Chad Sabora and Robert Riley Are Fighting 'the Perfect Storm' of Opioid Addiction in South City 

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Like so many human-made catastrophes before it, America's opioids crisis began innocently, with the best of intentions.

The match that lit the fuse, so to speak, was a one-paragraph letter published January 10, 1980, in the New England Journal of Medicine.

The letter's headline: "Addiction Rare in Patients Treated With Narcotics."

Its authors, physicians Jane Porter and Hershel Jick, stated they had examined the files of nearly 40,000 patients. Almost 12,000 had received at least one narcotic preparation, but only four cases were found "of reasonably well documented addiction in patients who had a history of addiction. The addiction was considered major in only one instance."

Then, in one of the most consequential sentences written in American history, Porter and Jick wrote: "We conclude that despite widespread use of narcotic drugs in hospitals, the development of addiction is rare in medical patients with no history of addiction."

The Porter and Jick letter "launched the pain revolution of the mid-1990s," says Brandon Costerison, who studies opiate abuse for the National Council on Alcoholism and Drug Abuse St. Louis Area.

At the time, Purdue Pharma was seeking to sell a powerful time-release tablet made from oxycodone called OxyContin. The company used the Porter and Jick letter to show that opioids aren't addictive, Costerison says.

"I don't think they fully understood," he says. "But it was used as justification. Purdue wanted a way to market oxycodone and make a bunch of money off it. So combining the development of oxycodone, supposedly a time-release tablet, along with this letter saying this brand-new drug is really, really safe, those two combined is what really led to the ramp-up in prescribing."

In May 2007, three current and former Purdue Pharma executives pleaded guilty in federal court to criminal charges that they had misled federal regulators, doctors and patients about OxyContin's addiction risks and potential for abuse. Its parent company also agreed to pay $600 million in fines and other payments, then one of the biggest amounts ever paid by a drug company to resolve criminal and civil complaints related to the painkiller's "misbranding."

 In 2016, Forbes magazine ranked the Sackler family, which owns Purdue Pharma, the nineteenth wealthiest family in America, with an estimated worth of about $13 billion, thanks to $35 billion in sales of OxyContin since it was released in 1996, according to journalist Sam Quinones, the author of Dreamland: The True Tale of America's Opioid Epidemic.

Last June, Missouri Attorney General Josh Hawley filed a lawsuit against Purdue Pharma and two of the other largest makers of opioid painkillers. In the lawsuit, Hawley accused them of violating Missouri's consumer protection laws.

Filed in St. Louis, which has the highest overdose death rate in Missouri, the lawsuit calls opioid abuse a statewide epidemic that is a "direct result of a carefully crafted campaign of deception" that "fraudulently misrepresented" the dangers posed by the drugs the companies make and sell, deceiving doctors and patients.

Hawley, a Republican, said he chose the companies because he is "confident about the evidence we have about their fraud" and because they comprise "the lion's share" of the opiate-based painkiller market.

As the 1990s progressed, another trend emerged: The American Pain Society designated pain as the fifth "vital sign" that doctors should use to detect or monitor medical problems. Pain control became a measure of patient satisfaction, which was often linked tied to a physician's compensation under the guidelines of the health insurance giants that were posting enormous profits.

Critics of the health insurance industry complain of the "Toyotazation" of medicine, because doctors under contract to these big insurers lost much of their autonomy and were forced to meet production quotas that limited the time they could spend with patients.

Insurance companies would pay for primary-care office visits and for pain pill prescriptions, while balking at alternative medical treatments or extensive physical therapy.

"'But we'll give you a bottle of Percocet for ten bucks,'" Costerison says.

The next major turning point in America's opioid crisis began about ten years ago, as states like Colorado and Washington legalized medical and recreational cannabis. With profits from illegal pot sales fading fast, the Mexican drug cartels went all-in on heroin.

"Why would Mexican drug cartels keep growing marijuana if you got to ship bales of it over, and it can't compete what's grown domestically?" Costerison says. "It just doesn't make any sense. So a lot of these cartels tore up their marijuana fields and started planting opium poppies. So they were able to use the same trade routes as for marijuana."

The heroin the cartels began bringing to the U.S. was much purer and therefore more deadly. Black tar heroin of the 1980s had a purity of between three and six percent. Today's heroin, in contrast, has a purity level of 55 percent.

