Sitting in a back room at a Kmart, Rachelle Allen came face to face with the woman she’d become.
There she was on the store’s security video, shoplifting a pair of tennis shoes. The blank-faced woman on the screen had matted, unwashed hair. On that cold winter night two years ago, she wore nothing but flip-flops, tattered jeans and a hoodie. As she watched, a security guard rummaged through her purse, finding illegal pills and drug paraphernalia.
It was a moment of deep humiliation for Allen, 40, of Kansas City, who had become addicted to prescription opioid pain pills after surgery in 2005.
“I realized what I was doing was disgusting,” she said, “and I needed to do something different.”
America is in the throes of an epidemic of pain pill abuse — abuse that in many cases, including Allen’s, began with a doctor’s prescription.
Since the early 1990s, the number of opioid prescriptions filled at U.S. drugstores has nearly tripled. In 2014, those prescriptions totaled 267 million, according to the Food and Drug Administration, more than enough to provide every adult in the nation with a bottle of pills.
These medications — including hydrocodone, meperidine, fentanyl and oxycodone, and sold under brand names such as Vicodin, Demerol and OxyContin — are chemically similar to heroin. They can cause physical dependence and addiction, as well as death, when an overdose slows breathing to a standstill.
The consequences are becoming increasingly clear and alarming:
Across Missouri, the rate of opioid-related inpatient hospital admissions and emergency room visits more than doubled over the past decade, Missouri Hospital Association data show.
Prescription opioid-related visits to Kansas City hospital emergency rooms jumped from nine in 2004 to 64 in 2013, according to the Kansas City Health Department.
Nationwide, overdose deaths related to prescription opioids climbed 16 percent from the year before to a record 18,893 in 2014, according to the Centers for Disease Control and Prevention.
Recreational drug use — experimenting with drugs to get high — is responsible for only some of this damage.
For growing numbers of people, the pain medications that doctors prescribe after injuries or surgery, or to ease chronic conditions such as back pain, have become gateway drugs to abuse and addiction.
People suffering chronic pain, and their advocates, say these medications are essential for controlling pain that would otherwise be unbearable. They say they use opioids responsibly.
But many doctors, such as David Terry, a University of Kansas Hospital psychiatrist who treats many patients who have become addicted to pain medications, say their colleagues often are too quick to prescribe opioids. They’re not paying enough attention to how vulnerable some patients may be to addiction, and they’re failing to offer safer alternatives such as physical therapy or opioid-free pain medications.
“Doctors have fallen into this culture of ‘it’s easy to write a script,’ ” Terry said.
For Allen, the price of addiction was her home, her family, her career. She describes her decade of drug abuse as “10 years of hell.”
“It’s got to get better,” she says with as much hope as determination. “It’s got to get better.”
‘I had to have it’
Allen grew up in small towns in Kansas and Missouri. Her mother abandoned the family when Allen was just 10. Allen’s anger simmered, and for many years until they reconciled, she would blame her mother for much of what went wrong in her life.
Allen’s father worked a factory job to keep the family together, but he was a silent and emotionally distant man. She grew up a wild child, expelled by her high school for phoning in a bogus bomb threat.
But she made an independent life for herself. She gained certification as a nursing assistant and a medication aide and held full-time jobs at nursing homes.
Allen said she never had been interested in using drugs for thrills. When she was about 20, she smoked crystal meth for six months, but only, she says, to maintain her relationship with the father of her first two children. She says she had no problem putting meth aside when she left him in 1997.
After her third child was born in 1999, Allen underwent a tubal ligation to prevent more pregnancies.
Several years later, she met her future husband in Johnson County. He was childless and wanted children of his own. Allen agreed to an operation to undo her sterilization.
The reversal operation in January 2005 bruised her abdomen and left her in severe pain. Ovulation also became painful.
“It was awful,” Allen said.
The doctor who performed the surgery prescribed Vicodin pills, a combination of hydrocodone and acetaminophen, the ingredient in Tylenol. It was Allen’s first experience with opioids.
About two months after her surgery, Allen noticed she became anxious when she stopped taking the pills. She had trouble sleeping. She’d vomit. And she had an irresistible urge to move her legs — the restless legs syndrome that gave rise to the expression “kick the habit.”
What she was going through, she realized, was drug withdrawal.
“My surgeon, he didn’t warn me of that. I researched that on my own and found out,” she said. “I knew that I was in trouble.”
