Prescription pills killing pain — and people

BY CARY ASPINWALL World Staff Writer
Sunday, July 17, 2011
7/17/11 at 7:01 AM

Listen to the 911 call from Austin Box’s friend to police and read the preliminary toxicology report from the Medical Examiner’s Office.

Click here to see a copy of the Medical Examiner's report

Dispatcher:"El Reno 911?"

Caller:"Yeah, I need an ambulance to uh, 1219 South Reno."

"OK, what's going on?"

"Uh, there's a guy, uh, that stayed with me last night and uh, he's not responding to me. He takes pain pills... and he's not responding to me."

"Is he ... is he breathing?"

"I don't think so."

"OK. What is your first name?"

"My name's J.T. Cobble. C-o-b-b-l-e."

"What's his name?"

"His name's Austin Box."

Oklahoma has a pill problem.

Over the past decade, the number of deaths annually due to accidental overdose of prescription drugs has nearly tripled, according to Oklahoma Medical Examiner's Office records.

In 2010, more than 80 percent of the drug-related deaths in Oklahoma involved prescription medicines, officials estimate.

Nationally, Oklahoma ranks among the top 10 states for accidental prescription overdose deaths per capita, according to data from the Centers for Disease Control and Prevention.

Hydrocodone is the most common culprit, followed by the anti-anxiety drug alprazolam and two other painkillers: oxycodone and morphine.

Those were four of the six drugs listed in University of Oklahoma linebacker Austin Box's toxicology report, released last week. Oxymorphone and hydromorphone also were in his system when he died of "probable mixed drug toxicity" on May 19, according to a preliminary autopsy report.

El Reno police confirmed last week that Box did not have legal prescriptions on file for any of the drugs he had taken. Investigators are trying to determine how he obtained the drugs.

The Oklahoma Bureau of Narcotics and Dangerous Drugs Control tracks all prescriptions for Schedules II, III and IV drugs in the state through its prescription-monitoring program. Oklahoma was the first state to use computerized prescription monitoring in 1990, but the system currently used came online in 2006.

A law that took effect in November 2010 requires all Oklahoma medical facilities to report any nonfatal overdoses to the OBNDD. Though there's not yet 100 percent compliance by state hospitals, the early numbers provide a staggering look at Oklahoma's prescription pill problem, spokesman Mark Woodward said.

Between Nov. 1, 2010, and July 5, there were at least eight nonfatal overdoses per day, most frequently involving alprazolam (one common brand is Xanax), alcohol or the opioid pain pill hydrocodone. Hydrocodone is the No. 1 most commonly prescribed drug in Oklahoma and the nation.

Pain primer

This is how pain works: When you get injured, sensory nerves at the site send messages to your brain.

The response may be as simple as "Ow!"

But it's really quite complex: Special pain receptors activate when you're injured or hurt, firing impulses all the way through your spinal cord to your brain.

It happens faster than you can measure on a stopwatch.

Part of the neuron reaction happens as a reflex: Letting go of a hot pan. Dropping the knife that cut you. Wincing and grasping the hand you smashed in the door.

But the reflex reaction doesn't stop the pain; there's still damage to your hand, even when you're no longer gripping the hot pan.

Your brain knows this because the neurons are still firing in response to the injury, communicating at points in your brain called synapses. They're cataloging the pain.

Typically, your body will release endorphins in response to the pain of an injury because they function as the body's natural painkillers.

This is how prescription painkillers known as opioids work: The drug binds to the sites in your brain where the body's self-made chemical would normally attach.

What nature would usually do, the opioid does instead, only it's much stronger.

This is useful in cases of acute and chronic pain where the body doesn't heal completely from an injury. The pain receptors continue to fire in the body's nervous system, so a doctor prescribes an opioid to slow the process and lessen what the body senses as pain.

The problem inherent with this is that over time - with continued, chronic use - the body begins to crave this substitute chemical.

Also, it can kill you.

