The battle over the nationwide opioid crisis is a matter of life and death for Jim Wolfe.
The 60-year-old Canton man lost his job as a welder, his wife of 30 years kicked him out, and an overdose in June nearly cost him his life.
"I had a good life, but the opiates snuck in and attacked me, and I guess I chose to do nothing about it," Wolfe said. "I became everything I despised."
His longtime struggle with addiction started with drinking at age 18 and meth at 28. He got clean and spent a decade sober before knee surgery set off a downward spiral from Percocet to heroin and crystal meth.
"I didn't think I had a problem with pills until I got hooked on it, and it's just been a battle," Wolfe said. "Opiate withdrawal sucks. It's painful. You're sick. You've got diarrhea. It's miserable. It's one of those things where you'd sooner use than be sick."
Wolfe's brush with death landed him in the hospital for a week, followed by a stay at an inpatient treatment facility in Dodge City and on to outpatient services at CKF Addiction Treatment. Clean for six months, Wolfe receives treatment, including counseling and the medication Suboxone, from a grant through the Department of Health and Human Services' Substance Abuse and Mental Health Services Administration.
Today, Wolfe is engaged to be married, has a relationship with his two adult daughters and four grandchildren, and helps others with their treatment at CKF Addiction Treatment.
"I don't even think about opiates. I don't hurt like I used to," he said.
Public health emergency
More than 1,500 Kansans have died from opioid or heroin overdoses since 2012, according to the Governor's Substance Use Disorder Task Force, which released a report in September. Drug poisoning killed more than 300 Kansans in 2016 alone, and prescription drugs were involved in 80 percent of drug poisonings from 2012 to 2016. Nationwide, opioid-involved overdoses killed 42,249 people in 2016, according to the Kansas Prescription Drug and Opioid Misuse and Overdose Strategic Plan released in July.
A number of factors contributed to the rise of opioids, starting with a focus on eliminating pain, according to Greg Lakin, chief medical officer for the Kansas Department of Health and Environment and chair of the Governor's Substance Use Disorder Task Force. The medical community also was led to believe that opioids weren't addictive by pharmaceutical companies that aggressively marketed the drugs, he said.
In 2016, the CDC issued guidelines for prescribing opioids for chronic pain that aimed to reduce the risk of opioid use disorder. In 2017, the Trump administration declared a nationwide public health emergency regarding the opioid crisis.
While Kansas hasn't seen the extent of problems that other states have, "We've still been hit hard. It truly is a crisis," Lakin said.
As far who is affected, "It's not who you think," Lakin said, pointing out that many who struggle with opioids are middle-aged professionals.
"Oftentimes these are very good people, but they're having to steal, they've having to burglarize, they're having to take money out of their mother's purse, they're having to do things they would never have done," he said.
While attention is on prescription drugs, many overdoses can be traced to illegal drugs, such as heroin laced with fentanyl that makes its way here from China, Lakin said.
The opioid crisis has evolved in three waves, said Karan Braman, senior vice president of the Kansas Hospital Association and a member of the task force. The first wave, starting in the 1990s, was prescription opioids, driven by overmarketing of OxyContin, she said. That was followed by a wave of heroin overdoses after Mexican drug cartels targeted areas where OxyContin was being abused. The third wave is fentanyl addiction.
"I think everything we're doing for opioids — because that's where the attention and the money is — is certainly going to help with treating other substances as well," Lakin said.
The state has received about $30 million in federal grant funding, which has supported prevention, awareness, education and treatment to combat the opioid crisis. But funding, which comes in "somewhat haphazardly," has been a source of frustration for treatment providers, Lakin said.
The Governor's Task Force made 34 recommendations in five focus areas: provider education, prevention, treatment and recovery, law enforcement, and Neonatal Abstinence Syndrome. Recommendations include establishing permanent funding sources for various programs, increasing awareness and use of the state's prescription drug monitoring program, expanding medication-assisted treatment and promoting the use of naloxone, an overdose antidote.
Lakin signed a standing prescription allowing anyone in the state to go into a pharmacy and get naloxone. Now he is working to spread awareness about the potentially lifesaving drug, which is marketed as Narcan, hoping to get it in the hands of more police and emergency medical service workers, along with friends and family members of those with the potential to be at risk of overdose.
"It's just a safe way to save lives," he said, noting that the nasal spray is harmless if administered unnecessarily.
"I have had many patients that had a wake-up call to their addiction, realized they were on the brink of death … realized it was time to get treatment," Lakin said.
Work to address the opioid crisis on the local level has included efforts to reduce opioid doses and prescriptions, use alternatives for managing pain and assess patients' ability to function rather than use a traditional pain scale.
"Every community is different, and solutions that work the best are local solutions," said Braman, with the Kansas Hospital Association.
Labette Health in Parsons has been a leader in combating the opioid crisis, receiving national attention for its efforts to improve patient safety and participating in national presentations to share success stories with other hospitals.
In 2014, the organization set out to reduce adverse drug events, with a goal of cutting the number of naloxone administrations for patients receiving opioids within the hospital by 40 percent by September 2016, said Teresa DeMeritt, director or quality.
The organization took a multimodal approach that involved peri-operative, pharmacy, orthopedic and frontline staff. Some measures that were adopted included giving smaller doses of opioids incrementally and using alternatives to opioids, such as regional blocks, IV acetaminophen and gabapentin.
Labette Health surpassed its goal, reducing naloxone administration by 73.2 percent, reducing opioid administration by 44 percent and increasing its pain management scores to the 90th percentile, DeMeritt said.
"Overall, we did not make significant system changes," she said. "We made small, incremental changes that made a significant impact. Being transparent with our data and sharing it to educate and engage our team was key."
