Colorado draws on CU Anschutz public health and addiction experts to understand link between drugs, fight 'public health crisis'
Lindsey Kato takes the opioid epidemic personally — the Colorado School of Public Health (ColoradoSPH) alumna has lost eight friends to heroin overdoses. She said most of those friends began abusing prescription opioid painkillers such as Vicodin and OxyContin in high school. Then they graduated to heroin, an even more lethal and addictive opioid.
Kato grew up in Juneau, Alaska, a community hit hard by opioid abuse and a surge in heroin use. “I still continue to lose friends,” said Kato, who in December received her Master of Public Health degree. “I want to understand how did I end up here, and how did my friends end up there.”
CU Anschutz fights the opioid epidemic
This is the second in a series of articles that examines how University of Colorado Anschutz Medical Campus faculty and students are finding ways to solve the opioid epidemic.
For Kato, “here” meant the University of Colorado Anschutz Medical Campus, where she studied epidemiology. That led to a job with the Colorado Department of Public Health and Environment (CDPHE). In May 2016 and while still a student, she began working as the department’s heroin strategies coordinator. The job helps bridge the public health and law enforcement communities, which in the past have not always seen eye-to-eye on how to deal with addiction.
Kato’s responsibilities included collecting all the data about arrests for heroin or opioid possession and distribution that Colorado law enforcement agencies could provide. She also studied the progression from prescription medications to street drugs, leading a project that conducted surveys in nine Denver-area methadone clinics. The CDPHE will publish the survey findings next month in a report titled “Heroin in Colorado.”
Kato’s work is an example of how CU Anschutz faculty, students and alumni help fight opioid abuse. Epidemiologists in the ColoradoSPH study demographic trends and social impacts in the hopes of helping individuals, families, communities and government officials come to grips with the epidemic. Other researchers at CU Anschutz study alternative pain treatments, develop continuing education programs for rural doctors and integrate databases used by doctors, dentists and pharmacists.
Understanding prescription opioids’ connection to heroin
The State of Colorado considers opioid and prescription drug abuse a public health crisis, and it relies heavily on CU Anschutz to coordinate the response, with the university providing the Colorado Consortium for Prescription Drug Abuse Prevention’s director and the chairs of many of its work groups.
The state has become especially concerned about the link between opioid abuse and heroin, said Robert Valuck, PhD, RPh, a professor at the Skaggs School of Pharmacy and Pharmaceutical Sciences and expert in opioid abuse. Valuck coordinates the consortium.
In 2015, 160 people in Colorado died of heroin overdoses, up from 37 in 2000 and 91 people in 2012, according to the state health department.
The idea that painkillers prescribed by a doctor or dentist could lead to heroin addiction surprises people, Valuck said. Some think it might be harmless to share meds with family members in pain or keep unused pills in the medicine cabinets. But that can lead to disaster — according to national statistics, about 69 percent of opioid abusers started that way.
The connection between the two epidemics seems to make sense. Heroin is in the same family of drugs as prescription opioids, and the nervous system reacts to them in similar ways. They share harsh withdrawal symptoms that cause people to become violently ill. Addicts become desperate to prevent withdrawal, Valuck said, and some will begin buying pills from drug dealers to avoid the pain.
“People who go through withdrawal say they would rather die than go through that again,” Valuck said.
Anecdotal evidence from law enforcement officers and health care providers supports the connection between the epidemics. But government officials and public health experts developing strategies for combatting the epidemic needed better data. One of Kato’s tasks for the state health department was to collect data about why and how people became addicted to heroin.
“We had a hunch about the connection between prescription drug abuse and heroin,” Kato said. “We wanted solid evidence, and we wanted to understand heroin abuse from the perspective of people who have experienced heroin addiction.”
Researching in methadone clinics
Heroin and opioid abuse in Colorado
160 people died of heroin overdoses in 2015
37 died of overdoses in 2000
70 percent of recovering heroin users abused prescription opioids
329 people died from misusing prescription opioids in 2015
To conduct the study, Kato and five ColoradoSPH students interviewed patients in nine methadone clinics around Denver. The clinics help patients recover by distributing methadone, which mitigates opioid withdrawal. The medication itself is a long-acting opioid, but unlike heroin or prescription opioids, it does not get users high. Patients receive their doses at clinics, and doctors supervise their treatment.
Kato and the team administered an in-person survey with 46 questions. They asked the clinics’ clients about their backgrounds and why they began using drugs. Kato also sought to find what recovering addicts thought about their treatment and what helps them stay sober.
Interviewers often started at 5 a.m. to meet people who went to the clinic before work. They conducted 713 surveys in 25 days.
What Kato found shocked her, especially what she saw during her first visit to a clinic.
“We couldn’t tell who was a client from who worked there,” Kato said. “Society paints a certain picture of addiction, we think of particular demographic, and that’s the stigma around methadone clinics. But it was so diverse — there were people in suits who looked like they could be professors, classmates or even your grandmother.”
Kato also found that about half of the recovering patients had college educations, more than a third were employed, and the majority rented or owned homes. The data confirmed what Kato saw happen to her friends. About 70 percent of the clients cited prescription pain medication use as one of the main reasons for transitioning to heroin.
Their stories shared certain traits—sometimes people got hooked as kids, sneaking a family member’s meds. Some became dependent on legitimately prescribed painkillers for a medical problem. When doctors stopped prescribing, they would borrow or steal pills from friends or family.
At that point, Kato found prescription drug abusers reached a crossroads. Some sought treatment, while others turned to drug dealers. Some of the latter were able to limit their addictions to prescription medications. Others couldn’t and tried heroin.
Someone in this situation isn’t necessarily trying to find a better high, Valuck said. Heroin is cheaper and easier to find on the drug market than prescription meds, and he said it is not uncommon for people to sell their prescription medication and use the money to buy heroin.
Creating a unified response
Controversy still lingers around methadone. Doctors and public health experts consider methadone a legitimate and effective treatment. Valuck said giving patients carefully managed doses that decrease over a few years has proven safer and more effective than making them quit cold turkey.
“We couldn’t tell who was a client from who worked there…. They could be professors, classmates or even your grandmother.”
Law enforcement officers historically have not been involved in drug treatment, Kato said. She believes that police see the crimes committed by drug addicts and often identify with victims affected by these crimes, rather than identifying or empathizing with the individuals experiencing addiction.
The difference in perception shows the different approaches between those who see drug abuse as a criminal matter or a medical issue. Kato plans to spend her career working to bring the sides together to help coordinate an effective response. Already, she’s seeing attitudes change among leaders in the law enforcement community.
“They have come to terms with knowing they’re not going to solely arrest their way out of this problem,” Kato said. “They are actively seeking to understand the process of addiction and how they can be involved in a public health approach.”