Interview with Dr. Blake Fagan, MD on Opiate Crisis in WNC

May 22, 2019

1. Please introduce yourself (background/education/experience/current organization & role, etc.)

Blake Fagan, MD

  • University of Missouri at Columbia

  • Medical School at Vanderbilt Nasheville TN

  • Residency at MAHEC in Asheville

  • Family physician for 20 years working with pregnant women and delivering babies (30% of practice working with kids)

  • Prescribing suboxone for patients with Substance Use Disorder for the last 3 years

  • Clinical Consultant for Opiate Crisis

  • Chief Education Officer at MAHEC


2. Please describe the extent of the opioid crisis in Western North Carolina and ways in which you measure that (include any common terms/phrases we should be aware of). Are there any statistics you think might surprise providers in our region regarding this issue?

I think all 50 states currently have an opioid crisis or problem. North Carolina is one of the top states (opioid overdose deaths per capita). WNC in particular (Appalachian chain) has high deaths by misuse of opioids. We know there is a high overdose rate and overdose death rate. More opioids are prescribed per capita in rural areas than in urban areas. 75-80% of heroin users started with opioid pills.

New terminology for Opioid addiction is “Opioid Use Disorder” (OUD). We no longer call them “addicts” we now call them someone with Opioid Use Disorder. Opioid is the umbrella term for semi-synthetics, synthetics (phetnel), and opiates (poppy derived like heroin, hydrocodone). Another concept we are hoping to share with patients and providers is that OUD is a chronic, relapsing disease.

All specialties in the medical profession are contributing to this epidemic and since 2012, North Carolina providers have prescribed increasingly less opioids every year. However, about 33% of new opioid prescriptions are coming from Dentists. One prescription of an opiate as an adolescent can equal a 6% chance of OUD in young adulthood, whereas when tylenol or ibuprofen are used instead, that chance reduces to 0.4%. While the data isn’t as available with other specialities, there is a concern about youth (under 25) being exposed to opiates unnecessarily, encouraging higher rates of addiction later on in life across all medical professionals able to prescribe opioids.

3. What causes do you believe initiated and/or exacerbated this problem (and when)? Which populations/areas are most vulnerable and why?

It’s a multifactorial issue. Access to opioids is unavailable in 85% of the world. No other country in the world is prescribing the amount of opioids that the United States is. We are the #1 prescriber of opioids per capita. Up to 75% of people who receive opioids after an acute issue do not finish their prescription, contributing to misuse and OUD. In Appalachia, it seems that Social Determinants of Health (unemployment, social isolation, housing, interpersonal violence, adverse childhood experiences, etc.) are contributing to increased use and individuals impacted in these ways are more likely to develop OUD. Increasing ACE scores linearly increase chances of OUD.

As a medical profession, we started prescribing more opioids in the 80s, overdose deaths began skyrocketing in the 90s into the 2000s and we believe that 2018 will be considered the peak of opioid overdose deaths. It’s likely that there are less deaths due to increased use of Narcan and other treatment or harm reduction efforts versus a reduced amount of people with OUD. In 2016, only 11% of patients that had OUD were able to find a provider to treat them. We hope that percentage has increased.

4. What efforts/programs are currently in place to address the issue? How are they performing? Are there any gaps in those efforts?

  • Prevention efforts

    • Increasing awareness among parents and kids about the dangers of opioids and encouraging parents to ask questions about opioid prescriptions for their children.  

    • Encouraging people to lock up their opioid medications and get them out of the house when they’re finished

      • Permanent drop boxes are available in 99 of the 100 NC counties

      • Add coffee grounds and water to pill bottle, then throw away or flush

    • Deactivation bags from pharmacies that seals and ruin opioids are becoming increasing available for patients to place their pills in and then throw away

  • Education efforts

    • State of NC is requiring providers that can prescribe opioids (Physicians, PAs, NPs, Dentists) to take CE about opioids annually

      • Increased focus on dangers of opioids and how to prescribe them appropriately

  • Treatment efforts

    • Encourage prescription of suboxone to treat SUD (included in medical student and residency trainings)

      • Western Counties have 4 federally qualified health centers with at least one provider that can prescribe suboxone

  • Harm Reduction

    • Multiple groups working in the harm reduction community

      • Increase Narcan access to the community

        • Buncombe county EMS calls to reverse opioid overdose have decreased

        • Narcan is saving lives until individuals are ready to engage with treatment services

      • Police departments have started using Narcan

    • 2 clean syringe access programs are available in Buncombe County and 1 is in Franklin County to reduce infections

      • There has been a 600% increase in hepatitis C in NC all suspectedly due to drug use injection

5. What can providers and/or other concerned individuals in the region do to help support those efforts?

Providers need to be aware of and screen patients for OUD and be prepared to refer when patients screen positive. Find out HOW to screen for OUD and know WHAT services are available in your area.

  • What to ask: Have you used an illicit drug or misused a prescription at any time? If yes, consider that a positive screen.

  • Have information available to share needle exchange and OUD services

6. Is there anything else you think we should be asking or important information you’d like to share on the topic?

Ensure understanding of OUD as a chronic disease and what works!

Think of a patient with uncontrollable with diabetes that you’ve perfectly managed with insulin. You wouldn’t take away their insulin or discontinue treatment after their diabetes became stable. You wouldn’t turn them away when if it were to become unmanageable again in the future. Imagine someone with OUD in the same position, as having a similarly chronic disease. Do not turn them away when they backslide. Continue to treat the problem as the ongoing, chronic condition that it is.