After six months, the pain was gone, but Allen kept taking the pills. She doesn’t fault her doctor. She was supposed to take the pills only while she was ovulating, but she used them all the time.
“I had to have it or I couldn’t function.”
Her wedding day came in July 2005. Allen, who was eight weeks pregnant, put on her white lace wedding dress. Then she started getting cramps.
She was having a miscarriage, a common risk from the surgery she’d had earlier that year.
“I was taking handfuls of that hydrocodone, so I was pretty high,” Allen remembered. “I didn’t feel much of it.”
The wedding went on as planned.
Public health crisis
How many people run into trouble with opioids prescribed for pain? Reliable numbers are hard to come by.
Reported rates have ranged from less than 1 percent of patients to as high as 56 percent. But the studies that produce these numbers define and measure addiction and abuse in different ways, making it hard to compare results.
One of the few large-scale studies interviewed 2,000 chronic-pain patients in Pennsylvania who had been receiving opioids long term. The researchers found that 35 percent met criteria for “opioid use disorder,” a medical term that covers symptoms associated with abuse or addiction.
Pain treatment advocates point to studies with lower numbers as evidence that chronic-pain patients generally manage their use of opioids successfully. They should be considered separately, advocates say, from opioid abusers.
But drug addiction experts — pointing to persistently high or growing numbers of opioid prescriptions, people entering treatment for opioid addiction and deaths from opioid overdoses — say that however useful the drugs are to some patients, opioids have become a public health emergency.
“Doctors are causing this addiction in patients they prescribe to,” said Andrew Kolodny, executive director of Physicians for Responsible Opioid Prescribing and a physician who treats addiction.
While “pill mill” doctors who sell prescriptions wholesale to addicts or street dealers may get the headlines, they account for a tiny fraction of the pills that get into circulation.
A Kansas City Star review of disciplinary actions by the Missouri Bureau of Narcotics and Dangerous Drugs found that one-third of the doctors flagged for questionable prescribing actually were taking the drugs themselves.
The vast majority of opioid pain medications here and elsewhere are prescribed legally, nearly half by primary care specialists such as family physicians, according to CDC researchers.
“Doctors need to re-evaluate their own practices for the benefit of the community,” said Terry, the KU Hospital psychiatrist.
“They need to have the conversation on opioids the first time patients come to their office and say, ‘These medications aren’t good for you.’ That takes more work than just writing a prescription.”
Opioids have a place in pain management, said Marsha Page-White, clinical director at ReDiscover, a Kansas City area mental health and substance abuse treatment center. But doctors should prescribe judiciously, she said.
“You don’t take a sledgehammer to a small nail. I don’t need 60 pills when two would do.”
Allen’s doctor eventually grew skeptical of her continued demand for opioids.
“I’m sure he knew I was seeking (drugs for abuse) at some point, and he would prescribe less and less, but he never said, ‘Hey, what’s going on?’
“Actually, I’ve never had a physician question me.”
Allen started doctor shopping. It’s a common practice among opioid addicts after the doctors who initially prescribed the drugs decide a patient has had enough.
The Government Accountability Office estimated that among Medicare recipients alone, 170,000 were doctor shopping, mostly seeking opioids, in 2008.
Allen would walk into doctor’s offices or drive to emergency rooms, traveling as far as Springfield and Columbia. She’d use excuses — whiplash, back pain — “anything I could think of. … I pretty much knew what I had to say and what I had to do.”
If she saw an ER doctor, she’d say she had a toothache. “After seeing the doctor, within 20 minutes, I’d have a script in hand.”
Hydrocodone was the standard prescription, but she would say it didn’t work for her and get the stronger oxycodone.
When she visited her mother in Marshall, Mo., she’d con neighbors. “I’d say, ‘I have such bad cramps. Do you have any pain medication?’ ”
People regularly arrive at the Truman Medical Center ER with the same kinds of claims, said physician Adam Algren.
“Some are a little better and sly about it. They get very dramatic,” he said. “ ‘Oh, I have (a doctor’s) appointment next week,’ or ‘I’m from out of town.’ Hard-to-verify stories. In a busy emergency room, it becomes a low priority to play detective.”
It’s not just the pressures of a busy ER that may lead doctors to prescribe opioids.
Doctors say they also feel financial pressure. Many work for hospitals, and their income is based in part on how they score on patient satisfaction surveys.
After an ER doctor in South Carolina refused to prescribe unnecessary opioids, a patient threatened a lower rating on the hospital’s satisfaction survey, the doctor told the South Carolina Medical Association.
