Multnomah Countys tough prescription
Second of Two Parts • Painkiller cuts send some patients to street drugs
A year ago, Dr. Gary Oxman, Multnomah County's public health officer, saw evidence that demanded what he calls a moral decision.
He had watched as each year the number of Multnomah County residents dying from prescription painkiller overdoses had grown.
Physicians with whom Oxman consulted, who had moved to Portland after practicing elsewhere, told him that doctors here tend to prescribe more pain medication than doctors in other cities.
Last May, Oxman's county health department dramatically changed its policies. Nine pages of guidelines were developed requiring that physicians, before prescribing painkillers, comprehensively assess the patient not only physically and mentally, but also from an addiction standpoint.
The result? Some patients at county clinics have been told they can't get prescriptions anymore. Others have had their doses reduced.
Compared to a year ago, about half as many of the county's primary care patients are on prescription painkillers.
But another disturbing trend has captured the attention of public health officials. The number of deaths in Multnomah County due to heroin overdoses has increased dramatically in the past year (see "Welcome to Heroin City," May 3). And a number of people in the local health care community have told the Tribune that part of that rise may be an unintended consequence of the new guidelines.
Pain sufferers and addicts, they say, cut off from their prescriptions, have begun looking for alternative sources of relief and have found it in the cheap heroin flooding Portland's streets.
None of the physicians or addiction treatment specialists the Tribune interviewed disagreed with the county's new policy. Someone had to draw a line somewhere and begin halting the cycle that creates new addicts in Oregon, they say.
The county's new policy -- followed by most other local clinics that provide health care to the poor and uninsured -- is an important first step.
Sarah Goforth, who oversees mental health and addiction services for nonprofit Central City Concern, says the county made a hard choice, but the right one.
"We have people getting cut off from their pain pills and turning to illicit drug use," Goforth says. "It's tricky. (The county) is letting us all know this is going to stop. We own that this is out of control and we don't want to be a part of it anymore."
TRIBUNE PHOTO: CHRISTOPHER ONSTOTT • Dr. Gary Oxman, Multnomah County public health officer, faced a tough choice a year ago -- overdose deaths due to prescription painkiller abuse were rising, but so were deaths from heroin overdoses.
Not like other addicts
Northwest Portland resident Pam Boyd can visualize a future as a heroin addict, and it frightens her.
Boyd, 56, was a substance abuser for years. She used Vicodin to excess, she drank and smoked pot. Depression and a variety of ailments allowed her to rationalize her habits. But she had her limit.
"As long as I didn't do heroin I figured I was OK," Boyd says. "I figured I wasn't as bad as all the other addicts."
In 2000, she was hit by a car, suffered a series of severe injuries, and, she says, couldn't find a doctor willing to prescribe enough of the pain medication she so desperately wanted. One night, she was at a party when she heard people making noise behind a bathroom door.
"I stuck my arm in and said, 'I don't know what you're doing in there, but give me some of it,' " she recalls.
Somebody stuck a needle into her arm. That was her first heroin injection. Eventually, she developed a major heroin habit.
Boyd has been clean of illicit drugs for four years. But injuries from her first accident and a second one, when she was hit by a car on Southeast 82nd Avenue, have left her in constant pain. When she gets up in the morning, the first thing she does -- has to do, she insists -- is take OxyContin and lie still for 20 minutes before the pain subsides enough to allow her to get out of bed and begin the day.
She takes painkillers throughout the day.
Boyd's physician, Dr. Rachel Solotaroff, says Boyd's prescriptions exceed the recommended ceiling of 120 milligrams total morphine per day. Her plan is to taper the doses so Boyd gets under that ceiling, but she won't do it in a vacuum.
The Old Town Clinic, where Boyd receives care, has developed a program called RENEW for patients who need alternative therapies. Boyd has taken relaxation and meditation classes there. She's tried acupuncture at the clinic as well as nutrition classes, and next week she is scheduled for physical therapy and an aromatherapy class.
One-on-one, Solotaroff, with patients such as Boyd, is re-enacting the hard choice that Oxman has dealt with on a countywide level. But it's not easy.
Boyd says all the alternative therapies provide only temporary pain relief. If she were to be cut off from her prescriptions -- Solotaroff says that won't happen -- returning to heroin would loom as a real possibility.
