Farmers are accustomed to hearing Tom Vilsack talk about farm bills and crop insurance — perhaps also trade and conservation. But when he speaks of addiction, it’s both serious and personal. And he’s speaking directly to rural America.
That’s because in small towns across the country, opioid addiction — including heroin and prescription drug misuse — has created an epidemic. More than 28,000 Americans died due to its misuse and overdose in 2014 alone, and 44% of Americans say they or someone they know has been addicted to prescription pain medicine. Every day, 84 people die due to opioid use or abuse.
A year ago, Vilsack, the U.S. secretary of agriculture, walked into President Barack Obama’s office with the intent to resign. He didn’t. Instead, he walked out with a new assignment: overseeing the administration’s response to the new drug problem that’s gripping small towns the way methamphetamine once did — prescription painkiller addiction. It disproportionately affects rural communities, in part due to lack of resources and treatment facilities. And while the president has proposed $1.1 billion in new funding to support states in expanding treatment options, Congress has not provided funding. In the meantime, USDA, led by Vilsack, has hosted a series of town halls and events to gather information and discuss solutions. USDA has also mobilized a series of grant programs to help communities, hospitals and local housing better address treatment and recovery in rural areas.
In an exclusive interview, Prairie Farmer recently sat down to talk about the situation with Secretary Vilsack.
PF: How would you describe the opiate epidemic, and what would the initiative do?
Vilsack: Nationwide, there has been a 300% increase in the amount of [pain medication] prescriptions that have been written for Americans since 1999. Physicians are writing prescriptions for pain medications. Dentists are writing prescriptions. Unfortunately, we haven’t had a 300% increase in pain since 1999. So these opiates have been over-prescribed, and the result is that people are getting more addicted to them. As they get addicted to them, they realize the cost of the medications is prohibitive, and so they begin to look for less-expensive alternatives and they move to heroin use. Today, 80% of new heroin users have their introductions into heroin through opiates.
The result of all of that is a significant increase in drug overdose poisonings and deaths and suicides that are connected in some way to addiction, and it has a disproportionate impact on rural areas because of the lack of support and the lack of treatment options in rural areas. And 76% of the shortage areas for treatment of substance use disorders or mental health issues is in rural America. So, it’s a big problem.
We have a significant increase in use of opiates in rural areas because of the nature of the work that people do. They get injured and they can have farm accidents, and so forth. So it’s understandable why medication would be prescribed.
The risk is great; there’s lack of treatment, more deaths, a significant increase in health-care expenses associated with opiate use, and significant loss of productivity as people lose jobs and don’t contribute to the economy fully. And of course, many of the folks get into trouble, and so you have more criminal justice cases. So it’s a very expensive and unfortunately tragic epidemic.
There are basically four aspects to how to control this or how to deal with it. First, there obviously needs to be a focus on prevention. Second, we need to make sure we expand treatment options. Third, when someone enters treatment, we need to make sure that the community is there to fully support recovery. And fourth, we need to take a look at our criminal justice system to make sure that those who are addicted are being treated appropriately instead of always incarcerated.
PF: Could you talk about those steps?
Vilsack: On the prevention side, it starts with the prescribers. It starts with educating doctors and dentists about when and under what circumstances to use opiates. Part of what we’re doing is working with the American Medical Society and the dental folks to better train prescribers on when to use opiates. The CDC [Centers for Disease Control and Prevention] has just come out with a series of new guidelines about when to use opiates and how much to use. And the FDA [Food and Drug Administration] is now putting a warning on the labels basically suggesting that there may be some addiction connected to this.
Secondly, it’s making sure that we identify early in the process those people who might be gaming the system by going to several different doctors to get several different prescriptions in order to get at a quantity of pills. That requires us to monitor prescriptions, and we’re asking states to consider establishing monitoring programs. Now, 49 states have monitoring programs; Missouri is the only that does not. It’s not uniform. So we’re trying to encourage uniformity. We’re trying to encourage the ability to communicate and the ability to input and check information.
We also want to prevent untimely death, and one way to do that is making sure that everyone has access to naloxone and Narcan, that would reverse the impact of the overdose and allow them to survive an overdose. Not every first-responder outfit, in particular in rural areas, has access to that, and not everyone has the ability to get a prescription for it, naloxone. So working with the CDC, working with HHS [Department of Health and Human Services], we’re providing grants to first-responder groups, police departments and fire departments so that they have overdose medications on board. We’re working with pharmaceutical companies and pharmacists to make sure that they can provide them naloxone, maybe on a general prescription, and working with state regulators making them more readily available.
