While gruesome images of meth addicts grab the billboards, the number of people abusing prescription painkillers statewide has skyrocketed, with a startling increase in fatal overdoses.
More Montanans die of prescription drug overdoses than any other kind, including illegal drugs such as heroin and cocaine.
In Missoula County, fatal overdoses of prescription painkillers have increased by 65 percent since 2001, and abuse of opiates - often initially obtained legally for very real medical conditions - has become one of the deadliest blights on the community. Overdoses from methadone, a synthetic opiate, have doubled in the past six years, with many addicts combining the drug with benzodiazapines such as Valium to create a toxic cocktail.
“I suspect we're only seeing a drop in the bucket of what's actually going on out here in Montana,” said Jim Hutchison, chief toxicologist at the crime lab. “We just don't see them unless the coroner gets involved.”
The problem is so serious that last week officials with the Missoula City-County Health Department announced the agency would take a hard look at prescription opiate abuse as a public health issue deserving immediate attention.
The crisis has driven officials in other statewide bailiwicks to ramp up vigilance as well.
Law enforcement agencies are reshuffling their priorities in a panic. Health care workers are dumbfounded by the lack of resources needed to treat the rising number of addicts. Policymakers feel blindsided by the plight of addiction pouring out of pill bottles and onto the streets, where the drugs are wildly popular, readily available and highly addictive.
A few years back, Mark Long, chief of the narcotics bureau in the state's Division of Criminal Investigation, detected a rampant number of drug cases involving several kinds of prescription opiates.
“At first it seemed like methamphetamine was most prevalent, but then I realized, ‘Whoa! Everyone is addicted to painkillers,' ” Long said recently.
It wasn't only the volume of drug-related crimes such as prescription fraud, burglary, robbery and street-level dealing that Long found disconcerting - though it was certainly cause for alarm - but “the number of overdose deaths was just staggering,” he said.
The upswing in opiate abuse that Long perceived, it turned out, was the overture to a more widespread addiction problem, and the opening salvo of what has become a relentless blitz on the lives of millions of Americans, with Montana setting, rather than following, the national trend.
It's not hard to see why prescription painkillers have soared to the top tier of law enforcement's catalog of priorities.
Missoula-area emergency rooms reported seeing 231 prescription drug overdoses in 2007, and six overdose deaths.
In the first half of 2008 in Missoula County, nine people died of overdoses of prescription opiates. Some victims died because they misused patches containing powerful painkillers such as Fentanyl, while others suffered from a mix of prescription painkillers and alcohol. Then there are the drugs' collateral effects:
The children of an addicted mother were recently placed in foster homes because a drug habit prevented her from caring for them. A 23-year-old man was arrested for an armed robbery he committed to feed his drug dependency. A woman was sent to prison on her 12th count of prescription fraud, sentenced by the same judge who arraigned her on the first charge more than 10 years ago.
Each vignette serves to illustrate a larger problem.
Nationally, nonmedical use of prescription drugs ranks second only to marijuana in illegal drug use, with Montana again marching at the forefront of the trend.
A recent study conducted by the federal government's Substance Abuse and Mental Health Services Administration (SAMHSA) found that Montana ranks third per capita, and ninth overall, in teen abuse of prescription pain relievers, with almost 10 percent of youths between the ages of 12 and 17 abusing the drugs.
Meanwhile, 13.4 percent of Montana's young adults between the ages of 18 and 25 reported using pain relievers for nonmedical purposes in 2006.
Without the benefit of hindsight, however, the incline has gone largely unchecked, due in part to the perceived dawn of another devastating drug problem, the meth epidemic.
Some experts say Montana's meth crisis obscured the surge in prescription drugs, even as powerful, narcotic painkillers like OxyContin surpassed methamphetamine as a major source of addiction. Still, meth captivated the state's attention and drew heavily on its resources.
“Certainly drug enforcement in the past five, six years has been 95 percent focused on meth, and this situation (opiate abuse) has really fallen through the cracks,” Long said. “We've been facing a decision to either chase down some meth cookers, or grab some people selling pills. So who do you think we went after?”
The answer came with the unveiling of a $5.5 million effort to quash teen addiction - the Montana Meth Project, bankrolled by billionaire software mogul Tom Siebel.
As the public turned its attention to the gripping, in-your-face anti-drug campaign that characterizes the Meth Project, the spike in prescription drug abuse was all but eclipsed by the furor. In the past year, however, as teen meth use has continued to taper off and much of the public outcry has fallen to a murmur, the Montana Justice Department has begun funneling a majority of its resources toward another crisis - prescription pain pills.
“It has become our No. 1 issue,” Long said.
In 2005, the year the Montana Meth Project launched its campaign to reduce teenage meth use, the number of high school-age kids abusing prescription drugs in Montana had already surpassed those who reported using methamphetamine, according to the SAMHSA study.
Nationally, almost half (47 percent) of teens using prescription drugs say they get them for free from a relative or friend, and 62 percent say prescription pain relievers are easy to steal from parents' medicine cabinets.
