The Opioid Crisis

Unique Clinic
Battles Addiction

Steve Cummings, PharmD, BSPha’85, founded the nation’s first retail pharmacist-operated long-acting injection clinic at a behavioral health center. Read more here.

A Campus-Wide Approach

Many Creighton faculty members are addressing the opioid crisis through research, education and outreach. Read more here.

The Opioid Crisis: A Creighton Perspective

By Cindy Murphy McMahon, BA’74

The two friends have forged many bonds over more than 20 years.

A primary connection is their profession, pharmacy. There’s their mutual interest in soccer — one referees, the other one’s sons played. And then there’s the strength they both find in their respective faiths.

But one of their strongest bonds concerns loss. The gut-wrenching loss of loved ones gone too soon from this life. The missing memories that will never be. The grief and mourning that take turns beating a person up with “Why?” and “If only.”

And because of those losses, Curt Barr, PharmD, BSPha’74, assistant dean for alumni relations in the School of Pharmacy and Health Professions, and friend and colleague Ed DeSimone, PhD, professor of pharmacy sciences, share another commitment: fighting substance abuse, addiction and, especially, the opioid epidemic.

According to the National Institute on Drug Abuse (NIDA), more than 115 Americans die daily after overdosing on opioids. The NIDA, among other federal agencies, has called misuse of and addiction to opioids — including prescription pain relievers, heroin and synthetic opioids such as fentanyl — a national crisis.

The Centers for Disease Control and Prevention (CDC) estimates the U.S. economic burden of prescription opioid misuse alone is $78.5 billion a year, including the costs of health care, lost productivity, addiction treatment and criminal justice involvement.

How did we get in this situation? According to the NIDA, in the late 1990s, pharmaceutical companies reassured the medical community that patients would not become addicted to prescription opioid pain relievers, and health care providers began to prescribe them at greater rates.

The opioid battlefront is three-pronged: prevention, treatment and law enforcement. Barr and DeSimone are concentrating their efforts on prevention through education. It’s a fight that keeps them doing all in their power, in the classroom and in the community, to save other families from the pain theirs have experienced.

DeSimone’s 24-year-old nephew died from heroin, and Barr lost his 24-year-old son to an accidental prescription drug overdose.

“I’m not me anymore. Anyone who loses a son or daughter has a new normal,” says Barr, whose youngest son, Brad, died in 2005 after ingesting prescription painkillers with friends.

At the time, Barr was teaching pharmacy at Creighton, owned a community pharmacy and a medical supply business, and had been serving in leadership roles for multiple pharmacy and community organizations — local, state and national.

He was attending a meeting for one of those organizations on Brad’s last night. The meeting ended early and he got home in time to talk to his son, who had stopped over to see Mom and Dad before going out with friends. “He visited with my wife and then he waited for me to come home from my board meeting. I got to see him and spend a few minutes with him,” Barr says.

“Brad and I were so much alike. We thought alike. We’re both risk-takers, and he had an entrepreneurial spirit like me.”

Brad had played soccer on his high school team, taking state his junior year. He was studying accounting. He did not have a substance abuse problem, and Barr says his son knew not to mix drugs and alcohol. The events that took his life were more of an aberration, a fluke.

Medical records showed Brad had the equivalent of one beer in his system, in addition to the prescription drugs, Barr says. “According to the friends who were there, he had consumed two beers that night,” he adds.

“In the talks I give, I ask, when will two beers kill you? Alcohol changes your mind. It makes people, especially young people, think, ‘Maybe this won’t hurt me; I’m immortal.’ And the more alcohol you drink, your mind gets blurred, gets foggy. If you’re not used to it (taking prescription drugs for recreational purposes), and Brad wasn’t, you can die, and even if you are, you can die.”

DeSimone’s history with substance abuse, on the other hand, stretches back for his entire life.

“I’m an adult child of an alcoholic,” says DeSimone, whose father died at 49. “In my lecture ‘Adult Children of Addicts,’ I talk about how my father was in World War II and, in retrospect, if he were alive today, I think they would say he had PTSD. He drank heavily all the time.

