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A community curbs pain pill abuse, but heroin addiction grows

Interventions intended to reduce over-prescription of pain medicine may unintentionally be feeding a rise in heroin use in southwest Colorado.

 

In December 2014, as snow clung to the San Luis Valley in southwestern Colorado, four babies delivered by nurses came screaming into the community that month tested positive for opiates, a drug that had been passed down to them, just as a baby might be born with her mother’s smile. The children, born with neonatal abstinence syndrome, which occurs when exposed to addictive opiate drugs while in their mother’s womb, went into withdrawal in their first days of life. 

The newborns’ condition testified to the prevalence of the abuse of opioids — a class of drugs that includes synthetic painkillers like OxyContin and illegal street drugs likes heroin —that had been growing in the San Luis Valley, a rural agricultural region of approximately 46,000* people in southwestern Colorado. Over the past decade, drug-poisoning deaths from opioids had doubled in the area, rising from 20 in 2005 to more than 40 in 2013, according to the Colorado Health Institute. “For a tiny valley like us, that was incredible,” says Freddie Jacquez, director of the San Luis Valley Area Health Education Center (SLVAHEC), who is helping lead an effort to address the opioid crisis in the valley. 

The San Luis Valley’s prescription painkiller problem has become all too familiar in the West; more than 200 counties in the region currently have the Centers for Disease Control and Prevention’s highest overdose death classification: 20 deaths or more per 100,000 people. Just 15 years ago, only one county did — Rio Arriba in New Mexico. Opioid overdoses, the main driver of total substance abuse deaths, according to the CDC, have quadrupled since 2000 nationwide. 

A baby with neonatal abstinence syndrome from heroin use during the mother's pregnancy. Some symptoms of drug addiction in newborns include lack of sleep, tremors, excoriation, excessive sucking, poor feeding and vomiting.
Yanina Manolova

Healthcare providers, families and drug users nationwide have grappled with the fallout from that rise. After so many babies were born addicted to opioids in such a short time span, the SLVAHEC and local leaders implemented an array of interventions aimed at reducing opioid abuse, including changing how pain pills are prescribed and how law enforcement addresses abuse. There’s some evidence that the community’s efforts could be taking hold, but their efforts may have unintentionally fed a rise in heroin use, to replace the need once filled by pain pills.

Beginning in April 2014, hospital managers and doctors working with the SLVAHEC, the San Luis Valley Behavioral Health Group and the Rocky Mountain Prevention Research Center, gathered for a series of meetings to figure out how to limit the supply of opioids. One step they agreed to was standardizing prescribing practices across the valley.

Physicians from the area’s six hospitals and numerous clinics began using a uniform patient-doctor form that required an agreement about how a patient would use prescription painkillers. The form highlighted abusive practices, like using more medicine than intended and sharing prescriptions with family members or friends, and required patients’ signatures.

Along with the agreement, healthcare providers also updated their prescription guidelines, changing long-term write-ups to a one-month painkiller supply. As a result, fewer prescription opioids were going into the community, says Joseph Valdez, an Alamosa pharmacist that was involved in developing the guidelines.  The agreements were widely accepted by physicians and their patients, but some providers argue that the new policies don’t address how to treat chronic pain patients who have developed a tolerance to such drugs.

Meanwhile, rehabilitation centers have added more programs for addicts and their families, says Kristina Daniel, chief operating officer for the San Luis Valley Behavioral Health Group. “The more people we see in our rehabilitation centers and in counseling programs means there are fewer in our community that are facing addiction without help,” she says. Law enforcement departments in Saguache, Alamosa, Rio Grande, Conejos and Costilla counties in the valley have also implemented a drug court that focuses on addiction treatment. Judges agreed that instead of convicting people of possession of narcotics, they would push them to get treatment. If addicts successfully completed a recovery program, they could avoid charges. If they lapsed, they could face charges for possession.