A thin line

Dispatcher: "OK. I need you to go check for a pulse for me."

Caller: "K."

"OK, um, go on his right side. Are you laying next to him? Are you next to him?"

"Uh huh."

"Do you feel him breathing at all? Can you put your hand in front of his face? Can you feel any air?

"No."

"No?"

"No."

"OK, check for a pulse."

"He's not breathing. ..."

A frequently dangerous side effect of opioid painkillers is that they depress respiratory function in the body, said Dr. Craig Sanford, past president of the American College of Emergency Physicians' Oklahoma Chapter.

A part of your brain is responsible for maintaining the basic bodily function of breathing. If you take too large a dose of an opioid painkiller such as Lortab or Oxycontin, that stops working. The effect is multiplied by taking these medications with alcohol or with other drugs such as alprazolam.

You stop getting enough oxygen in your body to keep your heart pumping, and you die.

If someone finds you in critical condition and gets you to an emergency room, you might live.

First, paramedics or doctors may try CPR to restart your heart and respiratory function.

Then they may use a defibrillator to shock your heart back to life, if there's a shockable rhythm.

If it's soon enough after you've ingested the toxic dose of opioids, they can fill your stomach with activated charcoal to keep the drugs from being absorbed into your body.

In some cases, emergency workers will administer a dose of Narcan, a drug that blocks the effects of the opioid.

They may give you adrenaline to constrict your blood vessels to increase blood flow through your coronary arteries.

They may do all this, and you might die anyway.

Opioids are powerful drugs.

Best practices

Dispatcher:"Ok. Do you want to start CPR?"

Caller:"I don't know how."

"You don't know how? OK, I'm going to tell you how, OK? Hang on just a second."

"Box! Austin!" (You hear Cobble try to wake him).

Dispatcher:"OK. I need you to place your hand on his forehead and your other hand under his neck and then tilt his head back."

"What now?"

"Place your hand on his forehead - your left hand - which side are you on?"

"I'm on his right side."

"You're on his right side? OK. Place your left on his forehead and your other hand under his neck and tilt his head back. Put your ear next to his mouth and can you hear or feel any breathing?"

"No."

One of the chief problems with prescribing opioids for pain is that the body builds up a tolerance to them over time - essentially meaning that the more you take, the less effective they become.

Some people take one pill and can't stand the feeling or side effects. For others, the drugs have euphoric qualities that stimulate the brain's pleasure center.

There are Pavlovian responses that come into play when taking such powerful drugs, Sanford said.

For some, the euphoric sensation of taking an opioid analgesic becomes the ringing bell. They don't want it to stop. The tolerance builds, requiring larger and larger doses to sustain that euphoric feeling.

But the rest of your body's physiology does not build that same tolerance. Even if you need increasing amounts to feel euphoria, you may still need only the same amount to stop breathing.

The potential dangers from overuse of prescription opioids leads doctors at Tulsa Pain Consultants to take extra steps before prescribing them, said Dr. Andrew Revelis.

He and his colleagues check the OBNDD prescription-monitoring database to ensure that the patient isn't "doctor shopping." They also run criminal background checks on new patients and require all patients to submit to urine testing to screen for the use of other drugs.

"We take it very seriously that we have the obligation as doctors to take all reasonable steps to prevent abuse," Revelis said. "We control the supply of these medications. We're not fighting a war against smugglers."

But there are factors even doctors can't control: people taking pills they get from friends or family, patients turning around and selling prescriptions on the street to make a quick buck, pharmacy robberies, online dealers and pill mills that skirt state and federal laws.

That is why Revelis and his colleagues at Tulsa Pain Consultants have been asked to speak to members of the state House of Representatives this fall on how Oklahoma can improve physician and pharmacist education and practices with regard to opioids and other dangerous prescription drugs.

"The (prescription monitoring) database is a good start," Revelis said. "But if we need to make (doctor participation) mandatory, then I think that's a reasonable step forward."

