Opioid abuse has death grip on Tennessee

The pregame pills took some of the pain out of Will Bell's hard-hitting high school football games — but it wasn't the linebacker's name on the prescription.  

Bell was getting opioid-based painkillers — sometimes for free, sometimes for a price — from a friend who suffered from a chronic disease.

"They made me feel good. I didn't feel pain from tackling. I didn't feel pain from lifting," Bell said. 

As his friend's pain management regiment graduated from Vicodin to Percocet to hydrocodone to oxycodone, so did Bell's. His use of the powerful drugs only escalated in college, where, aided by even better access to dealers, he descended into addiction.

Bell, now 26, eventually sought help and has found an "incredible" recovery community in Nashville; the North Carolina native has been clean for 14 months. 

For many of the millions of Americans caught in the growing scourge of opioid abuse, the outcome is far worse. And few places have been hit harder than Tennessee. 

The state said at least 1,263 Tennesseans died from opioid overdose in 2014, the most recent figure available and one that points to rampant abuse, misuse and addiction impacting millions of Tennesseans, according to the U.S. Centers for Disease Control and Prevention. 

For every one person who dies there are 851 people in various stages of misuse, abuse and treatment, according to the CDC. That's at least 1,074,813 Tennesseans, or 1 in 6. 

More people died in 2014 from opioid overdose than in car accidents in Tennessee. 

As abuse and overdose reach unprecedented levels across the country, prescription painkillers such as hydrocodone and oxycodone are the target of a growing number of federal, state and industry initiatives.

Overprescription by providers is a gateway to addiction for many people, who may turn to heroin as a cheaper high when caught in the throes of abuse. 

The national spotlight on substance abuse and addiction is shining brighter as several federal agencies and institutions look for ways to curb the number of prescriptions, as well as the quantity of prescribed pills, while increasing access to treatment.

More than half — 55 percent — of those who abuse painkillers get them from a friend or relative who has a prescription, according to a 2014 report from the Tennessee Department of Mental Health and Substance Abuse Services. Seventeen percent have their own prescription. 

The CDC issued guidelines to address, and reshape, the prescribing habits of providers. The U.S. Food and Drug Administration is requiring opioids to have black box warning labels on pill bottles as an additional measure to warn providers and patients of the potential risks.

The U.S. Department of Health and Human Services on Tuesday proposed to double the allowed number of patients a doctor can treat per month from 100 to 200 in what Dr. Darrell Arnett, a Nashville-based pain management and addiction specialist, called "a huge bulletin of hope."

The moves come as part of a broader effort by the Obama administration to fight opioid abuse, which began to spike about 20 years ago when controlling pain — also called the fifth vital sign — became a focus. A pilot study showed that while opioid use has grown, patients' self-reported levels of satisfaction with pain control have not improved. 

Too many pills dispensed 

Tennessee has the second highest rate of prescriptions per person, behind only West Virginia. Extra pills can be given away with good intentions — to help someone who has pain — or sold person to person in casual, yet illegal, trades. 

A patient may get dozens for a broken bone or a chronic disease and then another amount at a follow-up a few weeks later. The person might become physically dependent or wind up giving them to acquaintances. 

Many take a path similar to that of Bell, who got started with pills from someone else's prescription before moving on to heroin.

Officials are trying to reduce the number of pills in medicine cabinets as well as increase awareness about the dangers of prescription narcotics.

"People taking a Percocet from a friend or relative are not thinking, 'One day I might end up on heroin.' We need to make people aware these are connected,” said Dr. David Reagan, chief medical officer of the Tennessee Department of Health. 

The state has been tracking opioid prescriptions for several years through its controlled substance monitoring database. Providers should check to see what a patient is taking before writing any controlled substance prescription.

There are 42,835 people cleared as registrants — or those authorized to check patient history — to use the database as of 2015, up from about 14,000 in 2010, according to a recent report from the Tennessee Department of Health to the legislature. There were 6.4 million patient reports requested the same year.

The number of providers and others designated to search the database continues to grow, albeit at a slower pace than in previous years, Reagan said. The number of queries also is growing: In 2010, there was one search for every 14 prescriptions. In 2015, there was one search for every three prescriptions.

However, one of the problems with the database is providers are not consistently using it, Arnett said.

State and industry officials as well as providers say that the state would benefit from a national database or access to bordering state databases given how frequently people cross state lines to get a prescription. 

Even with the database, the state's overdose death rate has grown. The total for 2015 will not be available until midsummer, and Reagan is not sure which way it's going to go. 

Rethinking prescription habits

Changes to how some narcotics are prescribed — in 30-day prescriptions with no refills — are changing how doctors dispense medicine. 

Dr. John Hale, a doctor in Union City and the Tennessee Medical Association's president, said taking away refills has been "the best thing they've done" to address the problem. Patients have to come back to get another round, giving providers another opportunity to assess use and need.

It's also changing the size of prescriptions.

Data from BlueCross BlueShield of Tennessee correspond with anecdotes that doctors are prescribing more tablets per prescription since the no-refill rule went into effect. Instead of 20 tablets with a refill, a provider will prescribe 30 or 50 with no refill, said Natalie Tate, vice president of pharmacy management for BCBST in Chattanooga.

The number of paid claims for opioids from BCBST's commercial, marketplace and Medicare Part D plans totaled 921,439 in 2013. It jumped to 1,068,050 in 2014, which coincides with BCBST selling plans on the federally run exchange and in growth in Medicare plans. Total claims, including refills, then fell by 53,525, or 5 percent, in 2015. 

The insurer's data on total units dispensed shows a 1.2 percent decrease from 67.4 million to 66.6 million from 2014 to 2015. In 2013, before adding some members, there were 58.2 million units dispensed.

Tate said people may not know how to dispose of excess tablets or "hoard and save for a rainy day."

People with excess medication can take it to police stations to turn it in without consequence. State health officials are working with some pharmacies to be drop-off points under a recent change in legislation. 

Bell understands overprescription and the access he readily found to painkillers. He recalled, in high school, going back to the dentist three times after having his wisdom teeth removed and faking nausea from the pills to get another prescription.

In college, he saw a provider for two years to get suboxone but alternately held onto the drug, used to treat addiction, as a backup for when he didn't have pills or heroin — or trading it on the street for drugs.

He dropped out when he stopped being a "pretty functional addict" and his life shattered into pieces. He knew he was physically addicted at 19.

Now clean for 14 months, he's about to start the final two courses he needs to graduate with a degree in English and a minor in psychology. He's found solace and opportunity in painting.

"It's been amazing to see the turnaround in my life," Bell said. "Addiction and recovery in the community is something that I've become passionate about."

Reach Holly Fletcher at 615-259-8287 and on Twitter @hollyfletcher.

Want to share your story about opioid abuse? Email your story to health care reporter Holly Fletcher at hfletcher@tennessean.com.

If you go

The Tennessee Pain, Opioids, Problems and Solutions forum is open to the public.

When: 8:30 to 4:30 p.m. Tuesday

Where: Music City Center, 201 Fifth Ave. S., downtown Nashville

Free registration required: http://bit.ly/1UQIDyl

Lunch included

12-page guide

On April 10 The Tennessean is publishing a 12-page guide for those who are confronted by addiction.

Resources for help with substance abuse

• The Tennessee REDLINE from the Tennessee Department of Mental Health and Substance Abuse Services offers information about resources and guidance about abuse for those who are dependent or a loved one.
• www.tn.gov/behavioral-health.
• http://www.recovery.org/
• http://www.nashvillerecovers.org/treatment-and-detox/