When it comes to the opioid epidemic overtaking many parts of the country, southwest Kansas has been lucky — so far.
Area treatment providers, EMS and law enforcement officials agree that the epidemic hasn’t hit the region too hard. Still, the consensus among treatment providers is that the problem may be brewing below the surface. And with limited treatment options in the area and a rising tide in the epidemic’s national footprint, rural areas like western Kansas and eastern Colorado could be ripe for trouble.
Using Garden City as a litmus test for the larger region, southwest Kansas seems to be faring well at the moment. Overdoses are a key indicator of opioid prevalence and abuse, and Skylar Swords, director of Finney County EMS, reported that overdose rates in the county are fairly level and incidents are infrequent.
From Jan. 1 to Oct. 23, 2016, there were 20 overdoses in the county, and naloxone — a drug used to treat opioid overdoses in emergency situations — was administered 22 times, suggesting some patients received more than one dose, Swords said. In 2017, there have been 23 county overdoses over the same period, with naloxone administered 24 times.
Swords was unable to trace further back along Finney County’s timeline, but as acting director of Finney County EMS for four years with 15 years spent with the agency, he can attest to the changes over time.
“The numbers here aren’t showing an extreme increase,” he said, adding that though there has been a slight rise in overdoses, the prescription epidemic hasn’t been seen in southwest Kansas to the same degree as it has in other states.
“When it was really hitting the media there the last couple of years, we were not seeing that here, at least from our perspective,” Swords said. “Now, here within this last year, we’ve kind of noticed some more… So maybe we are seeing a little bit of an increase, but it has not been major. It has definitely not been epidemic proportions.”
According to Swords, Finney County EMS received a total of 2,626 calls from Jan. 1 to Oct. 23 in 2016, and 2,837 calls in 2017 over the same period. Considering that there were 20 and 23 EMS overdose calls in 2016 and 2017, respectively, all of which were presumably related to opioid abuse as indicated by the use of naloxone for treatment, that means that at most, .76 percent of Finney County EMS calls in 2016 were related to opioid overdose and .81 percent in 2017 over the same period.
And while Finney County has seen a slight year-over-year uptick from 2016 to 2017, the state as a whole has seen an overall reduction in recent years.
According to an August report from the Kansas Board of Emergency Medical Services, data shows an overall five-year trend of decreased naloxone administration in the EMS and/or pre-hospital setting in Kansas. That drop includes a 47.2 percent reduction in Kansas EMS administration of naloxone from 2016 to 2017.
The same report shows that most Kansas patients receiving naloxone in the EMS setting are 51 or older with a greater occurrence among patients ages 45 to 64.
A Growing Problem
Data provided by the Centers for Disease Control and Prevention portends an alarming spread nationwide. The agency offers an overview of opioid prescription prevalence of every state in the U.S., and many of the states with the highest documented prevalence — 96 to 143 opioid prescriptions per 100 people — are right next to each other.
Those states include South Carolina, North Carolina, Tennessee, Alabama, Kentucky, West Virginia, Ohio, Indiana, Michigan, Mississippi, Louisiana, Arkansas and Oklahoma. These states are at the epicenter of a crisis that has seen the prescription of opioids in the U.S. nearly quadruple from 1999 to 2014, despite no overall change in the amount of pain reported by Americans, according to the CDC. Prescription overdose deaths caused by opioid abuse increased similarly over the same period.
Meanwhile, Missouri and Kansas are seeing the second-highest CDC category of prescription prevalence at 82.2 to 95 prescriptions per 100 people while straddling the constellation of most affected states. If one were to look at the opioid epidemic as a spreading disease, arguably states like Kansas and Missouri could be next in line.
But some states, such as Illinois, are enjoying the lowest category of prescription prevalence, at 52 to 71 prescriptions per 100 people, despite being right along the same cusp of the epidemic’s national footprint. However, prescription prevalence doesn’t necessarily speak to the spread of heroin, a powerful and illegal opioid drug.
According to a December 2016 report from the Chicago Tribune, Will County, Ill., saw a significant increase in opioid-related deaths, specifically related to abuse of heroin and fentanyl, a potent opioid prescription drug.
Deaths in Will County increased by 42 percent in 2016, up to 75 from the previous record of 53 heroin- and fentanyl-related deaths in 2012 and 2015. The Tribune described fentanyl, a legal drug, as a “far more lethal heroin substitute,” and reported that another Illinois county, DuPage, saw heroin-related overdose deaths climb from 51 in 2015 to 78 in 2016, a 53 percent increase.
Other Tribune stories report that heroin in Illinois, and especially in Chicago, is sometimes laced with fentanyl, which is 40 times as potent as heroin. Stories like this show that, beyond the footprint of conventional opioids like oxycodone and Percocet, the opioid epidemic extends to a largely undocumented black market.
A Closer Look
Whether the prescription epidemic will spread into Kansas is uncertain, but rural communities powered by the agricultural industry along the state’s southern border may be most vulnerable to the spread of opioids, especially when one considers the manual labor involved in agricultural production and the resulting predisposition to physical injury.