On the medication side, it’s all about medication-assisted treatment. Some people can cold-turkey this. Most people cannot. They need to be tapered down and ultimately off. But to do that, you have to have access to the medications that will allow you to taper off. To do that, you have to have the people that are trained to administer those medications. And so we’re expanding the number of people trained. We’re expanding the capacity of those people to treat more people. We’re providing grants for the medications, and we’re also looking to potentially pilot in rural areas where physician’s assistants or nurse practitioners could be authorized to assist in medication-assisted treatments.
On the recovery side, it’s really working to understand that there needs to be an openness about this. There needs to be an awareness and ability to talk about it, and there need to be places where people can congregate and meet who are in similar situations. So we’re asking the faith-based community, particularly in rural areas, to get engaged.
On the criminal justice side, it really is about alternatives to incarceration — drug courts and things of that nature. They steer people more into mental health treatments and not into jails.
PF: What will success look like? And over what period of time?
Vilsack: A lot of it has to do with how cooperative Congress is, in terms of providing the resources to fund expansion of treatments, more rural direct access, and how quickly the medical society and dental society can train. And how open and willing medical schools and nursing schools are to training people properly on opiates.
This is not a situation that has been created in a single year or a couple of years. This is something that has evolved over a period of time, and it will take a period of time for us to reduce the number of deaths significantly. And to reformulate drugs so that they are not as addictive.
This is a long-term challenge, but first and foremost, it requires a plan. We have the plan. It requires resources. We have those resources.
So, the answer to your question is, it will be certainly faster if Congress finds a way to fund additional treatment and access to reversal drugs. The president has proposed a billion dollars, and that would certainly be a good start to expanding hundreds of these treatment facilities and encouraging more health-care personnel into the system.
Absent that, we’ll continue to see somewhere in the area of 84 Americans dying every day on average as a result of heroin or opiate abuse.
PF: How does the opioid crisis compare to the methamphetamine epidemic?
Vilsack: I don’t want to suggest that we’ve solved the problem, but we’ve certainly have made great strides with methamphetamine. But it was simpler because one of the key ingredients to methamphetamine was pseudoephedrine, and it was easy to limit access to pseudoephedrine. They couldn’t go into a Target and buy all the pseudoephedrine that was on the shelf and walk out. Now, it’s very difficult to get pseudoephedrine. It was easier for us to regulate raw materials for methamphetamine.
This is a different situation. This is a situation where you go in with a separated shoulder, you’re in a farm accident, you’re in a car accident, you’ve got a neck that hurts — your doctor prescribes these medications. Before you know it, it’s part of your life and you need more and more and more. Then you can’t afford that, so you move into a cheaper alternative. And what’s really troublesome about that cheaper alternative is it’s now being laced with a synthetic, which is really dangerous. It’s about 50 times more powerful than morphine, and the reality is that people take this stuff and their system is not prepared for that kind of a jolt. So we’re seeing more and more deaths related to the synthetic.
Opioids are a much more difficult problem, I think. It requires a much more comprehensive approach to get the medical community to understand alternatives to opiates and to get the pharmaceutical industry to reformulate these drugs so that they are not as addictive. It also requires state governments to put together monitoring requirements; it requires Congress to expand treatment options; and it requires the faith-based community to get involved in expanding a recovery support.
It’s complicated. It’s much more complicated than methamphetamine.
PF: Young people tell us there’s a hopelessness in the broken homes and domestic lives of small towns, so they turn to drugs for a good time and to forget. How do we address that? How do we fix that?
Vilsack: Well, I think first of all, we have to recognize it. Second, we have to understand the economic roots of that desperation and frustration, and understand the cause of that economic frustration. In a sense, many small towns are a victim of success in the sense that as we got more efficient and effective with farming, we needed fewer farmers. The result was that more and more young people who weren’t needed on the farm looked for opportunity elsewhere, and they went into the cities. Cities got larger. Small towns got smaller. The support system for the school, for the hospital — for the things that define the quality of life — is not as significant. People started losing their school districts, started losing their main streets, and it creates this impression that there’s no hope.
The goal here, and I think what we’ve attempted to do in the last seven years, is to come up with a plan, a strategy, a vision to change the dynamics of the rural economy. To say, production agriculture remains critically important, but it must be complemented with other opportunities. One opportunity is local and regional food systems — the ability to have smaller-sized operators be able to survive and to not require a thousand acres to be able to be profitable. How do you do that? You give those smaller markets the ability to define their own price rather than depending on market-based commodity prices.
The second aspect is conservation — continuing to look for ways in which we can leverage the conservation benefits, through more recreation and agritourism, creating what we call ecosystem markets, where regulated industries invest in conservation on the ground. And we’re seeing literally hundreds of millions of dollars of investment taking place now in these ecosystem markets.