Legally, only pharmacists are required to use the database, to enter information each time they dispense a prescription for one of the drugs it monitors. Doctor participation is voluntary, and the OBNDD estimates that it's used by about 75 percent of the state's physicians who write prescriptions for the targeted medications.

However, some of the responsibility for stopping prescription abuse must fall on patients, Revelis said.

"I think we also have to look at upping the criminal penalties for trying to resell your prescription," he said.

Whatever investigators uncover about how Box obtained the prescription drugs that killed him, perhaps his tragic death may serve to focus attention on the broader issue of prescription abuse in Oklahoma, Revelis said.

"It's staggering for a state our size," he said.

Woodward said many mistakenly assume that because the pills come in a pharmacy bottle with a doctor's name on it, they're somehow safer than street drugs such as cocaine and heroin. But far more people in Oklahoma overdose each year on prescription pills than on street drugs.

"And the addicts are often so much more in denial than with street drugs because it's a prescription," he said.

And with such powerful drugs, addiction can grab hold of anyone.

"Almost everybody's had an accident or gotten ill and gotten a prescription for these types of drugs," Woodward said. "For some of them, they just can't walk away from it."

An alarming increase

In 1995, only one person died in Oklahoma due solely to hydrocodone overdose, according to the Office of the Chief Medical Examiner's annual report.

There were no overdose deaths in Oklahoma due solely to oxycodone in 1995, the same year OxyContin entered the market.

By 2000, the Tulsa World was reporting statewide deaths each year from those in the terms of "several dozen."

Preliminary figures from the ME's Office for 2010 show nearly 650 deaths due to prescription drugs, frequently in combination with other drugs or alcohol.

Americans constitute 4.6 percent of the world's population but consume 80 percent of the opioid medication supply, according to the American Society of Pain Interventionists.

From 1997 to 2007, there was a sevenfold increase in the volume of opioid analgesics prescribed per person in the U.S., according to an article in the April 2011 issue of the Journal of Clinical Psychiatry. This increase closely paralleled the increase in unintentional overdose deaths from those drugs during the same period.

By one calculation, the volume of prescription opioids consumed in the U.S. is enough for every American to take 5 milligrams of Vicodin every four hours for three weeks, said Dr. Richard Weisler, one of the authors of the journal article "A National Epidemic of Unintentional Prescription Opioid Overdose Deaths."

Story sources

Resources for this story included materials and information from the Addiction Studies Program for Journalists, sponsored by Wake Forest University of Medicine and National Families in Action. This story also contains portions of the 911 call made by Austin Box's friend J.T. Cobble, transcribed directly from the recorded phone call.

Agents intervene in Sutton drug case

In some cases, the Oklahoma Bureau of Narcotics and Dangerous Drugs Control can intervene when someone is caught doctor shopping or trying to illegally obtain prescriptions - and potentially save a life.

In 2010, former Oklahoma State University men's basketball coach Sean Sutton was struggling with addiction when state drug agents began investigating him for fraudulently obtaining prescription painkillers and anti-anxiety drugs.

Sutton pleaded guilty to four felonies and spent four months in a treatment center.

"It was a wake-up call, and in some ways as painful as it was to walk through it and as embarrassing as it was - because I felt like I'd really ruined my reputation - it was also a lot of relief that my secret was out there. Because the lies and the hiding, all that beats your spirit down," Sutton told the Tulsa World in June.

Now living in Tulsa, he regularly speaks at events and meetings about the dangers of addiction and his path to recovery. He was recently hired to help his brother, Scott Sutton, coach the Oral Roberts University basketball team.

Public health impact of opioid abuse

For every one overdose death in the United States, there are …

9 abuse treatment admissions

35 emergency room visits for misuse or abuse

161 people with abuse/dependence

461 nonmedical users

Source: Centers for Disease Control and Prevention

Original Print Headline: Killing pain — and people

Cary Aspinwall 918-581-8477
cary.aspinwall@tulsaworld.com

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