A July study by the CDC measured per capita the amount of opioid prescriptions filled in 3,000 U.S. counties and the opioid concentration or potency of each prescription. This collective measurement, termed MME (morphine milligram equivalent), was conducted on a county-by-county basis across the country. The results indicate that rural counties may be at greatest risk for high opioid saturation, and micropolitan counties not unlike Finney County saw the highest prescribing rates. The study suggests that prescribing rate is due to less access to quality health care and other treatments for pain, like physical therapy.
But with hospitals such as St. Catherine that deliver an array of physical therapy options, Finney County is more susceptible to a second, more likely possibility cited by the study: that people in rural areas are traveling to micropolitan areas that often serve as an “anchor community” for a larger rural region to receive medical care and pick up medications.
The CDC found that in 2015, Morton County in far southwest Kansas had the highest MME, 2,445.1, of any county in Kansas. Though that number reflects an overall decrease from the MME data collected for Morton County in 2010 — when its MME score was 3,291.2 — other southwest Kansas counties shared Morton County’s place in the highest quartile category nationally of MME saturation. Those counties include Scott, ranked 660th; Seward, ranked 582nd; Grant, ranked 685th; Lane, ranked 579th; and Greeley, ranked 404th.
Those rankings show just how expansive the study’s highest quartile is, and Cindy Samuelson, vice president of the Kansas Hospital Association, noted that those high quartile rankings may be linked to low county populations and a corresponding inflation of per capita influence. For example, Finney County is ranked in the second-lowest quintile for drug-related mortality, according to a joint September study by KHA and the Missouri Hospital Association.
As Swords said, in Finney County naloxone was administered 24 times in attempts to treat overdoses in 2017 alone, meaning most of those incidents are presumably opioid-related.
Conversely, Alan Hanson, Hamilton County EMS director and special deputy county coroner, said naloxone, known more commonly by the brand name Narcan, has been administered once since he took his position in January 2015. That incident, he said, involved the county’s only drug-related death in that time period that he is aware of. He was unable to determine if the death was actually opioid-related.
“I’ve been a deputy coroner a year and a half maybe, and we’ve had one drug-related death, and we still don’t have a toxicology report to tell us what that drug was,” he said. “We only have less than 3,000 people in the county, so one would be quite significant.”
But while Finney County, with a population of roughly 37,000, is ranked in the second-lowest quintile for drug-related mortality after more than 20 overdoses in less than a year, Hamilton County is ranked in the fourth-highest of five quintile categories after just one unresolved drug-related death resultant of one overdose.
“Drug overdoses kind of come and go,” said Hanson, who has four years of EMS experience. “It runs in cycles… You don’t really know what you’re going to see.”
For places like Hamilton County, methamphetamine is a bigger problem than opioids, and Hanson said some users combine meth with fentanyl.
Hamilton County Sheriff Mike Wilson said heroin and fentanyl are coming into Hamilton County from Lamar, Colo. He characterized the amount crossing the state border as “a little bit,” but noted that amounts have increased since January.
“It’s out there. It’s available. It’s killing people,” Hanson said. “We’re lucky that we don’t see it all the time, but there is surely the possibility that it could happen.”
Boots on the Ground
Another factor measured in the KHA study was opioid-related hospital utilization rates. Lane County ranked highest in southwest Kansas by that metric, but officials at the Lane County hospital did not corroborate the frequency suggested by the study.
Lane County Hospital Administrator Donna McGowan and Chief Operations Officer Brian Sarpy said there is little if any suspected opioid abuse by patients at the hospital. Samuelson noted that the statistics in the study were based on illicit, prescription, inpatient and emergency department encounters involving opioid use in hospitals.
“Because of this latest crisis within the nation and the state, we’re continuously meeting with our providers, making sure that they’re following best practices,” Sarpy said. He added that the hospital has partnered with KHA and the Hospital Improvement Innovation Network to ensure that providers are using K-TRACS, a program established in 2010 that allows providers to monitor medications issued to people.
Sarpy and McGowan noted that the hospital has seen “no drug-related mortality,” and hasn’t seen “any signs of opioid abuse by patients.”
“Being a newcomer, I would say the physicians are very sensitive to the opioid abuse within the nation, and they only prescribe them on an absolutely necessary basis,” Sarpy said. “Someone coming in and just wanting them, that’s not going to fly. The providers are educated, they’re aware of everything, and they will try other methods prior to issuing any (opioids).”
According to the CDC, opioid prescriptions began to decrease in 2011. But in 2015, at 640 MME per capita, the U.S. opioid prescription rate is still approximately three times as high as it was in 1999, when the country’s per capita MME score was 180, and almost four times as high as in Europe.
The CDC reports that opioid prescription rates leveled off from 2010 to 2012, then decreased by 13.1 percent from 2012 to 2015. The report attributes the decrease to a growing awareness among clinicians and patients of the risks associated with opioids. Still, prescription durations have increased over the same period, so while less prescriptions are being given, those who are already getting them are more likely to continue getting them.