And then the cartels began bringing in fentanyl, made in China, to the U.S. Fentanyl is 50 times stronger than heroin, but it costs 95 percent less.

As a business strategy, "It makes perfect sense, you know," Costerison says.

Seated behind his desk, contemplating the Red Bull in front of him, Sabora reflects on the vicious cycle he's seeing, an accelerating conveyor belt that's sending young people to early graves in ever-growing numbers.

"It's a perfect storm," he says. "You couldn't have scripted this better."

What will it take to end America's opioid crisis, or at least make a meaningful dent in it?

Everyone who studies the problem agrees that America's medical community needs to get out of the mindset of over-prescribing opiates. And that's starting to happen, says Costerison, of NCADA St. Louis.

Experts also agree that America needs to spend many billions of dollars more on effective treatment programs, to cut down on the long waiting periods — ranging from a month to more than five months — between when addicts choose to get clean and when they can get beds in treatment centers.

Prescription drug-monitoring databases have been set up in every state, including Missouri, which this year became the last in the nation to do so (even as critics note its database is far from comprehensive). But it will likely take years for them to make a significant impact on the rate of overdose deaths. As long as there is no uniform, national database, then illicit drug users would still be free to go from one state to another to find physicians willing to prescribe them painkillers, according to the DEA's Shroba.

"The DEA's position is that there needs to be a national system," Shroba says. "It needs to be legislated by the federal government and not run by the federal government. .... So that doctors coast to coast can see what's being prescribed because that'll eliminate doctor shopping."

Physicians also need to be better educated about addiction and have greater freedom to prescribe medication therapies, which help impede the cravings that pull opioid addicts into relapse.

Problem is, while literally anyone with an M.D. behind their name can prescribe opioids, physicians who endorse medication-assisted therapies must take eight hours of special education classes.

Even if they take the required classes, physicians are limited by a federal law that requires them to obtain a waiver from the DEA to prescribe buprenorphine or buprenorphine-naloxone. And once they get the waiver, there's another hurdle — the physicians can't treat more than 30 patients in the first year, and no more than 100 patients per year going forward.

The result: a huge bottleneck in providing access to treatment, a bottleneck that Congress could end at any time, but won't, Riley says.

"It's all political," he says.

While drugs like buprenorphine have an 85 percent effectiveness rate, programs modeled on twelve-step programs reject medication therapies. Riley believes that's a huge mistake.

"We're still treating this based on 1937 methods," Riley says. "Yet this is 2017 and we know far more about the science of the addictive brain than we knew in 1937. Then we still treated it as a moral failing, as a choice. Today we know, we know through science, that this disorder of the brain, that the brain actually sets a higher value for the release of [the neurotransmitter] dopamine than it sets a value for going to work in the morning or being honest with my parents."

There is another reason the abstinence-only model is being blamed for a rising death toll. After only a few days off opioids, especially powerful narcotics like heroin and fentanyl, an addict's tolerance drops sharply, according to Costerison.

"Their tolerance is gone and they're at a much higher risk for an overdose if they relapse," Costerison says. "The same thing happens if someone is locked up in jail for the weekend. They get out. Then they have a very high chance for an overdose."

Finally, America needs to move away from its current system of drug enforcement, which sets a premium on shutting down dealers and incarcerating addicts. By focusing on the supply side, America's "War on Drugs" does nothing to deal with the demand.

What America needs to do is adopt the strategy adopted by Portugal, Sabora says, which decriminalized drug use but made treatment programs easily accessible.

"The bulk of the blame lies on our failed drug policy in the United States," Sabora says. Since Portugal decriminalized drugs, he says, "and people are getting treatment instead of jail, their rate of addiction has gone down."

Shroba, the DEA special agent in charge of the St. Louis area, pushes back against Sabora's suggestions.

"We are the Drug Enforcement Administration, not the Drug Treatment Administration," Shroba says. "And so while we want to help people in that regard, if we don't interdict the supply, if we don't interdict the most dangerous drug traffickers out there, does anyone think that will make our streets safer or limit the availability?"

Shroba called it unrealistic to stop going after the suppliers of illegal drugs, especially the most addictive and powerful.

"Because then we're going to have increased availability," he says, "which means we'd have an escalating number rising exponentially, each and every day of individuals trying to seek treatment because we're not restricting the supply."

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