The National Institute on Drug Abuse reports the number of opiate prescriptions escalated from about 40 million in 1991 to 180 million in 2007 - a 350 percent increase at a time when the nation's population increased by 19 percent.
Even medications that are designed to curb abuse have emerged as favorites for many addicts. Billings has become a federally designated hot spot for the sale and abuse of the narcotic opiate Fentanyl, which is 80 times stronger than morphine and usually comes embedded in a patch meant to be absorbed over time through the skin.
Addicts will steal the patches, in some cases right off the bodies of elderly patients, cut them up and eat or inject the potent goo inside, Long said.
“Access is unlimited,” he said. “It seems like we had a doubling of these kinds of cases in the past year, but we really only started getting vigilant about six months ago.”
Solving the crisis, experts say, means enlisting every branch of a system that has become increasingly fragmented. It entails coordinating health care professionals, social services, addiction treatment specialists, mental health experts, law enforcement agencies, lawmakers, addicts and the public.
“What's strange is how the opiate overdoses have really slipped under the rug,” said Melody Barnes, a licensed clinical social worker who, since 2001, has been treating a rising number of recovering addicts from her Missoula office.
“The same social problems we attribute to meth have been happening all along with prescription drugs. I just don't think there's a lot of awareness about the extent of the problems.”
Barnes has long known of the growing opiate problem in Missoula and western Montana. She hears about it from her clients as they struggle to cope with friends, family members and acquaintances who have died of drug overdoses.
The most unsettling news is that there is no organized public entity to identify the new trends, even as the consequences seem so obvious and dire, she says.
Barnes has been near the front line of recognizing a drug presence before it registers elsewhere, in part due to the credence she places on addicts themselves.
“They're the ones who I learned from,” she said. “The addicts are the real experts, and they are the population most affected by this. They know how to manipulate the system and gain access to opiates, so they know what works and what doesn't. We must bring them into the conversation.”
The first step toward curbing the problem of opiate abuse must be to determine where the onus lies and under whose aegis the responsibility to monitor the problem falls. In Montana, a state woefully under-served by mental health and addiction services, answering that question is no easy task.
“There used to be more coordination between services, but that broke down several years ago,” Barnes said. “There's no organized entity to bring the community together on this issue. We literally have a public health crisis on our hands, but whose job is it to say, ‘We've got a problem?' ”
Dr. Randale Sechrest, medical director of the Montana Spine and Pain Center at St. Patrick Hospital, has been trying to answer that question, among others, for the past six years.
“I can attest to how difficult it is to impact a system that is fragmented. And it is far from coordinated,” Sechrest said. “We don't have access to the two primary services we need: mental health and addiction services. We're not even close. All three systems - addiction, mental health and chronic pain - are totally overwhelmed.”
It's telling that Barnes and Sechrest each begin relationships with their patients by evaluating them for mental health disorders, since most addicts are self-medicating for a range of disorders like anxiety, or to hold trauma issues like rape and molestation at bay.
“You can't treat the addiction without treating the mental health issues,” Barnes said.
Unfortunately, she said, Montana communities are just as short on publicly and privately funded mental health facilities as they are short on chemical dependency treatment facilities.
“There's a whole patient population who will put anything in their mouth if it will somehow dull their sensorium,” Sechrest said. “They're self-medicating and trying to blunt these past issues of trauma. They're literally using every internal resource available to them to keep the lid on these issues. A big part of the problem we're facing is there is no adequate mental health system, so people resort to pharmacology.”
Pills help keep those mental health problems at arm's length, but they come flooding back during withdrawal.
“If they're coming off opiates, they are going to be extremely anxious. They're ready to tear their skin off. And if you don't treat that, they're going to use again,” Barnes said. “The anxiety is just overwhelming.”
Without the necessary social systems in place, however, it is increasingly difficult for doctors to adequately conduct responsible pain management, while licensed addiction counselors cannot successfully treat the addiction issues.
“If it is well-coordinated, this is very manageable, but there needs to be a multi-disciplinary approach. Resources need to come from various elements of the community,” Sechrest said. “There's a huge amount to be gained simply by coordinating what already exists, including law enforcement.”
Sechrest believes the previously existing networks have eroded as the result of a cultural problem. In the past two or three decades, he says, there has been a uniform move toward an economically driven health care system, while actual social problems fall by the wayside.
“It doesn't make sense to treat a disease process if you can't manage all of the symptoms. In Missoula, that's the case. We have these silos, these cottage industries to address certain sides of the problem, but we have nothing in place to address the problem as a whole.”
“We have created a problem here that is eventually going to break down the walls and flow into our gated communities,” he said.
Barnes says western Montana has lost some of its most valuable resources, including St. Patrick Hospital's Addiction Treatment Program, which shut its doors in September 2005 to make room for a Neurobehavioral Unit that helped the hospital obtain an attractive $15 million grant.
“We lost that resource, which is huge for a town this size, and for this region,” said Barnes, who had worked at the hospital-based treatment center, and saw an influx of opiate-addicted patients at her private practice when it closed.
The hospital-based program offered 18 beds for inpatient treatment, including six additional beds reserved specifically for drug and alcohol withdrawal, which is the most daunting hurdle of the addiction treatment process.