From 2010 to 2015, Scott County was the only county in southwest Kansas in the highest MME quartile with data collected over both periods that showed an overall increase in prescription opioid saturation, according to the CDC. Other counties with increased MME levels from 2010 to 2015 include Hamilton and Wichita counties, but the study cited insufficient data in 2010 for Wichita County.
Of any southwest Kansas county in the highest quartile of MME saturation, Grant County has the lowest MME count. Because there was insufficient data for Grant County in 2010, the study doesn’t truly show if the MME level there is getting better or worse. But according to Tyson Mullen, owner of Grant County Pharmacy in Ulysses, things are probably improving.
Grant County Pharmacy has just one location but serves the communities of Ulysses, Johnson City, Moscow, Hickok, Lakin, Syracuse, Hugoton and Satanta.
Mullen purchased the pharmacy in 2013, and with significant shifts in area prescribing doctors he noted that, “Our landscape has changed dramatically in the last couple of years for this place.”
He said that, in general, the pharmacy sees “a lot” of patients filling opioid prescriptions on a long-term basis for pain management. Mullen said such patients may have had multiple surgeries after a car accident, in which they perhaps broke their backs or suffered any other traumatic injury. After multiple surgeries, he said, sometimes there is nothing else doctors can do but attempt to manage the pain, and patient demographics are “across the board.”
“Pain is what the patient says it is,” Mullen said. “There really is no pain scale. You can take blood pressure and you get the actual reading. It’s hard to do that with pain. You say, ‘Well, how is your pain from one to 10 today?’ And it is what the patient perceives that it is, so I think it’s hard for doctors and practitioners to manage their patients.”
But overall, Mullen said he feels that opioid prescription numbers have decreased.
“I think it’s getting better,” he said. “I think with more awareness of the situation, I know that doctors are trying to be more conscientious about giving them shorter durations of medicines after they have an acute surgery because I think that’s where the abuse begins.”
He explained that doctors sometimes give patients a month’s worth of pills after a traumatic injury, instead of five days’ worth, “when they don’t necessarily need that many pills.” He added that there is a difference between addiction and physical dependence, noting that addiction is “where you need the medication and you’ll do anything, even harm those around you, to get it” and physical dependence is when the body becomes accustomed to the medication, “and if you just abruptly take an opiate away from the body system, you have severe withdrawals.”
Overall, Mullen sees one of the biggest problems afflicting southwest Kansas as a lack of resources to help patients wean off of opioid medications.
“We’re kind of limited on our pain management clinics,” he said. “We don’t have a lot of practitioners that help with addiction and abuse … any drug counseling and so forth. I think that is something that kind of hurts southwest Kansas is that our resources aren’t as good.”
Even care providers agree that options are scarce, but options exist nonetheless. Garden City has numerous physical therapy options at St. Catherine Hopsital, and psychological and drug-assisted treatment programs are available through organizations such as Compass Behavioral Health and Genesis Family Health. Suboxone treatment, the leading drug-assisted form of relieving and eliminating opioid addiction, is also offered by CBH through Dr. Fernand Gautier and GFH through Dr. Emmanuel Okeke, virtually the only two providers in southwest Kansas, according to the Substance Abuse and Mental Health Services Administration. Both organizations also augment Suboxone treatment with counseling.
According to Mullen, the National Community Pharmacists Association and American Pharmacists Association are working to increase access to naloxone for patients in case of emergency, and in July a bill passed by the state Legislature enabled pharmacists to begin dispensing opioid antagonists such as naloxone to patients, bystanders, first responder agencies and school nurses without a prescription.
While he doesn’t think the usefulness of certain opioid drugs for the purposes of pain management will ever diminish, Mullen said his pharmacy has been working with patients in the Ulysses community and beyond to get naloxone into their hands and promote overall awareness of the dangers opioids can present.
Mullen also noted that K-TRACS has been instrumental in fighting the epidemic. He said the expansion of the program into other states has allowed pharmacists to monitor the prescriptions of patients coming in from states such as Colorado and Oklahoma to prevent attempts at multiple fillings and subsequent abuse.
“I don’t really feel like we’ve had any major problems with somebody coming in that we know is abusing it in probably a couple years,” he said. “It’s been a long time since we have, because with K-TRACS, we’re starting to catch these people really quick, and eventually we just shut them off really quick … I think that those that are seeking are starting to realize we’re getting smarter on our side, too.”
As for the KHA report, Samuelson said that even with statistical anomalies in low-population areas, the report has generated conversation between member hospitals in all 105 Kansas counties to identify different causes for opioid dependency in different areas.
“This report was just in September, so we’re really just at the beginning of what we can do in regards to identifying causes,” Samuelson said. “It’s definitely a complex problem we’re finding. We’re going to have to work collaboratively, not just with our members but a lot of other stakeholders to really address what’s happening in the state.”
Contact Mark Minton at firstname.lastname@example.org.