Two years ago, Dr. Bill Hilty could count the opioid overdoses he'd see in a year on one hand.
But as local hospitals, health care providers and dentists have reduced the number of opioids prescribed to patients, Hilty, the emergency department medical director for St. Mary's Medical Center, now sees an average of three overdoses per week coming into the hospital.
Many patients are saved. Some are already dead when they arrive, while a few, Hilty said, go without oxygen for such a length of time that they will have brain damage if they can be saved.
"These are young kids from a variety of socio-economic groups," Hilty said. "It's sad."
The opioid epidemic has swung like a pendulum in the past decade, starting with the medical field overprescribing pain pills to the point where many were prosecuted, including some professionals with ties to Mesa County.
Upon recognizing the problem, a reduction of pills led some patients to seek alternative narcotics on the street. Today, local law enforcement says people are leaping straight to opiates such as heroin without ever getting hooked on pain pills.
Meanwhile, area health care providers are still looking for ways to reduce the number of pills prescribed by searching for pain management alternatives, joining state programs and obtaining grants to improve the situation close to home.
From 2013-2017, Mesa County had 64 prescription-related opioid deaths, according to a prescription drug profile by the Colorado Department of Public Health and Environment. Since 2018, the Mesa County Coroner has reported 40 drug-related deaths as of Aug. 19.
More than 50 percent of those deaths involved an opioid. Several of the deaths include mixed drug intoxication, many of which involve an opioid. Synthetic opioids such as fentanyl have also made their way into the county, contributing to multiple deaths in the past two years.
"There wasn't heroin in town several years ago," Hilty said. "Now people are buying street narcotics."
As overdoses remain an issue, the county has seen a reduction in opioid prescriptions and number of patients who receive a prescribed opioid. Colorado Public Health and Environment data shows a 15% drop in the prescriptions dispensed between 2015 and 2017.
"It's a really great success story on the prevention standpoint," said Kelsey Fife, health promotion specialist for Mesa County Public Health.
The recent drop in prescriptions likely continued in 2018 and into this year, according to Dr. Ryan Jackman, a family medicine physician with St. Mary's Medical Center, who said various efforts have led doctors to seek opioid alternatives when dealing with pain, particularly in emergency departments.
Yet the crisis continues to plague Mesa County, the state and the nation. More than 63,000 people died from drug overdoses nationwide in 2016. About two-thirds of those deaths involved an opioid, according to the state health and environment department.
Mesa County ranks below the state rate for opioid deaths. The county had an opioid death rate of 8.8 per 100,000 residents for 2013-2017. Colorado as a whole showed a rate of 10.1 deaths per 100,000, for 2016-17, a 9% increase.
Delta County showed the lowest opioid death rate in the state with 1.9 per 100,000 residents.
While Mesa County might not stand out compared to other areas, the issue remains a priority for medical providers, public health officials and law enforcement.
"It makes me more optimistic," Community Hospital Chief Medical Officer Dr. Thomas Tobin said of Mesa County's opioid numbers. "Other counties will have a much heavier lift to move the needle. At the same time, we don't want to look at numbers and say we don't have a problem."
In St. Mary's emergency department, Hilty says opioid prescriptions decreased "four-fold" in the past year since the hospital joined the ALTO Project, run by the Colorado Hospital Association.
The project stresses alternatives to opioids and trains providers working in emergency departments on other methods to treat pain. Launched as a pilot program in 2017, the project now includes 80% to 85% of hospitals in the state, including Community, Colorado Canyons in Fruita and Delta County Memorial hospitals.
"It was a critical priority for us because of the challenges communities are seeing," said Dr. Darlene Tad-y, vice president of clinical affairs for the Colorado Hospital Association. "We really wanted to step up and be part of the solution."
The pilot project started with 10 hospitals with the goal of reducing prescribed opioids by 15% over a six-month span. Those hospitals reported a 36% drop in opioids and a 31.4% increase in alternatives to opioids during that time.
"It's what you want to see from a demo project," Tad-y said. "I think our emergency medicine colleagues were very proactive. We're seeing impact pretty up close and personally."
At Colorado Canyons Hospital in Fruita, Chief Medical Officer Dr. Korrey Klein said some patients are seeking alternatives to opioids because they have heard of the dangers.
"I think there has been a switch there," he said.
Since joining ALTO at the start of 2018, Klein said surgeons have used different blockers to reduce the need for opioids. In some cases, anesthesia is injected into certain nerves to lessen pain in the first few days after an operation. Access to physical therapy has also improved now that patients can schedule follow-up appointments while in the emergency department.
Hospitals across western Colorado are also working together through grants and programs to address addiction and over-prescription, including rural clinics in Delta County.
"In order for us to make a difference on the Western Slope, it will take partnerships to curb prescription and addressing addiction," Delta County Memorial Hospital CEO Jason Cleckler said.
Jackman said St. Mary's and its partners across 12 western Colorado counties are taking this year to form a plan to address opioid prescribing, use disorder, prevention, treatment, recovery and workforce development around opioids.
Next year, the St. Mary's Foundation will apply for a three-year implementation grant for its plans.
In a separate project started last year, Mesa County Public Health organized more than 40 groups to form the Mesa County Opioid Response Group, which aims to reduce opioid use in the community and help addicts through treatment on the way to recovery.
"We've focused on looking at the whole spectrum from prevention to long-term recovery," Fife said.
ADDICTION TREATMENT AND JAIL PARTNERSHIP
Mesa County has three medication-assisted treatment facilities, including ones at St. Mary's, Mind Springs Health and the Grand Junction Metro Treatment Center, that try to help those addicted to opioids wean off drugs.