“He actually had, around the time I was born, three-quarters of his stomach removed because it had been eroded so badly by alcohol, a subtotal gastrectomy. He didn’t eat much ­and he was very thin. He drank more than he ate.”

As a kid, DeSimone knew every bar in the neighborhood because his mother would send him out to find his father. “I would hit the bars until I found him. He also was a smoker. He developed cancer of the mouth and throat. They took out two pieces of his jawbone and half of his tongue.”

One of DeSimone’s most painful memories is playing ball in the street with his friends in North Jersey, where he grew up. “The worst thing was for my dad to come home while I was playing ball with my friends. He was obviously drunk, staggering, and to be a teenager and have your friends see that, was very embarrassing, and frustrating, and I spent a good part of my life trying to recover from that.”

More recently, about six years ago, his family was thrown into grief again when his nephew died during a heroin relapse.

“My nephew had an anxiety disorder, he had depression, he had bipolar disorder. The drugs of abuse took away the pain, the effects of all these psychiatric disorders,” DeSimone says. “And the drugs that were used to treat the psychological problems made him feel worse.

“He’d call me all the time. He’d say, ‘They put me on seven different drugs,’ and I’d say, ‘Don’t stop taking them,’ but he would say, ‘I already did.’ He would go back to using heroin because heroin made him feel better.”

His nephew started using heroin at 16 and eight years later it killed him, even though he was in recovery multiple times. “He was on medication, going to Narcotics Anonymous,” DeSimone says, “but one day he just relapsed.”

This heartbreaking personal example points out the complexity of substance use disorders, which DeSimone teaches to Creighton pharmacy and physical therapy students, as well as health care professionals and community groups.

In his presentations, DeSimone explains the components of psychoactive substance abuse, which include varying neurochemical factors in the brain related to genetics, pleasure, memory, stress and craving.

“There’s a subgroup of people who get legitimate prescriptions for legitimate problems in terms of pain who become addicted to these drugs. Once the addiction sets in, they have to fight the addiction the rest of their lives,” says DeSimone.

“The majority who have an addiction problem chose to use in the first place. My nephew initially chose to use, it was recreational. But these drugs are powerful. The newer drugs are even more powerful.

“Once you cross that line into addiction, you’ve got a different situation. A door behind you closes, as these drugs change your brain chemistry. Would that line vary from person to person? Yes. This is a disease of stress, environment, genetics — it is not a simple disease.”

Coalition Rx, a nonprofit community advocacy organization of which DeSimone is president and chairman, recently produced a video for the Nebraska Regional Poison Center that featured several parents of young people who had died from overdoses. Barr was one of those in the video.

“The biggest users of drugs are the young people,” DeSimone says. “According to SAMHSA (Substance Abuse and Mental Health Services Administration), it’s the 18- to 25-year-old age group where you see the highest levels of drug use. That’s why I’m big on education and prevention — we need to get them to think about what they’re doing before they start to do it.

“The dads in the video all basically said the same thing — their sons were just going along with everyone else, they didn’t even think it was dangerous. Especially with prescription drugs made by legitimate pharmaceutical companies, with prescriptions written by physicians and medication dispensed by pharmacists, they think they (the drugs) can’t be bad.”

Barr says after his son died, and some time had passed, he decided he needed to do more research about substance abuse.

“I found all the talks I gave here and all around the country about addiction were basically wrong in their approach. I found that if you tell young, developing minds something will be addictive, they want to disprove it. The psyche of mankind is, ‘It will never happen to me; I can do all this and it won’t hurt me.’ Their brains haven’t matured completely.”

So his focus changed to initiating prevention strategies for parents to use with children as young as 3 years old. He uses information and an approach from the Search Institute, which emphasizes talking to children and youth early and often about all risk behaviors and good behaviors, among other topics.

“Let’s talk about the broader spectrum of risk behaviors and how you can create resiliency in your sons and daughters.”

DeSimone and Barr are joined by many others in the Creighton community who are doing their part to combat the opioid crisis. The Creighton campus comes at the issue from multiple angles — medicine, nursing, pharmacy, public health, law and emergency medical services, for starters. (See article on Page 28.)

