This is the second story in a six-part series on mental health and drug abuse in Columbus County. Today, writer Sammy Feldblum examines the conjunction of mental health issues with overprescribed opioids and opioid addiction, the biggest health crisis in the nation. On Thursday, Part III will examine how law enforcement picks up the slack of the behavioral health care shortfalls.
More opioids are prescribed in Columbus County than anywhere else in North Carolina.
In a county opioid forum at Southeastern Community College on November 8, Lt. Steven Worthington of the sheriff's narcotics division fixed a number to that statistic: 141 pills per person per year. And that is only through legal medical channels—heroin looms as a cheaper fix when prescription medications become unavailable or not strong enough.
This series is examining mental health care in North Carolina, a story in which opioids play an enormous role. Last week, the News Reporter and Scalawag looked at changes in the state mental health care system in the latter half of the last century and beginning of this one, when deinstitutionalization left more psychiatric patients back in their home communities, and an underfunded state privatization effort left those patients often without adequate care. For many North Carolinians, plentiful opioids rushed in to pick up the slack.
Around the same time as the privatization movement was heating up, pharmaceutical companies were making a push at the end of the last century to market newly developed pain medications. Before then, fears of the addictive potential of opioids left doctors skittish to prescribe them. Opioids—drugs derived from the opium poppy plant and synthetic copycats—bind to opioid receptors in the brain, relieving painful sensations and typically producing feelings of euphoria.
In 1995, Purdue Pharma released OxyContin, a powerful and long-lasting painkiller, and rolled out a marketing campaign meant to convince doctors that fears of its addictive properties were unfounded. The company funded studies and paid doctors to publicize that message, and the medical culture around opioids changed, as doctors began using the drugs to treat a wider variety of complaints. But their assurance that opioid painkillers were not addictive was a lie.
The breezier attitude toward opioid prescription is directly connected to the ongoing national crisis, which has claimed the lives of more than 200,000 Americans in the last 20 years.
As more and more patients were being prescribed the painkillers, mental health provisions were fading in North Carolina. Without access to effective mental health care, more and more people facing psychiatric disorders turned to opioid pills for imperfect relief. Research published in the Journal of the American Medical Association has found that 47 percent of users seeking treatment also have psychiatric disorders, particularly personality and mood disorders like depression and bipolar. Those with mental health issues, in turn, had more severe substance problems than those without.
In Columbus County, it's common knowledge which doctors patients can turn to for easy access to the drugs. And with a severe shortage of practitioners able to prescribe psychiatric medications and adequate mental health care, those clinics offer a seductive alternative.
A family's saga
Patients need not have a mental health issue to become addicted, however. Some get there through experimentation. Some get there through a hazy combination of the two, tumultuous life circumstances and fast living feeding one another. For those who do develop substance use disorder, its gravity pulls in the people around them, scattering trauma outward.
One man in Whiteville contacted the News Reporter and Scalawag to share his story. The News Reporter and Scalawag are using pseudonyms to protect the identities of those involved in the story.
When he was 18 years old and still in high school, Jeremy fell in love and got married. Within a year, he and his wife, a classmate, had a daughter, Kathryn. Jeremy was untroubled by his youth—he was working in a textile mill in those days, making enough to support a child even as he was going to school full-time.
His wife, though, was less ready to settle down. As Jeremy describes it, "she still wanted to go out and do things, party and all that."
"To be fair," he adds, "she was probably being a typical 18-year-old at the time." The two eventually split up, leaving him to take care of their baby.
After a year, though, Jeremy's ex took custody of their daughter. For years, he saw Kathryn every other weekend. When she was in middle school, Kathryn let on to him that her mom would coach her to go to the doctor and complain about pain. Kathryn's mother "used her as a tool to get more painkillers," Jeremy says.
The breezier attitude toward opioid prescription is directly connected to the ongoing national crisis, which has claimed the lives of more than 200,000 Americans in the last 20 years.
By eighth grade, Kathryn had missed more than 180 days of school, the equivalent of an entire year. She fell in love with an older boy, and Jeremy found notes she had scribbled admitting dreams of getting pregnant. Soon, she was. She had a baby in her mid-teens, and in his early 30s, Jeremy became a grandfather.
Kathryn's daughter, Blanca, stayed with her relatives on her grandmother's side. Kathryn "was not going to school, not doing anything, just existing," Jeremy says. Within three years, Kathryn was pregnant again. This time, when it came time to deliver, something was amiss. The doctors were stopping Kathryn's labor, leaving her confused and upset.