Mind Springs offers a variety of treatment programs, including a women's recovery center, which is a 90-day program. The organization will also open a Grand Junction detox facility in September.
Mind Springs' medication- assisted treatment option has grown in the past few years and provides drugs like Suboxone to patients looking to reduce opioid cravings. The drug is something those suffering from addiction take temporarily while they learn to change their lifestyle. Suboxone is less potent than another drug, methadone.
"In general, health leaders have done a lot of work around this, creating pain management protocols, and I think there is a whole community response to this that has been helpful," Mind Springs Health Executive Vice President Michelle Hoy said.
The Grand Junction Metro Treatment Center is the only facility that distributes methadone in the region. Methadone blocks the urge for opioids and can help with addictions to drugs such as heroin or fentanyl.
The center opened in Grand Junction seven years ago and has "seen a substantial increase (in patients) in the past year," program director Trudy Fogg said.
Fogg said the clinic sees two to four new intakes per day. Clients can receive a daily dose of methadone along with counseling at the facility. Clients often return to take methadone for one to two years, but some stay longer.
Others can relapse, but Fogg said those clients are welcome back when they want to get well.
The center is also working with the Mesa County Jail on a program to allow clinic patients in jail to still receive their dose of methadone so they do not go into withdrawal while incarcerated.
The jail recently received a $150,000 grant from the Colorado Department of Human Services to administer methadone to those already in treatment programs when they enter jail.
"It is being successfully done at other locations," said Capt. Art Smith at the Mesa County Jail. "Other agencies are moving in this direction."
The grant was spurred by a Senate bill passed this year that sets policies related to people with substance abuse disorders who enter the jail. The grant includes the partnership with the treatment center and the medical provider to administer the drugs.
"We want to make sure we are continuing that care," Smith said.
Smith hopes this grant can be the start of such treatment on a larger scale at the jail.
"The longer-term goal would be induction into treatment when and where clinically needed," he said.
While prescription opioids have decreased in Mesa County, police are seeing a significant uptick in drugs such as heroin and fentanyl — a synthetic opioid significantly stronger than other drugs,
Grand Junction Police Department Cmdr. Clint Newton said he first remembers seeing criminal opioid abuse around 2006. Later, people turned to other places where it was easier to get drugs.
"We were seeing people addicted to pills and making the leap to heroin. Now we're seeing people just leap straight to heroin without being addicted to pills," Newton said. "It seems to me like there is more heroin out there. The availability has gone up immensely."
Newton said he is hearing that heroin may be as prevalent in the area as methamphetamine, if not more.
Tanya Brechlin, an investigator with the Western Colorado Drug Task Force and Mesa County Sheriff's Office, said it's hard to quantify which drug is more prevalent as it takes a higher dose of meth to produce a high comparable to heroin. She said they are the top two drugs that law enforcement deals with.
Another issue is drugs that are laced with fentanyl because the dosage can vary and lead to overdoses.
Officers have adjusted by carrying Narcan Nasal Spray, which contains naloxone. It can counteract the effects of the drug and stop an overdose.
Mesa County Sheriff's Office Operations Capt. Todd Sorenson, said officers first started carrying naloxone last summer. He said drugs have become more prevalent in the area, which is something the rest of the country was already seeing.
"It's a trend that has been slow to arrive here, but it's upon us," he said. "It's not good. It's not a good presence. We're doing everything we can to have a swift response to this."
The Grand Junction Veterans Affairs Medical Center often deals with veterans who have long-term chronic pain, including some who have taken opioids for several years. The hospital opened a wellness center on campus in early 2018 focused on working with veterans to improve their physical issues through therapy.
Dr. Ben Atwater, the director of the wellness center, said many veterans are receptive to staying away from opioids.
"It does not mean all patients are off opioids, but we try to identify patients who are at high risk for opioid abuse," Atwater said.
Aside from overdoses, Atwater noted that overuse can result in slowed breathing, a buildup of tolerance, reduction of testosterone in men and, in some cases, increased pain.
In the dental field, Dr. John Poovey, a dentist with JP Dental and Implant Center in Grand Junction, said he used to see patients come in with addictions to the point that he had to press charges against one who tried to falsify a prescription for Vicodin.
While dentists don't prescribe as many opioids across Colorado as doctors, physician assistants and nurse practitioners, 90% of prescriptions dispensed by dentists over a one-year period from August 2017-18 were opioids.
For physicians, that number was less than 50%, according to the Colorado Prescription Drug Monitoring Program.
Poovey said after reading studies in the British Journal of Medicine and through the American Medical Association, he started using ibuprofen and Tylenol to treat pain after oral surgeries instead of opiates.
"I'm trying to minimize their exposure to opioids as much as possible with protocols and taking a heavy hand with suspicion for addiction," he said.
Jackman feels scrutiny over opioids began when physicians were dissatisfied with their work and were noticing overdoses and deaths related to the issue. In the past five years, that scrutiny has advanced to the political and public level.
"I think the epidemic has increased scrutiny. I think physicians have been decrying the situation of how pain is being treated," Jackman said.
He traces the start of opioid issues to when doctors were trained on pain as a vital sign that needed to be treated. Physicians were also rated by patients on how they helped them manage their pain, which gave doctors incentive to prescribe pain medicine, Jackman said.
Now, he said it can be difficult for those who are not addicted to opioids to get drugs for chronic pain. He said continuing education will help level things out in the future.
"I think we're all at fault, but there is a lot of education that needs to take place so patients understand they don't need these pills long term," he said. "These are all new frontiers that people weren't getting trained on in med school until recently."