“We don't even start counting treatment days until a person completes their detox and enters group therapy,” says Dave Fields, a licensed addiction counselor who worked in the hospital's treatment program, but now works in the Mental Health Unit. “They literally don't remember talking to you during that initial withdrawal stage.”
But most opiate addicts turn to someone for help because of a precipitating crisis, or become so out of control that it takes a medical or legal intervention for them to begin the process of recovery. With nowhere to turn, the alternative to treatment is often jail.
“Nobody wants to deal with addicts,” says Barnes, “so most wind up in Corrections and break their addictions while locked up.”
Even as addicts in Montana flood a crowded and costly state prison system, the kind of treatment that experts say works best remains out of reach for those who need it most.
Many of the newly developed corrections-based addiction programs focus on meth, and there is no clearly designed treatment protocol for opiate addicts.
Meanwhile, other state addiction services available to the public are either harried by waiting lists or are unaffordable to most addicts. Others are so underfunded they offer only standard treatment, which barely gets addicts past the withdrawal stage.
If addicts cannot afford private treatment, they find that public beds across the state are full. When their number is called, they “spin dry” - or move immediately from an inpatient detox back onto the street, with no planned course for further treatment.
Private programs are not affordable for the uninsured, and even for those with insurance, a private inpatient program requires at least several thousand dollars in advance before admission.
“I've tried to get clients into inpatient treatment centers throughout the entire Northwest region and failed,” Barnes said. “Addiction work needs to be about public health, but right now it's all embedded in the criminal system.”
Barnes said she had even more difficulty getting inpatient programs to accept patients with dual diagnoses, where mental health and chemical dependency problems coincide.
“They wanted one or the other,” she said. “Even though dual diagnosis is the rule rather than the exception, both publicly funded and private facilities are struggling to develop and provide integrated care.”
In the state as a whole, there is no uniform protocol to assist opiate addicts with their initial phase of recovery - the detox. For addicts, finding a place to withdraw is a crapshoot, and the odds are never good.
Tammera Nauts, deputy director at Turning Point Addiction Services, Missoula's county-identified treatment provider for underinsured addicts, said on average her staff turns away two opiate addicts every week.
“These are people who really need help,” Nauts said. “And that is the incredible frustration in this community. They have no place to go. We are suffering as a community. And our biggest problem is that we simply do not have the resources to help them detox.”
“We do not want to turn away anybody at the door. We will treat anybody we can. But the one place we cannot touch is the opiate detox. Once they are detoxed, we can offer lots of resources. Once they are past withdrawal, we can give them the moon,” Nauts said.
The “opiate detox” is the principal reason that doctors tend to avoid working with recovering opiate addicts, “because there is a uniqueness to a recovering opiate addict,” Nauts said.
Unlike alcohol, there is no risk of death for opiate withdrawal, but it requires constant monitoring, it is messy, and “it is one of the most uncomfortable, distressing withdrawals a person can go through,” she said. Detoxing involves uncontrollable fits of diarrhea, vomiting, fever and tremors.
“It takes opiate addicts months before they're functional,” Barnes agreed.
Meanwhile, as more addicts are being channeled toward private practitioners like Barnes for counseling, the costs to Montanans have increased exponentially.
Even after Missoula lost its Addiction Treatment Program, the city failed to compensate by qualifying for one of the seven new treatment facilities the state Legislature funded in its last session.
“Whenever you see it surfacing with kids, you can see how saturated your community really is,” Barnes said. “And based on those (SAMHSA) numbers, we're extremely saturated.”
Barnes has seen the impact on the lives of patients in her counseling office. Long has arrested dealers and addicts and understands the culture of opiate addiction on the street. And Sechrest has seen firsthand the chilling effect that widespread opiate abuse has on the medical profession.
“This is a very, very bad addiction,” Barnes said, “but once you have the community resources developed and coordinated, I think the intervention and treatment process can be much more manageable.”
Reach reporter Tristan Scott at (406) 523-5264 or at tscott@missoulian.com
About the series
In this four-part series, the Missoulian examines the rising use and abuse of opiate painkillers in Montana and the skyrocketing number of people dying from prescription drug overdoses.
Rather than just look at statistics, we talked to real people who, by publicly telling their stories, believe they can make a lasting difference.
Today: More people are dying from legal drugs in Montana than any other kind, yet there's no system in place to address the crisis. Health care workers, addiction counselors and law enforcement say it's time to marshal resources and deal with the deadly issue.
Monday: Initially prescribed pain pills for a crippling medical condition, Todd Havelka developed a drug habit that nearly killed him. Today, he's acclimating to a future that doesn't include drugs, and wants other addicts to know how he found the way.
Tuesday: Amy Johnson's dependency on opiate painkillers left her life in ruins. Her brother's overdose death helped her get sober, but years of drug use took a devastating toll.
Wednesday: Andrew Bagley burglarized a pharmacy in Missoula to feed his addiction to opiate painkillers. He's been sober more than a year, but says injecting opiates almost cost him his life.
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