What will it take to quell scourge of opioid addiction? More than 3.5 million opioid prescriptions were written in Minnesota last year.
ST. PAUL — Joe Nickelson and Tom Johnson never thought they'd end up shooting heroin.
Dave Baker never imagined he'd lose his 25-year-old son Dan to a heroin overdose.
But prescription opioids hooked all three.
"It's the devil's drug. I wouldn't wish it on anyone," said Johnson.
"It took 10 years from my life," added Nickelson. "I'm not going to get that back."
"This drug got a hold of his mind," said Baker, whose son Dan was first prescribed opioids for a back injury. "His brain didn't know what to do with it."
Dan died in 2011.
Nickelson, 28, of Belle Plaine, Minnesota, and Johnson, 33, of St. Cloud, Minnesota, both experienced trauma at a young age and turned to drugs and alcohol to cope. Now they are on the verge of completing a 13-month treatment program at the Minnesota Adult and Teen Challenge in Minneapolis and hope to move on with their lives.
Baker's frustration with the flood of opioids in Minnesota drove him to run for the state Legislature. The small-business owner from Willmar, Minn., was first elected to the House in 2014 and has been a dominant voice in the debate over how to address the crisis.
These are just three examples of the thousands of Minnesotans and their families who have been ravaged by the state's growing opioid epidemic.
A flood of pills
Last year, more than 3.5 million prescriptions were written for opioids in Minnesota, state data show. That's enough for roughly 63 percent of the population to have a bottle of the powerful narcotics.
Opioids like hydrocodone and oxycodone, which are commonly prescribed to treat acute and chronic pain, have become so ubiquitous that their misuse has led to addictions in Minnesotans of all stripes.
Prescription opioids killed 186 residents in 2016, accounting for more than half the state's opioid-related overdose deaths. All drug overdoses killed a total of 637 Minnesotans last year, more than car accidents, and nearly six times more than in 2000.
The epicenter for Minnesota's opiate prescriptions is just 100 miles north of the Twin Cities in Aitkin, Kanabec and Mille Lacs counties. Last year, enough opioid prescriptions were written in each of those counties for every resident to have one, state data show.
Yet, opioid use in Minnesota remains below the national average and pales in comparison with Ohio and Kentucky, where the drugs are prescribed twice as often, federal data show.
Overall, opioid prescriptions declined statewide in 2016, dropping nearly 9 percent from the year before. Since 2014, they are down just slightly.
The prescription numbers were eye-opening for Cynthia Bennett, Aitkin County director of health and human services, who said the state data gave her county's health officials their first detailed look at what they suspected was a growing problem. They've responded by working with prescribers and patients to reduce the use of opioids and provide alternatives for pain management.
"Once we became aware there is a problem and have data to back it up, we can move forward with solutions," Bennett said.
The rate of opioid prescriptions per resident has routinely been higher in rural Minnesota than in the Twin Cities metro area, state data show. Health officials suspect the difference is due to a variety of factors, including the more limited availability of illicit drugs.
The growing use of opioids in Native American communities also plays a role in the disparity of prescription rates across the state. American Indians are nearly five times more likely than white Minnesotans to die of an opioid overdose, while black residents are twice as likely.
"It has become an epidemic," said Johnson, who added that he believes poverty and a lack of opportunities have played a role in the rising rates of addiction among fellow Native Americans.
The main reservation of the Mille Lacs Band of Ojibwe, which is located near the counties with Minnesota's highest opioid prescription rates, has seen opioid overdoses skyrocket in recent months. Late this summer, there were 29 overdoses on or near the reservation within a month, compared with 44 overdoses reported to tribal police in all of 2016.
Melanie Benjamin, chief executive of the Mille Lacs Band, recently asked federal authorities for help because tribal leaders have been unable to resolve a dispute with Mille Lacs County that led to the end of a joint-powers law enforcement agreement. Tribal leaders have already worked to limit opioid prescriptions from reservation clinics and make naloxone, an opioid antidote, more widely available, but they need more help.
"We are in a public-safety crisis, people are dying and we need extra help right now," Benjamin wrote in a recent Facebook post.
