The staff of the tiny Morton County Hospital in southwest Kansas has gotten good at identifying repeat customers: people who regularly show up looking for opioid pain medicines.
“It seems like it’s just the same people every so often come in and you know who they are,” said CEO Richard Bergling. “It ties up the emergency room and you know when they come to the emergency room they have to be seen. We can’t say ‘sorry.’”
The Centers for Disease Control released a county-by-county study this month showing that the opioid addiction epidemic has hit rural areas hardest — in Kansas and Missouri, and across the country.
In Kansas, the counties in the northwest, southwest and southeast corners were the most opioid-saturated. Missouri’s hottest spots were also largely rural areas, including the northern part of the state, the southeast corner and a large swath of southern counties around Springfield.
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The CDC study counts how many opioid prescriptions are filled within a county and how concentrated those prescriptions are. Then the CDC combines the two counts to describe how much opiate-based medicine is circulating in the county. It calls that number a “morphine milligram equivalent,” or MME, per person.
In 2015, the most recent year the CDC measured, Morton County had the highest MME in Kansas or Missouri — 2,445.1 MME per person. That was the 17th highest rate among about 3,000 counties nationwide that submitted data (180 counties did not).
In Missouri, the highest ranked was Howell County near Springfield. It ranked 30th nationally in the CDC study, with 2,157.8 MME per person.
The lowest ranked counties in each state recorded rates in the single digits. All the counties in the KC metro area were below 800 MME per person.
Medical professionals and addiction specialists gave several theories as to why rural areas tend to have higher rates.
They have older populations, physical jobs in agriculture and manufacturing that are more prone to workplace injuries, and fewer alternatives for pain relief such as physical therapy, acupuncture and surgery.
Jerry Scott, the owner of the only pharmacy in Morton County, had another theory. Scott, who owns C&R Pharmacy in Elkhart, said the CDC’s data can change dramatically from year to year because the county has only about 3,000 people.
Scott said he’s been working with the rest of the town’s medical professionals to bring down the opioid rate. He checks the Kansas prescription drug database, which is linked to others in nearby Oklahoma, Colorado, Texas and New Mexico, and said he denies opioid prescriptions to people getting them from multiple sources.
He’s also become more strict about not refilling prescriptions early.
“I feel like a babysitter at times, you know,” Scott said. “‘No, you can’t have your prescription until next Thursday.’ We do that a lot.”
Bergling said the staff at his 28-bed hospital has also gotten better at saying ‘no’ when people come to the ER.
“Usually what we do is we offer them something besides a narcotic and a lot of them get the picture after a while,” he said.
It appears to be working. Morton County’s opioid rate is high, but it’s way down from where it was seven years ago: 3,291.2 MME.
“I think it will come on down a little more too,” Scott said. “Hopefully we’re doing the right thing here.”
The lowest-ranked counties in each state were Jewell County along the Nebraska border in north-central Kansas at 1.3 MME and Carter County near Poplar Bluff in southeast Missouri at 7.6 MME.
The core counties of the Kansas City metro area were in the middle of the pack nationally, with Platte County at 565.4 MME, Jackson County at 646.8 MME, Johnson County at 650.5 MME, Wyandotte County at 700.3 MME and Clay County at 774.1 MME.
Opioid prescribing dropped a bit in the five-county metro area from 2010 to 2015, mirroring a national opioid prescribing rate that seems to be leveling off. But at the same time, overdose deaths have not gone down because more people are turning to the illegal opioid alternative: heroin.
According to the most updated CDC data available, about 33,000 Americans died of opioid overdoses in 2015 — a record number. About 20,000 of those deaths were due to prescription opioids and the other 13,000 were heroin-related, according to the American Society of Addiction Medicine.
The group estimates that about 2.5 million Americans are addicted to opioids in one form or another.
Susan Whitmore, the president and CEO of First Call KC, said her addiction treatment referral non-profit is busy as ever, and a lower rate of legal prescription opioids within the city doesn’t necessarily mean the metro area is doing a better job addressing the problem than rural areas.
“In urban areas there’s more access to street drugs,” Whitmore said. “So if someone has a substance use disorder, if they’re addicted to opiates, they have another resource, as opposed to having to go to the trouble of doctor shopping.”
Meanwhile, medical providers in higher opioid counties, including Cass County just outside the metro, say they’re trying to cut back on the controlled substances.
Cass County sits at the western end of a strip of four high-opioid counties along Missouri Highway 7: Cass, Henry, Benton and Camden.
Cass came in at 1,015.5 MME in 2015, which ranked about 600th nationally and was the highest rate among counties close to Kansas City.
The CDC data are based on where people fill their prescriptions, not where they get them or where they live. Det. Sgt. J. Becker-Schutte of the Cass County Sheriff’s Office said it’s possible the data were skewed by people from other counties coming down Highway 7 and into Harrisonville, Clinton, Warsaw and Camdenton to get their medications.
“We deal with it pretty regularly,” Becker-Schutte said. “Not every day here at the sheriff’s office, but we will do car stops with people who have prescription medications that belong to them or don’t belong to them and that’s when it’s illegal, obviously, when it’s not their medications.”
