Dr. Fred Holmes

December 5, 2008

Testimony of Dr. Fred Holmes
Before the Senate Judiciary Committee
on Community-Based Solutions to Drug-Related Crime in Rural America

"I have a pill problem."

Wednesday, May 3, 2006, sitting in my office, a 19-year-old youngster asked, "if I could get him some of that medicine, so he wouldn't do pills". He'd just completed a stay at Phoenix House. I didn't know what a "pill problem" was. I didn't know what that medicine was, and I could find no one who could help answer his specific question. But, I immediately did realize that for all of the years I'd been treating his asthma and ADHD, while working with his special education team, he had been snorting four 80's a day. He was back last week, fresh out of jail. Again he asked me, "If I were to start using, could I get some of those pills instead?"

After several months of tutelage from others far more experienced than I, I was licensed to prescribe Suboxone, and met my second patient with addiction in October of the same year.

Two years, 400 phone calls and 100 patients later, I now know far more about youngsters struggling with addiction than I would have ever wished to know.

He's 20, second of many of a successful farm family, tried alcohol at 12, marijuana at 15, and knowing better but convinced he could "handle it" began recreational pill use at 15. By 16 he was addicted. Unable to not use for fear of "jonesing", and always in search of that first best high, he was soon snorting 6 80's a day. Eventually a high school graduate, employed on the family farms, his good pay and all savings were immediately exhausted, and he stole from his family. All of the available scrap material, building supplies, many tools and frequent checks forged against the families business account barely paid for his $500.00 a day habit. He cost his family $15,000.00. Early this year, caught when their accountant recognized his forgeries, he detoxed at Act One, completed a stay at Maple Leaf Farm, and then outpatient counseling at the Howard Center. But, unless taking pills, he always felt angry, and when frustrated three months ago, he again snorted an 80, and was soon struggling. As we tried to unravel his present dilemma, and get him back to rehab, he was teary eyed agitated; his mother sitting beside him frustrated, angry, crying.

17 years old, ratty beard, a huge smile and a goofy Yankees hat on half sideways. Big garish hoody jacket and pants hanging much too low, wrinkled at the bottom, over his shuffling shoes and onto the floor. With today's script for Suboxone, he was quickly out the door, on his way to IOP, on to Subway for lunch, and then to adult learning. His prognosis for today was excellent. My notes from a year before suggested he was depressed, having just finished a stay at Centerpoint, after admitting to the use of Marijuana. By then he had been in DCF custody for three years. By now he had been in Woodside 12 times, jail twice, released 2 days before after a stay of 20. He had been placed with his Grandmother, and desperately wanted Suboxone, now acknowledging that he began with alcohol and marijuana at 10, and was addicted to pills at 14. I said Valley Vista, not negotiable! He went, but only lasted 2 of the recommended 8 weeks, because he missed his Grandmother. He was immediately back looking for Suboxone. I told him I could not help unless he was in counseling, referring him back to Andrea at NCSS who had supported him through his previous years of "drug court". Having exhausted all she had to offer, he was referred to The Howard Center for IOP, which he did eagerly, soon back at my door in search of Suboxone. He had completed his half of the deal, so I did mine and began him on a low dose. The focus of his rehabilitation was his intense determination to play hockey. A week before today's visit, he had failed to make the team, was deeply despondent and completely non-compliant, even with the requirements of his "conditions of release". His Grandmother was in tears, in fear of losing him again. Today his hat was on half-sideways, and he was on his way back to IOP and Adult Learning. The Suboxone had nothing to do with it.

Two parents sitting in my office, each with a good job, together with funds so sufficient they never checked the balance of their joint account; never until the balance was $0.00, their 18 year old son having used their debit card to pay for his Oxycontin.

19 and very pregnant, she has been a patient of mine for years, with a brief interruption for some time in jail, after we caught her trying to fill a forged prescription for Oxycontin. She had started with alcohol at 13, marijuana at 14, and was addicted to Percocet at 16. She began her career with cocaine a year ago. At my insistence, she is back receiving support from the Howard Center, and I am trying to help with Subutex. In a boy-girl relationship, fueled with Oxycontin, it's the girl who gets pregnant. The relationship is temporary. The baby is permanent. She will have to deliver through the high-risk clinic at Fletcher Allen, and in withdrawal, her baby will begin a course of Methadone. We now care for at least 10 young women, alone with a young child, frequently homeless, locked into abusive relationships, with minimal education, little money, no family and minimal prospects for a job because of a felony conviction. Their young child then becomes the most important person in their lives, their single source of reciprocal unqualified love, a responsibility no child should be expected to fill, and they then can't go to rehab because "there is nobody who can take care of?"