The association followed up in 2012 with a survey of the state’s doctors. Nearly half said they had prescribed opioids inappropriately because of satisfaction surveys.
In a survey by the Partnership for Drug-Free Kids, most primary care doctors and pain specialists said medical school didn’t prepare them to identify opioid misusers. Nearly one-third of the primary care doctors said they received no formal training for that.
“I think the basis of a lot of our problems with these medications is a lack of education,” said Smith Manion, a pain specialist and member of the University of Kansas School of Medicine faculty.
A study that examined the curriculum of U.S. medical schools in 2009 and 2010 found that students were averaging just nine class sessions on pain; some were getting as little as one hour of instruction.
At some schools, including KU, that’s beginning to change.
A year ago, the university started to revamp its curriculum for a rollout in 2017. Instruction in pain management, integrated into pharmacology and neuroscience classes, will start in the first year of medical school, Manion said, and will continue into residency programs.
At KU Hospital, opioids remain an important treatment option, particularly for severe pain from traumatic injuries, Manion said. But the trend is to minimize their use: “We try to use opioids as needed ... not using them as a first resort, but also not as a last resort.”
‘Everything in a pill’
People who take opioids may go through several stages. There is tolerance, meaning people need increasing amounts of opioids to obtain the same pain relief. And there is dependence, meaning their bodies need the drugs to feel normal. Stopping them can be agonizing.
Terry compared opioid withdrawal to “being put on a hot bed of coals and having ice water thrown on you.”
The final stage is addiction. Many opioid users never become addicted. But for those who do, it means their lives have become obsessed with endless cycles of obtaining and using the drugs.
By late 2005, Allen was addicted.
Getting drugs had become her highest priority, she said, more important than caring for her children or her personal hygiene.
No longer able to deal with her quest for drugs, additional miscarriages, a troubled marriage and her work responsibilities, she walked off her job early in 2006.
“I had no coping skills,” she said.
But she did have the pain pills. They could make her euphoric, give her energy. They could erase her sadness and ease her stress. “They were relieving everything in a pill. They were taking it all away.”
Opioids do more than just dampen pain. They can have a calming effect. And by flooding the brain’s reward system with a neurotransmitter called dopamine, they can create euphoria.
These soothing and pleasurable effects can become an additional enticement to addiction for people who begin taking opioids for pain.
“Anybody with a stressful life will benefit from the release of dopamine, the pleasure from opioids,” said Don Teater, a North Carolina doctor who treats addiction and advises the National Safety Council. “When you take opioids, it’s like your football team just won a game in the last play. A pretty cool feeling.”
Teater’s patients include women who received pain pills after childbirth.
“They take this Percocet and feel they can be a great mom. They feel they can get things done and feel good about themselves.”
But these new mothers find that if they stop taking the drugs, their stress returns, Teater said, so they take more. “None of them intended for this to happen, and none thought that this would happen.”
Allen had been keeping her addiction a secret, but by early 2006 she no longer could.
Her husband had moved out, and she and her three children, all in grade school, moved into the Spring Hill home of her brother and sister-in-law, who supported them. She confessed her problem. They reacted with disbelief and anger.
Allen found temp jobs at hospitals and nursing homes, but all her money went to pills.
“I could barely make it to a shift, no matter how many dry days I gave myself. After six days I’d find some pills, and it was the same cycle, over and over.”
Her children had to deal with a mother who had become erratic and temperamental. “I said some very horrible, hateful things to my kids that I still remember and they still remember,” Allen said.
She eventually admitted her addiction to them as well. “They helped me through withdrawal several times.”
By 2008, Allen was back with her husband — their marriage would last four more years — and had moved to Kansas City. She was weary of the search for drugs. “It just consumed me. I wanted help.”
She tried methadone, a long-acting opioid provided at clinics as an alternative for heroin and other opioid addicts that doesn’t offer a high. But it wasn’t enough.
Distraught when her husband left her a second time, Allen stopped working and fell out of the methadone program.
In September 2009, she ran into trouble with law enforcement.
Police in Marshall, where she was staying with her mother, stopped the car she was driving. Allen was charged with felony drug possession and driving under the influence. She spent a month in jail and then started drug treatment at a state correctional center. Her children stayed with her husband in Olathe.
She got out of prison in April 2010 but soon faced new temptation.
In 2011, an excruciating bout of gallstones sent her to an ER, where she received a shot of morphine. Thinking she could manage her addiction, she didn’t warn the doctors about her drug history.
