Opioid crisis averted or inevitable?

KAILUA-KONA — There’s one thing to understand right away about the root of the opioid crisis — there is no one thing.

Or, as Dr. Michael McGrath at his Recovery Enhanced Medicine Institute on Alapa Street in Kailua-Kona, put it:

“Any time you try to reduce this complicated thing down to a very simple answer,” he said, “you’re missing a lot.”

Reasons are plenty how the nation entrenched itself in the middle of a dark opioid problem — doctors who over-prescribe, pharmaceutical companies pushing pills onto the public, to name a few.

But for McGrath and the many others on the front lines of the opioid fight on Hawaii Island, the focus is on the scores of people in the community seeking a life beyond opioid use disorder and the elements that are within their — and their clients’ — control.

A quick look at national figures would suggest all is well in the Aloha State — Hawaii’s death rate for opioid-related overdoses is among the lowest in the country and has the nation’s lowest rate of opioid prescriptions, but health experts are wary, noting the state often experiences a delayed impact of national trends.

The experts know the stakes.

“It is life or death for most of our clients, and they don’t all make it,” said Eliza Wille, program director and therapist at Hawaii Island Recovery. “That’s the reality that I think we all hold with us as the gravity of the situation.”

By the numbers

The death rate for opioid-related overdoses in the state is less than half the national average, with just 77 opioid-related overdose deaths statewide in 2016, according to the Centers for Disease Control and Prevention.

Similarly, the state had the lowest prescribing rate for opioids in the country, with just 41.9 prescriptions for every 100 people in 2016, a third the rate of Alabama, the state with the highest prescribing rate at 121 prescriptions per 100 people.

On a local level, however, Hawaii County has by far the highest prescribing rate in the state at 66.4 prescriptions for every 100 people, double the prescribing rate of the City and County of Honolulu.

But the statistics obscure what some see as a serious public health issue in the community: Addiction. And Hawaii is by no means immune to the plague that has engulfed the rest of the country.

“I think addiction rates are incredibly high, shockingly high,” said Alysa Lavoie, case manager at the West Hawaii Community Health Center. “I don’t think any of the data that you’re going to find or see really reflects the true picture of not just what we’re seeing at the health center, but just in general.”

While maybe not measured as an epidemic in Hawaii, she said she believes there is one, just “behind closed doors, in a sense.”

“We see our typical houseless person walking down the street, and we assume addiction,” she said, “but I think that there’s so much more than that that we’re not seeing or that’s not coming to the clinic and not identified.”

Policymakers on the state level are also wary despite the numbers.

A state report published in December about Hawaii’s response to the misuse of opioids and other substances notes that Hawaii “often experiences a delayed impact in relationship to national trends in substance use.”

“It would be a mistake,” the report states, “to assume the difference in trend patterns between Hawaii and the contiguous U.S. means that there is no need to be vigilant.”

While non-fatal overdoses peaked in 2010, there have still been an average of close to 400 nonfatal incidents yearly, nearly half of which required hospitalization. Close to three quarters of opioid-related overdoses treated in hospitals involved only opioid pain relievers while a tenth involved just heroin.

“If you are an opioid addict, you are a heroin addict,” is how Hawaii’s DEA Assistant Special Agent in Charge John W. Callery put it at a recent Hawaii Police Commissioners Conference in Kailua-Kona. “Oxy is heroin in a cuter outfit.”

The report indicates that opioid-related overdoses cost about $4,050 per emergency department visit in the state and about $40,100 for each hospitalization. In 2016, opioid-related overdoses led to a total of about $9.8 million in hospital charges.

Locally, said Dr. Diane Logan, a clinical psychologist and substance use coordinator at West Hawaii Community Health Center, the community is seeing the same issues the mainland is.

Hawaii, however, has been buffered from the international supply of drugs like fentanyl that have been driving up overdose rates in some parts of the mainland. Fentanyl is an opioid considered 50-100 times more potent than morphine, according to the U.S. Drug Enforcement Administration.

“And yet, the day-to-day toll, heroin use, (hepatitis C) rates, those types of things are not really inconsistent with the mainland either,” Logan said.

Addiction beyond the drug

So why do people get addicted in the first place?

The reasons there also vary.

Critical to understanding addiction and ultimately bringing people through recovery is an approach that looks beyond just the drug itself and considers the totality of factors that manifest themselves through substance use disorders.

“The substance is a symptom and you have to get to the cause and conditions,” said Jimmy Kayihura, admission director at Hawaii Island Recovery. “If you put down the pill, but you continue to struggle in the same fashion, then that’s not living either.”

A paramount consideration is the role of trauma and life experiences that can make a person more vulnerable to addiction.

“We recognize that trauma creates an enormous vulnerability to addiction,” Wille said.

Most often, she said, citing their experience and research, people with an addiction have experienced some sort of developmental trauma in their lives, which has a “profound impact” on everything from a person’s energy level to their mood and personal affect. That creates an opening for substance use to enter the equation.

“Because that substance offers relief,” she said. “It offers a person a feeling of — not even necessarily a high — but a feeling of normal. … They’re not using necessarily to feel high or low or calm, they’re using to feel normal.”

Having that consideration for trauma and life experiences is not only critical when considering opioid use disorder, but also in the treatment of complex chronic pain patients, who along with a need for appropriate and sensitive pain treatment, can also be at high risk of developing problems with opioids because of factors that might go unconsidered — and therefore untreated — by a one-size-fits-all treatment plan.

What starts with an injured knee or bad back can cause a person to lose a job or their position in a relationship and even their goals and aspirations can fall to the wayside — all of which will amplify how someone experiences that pain.

“Our current medical system focuses on the lesion — the knee or the back,” McGrath, a psychiatrist and board-certified addictionologist, said at his clinic, where he treats patients with complex chronic pain, opioid use disorder and those with a combination of the two. “They don’t look at the complicated factors of what it’s done to the person’s life, how it affects their mood, how it affects their sense of self, how it makes them anxious and fearful about their future and their relationships with people.”

“Why’s that important?” he added, “We know from research those things worsen pain.”

It’s not just the effects pain has on a person’s experience, McGrath said, there’s also “the canvas on which the chronic pain occurs,” — factors like mental illness or child abuse or a family history of substance use (factors called “adverse childhood experiences”) — which can also amplify pain.

Given two patients, one with a “perfect upbringing” and another with a history of adverse childhood experiences, who experience the exact same lesion, research shows the second patient is going to have a worse pain experience, McGrath explained. And those patients are the ones more likely to develop problems with opioids, including higher doses at rates considered to be unsafe.

It’s why screening patients, he said, is so important, noting that he’s working on developing screenings and evaluations himself that physicians can use, raising the importance that physicians ensure medication isn’t simply withheld from people without good reason, noting that “the majority of people that get a bad back or bad knee and get put on hydrocodone or something don’t have problems,” he said.

The challenge then is to consider the full picture of the opioid crisis and develop solutions without losing sight of the individual needs and situation of each client or patient and treating everyone in an individualized way best suited to their needs.

“Real pain patients should not have to worry about having the medicine taken away that makes their life bearable,” McGrath said. “And if we have an overreaction to this opioid crisis, that’s at risk.”

Email Cameron Miculka at cmiculka@westhawaiitoday.com.