy, but in time, Johnathan was de-escalated and eventually stopped coming in. 

Opioid overdose is now the leading cause of accidental deaths in the United States, surpassing car accidents.  The signs we see on the side of the highway have unfortunately yet to be updated; to be most effective, they should be advertising this public health emergency.

In time, our opioid problem gives rise to a heroin problem when opioids become too expensive; 86 percent of heroin users begin as opioid users.  Recently, 11 Alive published a series on our “heroin triangle” based on a 4,000 percent increase in heroin-related deaths inside a geographic location north of Atlanta identified as “The Triangle”.  Since, the triangle has grown from the epicenter of Alpharetta, Roswell, and John’s Creek to include Kennesaw, Acworth, Cartersville, Cumming, Flowery Branch, and Gainesville.

Johnathan wrote recently that he’s one of the lucky ones.  “We must do more while we still can,” he said.   

Ashish Advani is a pharmacist and founder, InpharmD, and blogs at Stay InpharmD.

Image credit: Shutterstock.com

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