Opioid overuse kills more Minnesotans than homicide

David Taylor, 47, had crushing leg pain from a degenerative knee condition. Michael McAlpin, 37, struggled with a bad back and the stress of losing a million-dollar business. Debbie Thomas, 60, just wanted to garden and work again after a head-on car collision.

The trio of Minnesotans had no common ties save one: When they died last year, it wasn't from the physical or mental disorders that hijacked their lives. It was from the medication that was supposed to take their pain away.

The runaway use and abuse of prescription opioid painkillers such as oxycodone and hydrocodone has emerged as a public health threat in Minnesota. They now cause more deaths each year than homicides, according to a Star Tribune review of state death records.

Combined with other prescription-related deaths, they also account for more fatalities than car wrecks. Deaths from prescription and illegal opioids such as heroin have risen nearly sixfold since 2000, reaching 317 last year, state records show.

That sharp increase precisely tracks the rise in opioid prescriptions — caused by pharmaceutical company promotions, patient demands for quick fixes, and doctors who unknowingly hooked their patients on addictive drugs by providing excessive quantities for minor pains or procedures, said Dr. Chris Johnson, an ER physician who worked the last 12 years at Methodist Hospital in St. Louis Park.

"What has been the consequence?" Johnson said. "Well, we're dying."

David Taylor had been taking painkillers since 2005 and tried to wean himself for good last fall, when he gave a pill bottle to his father for safekeeping and took a week off from his IT job. A week later, his sister found him motionless in front of his TV at home in St. Peter. His father found a fresh bottle of 120 oxycodone pills that had been prescribed by a new doctor.

"All I know is he knew that he had to quit taking these things when he gave me his prescription," said his father, Roger Taylor, of Nicollet. "At least for a while, he tried."

Now state health officials are pushing back. They are trying to expand the use of an online monitoring program that informs doctors and dentists if addicted patients are shopping around for painkillers. And last week, the state gathered experts to create a program that will identify and retrain doctors who prescribe the pills too liberally — or boot them from the state Medicaid program if they don't change their ways.

Johnson said the preoccupation with pain pills accelerated in 1995, when the American Pain Society made pain the "fifth vital sign," akin to blood pressure. Oversight groups such as the Joint Commission then required medical clinics to routinely assess patients' pain levels, to display 10-point pain rating scales in exam rooms and to check patients' pain levels. That pushed doctors to treat pain in and of itself, Johnson said, and they could do little more in brief office visits than write prescriptions.

Some of the doctors behind the vital sign decision received financial support from drug manufacturers, and promoted junk science suggesting opioids were safe and caused addiction in less than 1 percent of patients, Johnson said. Meanwhile, drug companies pumped millions into marketing and coupons for free first prescriptions.

"Tell me that doesn't sound like the guy hanging around the high school," Johnson said.

In Minnesota, records show 212 deaths linked to prescription opioids last year, up from 23 in 2000. Deaths from heroin overdoses also increased, from two in 2000 to 98 last year, which isn't surprising considering that most heroin addicts start out abusing prescription pills.

The cost of opioid abuse also is reflected in deaths from methadone, an addictive pain reliever used as a replacement therapy for opioid addicts. Methadone-related deaths increased from five in 2000 to 79 last year.

None of those figures includes ancillary victims, such as the two Carlton County road workers killed in 2012 when a woman who had injected an oral dose of methadone drove her car into their truck.

Johnson, who is part of the state's new opioid prescribing work group, asserts that "all opiates are heroin" because legal and illegal versions are chemically similar. Opioids block receptors in the brain that transmit pain signals to injured parts of the body, and stimulate "reward" signals in the brain via the release of dopamine. They also slow the portion of the brain responsible for breathing — and when taken to excess cause respiratory failure.

In the case of Michael McAlpin, he'd built up a $5 million per year storm repair company before his troubles began. Complaining frequently of back pain, he started taking more medications. Along the way his business and marriage failed and he isolated himself from friends and family. Now his parents have little doubt that he was addicted to opioids that had proved far too easy to obtain. McAlpin died from a combination of two opioids along with an anti-anxiety medication.

McAlpin's case is a snapshot of a greater trend. Last month, Princeton economists found a surprising increase from 1999 to 2013 in the U.S. death rate of white, middle-aged Americans, and cited opioid overdoses as a principal cause. Their findings challenged misconceptions that opioid and heroin abuse was a problem confined to minority or low-income populations.

A Star Tribune review of state records for 132 people, whose deaths in 2013 and 2014 were caused by prescription opioids, found similar results. Nine in 10 victims were white, and 114 had jobs (ranging from psychologist to DJ to gemologist) or were students. The average age was 45, though five deaths were among teenagers, including an 18-year-old who received oxycodone following a dental procedure.

Of those deaths, 21 were suicides — though doctors say the line between a suicide and an overdose to make pain go away can be thin.

Thomas, the Buffalo woman injured in a car crash, was taking 14 different medications for pain control when she was found dead in her home in June 2014. She had grown discouraged by her lack of mobility, and her husband clashed with her over her reliance on the medications. The husband, Paul Thomas, believes she got confused.

"She had a tendency of forgetting that she took her medication. If I were taking the amount of stuff she was taking, I would forget too," he said. "She was home alone and she took too much of the morphine sulfate."

"If people are solely focused on a pill for solving a complex problem," he said, "it is really setting them up for failure."

Therapy should focus on managing pain so patients can work on recovery, rather than eliminating pain itself, said Dr. Jeffrey Schiff, medical director of Minnesota's Medicaid programs and the leader of the state's opioid work group. "From a medical point of view, pain is necessary for life. You need to know a burner [on a stove] hurts so you don't keep your hand on it," Schiff said. "How we deal with the suffering associated with pain is really something we need to rethink."

Minnesota leaders are hopeful additional monitoring of patients and doctors will help. Nearly 10,000 prescribers (including doctors and dentists) are now registered with the state's monitoring program, meaning they can instantly check on patients who might be acquiring opioid prescriptions from multiple locations. Some lawmakers will seek next year to make registration mandatory. The Minnesota Board of Pharmacy also has received funding to search the system for patients who appear to be "doctor shopping," and has sent letters to doctors about 212 suspect patients.

"After we sent out letters, 80 to 90 percent of them did not show up again in the system as being doctor shoppers," said Cody Wiberg, executive director of the pharmacy board. "We hope doctors aren't just saying 'Get out of my office and don't come back!' We hope … they are referring their patients to whatever treatment is needed."

Some doctors worry the fervor to reduce opioid prescriptions will go too far. While alternatives are needed, it remains possible, though unproven, that opioids work for chronic pain, said Dr. Lynn Webster, a Utah physician who has written a book on chronic pain.

HealthPartners has launched an alternative pain clinic in Anoka County, where a spike in heroin deaths drew attention to the state's opioid problems. The clinic gives patients medical care but also physical therapy and oversight by a psychologist and an addiction specialist. The clinic also emphasizes patient self-help through diet and exercise, and Clavel said in its first four months it has helped 10 patients wean themselves off opioids.

Patients need to cope with pain as part of their recovery, and excessive pain relievers make that challenging, Clavel said.

"People who are on high-dose opiates can't do any of that because they are disconnected from it all … and we say we are treating their suffering."