Jeremy asked around the maternity ward for answers, and found out that his daughter was testing positive for opioids and cocaine. "What they're trying to do, especially with the cocaine," he relates, "if they can hold it off a few days, the baby won't be born addicted to cocaine." At the time, he was blown away—he thought his daughter drank a little bit and was "boy crazy."
"That was the moment that I realized that we went to nuclear versions of drug abuse here. I did not understand how badly things had deteriorated," he says.
After the strained birth of Kathryn's second daughter, Jeremy was asked to take custody of Blanca from his ex-wife's mother. He and a social worker went over to the house to find the homeowner in a daze, and food wrappers covering the entire living area. Paths snaked through, like a "dog or a cat makes when it walks through the grass," Jeremy remembers. Someone brought Blanca out—"her legs were tore up," Jeremy says. "Not sores now, I'm talking about bites all over her legs. You ever been in a place that has fleas?"
After Blanca got cleaned up, and her sores healed, she fell into a more normal routine. But one tic puzzled the couple. Whenever he and his wife—he had remarried—would serve Blanca food, she would ask him, "can I save this for later?"
"We didn't understand what was going on at first, because we couldn't get her to eat much," he says. One day, cleaning her room, he picked something up, and peeked underneath a chest of drawers. "And I looked—food. There's food up under there. The child had learned, at that age"—three and a half—"that, one, she needed to ration food, because she didn't know when she was gonna eat. And two, she had learned that she needed to hide her rations from other people."
Within a couple of years, Kathryn's boyfriend, the father of her second child, was locked up on drug charges. At that point, Jeremy remembers, "she lost her supply of drugs," and spiraled.
"You just don't want to know as a father how bad things are," he says. "Since her drug supply was gone, she needed a drug supply, so she would just go from drug dealer to drug dealer. And different drug dealers would make her do different things."
Jeremy checked her into a detox program in Lumberton, thirty minutes northwest. But she was over 18 now. "And this is the problem, when you have a girl, especially a half-way pretty girl," Jeremy says. "The drug dealers go get her. They need her to work. So they go and get her out. It's not jail. She can walk out of any facility." This would happen again, more than once. He took her to a 30-day facility four hours away. Same result: This time checked out by her grandmother.
Jeremy took her back in for what he called "daddy rehab." "I kept her with me every moment," he says. Within a few months, that strategy ended when she tipped off friends about the family's schedule, and they broke in and stole Jeremy's wife's jewelry.
"That ended the her-staying-with-me thing," Jeremy says. "And it also made me realize something else: The people that she is dealing with, the people in this pill stuff, there is an aura around them of danger. They aren't just simply addicted to pills. They are networked in to people that are stealing, that are doing all kinds of god-awful horrible things. Human trafficking, sex trade."
Jeremy did not see Kathryn for a few months. The next time he did, she had been living in "a drughouse—a whorehouse," says Jeremy. She had been dropped at the hospital to get more drugs, and he found her wandering beside the highway, dazed and frail, less than a hundred pounds, blood spattered on her clothes.
"Hopelessness is what keeps you out there," Mills says. "Because you don't think there's hope. As addicts, you do things that you're ashamed of. I did things that I was ashamed of that the Devil tries to remind me of from time to time."
More rehabs failed. Kathryn contracted hepatitis C and got pregnant again. This time, the father's identity was a mystery. Her third child, a boy, was born addicted to opioids, his lungs underdeveloped, and spent his first few days of life going through withdrawals in the hospital.
All three children eventually found stable homes. Kathryn's son, born dependent on opioids, is now healthy. Kathryn tried rehab in Florida, but found her way back to a fix, and is again living in Columbus County.
"The real world is a tough place to live," says Jeremy, considering his daughter's inability to beat her demons. "It's a constant battle. I'm just trying to keep her alive."
Reducing the Supply
Lieutenant Worthington, pacing the stage at the November 8 conference on opioid use in Columbus County, advocated for stricter oversight of prescribers. "Those of us who are professionals, no matter what field we're in—whether it's law enforcement or medicine—have to be really, really careful," he said. "Because the decisions we make can affect many people."
"Who is policing the ones who prescribe these medications?" Worthington asked. "We've got to address it from both sides, from the supplier to the guy on the corner."
Mary Ashton Gore, who manages a pharmacy in Whiteville, shares Worthington's distaste for lax prescribers. She has been asked to fill out prescriptions, she says, for more than 300 Percocet—oxycodone mixed with Tylenol—for more than 200 Methadone, and for over 100 Roxicodone, which is unadulterated and immediate-release oxycodone. (She did not want to give exact numbers for fear of violating patients' confidentiality—Whiteville is home to only 5500 souls—and preferred her pharmacy go unnamed.)
