DRUG OVERDOSE NUMBS APPALACHIA

Eastern Kentucky Led Nation In Narcotics Distribution Per Capita For 1998-2001

April Vallerand, a Detroit pain expert, thinks doctors should manage
patients' real pain more aggressively. But "I can't imagine that Kentucky
has any more pain than Detroit has. There's something going on," she said.

In truth, Eastern Kentucky has plenty of pain: the pain of an addiction
epidemic, state health officials say.

. A state police captain says that for every prescription-drug dealer his
officers take off the small-town streets, four replacements are ready to
take over.

. A public defender in Perry County estimates that 95 percent of his
clients either sell or abuse prescription drugs.

. Eastern Kentucky circuit court dockets are jammed; possession and
trafficking charges for all controlled substances jumped 348 percent from
1997 through 2001.

. Residential drug-treatment centers are overwhelmed. Their admissions of
prescription-drug addicts tripled from 1998 to 2001.

"This may be the first epidemic -- if it is an epidemic -- that started in
rural areas," said Richard Clayton, an addiction expert who heads the
University of Kentucky's Center for Prevention Research.

Clayton and others have known for some time that Eastern Kentuckians use
lots of prescription drugs, legitimate or otherwise. He said he suspects
that many turn to drugs for relief from poverty, unemployment and low
educational attainment.

The nation caught a glimpse of Appalachia's drug dependency in 2001, when
major media outlets carried stories about the abuse of OxyContin, a
painkiller linked to dozens of overdose deaths in Eastern Kentucky and
elsewhere.

Still, national experts said they were surprised by the Herald-Leader's
analysis of data from the federal Drug Enforcement Administration. The DEA
tracks the distribution of all controlled substances used in medicines.

Dr. Eduardo Bruera, who directs pain treatment at the noted M.D. Anderson
Cancer Center in Houston, said he was amazed.

"Ten years ago, I would have said, 'Hooray for you, your region is to be
commended'" for treating pain, Bruera said. "Now, I have to ask who is
being treated for which condition."

More pain treatment

Eastern Kentucky counties led the nation in per capita narcotics
distribution in 1998, 1999 and 2000, the newspaper found. In 2001, the St.
Louis area passed Kentucky, driven by large increases in the amount of
OxyContin and of morphine, which is widely used to treat pain after surgery.

St. Louis is home to many oncologists, plus a teaching hospital, which
accounts for some of its numbers, said Susan McCann, administrator of the
Missouri Bureau of Narcotics and Dangerous Drugs.

As a whole, the nation saw rapid growth in the amount of prescription
narcotics distributed during the late '90s, which reflected a national
trend toward treating chronic pain more aggressively.

Legitimate need?

One Appalachian pain specialist suggested that Eastern Kentucky, with its
older population, many injured coal miners and high rates of lung cancer,
might need large amounts of narcotics to treat legitimate pain sufferers.

"An older population with more chronic disease and more chronic pain would,
of course, explain at least part of the need for more pain meds," said Dr.
Philip Fisher, head of the Huntington, W.Va.-based Appalachian Pain
Foundation, a non-profit organization.

The foundation, which tries to teach health care providers and law
enforcement officials about the proper use of painkillers, is funded by
dues-paying members, most of them health care providers, Fisher said. As it
was forming in 2001, however, it received a $20,000 matching grant from
Purdue Pharma, the maker of OxyContin. Fisher said the grant has had no
effect on the foundation's work.

Fisher and other pain specialists argue that law enforcement intimidates
too many doctors into avoiding the use of OxyContin to treat pain. The
American Pain Foundation, a non-profit that lobbies for better access to
pain treatment, says that 33 million to 125 million Americans suffer from
undertreated pain -- a claim other experts find hard to believe.

"Pain in the butt, I can believe," said UK's Clayton, laughing at the
suggestion that more than 40 percent of Americans are in pain.

Deciding who really needs narcotics isn't easy for doctors whose practices
serve low-income people, said Dr. Danny Clark, a Somerset physician and
chairman of the Kentucky Board of Medical Licensure.

Such patients "do not have the money to go to places to be evaluated for
chronic pain," Clark said. So to relieve their pain, doctors prescribe pills.

It ought to be easy to tell the difference between legitimate sufferers and
addicts, said April Vallerand, an assistant professor at Detroit's Wayne
State University who serves on pain advisory panels. In 2000, she won a
three-year, $489,000 grant from the National Cancer Institute to study
cancer pain management in the home.

"My patients with pain take these drugs so they can go back out and do the
things that are important in their lives," Vallerand said. "My addicted
population takes them to escape."

Trying to get away

Peyton Reynolds, head of the Hazard office of the Department of Public
Advocacy, said he sees many addicts among his clients -- 95 percent of whom
sell or use prescription drugs, he said.

"Our economy has failed," Reynolds said. "Young people are in despair. They
have no future."

Police who try to stop the pill-sellers say the nature of the crimes makes
enforcement seem like trying to hold back the tide.

With drugs such as cocaine and marijuana, police could occasionally work
their way to Mr. Big, said Capt. Mike Reichenbach, who heads drug
investigations in Eastern Kentucky for the Kentucky State Police.

"You work it long enough, you get back to the head and take it out,"
Reichenbach said.

But in the prescription-drug trade, each day brings a new kingpin: whoever
"has got their prescription filled at 9 a.m," he said.

Those who get arrested sometimes wind up in the care of people such as
Scott Walker, the substance abuse program director for Mountain
Comprehensive Care.

Every person in Mountain Comp's 21-bed Layne House in Prestonsburg is a
recovering prescription-drug addict. Each might have another addiction as
well, but it's "Lorcet, Lortabs and Oxy, mostly," Walker said.

"They are younger and sicker," Walker said, compared with clients from
previous years. Layne House residents are rarely older than 30.

The number of people seeking residential treatment for painkiller addiction
in Eastern Kentucky nearly tripled from 1998 through 2001, and the wait for
admission to one of the region's five community treatment centers can take
several months.

Prescription-drug abuse has been "slow and insidious over the years; the
last three or four years, it's been overwhelming," Walker said.