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Small northern Minnesota county hires its own opiate fighter

PINE RIVER, Minn.—Amidst the growing epidemic of opioid abuse, north-central Minnesota's Cass County has hired a fulltime person to help respond to the epidemic.

The position is unique in Minnesota.

"We are the only ones in the state with this position who is really focusing on it like this," said Richie Bean, whose title is Rx prevention coordinator.

He said Cass County, which only has a population of about 28,500 people, will become a hub for some of the most targeted efforts to combat opiate addiction.

He will work from the Pine River-Backus Family Center and is the first to hold this position, which started Jan. 1 thanks to a five-year substance abuse grant from the state.

With the family center, he is forming community coalitions and working to raise awareness of and resistance to the epidemic.

Opioid abuse and addiction might not seem to be pandemic in the county. Overdoses are often seen as indicators of a drug issue in communities, but that indicator isn't necessarily the case in Cass County.

There are, however, indications that opioid abuse may be more prevalent than believed. That is why the county was chosen for this grant, he said.

"I was a little confused when they first started talking to me about this," Bean said. "Then I began to research it and one of the things I found and one of the reasons the state chose Cass County is that in Cass County for every 100 people, there are 100.6 opioid prescriptions written in a year. To put that in perspective, Cass County has approximately 28,000 people in it. In 2016, they wrote over 29,000 opioid prescriptions in Cass County alone."

On average, other counties prescribe 50-70 opioid prescriptions per 100 people.

However, Bean sees other problems, too.

"The problem we are seeing isn't so much the opioid abuse in our county," Bean said. "It's heroin. Eighty percent of all heroin users abused prescription drugs before they became heroin users. What is happening is they get the prescriptions from dentists or doctors wherever they go and then they are getting addicted. Once they get addicted it gets harder and harder to get a prescription refill. It's harder and harder to get more opioids."

Bean said heroin is surprisingly easy to get in Cass County, as well as fairly cheap, making it a tempting substitute for those already addicted to prescription opioids.

A Minnesota Department of Health map infographic of drug overdose deaths by county in 2016 shows that Cass County had zero opioid overdose deaths among residents. The same map from 2000 showed zero overdose deaths, with between one and five deaths in 2010.

The maps demonstrate the growth of the opioid epidemic. While most counties in the state reported zero opioid deaths in 2000, there was a visible increase by 2010, and many counties had at least one opioid overdose death in 2016.

Not your typical drug

Opioid abuse isn't always visible, and the first-hand impacts on users aren't necessarily obvious in a community, especially where overdose deaths are uncommon. However, even where users aren't overdosing, abuse correlates with an increase in social services. Abuse of this drug, like many others, affects families.

"We are having a lot more issues with social services," Bean said. "A lot more kids involved in the foster programs. A lot more kids needing in-home social services like CSS (county social services) workers and things like that. A lot more home visitors. Problems with WIC agents, home agents, neonatal problems and developmental problems with our younger population. We are seeing that with that portion of social services."

Children in these households are sometimes more likely to be developmentally disabled, or they are missing life lessons like potty-training, shoe tying and dressing. Children in these households are requiring more help in schools.

"When we talk about a drug epidemic going on in our county," Bean said, "we're not talking about deaths. We have relatively few deaths, but we are talking about a huge financial cost to our social services, schools and our families."

Prescription opioids are not a typical drug in many ways. They have a legitimate use. They aren't bought from a shady dealer. They are prescribed by a doctor, or sometimes stolen from friends and family. Bean said 48 percent of pills being abused come from family members. That's a number that could be reduced if pills are properly disposed of rather than stored. Dr. Peter Henry, chief medical officer with Essentia Health, agreed.

"The great majority of people experimenting with these are teenagers or young adults who get them out of medicine cabinets of their relatives, immediate family or grandparents," Henry said. "When you have one of these medications prescribed to you, you should make sure you don't just keep it in your medicine cabinet where it can often be diverted to an illicit use."

Abusers are often getting their pills from friends or relatives for free, "doctor hopping" to get prescriptions from multiple physicians to avoid detection or stealing them from friends or relatives. Henry said less than 3 percent are being purchased from drug dealers.

High risk of addiction

Opioids are more addictive than people might think. Five percent of people who are prescribed opioids for just one day will develop a dependency. Henry said there is a nearly 1:1 correlation between the number of days a person takes opiates, and his or her chance of still taking opiates a year later.

Bean shared statistics that support that correlation. Of those who take a prescription opioid for 30 days, 30 percent will be dependent or addicted. The longer someone takes opiates, the more likely they are to become dependent on them. Likewise, the amount of opiates used correlates with addiction or dependency.

"Once you get beyond three to five days of an acute opiate prescription, your likelihood of being on opiates a year later is dramatically increased," Henry said. "That's a critical time frame, three to five days. Most of the new guidelines show if you can reduce prescription totals to less than three days or 100 morphine equivalent units for the initial prescriptions, then you reduce the likelihood of being on opiates long term."

There is also a correlation between the number of refills and the likelihood of long-term use.

Henry said half of opiate overdoses involve a prescription opiate, but for some people, opioids are not the end of the addiction. Once prescriptions run out, opiates become that gateway drug to heroin.

Combating the epidemic

Bean's position is designed to use this type of information to combat the opioid epidemic in Cass County with the help of educators and health professionals. Knowing that opioids are coming from family medicine cabinets, and knowing how fast addiction can take hold, Bean said there are efforts now to encourage doctors to help patients manage pain while prescribing fewer opioids.

That can mean prescribing fewer pills, or none at all in some cases and seeking alternative pain management.

"Essentia and the medical communities are moving forward to do things, but one of the things we are finding is the average MD receives eight hours of training of how to manage pain for a patient," Bean said. "For a veterinarian, they get 80 hours of instruction for managing pain in their patients. That doesn't correlate, but that's still a huge difference."

Essentia Health has developed a program called Chronic Opiate Analgesic Therapy (COAT) based on scientific research. Henry said all primary care physicians and advanced care providers have been educated on the COAT program.

Under COAT, Essentia Health has reduced the number of chronic pain sufferers started on opiate therapy by 35 percent. Essentia has also reduced the number of chronic pain sufferers on opiates as a whole by 35 percent.

Likewise, Essentia has reduced prescription of opiates for acute pain sufferers, preferring the use of surgeries that cause less pain, use of nonsteroidal anti-inflammatory medications, use of ice or heat, immobilization and nonaddictive medications like topical anesthetics (lidocaine patches, for example).

Henry said most chronic pain sufferers are experiencing muscle-related back pain, fibromyalgia and headaches. He also said medical professionals are becoming more aware that opiates are not only inappropriate for many chronic pain sufferers, but also counterproductive.

"We weren't saying we wouldn't prescribe them," Henry said. "We were just saying we wanted to make sure they were being prescribed for an appropriate diagnosis, recognizing that long-term opiates probably have no role in control or management of these types of pain as they cause significant adverse effects and they also in time become very ineffective. They cause hyperalgesia or an increase in pain."

Essentia's program to reduce opiate prescription applies only to non-cancerous causes of pain and non-terminal patients.

Henry said Essentia's next goal is to increase services to help those who have become opiate dependent or addicted. In Minnesota, medical assisted therapy for opiate addiction is low.

"There is a significant shortage in the number of people who have the ability to prescribe that medication assisted therapy within the state of Minnesota across all the organizations in our state," Henry said.

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