"That's blatantly not caring about patients," Gore says. "Some of these practitioners—I don't understand. They think it's just candy, and it's not candy. It's poison that we're putting in our bodies."
In 2015, 1,483 North Carolinians died of drug overdoses, more than four every day, according to the state Department of Health and Human Services. The vast majority of those overdoses were from opioids, legal and illegal. In June 2016, the state passed legislation allowing pharmacies statewide to make naloxone available without a prescription. Naloxone, a nasal spray that commonly goes by the brand name Narcan, reverses the symptoms of opioid use, and can save the life of someone experiencing an overdose.
In June of this year, North Carolina took a more direct step with the Strengthen Opioid Misuse Prevention (STOP) Act. The bill limits the pill count and length of opioid prescriptions for patients after acute injuries and after surgeries, and it requires prescribers to consult the state Controlled Substances Reporting System before prescribing the pills.
A study this year by the Centers for Disease Control put the pills' addictive qualities in perspective, especially when they are prescribed in longer courses. Of patients given prescriptions of eight or more days, 13.5 percent were still using opiates a year later. For patients prescribed a month of the medications, that rate spiked to 30 percent.
State Representative Greg Murphy of Pitt County sponsored the bill and led much of the public advocacy. A physician himself, he calls the opioid crisis "the biggest healthcare crisis we face in the country today."
"The crisis is affecting all other segments of society," Murphy says. "Business, because people have lost work. Families, because of tragedies that occur in families. Healthcare crises—these people are often times uninsured."
Through his career, Murphy has seen the crisis develop and deepen. "Twenty-plus years ago, there was a great uproar that physicians were not treating pain adequately," he recalls. "So, as pendulums swing, it probably swung too far, and we are overly medicating pain. The purpose of this legislation is not to take pain medications from those who need it chronically to survive. It's to stem the flow of people that need it in acute situations, who are overprescribed and then become addicted."
Multiple sources suggested that the DEA has been investigating two practitioners in Columbus County. Who these doctors are is an open secret. Gore, the pharmacist, relates tales of arguments she's had with doctors she thinks are doling out pills irresponsibly, and with patients holding bunk prescriptions. "I sound like a confrontational person," Gore says. "I'm not. It's just what the job does to me."
"The crisis is affecting all other segments of society," Murphy says. "Business, because people have lost work. Families, because of tragedies that occur in families. Healthcare crises—these people are often times uninsured."
But shortening prescriptions, and even locking up "candyman" doctors, will not solve the county's opioid problem. In populations with substance use disorder, when prescription medications are unavailable, heroin use often rises to meet the need. Heroin, both more powerful than its medical cousins and less regulated, comes with a higher risk of overdose and death.
To help those struggling with dependence, practitioners of "medication assisted therapy" administer courses of methadone and suboxone, two drugs that bond to the same receptors as more powerful opioids without the same psychotropic effect. They can help substance users taper off by reducing withdrawal symptoms, and without giving the same high as more powerful drugs.
Even these drugs come with risks: both can provide a milder high, so are themselves potentially subject to abuse. There are cases of methadone overdose, which can be deadly, as well as suboxone overdose, which is rarer and unlikely to be fatal—suboxone includes naloxone, the drug that reverses symptoms of opioid overdose.
Heidi Herring, a counselor in Whiteville whose clients include substance abusers, notes concern that people can become dependent on suboxone and methadone instead of the drugs they are replacing. "And it also can be sold on the street. You can get high off it if you take too much of it."
But both have been shown to substantially reduce mortality risk in people dependent on opioids, in some studies by up to 70 percent. Methadone and suboxone clinics try to use innovative strategies to ensure people are taking the medicines as prescribed. Whiteville Pain & Spine, with whom Herring collaborates, provides patients suboxone in the form of a strip. Each week, Herring says, patients must bring back the peeled strips to get next week's prescription.
While drugs to taper off opioids are not perfect, for many users simply quitting cold turkey is unrealistic. "There's always those people who can say, 'well I just quit on my own,'" Herring says. "There's some people who can do that. But then you've got those people who can't. Everybody is an individual, and everybody's body chemistry is different. There's no way to know how one person's going to react to sobriety, trying to get off a drug, versus another."
Where faith fits in
Differences in individual style aside, many patients have trouble even accessing care, whether because of lack of insurance, lack of transportation, or lack of knowledge where to go. Faith-based organizations in Columbus County have tried to pick up the slack, and offer some of the most accessible support for people in the county.
