Coming together to address the problem

A southern Ohio psychiatrist who has worked in the opiate epidemic environment in his city for years urged Columbus area residents to accept reality when trying to solve their current heroin-addiction crisis.

The problem isn’t the opiate epidemic, Dr. Kendall Stewart told a standing-room-only crowd of 650 people who gathered Wednesday night at The Commons to learn more about what could be done to stop the overdoses and deaths that continue to increase in Bartholomew County.

“The problem is the human brain,” said Stewart, who is vice president for medical affairs and chief medical officer at Southern Ohio Medical Center, in Portsmouth, one of the cities profiled in author Sam Quinones’ book about the heroin crisis in America, “Dreamland: The True Tale of America’s Opiate Epidemic.”

Stewart took on the presentation duties on his own at the kick-off community forum, designed to provide an overview of this area’s problem with heroin addiction.

Quinones had been scheduled to speak, but suffered a heart attack earlier this week and had been hospitalized, Columbus Regional Health President and CEO Jim Bickel said.

Instead, a video of Quinones talking about his book, and the effect of the heroin epidemic on Portsmouth, where Stewart practices as a psychiatrist, was shown before Stewart’s presentation.

Stewart used a homespun approach to his talk, describing his arrival in Portsmouth more than 35 years ago in deadpan humor about experiencing the culture shock of the area, leading his audience to link his cluelessness as to why anyone would move to Portsmouth as an analogy to explain why anyone would use heroin.

Food for the brain

“Have you noticed that your brain and every brain you ever met is good at creating feelings?” he asked.And while those feelings may be pleasant, unpleasant or mixed, there are parts of the brain that encourage an individual to pursue and do things that are pleasurable, Stewart said. When that happens, the brain delivers what Stewart described as a “squirt of dopamine,” a substance that gives a feel-good sensation.

Opioids, and heroin, are extremely effective in stimulating the part of the brain that squirts out dopamine, Stewart said.

“If you take a hit of methamphetamine, your brain squirts out 1,000 times more dopamine than when you have an orgasm,” Stewart said. “So here’s why your brain is the problem. Imagine the pleasure hit of the drug and how hard it would be to resist it.”

Stewart caught the audience’s attention when he pointed out that building inpatient treatment centers for people addicted to opioids or opiates will not completely solve the underlying issue with individual’s brains.

“If you had enough in-patient beds so that anyone could be admitted within 60 seconds and stay as long as they wanted at no cost, and if you had a system where anyone could get suboxone — a drug used to treat heroin addiction that is designed to reduce cravings — within 60 seconds at no cost, people would still be abusing these drugs and dying,” he said.

“The problem is we don’t always choose what is best for us because our brain urges us to do things that are not good for us,” he said. “If you and I want to make significant changes in our lives, we must change what we believe and how we behave in spite of how we feel,” he said.

Stewart urged people in Wednesday’s audience to make expectations clear about how the community views the use of alcohol, tobacco, marijuana and narcotics — and offered up a few solutions for Bartholomew County to consider.

He said the best way to reduce the epidemic is to prevent people from turning to heroin in the first place, reducing the common practice among physicians nationwide to overprescribe pain medication to patients undergoing minor surgical procedures, including dentists, and to seriously consider the benefit of placing people on long-term suboxone or methadone therapy, perhaps for years.

The third suggestion brought audible gasps within the audience, but Stewart said the relapse rate for opiate addicts is so high that former opiate pill mills in Ohio are being replaced with suboxone pill mills.

The entire process needs to be supervised by doctors who determine when and if a patient can go off suboxone, he said.

Author’s point of view

During the Quinones video, the author described how pill mills, doctor’s offices where patients could line up for prescriptions of opiates that were handed out like candy, emerged in an area around Cincinnati, north to Columbus, Ohio, and then into eastern Kentucky and a large chunk of West Virginia.In the video, Quinones said pill mills were the result of an area caught in a severe economic downtown combined with a time when pain became a new, important symptom for doctors to treat and alleviate. When the pill supply dried up, individuals who lacked economic resources turned to the cheapest and most widely available drug source available, heroin, Quinones said.

Much of the epidemic continued unnoticed for more than a decade, until the number of heroin overdoses and deaths began to become something that was talked about in communities, Quinones said in the video.

He acknowledged that much of the dosing began after doctors were told by drug companies that the substances were non-addictive, which wasn’t true.

“The silence and quiet about the national spread of heroin for 15 years is coming to an end,” the author said. “And I still think doctors should be more judicious and nuanced in the prescribing of drugs,” he said, describing a common practice of some patients getting 60 Vicoden pills when having wisdom teeth pulled.

“We need to take more time when working with chronic-pain patients and think about what else can be done rather than massively dosing patients,” Quinones said in the video.

Quinones contends that Americans argue about what creates a drug problem — whether it’s supply or demand, and most people think it’s demand.

“In this case, it’s most definately supply,” the author said, describing how Mexican drug cartels began franchising heroin sales to cities throughout the United States like fast-food chains.

“My belief is the supply (of the drug) is the detonator,” Quinones said of the heroin being sold in the United States. “That’s why the behavior of doctors is so crucial.”

Quinones said that while law enforcement is tasked with taking care of the drug activity, communities need to focus on not creating more addicts — and that begins with physician behavior when prescribing drugs after a procedure.

During a question-and-answer session after the presentation, Stewart was asked what was the one thing local residents could do immediately to combat the heroin epidemic in Bartholomew County.

His answer: Go home, look in your medicine cabinet, and dispose of the unneeded opiates in an appropriate manner so they cannot be accessed by anyone as a gateway to opiate addiction, he said.

“That way, they won’t get to brains that are susceptible to addiction,” he said.

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During Wednesday’s “Moving the Needle: Community Forum,” organizers for the Alliance for Substance Abuse Progress (ASAP) in Bartholomew County were asked about what is coming next for the initiative.

Jeff Jones, a retired Cummins, Inc. executive who is serving as executive lead for the initiative, said the community can expect to hear recommendations within the next six months, with an implementation time over the next two years.

Jones said he is receiving support from law enforcement, the faith community, healthcare resources and employers in the community who are already working on the problem.

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Opiates are derived from the poppy plant. Examples of opiates include heroin, morphine and thebaine. Examples of opioids are perscription pain medications Vicodin, Percoset and Oxycontin.

— Provided by Healthy Communities, Columbus Regional Health

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“We must change what we believe and how we behave in spite of how we feel.”

— Dr. Kendall Stewart, vice president for medical affairs and chief medical officer at Southern Ohio Medical Center, Portsmouth