One of the state's most successful tools in fighting the opioid crisis has been the prescription drug monitoring system K-TRACS. Established in 2010, K-TRACS alerts prescribers and pharmacists when patients reach a threshold of getting at least five controlled substance prescriptions from prescribers and visiting at least five pharmacies to fill those prescriptions in a 90-day period.
Lori Haskett, assistant director of the Kansas Board of Pharmacy, pointed out one such patient who received 15 controlled substance prescriptions from 14 different prescribers, which were filled at 15 different pharmacies in Kansas and noted that grant-funded enhancements to K-TRACS have helped significantly curb such suspicious patient behavior.
The number of threshold patients dropped from a high of 300 in September 2013 to 118 in December 2017, according to the Kansas Board of Pharmacy.
The Kansas Board of Pharmacy and KDHE are partnering on a CDC grant-funded effort to integrate K-TRACS into health care providers' electronic medical records. Integration saves an average of four minutes per patient because providers don't have to log in to separate systems. Thirty hospitals and 127 pharmacies are integrated.
Eric Voth, vice president of primary care at Stormont Vail Health, said combating the opioid crisis requires a balance between conflicting demands. On one hand, there are those who have a legitimate need for opioids. But the consequences can be severe when the drugs are misused.
Stormont Vail is participating in a national research project with the Centers for Disease Control and Prevention to study the effect of using electronic medical records to track opioid prescriptions.
The organization has integrated K-TRACS into its electronic medical record, allowing health care providers to easily access a patient's prescription history. Stormont Vail also screens patients with detailed questions, administers drug tests and obtains informed consent agreements before prescribing opioids.
"You can't just withhold opiates," Voth said, "but by the same token, if there looks to be a clear pattern of drug abuse, it's really not wise to put the opiates in on top of it."
The problem is far more complex than careless doctors overprescribing opioids, Voth said, cautioning against overreactions that might vilify physicians or lead to changes that might somehow harm providers.
"There are some providers that are looser than others, no doubt, and there's been a lot of marketing, of course, but I've always sensed that the providers I've been around have been really careful and are trying to do what's best for patients," he said.
The opioid crisis requires a holistic approach to solving it, one that considers policies, funding, education, social factors and traumatic childhood experiences, with three major steps: diminishing supply of opioids, diminishing demand and saving lives, said Gianfranco Pezzino, senior fellow and strategy team leader at the Kansas Health Institute.
"There is really no doubt at this point that it is a brain disease and needs to be treated as such. It's not the result of poor personal choices," he said.
Braman, with the Kansas Hospital Association, emphasized the need to increase access to addiction treatment services.
"Addiction is a disease. It's not a moral failing," she said.
Based in Salina, CKF Addiction Treatment treats about 2,000 Kansans a year at its outpatient treatment facilities in Salina, McPherson, Abilene and Junction City and sees an additional 5,500 through a screening program at Stormont Vail and Salina Regional hospitals. Treatment includes doctors' appointments, counseling and medication, and the CDC grant covers all of it for qualifying low-income Kansans. Lindsey Ray and Shilo Redger are two such Kansans receiving treatment through CKF Addiction Treatment.
Ray had been addicted to opioids for about 10 years, having gotten hooked after receiving treatment for chronic back pain. A longtime addict who was introduced to cocaine by her father at age 14, Ray had tried to quit using drugs many times when she sought help after the birth of her fourth child in 2013.
"After she was born, I realized I didn't want to live like this anymore," the 33-year-old Stockton woman said. "I didn't know there was a way out. I didn't think I was ever going to get better."
She said she used drugs throughout her pregnancy and lucked out that her baby didn't suffer any withdrawals.
"It's not something I'm proud of, but it's part of my story," she said.
In October 2014, she started taking Suboxone, which combines an opioid and opioid blocker. She said she was doing well with her recovery until relapsing after she missed an appointment and stopped taking the medicine. She is back in recovery and has been taking Suboxone for about a year.
"For me it's a miracle drug. It has enabled me to live a normal life and be a good mother to my children and be a good wife," said Ray, whose children are now ages 17, 15, 9 and 4.
Medication-assisted treatment is controversial, with critics saying it amounts to replacing one drug with another. Ray said two of her siblings, who also have struggled with addiction, were skeptical. Since seeing her get sober, they have started treatment, she said.
Shane Hudson, CEO of CKF Addiction Treatment, said that while patients on Suboxone are physically dependent on the medicine, it allows them to move past the chaos and negative effects of addiction and find balance and stability in their lives.
"I'm not using it to get high," Ray said. "I want to feel normal, and people don't understand that. I had already done so much damage to my brain from being an opioid addict."
Opioid addiction also ran through Shilo Redger's family, including her grandparents, parents, aunt and uncles. The 29-year-old Plains woman said she began struggling with opioid addiction in her teens after a surgery and has been in and out of treatment. She also has struggled with addiction to meth.
Redger said traumatic experiences contribute to addiction, and she's had her share, including a series of health concerns, the sudden death of her fiancé of carbon monoxide poisoning, and losing and regaining custody of her two sons, ages 10 and 7.
She has little trust in doctors, who she says "were handing (opioids) out like candy." Redger credits Suboxone with saving her life, but she said she hopes to get off the medicine eventually.
"I do not like the fact that I am still feeding into this monster of pharmaceutical companies," Redger said. "It's ridiculous. They've got their hand in the pocket of each and every American in this country."
She points to two needs that she sees as downfalls of addiction and keys to recovery: a spiritual connection with God or a higher power, and strong social connections, particularly with family.
"Nobody wants to talk about addiction. Everybody has it, but nobody wants to talk about it. Nobody wants to deal with it," Redger said. "Almost every family that I know of has been affected by these drugs in some way, shape or form."
Jonna Lorenz is a freelance writer. She can be reached at firstname.lastname@example.org.