Emergency medical services (EMS) personnel are on the front line, often the first health care providers to begin treatment for a patient with an opioid overdose.  

“Education for EMS personnel has always included recognition and treatment of patients with opioid overdose,” says Michael Miller, EdD, program director and assistant professor of EMS education. “But as a result of the CDC labeling the crisis an epidemic in 2012, EMS educators emphasize the need for EMTs and paramedics to have a heightened suspicion for opioid overdose as part of their training.”

Miller says it’s a positive in Nebraska that LB390, Expanded Use of Naloxone, allows family members, friends, authorized emergency responders and law enforcement officials to administer naloxone, a potentially lifesaving medication, to patients who are suspected to have overdosed. Previously, naloxone could only be administered by EMS personnel and paramedics with advanced training.

Miller points out that emergency responders can be at risk in opioid overdose situations. “Due to the potent nature of synthetic opioids, emergency personnel must be very cautious when responding to scenes where a patient suddenly becomes drowsy or unresponsive,” Miller says. “Airborne powders may be inhaled, and powders and solutions may be absorbed through the skin, causing the same effects of an opioid overdose in EMS personnel.”  

Creighton alumni are at the forefront of the battle as well, including pharmacist Bob Greenwood, BSPha’77, and firefighter paramedic Dan Stein, BSEMS’12, MSEMS’16, who has two degrees from Creighton in emergency medical services.

Greenwood, who owns pharmacies in Waterloo, Iowa, has been involved at the community, state and national levels as past president of both the National Community Pharmacists Association (NCPA) and Iowa Pharmacy Association (IPA), and says the role of community pharmacists in combatting opioid abuse is multifaceted. He says the IPA has sponsored education programs for prescribers, nurses, substance abuse agencies, mental health professionals and law enforcement.

He notes that the Iowa Board of Pharmacy, which is responsible for regulating the practice of pharmacy and the legal distribution and dispensing of prescription drugs throughout the state, is promoting utilization of a national database to monitor the prescribing of controlled substances. He says the Iowa Board and the IPA also encourage take-back programs in Iowa pharmacies for all medications, controlled and noncontrolled.

A key factor, Greenwood says, is changing prescribers’ habits to writing controlled substance prescriptions for small quantities and trying nonsteroidal anti-inflammatory drugs (NSAIDs) as a first line. “I believe prescribers go to an opioid first too often,” Greenwood says.

When Stein, a firefighter paramedic with the Council Bluffs Fire Department in Council Bluffs, Iowa, first started his career in southeast Los Angeles, an uptick in opioid overdoses was usually associated with “a bad batch of heroin making its way through the community.”

But, he says, “These days, it seems opioid emergencies come in all shapes and sizes. It can be the working professionals, the young athletes, grandparents or stay-at-home moms. Opioids don’t discriminate. Every demographic is at risk, and this has really become a challenge for emergency responders.”

The opioid crisis in the U.S. didn’t happen overnight, and there are no quick solutions.

“People need to realize it’s probably going to take as long in this society to get rid of this problem as it did to form it, so we’re talking years,” says Barr. “The biggest piece that will pay dividends decades from now is the prevention piece.”

DeSimone, obviously, agrees with his friend. He adds that revised CDC guidelines on pain management, which came out in mid-2016, should help. “That’s one area we should be able to control, educating our health professionals, particularly physicians. There are subset guidelines for acute pain and chronic pain. How do you treat each of those? How do you treat people who have had a previous addiction problem who are in pain? How do you treat people who had an addiction problem to these kinds of drugs?”

For Barr, the loss of his son caused personal changes in his life in addition to professional ones. He resigned from several of his leadership roles, sold his pharmacy and became a lay minister and a hospital chaplain.

“I definitely feel God working in my life,” Barr says. “I tell students what’s really important in life, after God and spirituality, has got to be your family. Your profession has got to come third. Do I feel that if I had spent less time in professional organizations my son would still be alive? No, I don’t feel that. But I would love to look back now on a lot more memories … there are a lot of memories I don’t have.”