A note about this project: This story (the first of two) is part of an ongoing collaboration between InvestigateWest, an independent nonprofit newsroom covering the Pacific Northwest, and public broadcast station KCTS 9. An accompanying documentary airs at 9 p.m. Jan. 30 to be followed by a half-hour in-studio discussion.

Dr. Rosemary Orr didn’t see it coming that day. It was the morning after Mother’s Day. She needed a ride to work, so her 24-year-old son Robin drove her. She was in a hurry to get to Children’s Hospital and Medical Center in Seattle, where she is a senior attending anesthesiologist.. Otherwise, she says, she would have spent more time talking with him

She’d been worried about his sleeping habits, his weight loss lately. She knew her smart, handsome son had struggled with addiction to OxyContin in the past. But he’d kicked it. He’d assured her of that. He’d looked her in the eye and said, ‘You don’t have to worry about me, Mom.”

No parent wants to believe her child is using. Not even one who is a doctor.

“I was stupid and desperate enough to believe that explanation,” Orr says now, five years later, over coffee a few miles from her work, where she takes care of the pain of others. Her own pain, she takes with her.

When she got home from work that day, Robin’s phone was ringing, but he wasn’t answering in his room downstairs. She knocked. And knocked again. She went around her house and peered in through his bedroom window.

Her son was on the floor, dead of an overdose.

Orr’s son is one of thousands of Americans, including a growing number of young people, who have died from prescription pain medications, powerful opiates that one emergency room doctor described as “just a fancy form of heroin.”

With a law that took effect this month, Washington state is making a bold attempt to reduce overdose deaths by launching the first-ever dosing limits for doctors and others who prescribe these medicines. The law has been heralded as one of the toughest in the nation, but loopholes and pitfalls in the system remain.

Prescription drug abuse is at epidemic levels throughout the state, and elsewhere in the country, despite lawmakers’ attempts to get a grip on it.  Washington now has one of the highest death rates in the nation. Deaths from prescription drug overdoses in this state have skyrocketed nearly twenty-fold since the mid-1990s, and now outstrip those from traffic accidents.

In King County, deaths from prescription opiates exceed deaths from heroin, meth, and cocaine combined.

Washington has been one of the hardest hit states in the country, in part because of aggressive prescribing practices. That, coupled with lack of oversight of doctors who over-prescribe, has led to the spectacular run-up in the number of deaths from prescription overdoses.

Dr. Russell Carlisle, head of Swedish Medical Center’s Cherry Hill Emergency Department in Seattle, was shocked by the volume of painkillers doctors were prescribing in Washington when he first moved here from California in the mid-1990s.

Running between exam rooms during a recent busy afternoon in his ER, Carlisle recalled that California maintained tight control of pain medication, requiring triplicate documentation for opiate prescriptions at the time. But in Washington, emergency room doctors were routinely handing out prescriptions for 30 to 40 pills at a time, even to people with histories of drug habits.

Why? “Because then they wouldn’t come back,” he said. 

But that efficiency turned deadly. “The higher deaths, and probably abuse, too, I believe has to do with higher supply or availability,” said Jennifer Sabel, an epidemiologist with the state Department of Health.

An InvestigateWest analysis of U.S. Drug Enforcement Administration data shows Washington ranked fourth highest nationally in per-capita prescribing of methadone in 2006 (the most recent year for which reliable data is available) and 11th for oxycodone — the two biggest killers.

Even more disturbing, more than half of all prescription drug-related deaths in the state occur in the state’s poorest and most vulnerable population — people on Medicaid, a population that is itself exploding in our recent economy. A 2009 federal study showed the age-adjusted risk of death from prescription opiates in Washington was nearly six times higher for Medicaid enrollees than those not on the program.

“Medicaid has about a death a day from prescription narcotics, and in the last two years, it’s continued to escalate,” said Dr. Jeff Thompson, medical director for Washington’s Medicaid program. Many of those deaths are among young people, he said, a trend that also has public health experts concerned.

New addicts are getting hooked at younger and younger ages, said Caleb Banta-Green, a research scientist at the University of Washington’s Alcohol and Drug Abuse Institute.

“The largest group of people entering treatment for prescription abuse right now is made of young people between the ages of 18 and 24.”

The making of an epidemic

Washington’s emergence as a state with one of the highest rates of both opiate prescriptions and deaths was not, in hindsight, an accident.

In 1995, Purdue Pharma introduced OxyContin along with an aggressive marketing campaign pitching the drug as a salvation for chronic pain. The next year, Washington’s medical profession did an about-face in its approach to pain management. The state’s Medical Quality Assurance Commission issued new liberalized guidelines addressing the under-treatment of chronic pain. By 1999, they had been codified into law.

The 1999 law specified, “No disciplinary action will be taken against a practitioner based solely on the quantity and/or frequency of opiates prescribed.”

The relaxation of the rules resulted in a run-up in prescriptions. “Since the law changed, the average daily doses in morphine equivalents have gone through the roof,” said Dr. Gary Franklin, medical director for the state’s Department of Labor & Industries. In 1998, the average daily dose was 80 mg. By 2002, it had nearly doubled to 140 mg.

The same trend was going on around the country. In 1997, prescription opiate sales amounted to 96 mg per person in the United States. By 10 years later, they had mushroomed to 698 mg per person, Franklin said. “That’s enough for every American to take 5 mg of Vicodin every four hours for three weeks.” In 2010, the levels increased still further, enough to medicate every adult around the clock for a month.

Franklin was among the first to notice an alarming corollary effect: the drugs used to kill pain were also killing people.

“Workers were coming in for low back sprains, and dying,” he said. Franklin and his colleagues published the first paper in the country to link worker deaths to prescription drugs in 2005. But when he presented his findings at medical meetings, he faced backlash from the profession and the drug industry.

Many in the profession had fought long and hard to get access to these drugs for better pain management of chronic pain patients, Franklin said. “They didn’t want to hear it might be killing them.”

In May, 2007, Purdue Pharma sent Franklin a three-page letter blaming deaths on patient abuse and disputing Franklin’s contention the drugs were being overprescribed. A day after he received the letter, Purdue executives pleaded guilty to misleading the public about the addiction potential of OxyContin, and agreed to pay a $600 million fine.