A floating life
Solotaroff, Central City Concern's medical director, isn't a big fan of prescription painkillers, even for patients suffering chronic pain. The drugs, she says, dull the sensation but don't generally help patients learn to deal with their pain.
"Opiates don't help you set goals to improve your activity or occupation or socializing," she says.
Boyd exemplifies that half of the equation, according to Solotaroff.
"If we were just doing pain medication with her, she might just sit at home all day," Solotaroff says. "It's an isolated and not fulfilling life, kind of floating. What Pam is doing, which is remarkable, is trying to work with us to get opiate doses lower and understand it's only going to take away 10 or 20 percent of the pain."
Boyd says most of the people she knows will "go back to the street" if denied their pain prescriptions. That means heroin for their pain, as well as shoplifting and prostitution to make enough money to buy the heroin.
When Multnomah County issued its new clinic guidelines, Solotaroff says, it essentially changed the way all clinics in the county operated.
"Everybody was heading in that direction, but when the county made its changes it forced the other community clinics to do the same thing or all the county's patients were going to migrate to your clinic. You'd be the candy man," she says.
Solotaroff says at the Old Town Clinic most of her patients, when assessed using new guidelines, are considered at high risk for addiction. She says an unintended consequence of the new rules has an increasing number of patients going from one doctor to another or switching clinics or even visiting hospital emergency departments in an attempt to gain access to new prescriptions.
Some of her patients have told her that since their prescriptions have been reduced they have begun buying drugs on the street.
Solotaroff says the county was right to lead the way with its new guidelines, but she'd like to see other changes that could help head off some of the consequences.
A moral imperative
The Old Town Clinic runs a program from its new building in Old Town, which has space to offer a variety of alternative therapies. The goal, Solotaroff says, should be that every time a physician tells a patient his or her pain medications are going to be cut off or reduced, the patient has immediate access to resources such as a physical therapist and an addiction specialist.
The latter can advise a patient on the dangers of going to the black market for pain meds or heroin, and possibly check in with the patient once a week. The former can offer pain relief alternatives.
That won't be easy, Solotaroff says, and money is only one of the reasons. Most primary care physicians are not trained in addiction, and are unprepared for dealing with patients who might be gaming the system in search of extra painkillers they can use or black market.
"The primary care and medical community is very separate from the behavioral health and addictions community," she says. "I don't think they talk to each other very much. They don't sit as the same table."
Oxman says Multnomah County primary care clinics have social workers who can work with patients being weaned off painkillers. But, he says, a comprehensive pain package with a host of alternative pain therapies -- what Solotaroff is able to offer -- isn't something the county can provide now. He wishes it could, and he recognizes the potential short-term cost of cutting down on painkiller prescriptions without the alternatives.
"Should we have waited until we had all that stuff in place to change our prescribing practices?" Oxman asks. "I felt there was this moral imperative. We were in a position of knowing our own patients were dying and it would be years before we had adequate capacity."
Others are searching for alternatives. Volunteers of America's clinics treat a large number of county residents on probation and parole. Greg Stone, director of the VOA's inpatient men's residential drug treatment center in Northeast Portland, says the new 18- to 25-year-old heroin addicts are harder to keep in treatment.
"They can't tolerate the physical and emotional distress, and they're not sufficiently motivated to be able to hang in there," he says.
As a result, Multnomah County has provided money for a pilot project that will allow some of those new heroin addicts to be treated with methadone, an option that almost all recovered heroin addicts abhor, Stone says.
Typically, Stone says, recovered addicts see methadone as substituting one addiction for another, but rarely a path to sobriety.
"We have a crisis right now, so maybe it's worth giving it a shot," Stone says.
TRIBUNE PHOTO: CHRISTOPHER ONSTOTT • Chris Pin used heroin daily for six years, but waited until the day before he entered detox to first shoot himself up with the drug.
• An 'evil thing' takes over life
Chris Pin smoked heroin for three days and knew he was addicted.
Pin grew up in a middle-class home in the Johnson Creek area, partying with alcohol and pot and occasionally cocaine and all the while able to hold down a job as a cable installer.
Pin first tried heroin on a Sunday afternoon. His older brother and some friends called it "a Sunday smack down."