The CDC’s data were collected before Jackson County started a county-wide prescription drug monitoring program that allows doctors and pharmacists to flag possible pill-shoppers.
Cass County Commissioner Jim Odom said he feared the program might drive Jackson County pill-shoppers to surrounding counties like Cass.
“That’s just my guess,” Odom said. “I don’t have any hard facts, but we’re right next to it so it does kind of make sense.”
Missouri is the last state without a statewide prescription drug monitoring program. Gov. Eric Greitens has signed an executive order to create a statewide database, but it would not be accessible to prescribers and pharmacists like the ones in other states.
At a news conference Friday, Greitens described it as “step one” to break legislative gridlock.
“Nothing had happened,” Greitens said. “For years people had talked and talked and meanwhile we have people dying in the state of Missouri. Two people were dying every day. My cousin died of a heroin overdose last year.”
In the absence of state action, counties have started their own drug monitoring efforts. Rita Barnes, the owner of the only pharmacy in Carter County, said her county had the lowest opioid rate in the state in part because of a phone tree of 25 to 30 pharmacies in southeast Missouri. The set-up helps pharmacies share information about people trying to fill multiple prescriptions at multiple locations.
The key, Barnes said, has been standing firm when refusing to fill suspicious prescriptions.
“We get some (customers) that get very unruly,” Barnes said. “They don’t like it, and when they do that we know we made a wise decision in letting them go.”
Chris Lang, the CEO of the Cass County Regional Medical Center, said the hospital’s board voted Wednesday to urge the county commission to establish its own drug monitoring program.
The hospital has also enacted policies for people who come to the emergency room who aren’t having a medical emergency but are looking for drugs. Hospital staff won’t refill prescriptions for controlled substances that patients say have been lost, stolen or expired.
Staff have also been directed not to give repeat “chronic pain patients” any controlled substances while they’re at the hospital, but instead to offer a “medically acceptable substitute” and a “resource list of appropriate followup care.”
There are even rules for people who are having legitimate medical emergencies. If they’re given a controlled substance for their pain they must have a “responsible driver” with them before being discharged. Also, ER staff aren’t allowed to write them any refills for those medications when they leave.
Dr. Catherine White, the director of Cass Regional’s emergency department, said the hospital still needs to be able to dispense opioid pain medications on a short-term basis to people who come in with fractures, burns or other acute injuries. But having written policies helps her staff when they refuse to dispense narcotics.
The more difficult conversations, she said, are with patients who come in not seeking the drugs, but suffering from withdrawal symptoms. Often those are seniors who have been prescribed opioids for arthritis and may not have even been told about the risks.
“At 85 (years old), how do you tell these patients, ‘You have now become addicted to this drug,’?” White said. “It’s a sad situation.”
Lang said providers need to focus on the source of the pain, rather than the pain itself, but that’s hard when Cass County is short on primary care doctors, pain management specialists and psychiatrists. Patients are in a fractured system that sometimes results in them getting the quickest, simplest solution: a prescription.
Once they’ve been on the drugs for a while, Lang said, there’s limited options for treatment in the county.
“We have no inpatient services from a detox perspective,” Lang said. “We have some outpatient providers who work in dependency medicine, but, from the statistics, I understand that number is less than what the need is.”
Pat George’s phone keeps ringing, with families on the other end asking what they can do to help loved ones whose lives are spiraling out of control because of addiction.
George, a recovering alcoholic and former Kansas Commerce Secretary, is on the front lines of the rural opioid crisis as president and CEO of Valley Hope, an addiction treatment center headquartered in Norton, Kan.
Since its founding in 1967, Valley Hope has expanded to 16 locations in seven Midwest states. It has facilities in areas such as Overland Park, Wichita, Omaha, Denver and Oklahoma City, but it also has several in rural places such as Norton, population 2,900.
George said opioids are gaining on alcohol as the most common source of addiction among his clients, and because of how quickly they become dangerous, they’re bringing younger people to his doorstep.
“There’s six friends of mine, families, that have contacted me in the last week…that have children that vary from 18 to 23 years of age,” George said. “And this is just friends I know that are reaching out.”
According to the CDC, opioid prescriptions in Graham County, about 30 miles south of Norton, almost doubled from 948.0 MME per person in 2010 to 1,670.2 MME in 2015.
Dr. Kasey Nichols, the corporate medical adviser at Valley Hope, said another reason that opioid prescription rates are higher in rural areas might be that those areas have fewer treatment centers to help people wean off the drugs.
“It’s a lot harder to get treatment for it, so it propagates a system,” he said.
Nichols said research supports medication-assisted treatment with an opioid alternative like Suboxone, but “it’s better at reducing death than really increasing sobriety.”
The path to full detoxification can involve both inpatient and outpatient treatment for a long time, he said. In addition to the intense initial withdrawal symptoms there’s also a “post-acute” withdrawal period marked by mood swings, anxiety, irritability and other symptoms that can last as long as two years.
Valley Hope staff, including Nichols and Patrick Hall, a psychologist and vice president of clinical services, are embarking on a regional tour around Norton, visiting doctors and hospitals in the area to let them know there’s a nearby referral option.
“They need some more relationships with programs like ours that can step in,” Hall said.