Minnesota has more information than ever before about opioid prescriptions, but the data is still incomplete. The Legislature created a Prescription Monitoring Program in 2007 to track dangerous drugs, but to protect patient privacy, only a year's worth of data was retained at any one time.
Information is now available beginning with 2014 because state law was temporarily changed to give health officials more data to study the opioid crisis. In 2019, when the law reverts back, prescription records will again be discarded after a year.
And while pharmacies regularly report the pills they dispense, the state just started requiring prescribers to sign up for the monitoring system. They are not mandated to use it before they give a patient opioids, and fewer than 50 percent of prescribers do.
Cody Wiberg, executive director of the Minnesota Board of Pharmacy, said it has been hard to persuade lawmakers to change rules about monitoring prescriptions because the system includes individuals' sensitive health information.
"It's been very controversial and it will remain controversial," Wiberg said. But he believes the incremental changes have helped.
Health officials are more aware of and are working with top opioid prescribers. They also have more information to combat "doctor shopping," when a patient gets multiple prescriptions from multiple sources.
State and federal leaders think more could be done.
State representative and grieving father Baker expects the 2018 legislative session to include debates about how Minnesota can address the opioid crisis.
Baker is backing "opioid stewardship" legislation that he says has bipartisan support. It would impose a fee for each unit of opioid prescribed in Minnesota, and that money would be used to mitigate the hazardous effects of the drug — including combating addiction and addressing environmental contamination when pills get into state waters through the sewer system.
Baker noted that opioid manufacturers face a wave of legal actions from public officials nationwide, claiming they misled doctors and consumers about the dangers of their drugs.
"Drug manufacturers tricked the medical community into thinking this wasn't addictive," Baker said. "What has never been done before in Minnesota is charging them for the cleanup."
Baker also says he wants doctors to have more information about patients' medical history before prescribing them an opioid. The key to that effort is connecting the prescription monitoring system to doctors' electronic medical records.
That would make the system quicker and easier to use, hopefully increasing prescribers' participation and decreasing doctor shopping.
"It has to be treated like (doctors) are prescribing synthetic heroin, because that's what it is," Baker said of opioids.
These reforms can be accomplished without jeopardizing patients' privacy, Baker said.
U.S. Sen. Amy Klobuchar, D-Minn., is pushing for robust changes to prescription drug monitoring at the federal level. Klobuchar wants to require states to share their data about opioid prescriptions if they want to receive federal funding to address the opioid epidemic.
New requirements for doctors have largely been opposed by the medical community, but Klobuchar is hopeful that tide is beginning to change.
"Individual doctors are realizing people are getting hooked on these drugs," Klobuchar said. "People are dying at a rate we have never seen before. It is truly an epidemic now."
A turning tide?
The most recent data reported to the Minnesota Board of Pharmacy show opioid prescriptions remain on the decline in 2017, an encouraging sign to state health officials.
Wiberg, executive director of the pharmacy board, doesn't think the trend is just because of more state oversight. It's because the medical community understands the danger of opioids and is changing its prescribing practices.
In August, the federal Centers for Disease Control and Prevention released new opioid guidelines for doctors. They include giving patients more information about the risks, limiting the length of prescriptions and exploring alternative treatments.
In September, leaders from CHI St. Gabriel's Health medical center in Little Falls, Minn., testified before Congress about how partnerships between health care providers, social services and law enforcement helped drastically reduce opioid use. Their success has spawned state legislative proposals to replicate the partnerships.
Besides prevention, state and federal leaders are focusing on addiction treatment. Minnesota was recently awarded $9 million in federal grants to expand access to mental health and medical treatment for addiction.
The money is part of the first spending under the Comprehensive Addiction and Recovery Act, a bill sponsored by a bipartisan group of senators including Klobuchar that was signed into law last year. The legislation provides $181 million a year to combat the opioid crisis and is the first piece of federal legislation related to addiction to be approved in 40 years.
Author Carol Falkowski, who has studied drug and alcohol dependence for more than 25 years, hopes Minnesota can do a better job with treatment. For instance, she says, there is real promise in drug therapies like methadone that address addiction cravings, but they're not available to enough people in treatment.
"It's a shame. People keep dying because they are not getting the help they need," Falkowski said. "There is so much more to be done."