Pin smoked heroin, got sick, puked and settled into the relaxed state the dope provided. A couple months later, he paid $100 for the phone number of a heroin supplier. He smoked for three days and was hooked.
"I remember vividly a sickening feeling, and my mind was turning me toward heroin," Pin says, adding that his mind was telling him he could no longer make it through a day without heroin.
Oddly, the first time Pin gave himself an injection of heroin was the day before his mother drove him to Hooper Detox so he could attempt to get clean. Now clean and sober, he recognized the contradiction in his thought process:
"I'm going to be getting clean tomorrow, I might as well try it one time, today," Pin says.
Pin spent six years as a heroin addict. His favorite place to score was among the day laborers near East Burnside Street and Grand Avenue. He'd wade in asking for "chiva," and eventually find a supplier.
Pin recalls talking to a Mexican dealer while in jail, and hearing the man say he was going to get deported but he'd just use the opportunity to get more drugs in Mexico and come straight back.
Pin traveled all over the West and tried to buy heroin in cities ranging from Las Vegas to San Francisco and Phoenix, but never found it as easy as in Portland. He knew people who lived in Seattle and would come to Portland for their dope.
Pin, who now has a job as a machinist, says he is still dealing with the time he spent as a heroin addict, because once or twice a year he hears about an old friend dying of an overdose.
"It's just the most evil thing to me. I don't know how I ever thought it was fun," Pin says.
- Peter Korn
TRIBUNE PHOTO: CHRISTOPHER ONSTOTT • A heroin smoker, Jimmy vowed he would never stick a needle in his arm, until someone offered him a free injection. Now, he injects himself daily as the only way to ward off becoming "dope sick."
• Needle points to new level
Jimmy (not his real name) swore he'd never put a needle in his arm. A steady user of black market prescription painkillers -- OxyContin was his favorite -- Jimmy was accustomed to paying close to a dollar a milligram for his fix.
He was a University of Oregon student using recreationally until the night he had only $30 on him, not enough for the Oxy high to which he'd become accustomed. A friend offered him a free smoke of heroin and explained the drug's advantage -- its cost.
"I didn't know how cheap heroin was," Jimmy says, adding that he set a limit.
"I vowed at that time that I would never shoot. Once you bring a needle into it, that's a whole new level."
But it's a level most young users find themselves reaching eventually, say addiction specialists.
Now the only way Jimmy can get the rush he desires is from injecting heroin, which he does every morning and sometimes before bedtime.
Jimmy has left school. Until a year and half ago, he was able to work as a Web designer. Now he spends his days as a low-level drug dealer, a lifestyle interrupted by two and a half weeks in jail after one bust.
- Peter Korn
TRIBUNE PHOTO: CHRISTOPHER ONSTOTT • A coin beside his bed marks two years of sobriety for Mike Longatino, who has embraced a life free of heroin at a sober living house in Portland.
• Drug's heavy (and low) price
Mike Longatino wasn't an addict when he arrived in Portland in 1995 at the Greyhound bus station. But, he says, the drug found him quickly enough.
"I got off at the bus station and hadn't walked more than three or four blocks and I was asked if I wanted to purchase cocaine and heroin two or three times," he says.
He hadn't even liked heroin the couple of times he'd tried it at parties. But Longatino, 38, says he learned that a small bag of heroin and cocaine -- what addicts call a speedball -- could be bought for anywhere from $7 to $30. And price, he says, did matter, especially after he reached the point where he would try to shoot up as much as he could in a day.
Longatino began stealing from stores to support his habit. He then turned to burglary and panhandling. Some days, he'd earn $20 begging on the street, and occasionally as much as $200.
It all went for dope.
Longatino says he kicked heroin in jail, thanks to "a cocktail" of drugs offered there that helped him withdraw.
His last jail sentence included a visit to the Volunteers of America inpatient treatment center in Northeast Portland, and after his nine-month stay, with VOA's help, he moved into the nonprofit Oxford House in Northeast Portland, a facility for recovering addicts.
Longatino knows how lucky he is. Heroin, he says, is almost impossible to permanently leave behind.
"All the people I've been through treatment with at the VOA, I can count on one hand the ones who have stayed clean," Longatino says. "And it's a really good program."
- Peter Korn