And then finally, certainly in the Midwest, we can expand the notion of a biobased economy — not just the ethanol and biodiesel production facilities, but now chemicals, materials, fabrics and fibers being made from waste product from agricultural production. That offers new alternative options for farmers in terms of value added, and it also provides the ability through cooperatives for the farmers to benefit from processing. It creates manufacturing and processing jobs that farm families and small-town families can have; it creates construction jobs. All of a sudden you have growing opportunity. We’re beginning to see unemployment coming down. We’re beginning to see poverty rates come down, and we’re beginning to see some spark of vibrancy in rural areas. My hope is that we continue along this train, so that over a period of time, we will see more vibrant small towns, and the hopelessness will be less prominent than it is today.
PF: How do you think our rural socio-economic conditions compare to 10 years or even 20 years ago?
Vilsack: Well, there’s sort of good news/bad news. I think the difficult news is that there continues to be persistent poverty in rural areas. The statistic that we quote here at USDA is that 85% of the persistently poor counties in the country are rural. That’s not something that’s occurred over the last 10 or 20 years. It’s something that has been around for a while, but I think there’s a growing recognition to the fact that there’s a persistent poverty in rural areas. The good news is, we have a plan. The good news is, we’re seeing record investments in conservation and local regional food systems and new processing facilities, and the infrastructure that will support them.
So the good news is there’s a growing recognition, there’s a plan, there’s a process, and I think over time, we’re seeing some progress. So 10 years ago, maybe there wasn’t quite the recognition. There wasn’t the understanding that as we got better farming, there was going to be a negative consequence, which is that we weren’t going to have the need for three farm families on a farm. We can only support one farm family. What do the other two farm families do? Well, they might have a local/regional food system. They might have a conservation opportunity. They might be a family that operates and works at the local processing facility. Now they have more options than they have had. We just need to continue that.
PF: Do you think the average farmer out on his farm outside of town has any idea of what’s going on in town in terms of drug addiction and some of those kinds of things?
Vilsack: I’m not sure that farmers are immune to the drug addiction. I think you’ll probably find that they're no different than the general population in that respect. In fact, they maybe more at risk because of the nature of the work that they do and the injuries that can occur and the aches and pains that occur with farming. I would hope that they would be as aware. I would hope that they would be as engaged in their community, and understand and appreciate the challenges. The farmers that I know are pretty well connected. They are pretty well knowledgeable. I think that they may be searching for answers just like all of us are. But I would hope that they would be aware of this. If they’re not, they need to be. And they need to be aware of it if for no other reason than someone in their family maybe one of the millions of people that get hooked on this stuff, and they need to be on alert.
PF: Why is this important to you, and why are you dealing with it now as your tenure winds down?
Vilsack: There are two reasons. One, I obviously care about people in rural areas, and I know that rural folks are being disproportionately impacted by this epidemic. So I care for that reason, because it’s part of my job.
My personal reason is that my mom struggled with prescription drug addiction and alcoholism when I was growing up. She was an amazing woman who overcame her addiction on a daily basis until the day she died, but the reality is, she would never been able to do that if she hadn’t had access to a long-term treatment plan. If she hadn’t had access to community support in the form of multiple AA meetings that she could go to on a regular basis and sponsors that she could talk to when she was having a tough day, it would’ve been much tougher.
She had all the things that we are trying to create in this program: expanded treatment, recovery and criminal justice reform. She had all of that available to her. And so that’s why I’m convinced if you give everyone the suite of options my mom had 50 years ago, today we would have fewer people dying.
My mom came awfully close. She tried several times to commit suicide. One time it came very, very close. She was hospitalized, put in a mental hospital for a while; it was a tough period of time. It was one incident, one kid, one experience, but my guess is it’s not an unlikely experience for a lot of kids. A lot of families with an addictive mom or dad know the price that my mom paid. I know the toll it took on my dad, so I think I have somewhat of a sensitivity and understanding about this. I don’t want to say that I understand everybody’s predicament, but I sort of have a general understanding, and I feel particularly for the children.
My mom’s brother was not as successful as my mother was in recovery. Uncle Johnny died from alcoholism. So I saw the redemption of my mom’s efforts, but I also saw the pain of my grandmother having to deal with the loss of a child — and she was quite a woman.
She helped raise me, and she told me the worst thing that ever happened to her in her life — even though her husband had a stroke and she had to raise four kids during the Depression by herself — was losing her son. She said there’s no pain greater than a parent losing a child.
For more on USDA’s response and the grant programs available, visit usda.gov/opioids.