Janet McPherson is executive director of Living Hope Pregnancy Support Services, a ministry that counsels women through their pregnancies and early motherhood without charge. Over the two decades that she has been with the program, McPherson has seen the scope of her work change dramatically. Living Hope did not plan to focus on helping expecting mothers navigate opioid use during pregnancy, but it is "something that has just fallen into our lap, because of the need," McPherson says.
At work, "there's not a day we're open that someone doesn't come in who is pregnant and abusing substances," she says. "Or Grandma comes in. We had Grandma come in this morning to get diapers. What's really sad is when the mother and daughter come in and they're both strung out."
And the need is heightened by the county's relative poverty, which limits mothers' access to other, non-free options. "We have so few resources," McPherson explains. "This county is very poor. And the few resources we do have, nobody knows about them."
People are more aware of what happens in their church, however, and many recovery programs are housed there. Darren Mills runs a chapter of Celebrate Recovery at Living Word church in Chadbourn, a town west of Whiteville. He gave directions to come meet him at Living Word after crossing into town and seeing the church being built on the right. It was only when I hit a third church down the block that I knew I had gone too far.
Mills speaks openly about his decades of addiction, which have left him with a firmer take on substance abuse than some of his fellow-travelers.
"Most people tell you it's a disease, and you can't help it," Mills says. "Yes, you can. It is a process from start to finish. But there's got to be surrendering. And that surrendering comes when they hit bottom." He focuses on the enabling that goes on around substance abusers, particularly relatives willing to pass along a couple dollars in times of need. "That bottom's got to be forced. You know, if there's no reason to change, why are you gonna change? You're not."
When abusers do hit bottom—if, of course, they survive that bottom—Mills finds that a pious life helps them to stay on the straight and narrow. Among other things, what faith can offer is something that seems in short supply in certain corners of Columbus County: hope.
"Hopelessness is what keeps you out there," Mills says. "Because you don't think there's hope. As addicts, you do things that you're ashamed of. I did things that I was ashamed of that the Devil tries to remind me of from time to time."
The hope that Mills sees in the recovery program and the hope he finds in Christ build on one another: "The hope that we have to give people is that there's a better day. That if you'll do this, let me tell you what worked for me, and if you try it—just try it! There's hope there."
Herring, the counselor, knows something of hopelessness. When she was pregnant with her second daughter, "I was abandoned by an addict," she says. "Substance abuse changed my life. He was the love of my life, and he destroyed me emotionally. And my daughter's life. She's never had a father."
Herring went to school to be a substance abuse counselor hoping to save her family. "But that was not what God intended," she says. "It was not for me to help him. It was for me to help everybody else. And I did not know that."
Her painful experiences, though, allow her to connect with her patients. Her relationship with God, she says, is what allows her to continue day by day. "Me and God, we're okay," she likes to say. "And if I weren't okay with who I am, and with who God is with me, I couldn't do this. I could not."
Breaking the cycle
Faith offers one avenue to break the cycle of opioid abuse. Where hopelessness can be passed through generations, hope can, too. "I broke the cycle in my house. I broke many years of alcoholism," Mills says. "My mother was an alcoholic, my father was an alcoholic. I got sober. Guess what: my daughter is sober. She doesn't drink. She's seen what drugs and alcohol did to Dad. She's a nurse. I've got a grandson that's gone be 2 years old in May. The chances are that he won't be in the addiction program, because the cycle was broken with me."
Dealing with substance abuse, then, means treating more than just the substance abuse.
"It does no good just to stop the flow of medicine and think people are going to recover by themselves," says Rep. Murphy. "So where I think the biggest focus actually needs to be moving forward is mental health and substance abuse counseling and treatment." Alongside the STOP Act, state legislators earmarked $10 million in funding over the next two years for just those purposes.
Herring, the counselor, has noted this overlap in her work. "Hardly ever will you meet someone with a substance abuse problem where there's not gonna be some kind of mental health problem mixed in. Anxiety, depression, trauma. You're gonna find something. They coexist so much."
In her office, Herring shows off some shards of Kintsugi, a Japanese technique of reassembling broken pottery that she uses in art-based therapy. In the reassembly process, the patient accentuates the seams of the ceramics with gold paint. "In reality, they use real gold, but we're not. We use gold color," she laughs.
"You use gold, and you accentuate where the creases are," Herring says. "What it means is there's strength in life experiences, and you're strong through your brokenness. And through being able to piece yourself back together."