DEA: Heroin likely the next drug wave in Montana

Stacy Zinn and Tammy Ralston are two Montanans tackling the same complex problem of prescription drug addiction and distribution in different ways.

Zinn is a Drug Enforcement Agency agent in Billings who works to catch criminals including middle- to lower-tier drug dealers and unethical medical providers.

Ralston is a family nurse practitioner and pain management specialist at Northern Montana Health Care who works with patients to treat chronic pain in ways that reduce or completely eradicate the use of narcotics.

While abuse of and addiction to opioid painkillers has become rampant in Montana in the last decade, Zinn said, as a result of the opioid craze, north-central Montanans can expect a new drug craze to hit - heroin.

The problem for the illicit pill user, she said, is that pill habits are expensive.

"If you have a three-pill habit, that's $150 a day times seven. And it's only going to get higher," she said.

Since opioids are man-made opiates that provide a high similar to that of the poppy plant-based heroin, Zinn said, Mexican cartels have begun sending heroin up into the states. Last week, during a Jan. 26 presentation during Montana State University-Northern's Bitter Pill series on prescription medication addiction and abuse, Zinn said authorities in the Billings and Bozeman area already are seeing heroin.

"So, buyers on the street are saying, 'Instead of buying this pill, I can buy the brown stuff for a lot cheaper,'" she said. "So the cartels are sending the heroine in. It's reached our state lines, and we're seeing more of that."

Pharmacies push pain meds

Zinn and Ralston said a marketing push by pharmaceutical companies in the 90s, supported by the false narrative that certain narcotics aren't addictive, burst open the floodgates of physicians prescribing narcotics more freely, and that has helped create the nationwide opioid epidemic that very much includes Montana.

"Back in 1997, pharmaceutical companies said OxyContin - oxycodone - was not addictive, and therefore they did a big marketing ploy and encouraged the physicians to start prescribing it more so. That's when we started to see the uptick on addiction, overdoses, et cetera," Zinn said Wednesday.

"When they came out with their synthetic opioids, meaning Ultram - tramadol - they said they were not addictive in the very beginning," Ralston said Thursday. "I can remember the reps coming and saying, 'The new, nonaddictive, Darvocet.' When Darvocet was out years ago, it was nonaddictive, it was the choice."

Zinn said that was the start of major problems.

"It's been a uphill battle ever since then," Zinn said.

As a DEA agent, Zinn said, the good news is she hasn't seen any pill mills - doctor, clinic or pharmacy that is prescribing or dispensing narcotics inappropriately or for nonmedical reasons - in Montana. But prescription pills have spilled into every crevice of society, causing much concern.

"We had a report from an anonymous nurse that there was an elementary school in the southern part of Montana where a second-grader had got ahold of some prescription pills and brought them to school and just passed them out," she said. "Sometimes these pills look more like candy."

A serious problem in Montana, Zinn said, is doctor shopping.

Doctor shopping is seeing multiple treatment providers in a short span of time to get prescription medications illicitly, she said. People who doctor shop usually sell pills. Hill County court documents show that pills such as hydrocodone or OxyContin often sell for about $50 when sold illegally in north-central Montana. Dealers up here, Zinn said, get more for those pills than in the Billings region.

The Montana Prescription Drug Registry is supposed to combat doctor shopping.

"The information in the (pill registry) can assist providers in optimizing patient treatment plans and, potentially, deterring diversion of controlled substances for illegal use. In addition, by searching 'My Prescribing History,' prescribers can review all prescriptions that were dispensed under their DEA number, enabling them to identify any fraudulent use of their DEA registration," a statement about the registry on Montana.gov says.

But doctors are not legally obligated to use it, Zinn said, and many don't.

"What we hear is that doctors say, 'We don't have enough time. We have 15 minutes to get A, B and C done. We don't have time to go check the registry,'" she said. "There's some doctors that don't believe in it."

The DEA does investigate doctors when it has reason to, she said.

"When word gets out on the street that a doctor is an easy person to get pills from, that's when it kind of raises our interest," Zinn said. "We've had a case or two where doctors have just over-prescribed and there's been overdoses and have eventually led to death."

Drug habits also have indirect consequences that can affect the lives of people who have nothing to do with any kind of drugs, people who don't even know anyone on pain meds, she said.

Burglaries among addicts and sellers is common, she said. The thieves sell whatever they find of value to pawn shops and use the money to support their pill habit. Other times, Zinn said, users band into groups, take turns shoplifting from retail stores and then pawn the stolen items to buy pills.

Aside from getting doctors to use the pill registry, as well as other deterrents, Zinn emphasized education - warning people about the dangers of pills - as another major key to combating the problem, she said.

"I believe the more we educate people about this problem the better off we are," she said. "Unfortunately, everyone thinks that getting a pill from a doctor is OK because a doctor is not going to mislead us. It's not that the doctor is misleading us. It's that the doctor is prescribing something that's very addicting, and that's why you have to educate the public about how addicting some of these pills can be."

As a family nurse practitioner who specializes in pain, Ralston said, she works to curb narcotic dependency with patients in pain.

"Right now we are in an era where if you have pain, you need a pill. It's not accurate," she said. "There is some pain that should be expected. The aging process is painful. You are expected to have some amounts of back pain as you age, depending what you've done with your body.

"Narcotics are not the answer. In my opinion, narcotics for chronic pain should never be started at the family practice level," Ralston said. "They should be last-ditch effort, meaning everything else should have been tried.

"The problem is society is not there yet," she added. "Society is still in the pill fix phase. 'I don't need to go to physical therapy three times a week, I don't have time,' and 'I can just take a pill and I'll feel better.' Well, every pill that you take has another reaction on your body. Nothing comes for free. ... Pills are not a treatment for a pain. That's a misconception that we have as a society. Pills are not treatment."

Ralston said there are different kinds of pain, and therefore different approaches to treatment.

"There are pain pumps that can be put in. You don't end up with a systemic affects of medication," she said. "We do spinal cord stimulators. We have an interventionist that comes in from Great Falls - Dr. Craig Sweeney. He does all the procedures for us, and the anesthesia department here does some as well. And we have a new interventional radiologist who also does some of the procedures. There's a lot of choices."

Another part of Ralston's approach is teaching patients to cope, she said.

"We talk to patients multiple times a day on coping skills. I get a lot of patients that are on a substantial dosage already," she said. "I call them my legacy patients - they've been on it for years. You're trying to trial them down a little bit, to make them understand that it doesn't change. If they're getting a high dose of medication, lowering it by 10 percent isn't going to change the effectiveness that they're getting."

"So if you're feeling some pain, what are some things that you can do to deal with this?" she asked. "We talk about music, reading, exercise, dieta - redirection. And we talk about that every visit. They don't always take that in on the first one. We're all the same, we don't like change."

Ralston said her approach works and there are success stories. But it's not easy, she said, especially for her legacy patients. The question is usually about how long it takes to get on board with the program.

Ralston said she both is, and she isn't, a new kind of provider. Many providers around the country are doing what she's doing, but there are still others who are doing things the "old school way," she said.

Northern Montana Hospital officials, Ralston said, have been very open-minded and supportive of her approach.

"I believe they want to see change," she said.

Ralston said she is hopeful, adding that she sees that people with chronic pain want to do things different.

"They don't want to be bound to pills. They want to try other ways to get relief," she said.