After gallbladder surgery, she failed to tell the surgeon. She was released with a prescription for Percocet, a combination of oxycodone and acetaminophen.
The script gave her an illicit thrill. “It was an excuse to use them.”
Allen was hardly alone among opioid users who don’t want to tell doctors about their past problems.
When researchers looked recently at national data on patients who had survived an overdose of prescription opioids, they made a startling discovery: 91 percent of the patients kept getting opioid prescriptions after they had overdosed, usually from the same doctors.
Lead researcher Marc LaRochelle of Boston Medical Center said the prescribing doctors may not have had any way of knowing about the overdoses. He suggested that overdoses be added to the data collected by prescription drug monitoring programs, so doctors would have a clearer idea of their patients’ histories.
Forty-nine states have the programs, which monitor prescriptions for drugs such as opioids and tranquilizers. The goal is to make it harder for patients to shop for doctors and for doctors to overprescribe.
The only state without a monitoring program is Missouri, where conservative libertarian lawmakers have repeatedly blocked legislation.
Rep. Keith Frederick, a Rolla Republican and a physician, recently told The Star such a database would be “a complete overreach of government power.”
‘I’ve grown a lot’
After she slipped back into taking drugs regularly, Allen in 2013 turned over custody of her children to her brother and his wife. “I realized I didn’t have myself together. This was the best thing for them.”
She moved to Kansas City. She started — and failed — another attempt at methadone maintenance. She kept working but now was homeless, crashing at people’s homes for a week or two at a time. She lived for a time in a crack house.
Then came the arrest at a Kmart in Independence. Allen says she was in a blackout and doesn’t know how she got there or why she tried to steal the shoes.
The litany continued: Halfway house. Outpatient treatment. New temptations.
She moved in with a woman she’d met at the halfway house. They relapsed together. She tried living with another woman who was in recovery — another relapse.
Early in 2014, Allen confessed to her probation officer that she had resumed using drugs. That sent her to state prison for five months, followed by a month in the Jackson County jail. Serving real prison time was the final motivation Allen needed to quit drugs.
“That was enough,” she said. “I just decided I wanted it over.”
These days, she puts in five seven-hour shifts each week at a Kansas City restaurant — she recently received a promotion — and has moved into a downtown apartment.
She goes twice a week to the Samuel U. Rodgers Health Center for treatment.
“I’ve grown a lot,” she said. “I’m very careful who I have in my circle. When bad things happen now, it’s fine. I handle it.”
Vicky Gunn, Allen’s drug counselor at Samuel U. Rodgers, said Allen has had to work through anger, grief and guilt over not having been the parent she wanted to be.
But Allen is rebuilding relationships with her children. Her older son recently enlisted in the Marines, her daughter is expecting a child in May and her younger son is a star high school wrestler.
“I think she’s doing very well,” Gunn said. “She battled, she fought, she slipped, but she’s winning. She’s proving to herself that if she does slip, she can pick herself up.”
When Allen recently had a sore tooth, she let it fester. She’s wary of visiting a doctor, afraid she may be tempted to ask for pills, afraid the doctor will write the prescription.
“I don’t trust myself,” she said. “And I’ve yet to find someone accountable (among prescribers).
“I just know me.”
Root of crisis
Physicians weren’t always so willing to prescribe opioids.
After the urban heroin epidemics that followed World War II, the fear of promoting addiction hung heavily over the medical profession. Doctors prescribed morphine and other opioids sparingly.
Attitudes started to ease in the 1980s as researchers found that cancer patients could remain on opioids for months without becoming addicted.
But the big changes in doctors’ prescribing practices began in 1996 with a new opioid drug and a highly effective campaign largely financed by the pharmaceutical industry to improve the treatment of people in pain and expand the use of opioids.
The new drug from Purdue Pharma was OxyContin, a time-release version of oxycodone. The Food and Drug Administration thought it would be less prone to abuse because the drug would be absorbed slowly, with no immediate “rush.”
But according to the U.S. Department of Justice, Purdue knew from focus groups that doctors were worried about OxyContin’s potential for abuse. To counter the concerns, the company gave its sales force false information about the drug’s potential for abuse and addiction.
Purdue and other opioid makers poured money into medical organizations and other groups that advocated for more aggressive treatment of pain. But as opioid prescribing shot up, along with overdose deaths, health officials and federal authorities took note.
In 2007, Purdue and several executives paid $634.5 million in fines and pleaded guilty to federal charges that they had misled doctors and the public about OxyContin’s risks.