Still, it’s hard to know if these interventions are working. Statistics from the Prescription Drug Monitoring Program are not easily accessible, and when Jacquez tried to find out how many people in the San Luis Valley had died of drug poisoning, only one of the six counties —Alamosa—could provide that information. At best, the causes of death from prescription pills or heroin are recorded inconsistently across valley morgues, Jacquez says. What’s more, the latest data from the Centers for Disease Control and Prevention for both prescription pill and heroin deaths are current only through December 2015.

Yet anecdotal evidence suggests that the overhauls have had a positive effect. Pharmacists there say physicians write fewer pain pill prescriptions and more people are seeking treatment for addiction. (A Colorado Open Records Act request by High Country News filled shortly before publication also backs that up: In 2014, nearly 725,000 prescription opioids were filled, but in June this year, that number had dropped to fewer than 435,000 prescriptions, according to the state’s Prescription Drug Monitoring Program.) But even as the community has seen signs that pill abuse is declining, Jacquez and local leaders say heroin use is on the rise, potentially from pill users that have gone to the streets for their fixes — complicating the San Luis Valley healthcare community’s efforts to address the broader addiction crisis. 

“After all that great work, the shift has gone to heroin; it’s on the rise dramatically,” Jacquez says. “It’s frustrating.” 

[If you have observed effects of the heroin and prescription pain pill epidemic in your community and would like to share your experience, please fill out our tip form.] 

He and others theorize that opioid addicts have moved to heroin as it became harder to find pills. Though it’s hard to prove that, there’s research that supports their suspicions. Ninety-four percent of people in treatment for opioid addiction say they chose to use heroin because prescription opioids were “far more expensive and harder to obtain,” according to a 2014 study funded by the Denver Health and Hospital Authority. “We wouldn’t have people turning to heroin if we hadn’t gotten them addicted to prescription opiates,” says Tim Condon, a research professor for the University of New Mexico Center on Alcoholism, Substance Abuse and Addiction.

For nearby Santa Fe, even a multi-pronged approach similar to the San Luis Valley’s hasn’t broken the cycle of addiction. Healthcare providers have also implemented patient-physician contracts, and strengthened prescription pill monitoring programs that help limit doctor shopping and inappropriate prescribing practices. Still, New Mexico’s overdose rate remains among the highest in the country, and 6 percent of high school students in Santa Fe reported they had used heroin in the previous month, according to a 2016 survey by the Santa Fe Prevention Alliance.

In the San Luis Valley, too, rehabilitation centers have had to pivot to deal with heroin addiction — and the need is growing. A methadone clinic, which opened at the end of last year in Alamosa, plans to increase its capacity to serve 50 recovering addicts per day, twenty more than it can currently treat. But local healthcare providers still worry that won’t be enough. Valdez says the focus will need to be on prevention, not just treatment. “My vision would be that all schools would have a mandatory substance abuse program,” he says.

The San Luis Valley’s growing heroin problem has made local leaders question whether they are getting at the core of solving the core issue: addiction. “We have all of these solutions, but we don’t know for sure whether or not they’re actually working,” Jacquez says.

So, what Jacquez and the rest of the San Luis Valley healthcare community are left with are stories like one from April of this year: An Alamosa woman overdosed and police officers used naloxone to revive her. She regained consciousness, and, after returning from the hospital, enrolled in a new treatment program at Crossroads Rehabilitation Center. Several of the steps that helped save her life were made possible by the new opioid program.

Even so, her fate is uncertain; opiate addicts are likely to relapse and she’ll need ongoing support. “We didn’t get into this (opiate addiction) problem overnight, and we’re certainly not going to get out of it overnight,” Daniel says. “But we need to have the services to catch people that are suffering from this crisis. We are getting better everyday at being there.”

*An earlier version of this story included an incorrect population for the valley. There are approximately 46,000 residents of the San Luis Valley, not 9,500, which is the population of Alamosa. 

Paige Blankenbuehler is an editorial fellow at High Country News. She tweets

This story is part of the "Small towns, big change" project through the Solutions Journalism Network.