On Tuesday evening, Carroll Hospital played host to a special dinner and training organized by the Carroll County Health Department.
The title? Making a Difference in the Opioid Epidemic: Change Starts With You.
The "you" in this case being those practitioners who are prescribers, doctors, nurse practitioners and physician assistants, more than 30 of which turned out to the hospital's Shauck Auditorium for discussion of addiction.
A nationwide epidemic of opioid addiction has been claiming thousands of lives since kicking off in earnest in 2013, with more than 42,000 people dying from an overdose in 2016, the most ever on record, according to the U.S. Department of Health and Human Services.
In Carroll County, opioid overdoses claimed 15 lives in the first quarter of 2018, according to Sheriff's Office statistics, a number that is likely to rise if the Office the Chief Medical Examiner determines currently unexplained fatalities were due to drugs.
And as discussed by the three keynote speakers of the evening — Heather Asbury, a peer support specialist with the Health Department, Pharmacist Steve Seidel of Manchester Pharmacy and Charles "Buck" Hedrick, a group supervisor with the DEA — many people who struggle with heroin addiction first tasted opioids through prescription medications.
That was certainly the case for Asbury, who in addition to supporting those seeking treatment for addiction is also in recovery for opioid addiction herself.
"I am hoping that physicians will hear my lived experience, that I am a person in recovery," she said in an interview. "That my pathway here, that in my active addiction, prescription opioids played a big part."
It was a problem that started when she was 21 and injured her back, according to Asbury. Her doctor wrote a 30-day prescription for Percocet for her pain, and when it was gone and she went back to say her back still hurt, she got another 30-day supply.
"Not once did they order me to an X-ray or a CAT scan or anything like that," Asbury said. "I was prescribed opioids rather than finding what the underlying problem was."
Asbury said she hoped more physicians would consider prescribing fewer opioids to patients, even when opioids are needed.
It was, in part, to hear patient perspectives like that of Asbury's that some providers came out, including Carroll Hospital Emergency Department Physician Assistant Deanna Najera, who had a hand in organizing the event and encouraged her colleagues to attend.
"It's always helpful to hear people who are survivors, who have been through it and are now sober and learning what was helpful for them," Najera said.
But also of great interest to Najera was what Hedrick could bring in terms of DEA experience regarding what is happening with drugs on the street.
"We can see the headlines, but it's about understanding what is behind that," she said, "what trends are in the area."
The major trend of concern, and that which sets the current epidemic — the five year anniversary of which will be in July, according to Hedrick — is the increasing presence of the powerful opioid fentanyl, Hedrick said. In Baltimore area DEA wiretaps, he said, high level dealers can be heard asking for heroin with "fire," meaning heroin spiked with the more potent fentanyl.
Fentanyl is cheaper and more potent than pure heroin, Hedrick said, and since drug cartels want to make money, fentanyl is turning up in other drugs too, even marijuana. From the DEA's perspective, he said, the driving force behind the current epidemic is that "there are cheaper, more potent drugs out there. They are readily available and treatment is not readily available."
The DEA is currently taking a close look at potential problem prescribers in Maryland, Hedrick said, because the state leads the nation in hospitalizations for overdoses at the moment. What doctors and providers can do is help the DEA identify those people who may be breaking the rules.
"If there are pill mills or doctors that are doing the wrong thing, we need to know so we can at least take a look," Hedrick said. "We are not chasing doctors who are prescribing legitimately for pain."
In fact, in February, the DEA raided the offices of a Baltimore County pain management clinic suspected of acting improperly.
A large percentage of the more than 4,000 patients of that clinic live in Carroll County, County Health Officer Ed Singer told the crowd Tuesday evening, and so the Health Department has been struggling to try to get those patients with legitimate pain needs to other prescribers and those who need detox into the appropriate facilities.
"That's where you folks that are in primary care come in, we need your help," Singer told the providers. Without enough pain management providers or detox centers in Carroll, the Health Department is hoping physicians will help ween these orphaned patients down or direct them to the detox care they need.
"My biggest concern, though, is if those people cannot find some way to transition from where they are to where they need to be, they could turn to street drugs," Singer said. "And with the fentanyl and carfentanil that's on the streets, they may not get a second chance."
For Seidel, who lost his son to an opioid overdose in 2016, there needs to be better communication between health care providers, and between health care providers and the public.
"We have been remiss in our jobs as health care practitioners to discuss the realistic options for patients," he said, noting that it should be the goal of pain management to help patients regain life function, not to eliminate all pain.
And when so much pain is related to inflammation, Seidel said, he believes doctors and pharmacists should be considering anti-inflammatory drugs like ibuprofen more often as first line treatments.
"Narcotics just make you numb till the next dose," he said. "The medical community is starting to reassess the role of opioids in acute and chronic pain, and finding less and less of a role."
And providers need to remain alert to other hidden dangers, Seidel noted, such as the concurrent rise in the abuse of benzodiazepine drugs, such as Xanax, and even their legitimate use in a drug combo sometimes called "the holy trinity."
"The holy trinity is a combination of opioids; benzodiazepines like Xanax, Valium, Ativan; and skeletal muscle relaxers like Soma," he said. "In those combinations, you run the risk of a 580 percent increase risk of accidental overdose, even at normal therapeutic doses, used as prescribed."
For his part, Seidel said, he will no longer fill prescriptions for the holy trinity, even when they are a legitimate prescription from a physician. As he told the other providers Tuesday, it is vital that they all use their training and experience to make their best possible judgments.
"I am paid to use my best judgment," he said. "If I can't do that, then there's no point in me being back there."