When I walked into the exam room, there was no child. A couple I guessed to be in their mid 30's were sitting uncomfortably. He leaning forward, anxious with his elbows on his knees, his hands clasped tight. She sitting up right and apart, with her left arm over his shoulders. Brother and sister. For years he had been using four 80's a day, and more recently five "bupes", now none for 5 days. He was sick, very sick. His only question, "How much longer will I feel like this?" A couple of days. That was it; they left. She said, "Don't worry we'll take care of him."

29 years old, a patient of mine since birth, now married with children. Sitting with her husband, both very nervous, he told their story. She had been in a minor auto accident several months ago, her doctor gave her a bottle of Percocet, when she ran out, and felt ill, she complained of more pain and received another. Months later, her doctor refused to fill her prescription again, and when she became ill, her husband started buying Percocet on the street. When he could no longer afford them, he switched to Suboxone. He had been carefully treating her for months, but could no longer. Unemployed, he had sold everything he could. I suggested Valley Vista. "But what are we going to do tonight? I don't have any money." 20 minutes later, they were on their way to Act One, for detox before transfer to Maple Leaf or Valley Vista. One week later they were back in my office. She left Act One the next morning because she was home-sick. I called the Howard Center, arranged for an intake, and calculated a fairly rapid detox using Suboxone. Two weeks later they were back in the office. He was spending $10.00 a piece for 8 mgm Suboxone, which he then carefully controlled, cut into quarters, giving a piece to his wife 5 times a day. It was all he could afford; "I just couldn't stand seeing her like that."

A very successful local business man with a large family in a large house, but no savings, called to ask how to manage the last of the Bupes he had, to get to the end of what had been a four 80's a day habit for years. I told him. He said thanks and hung up.

20 years old, high school graduate, full time job on the mountain, alcohol at 13, marijuana at 16, 4 percs a day for 4 years, now buying bupes on the street, and expecting her first child in July. Gentle, insightful, pleased with herself, determined and confident. Howard Center, Sebutex, low dose to taper off and enjoy your new baby. As she turned to leave, sadly, "I was supposed to have a baby in January, but I didn't think I should, 'cause I was really into pills??."

* *

On average, they are 19 when they seek to stop their dependency on prescription drugs. The youngest having tried alcohol at 7, and marijuana at 8, most are using both at age 13. Their random pill use at 14, and dependence at 16, mean three years of addiction before they seek help. Oxycontin 80's are their drug of choice, virtually all use two a day, many as many as 6. At $100.00 per pill, habits cost hundreds of dollars a day, the aggregate pill cost for this population, seen by me, is in excess of 20 million dollars. Whether or not they have been arrested, may well depend on little more than from whom they steal. 39% have an officer at Probation and Parole, and 1/3 come to see me already appropriately treated with Suboxone that they "bought on the street".

Mac's quick stop, Pie in the Sky, Welden Theater, Champlain Farms, The health clinic in Northfield, Hodgdon Brothers, Quizmos, many catalytic converters, and multiple homes though out Swanton and down by the bay, are all crime episodes discussed in my office, frequently by the perpetrators. I now have patients who have been beaten, robbed frequently and stabbed. Some visit my office with an ankle bracelet.

The single most Northern Confederate raid occurred just a block away, and today once again we are locked in a "civil" war. Ours is a very powerful wonderful community where we all work well together, and refer back and forth on a first name basis. These are not "those kids". They are our kids! Ours are not bad kids. Even the relatively few that I see are good kids who made painfully naive bad choices when they knew no better. On average they start pills at 14. They then knew nothing of addiction. And they certainly didn't plan on losing their adolescence trying to avoid getting "pill sick", always in search of that "first 2 pill high", or in jail. The apparent current trend toward "booting" (IV) their pills makes this conversation that much more critical.
My thoughts:

1. Conversation, respectful consideration of shared concerns, just like today, held in public.
2. All of us should know what each of us has to offer: prevention, education, treatment, and law enforcement, and include a consideration for us all in every conversation.
3. Education. Don't smoke. Look both ways before you cross the street. Don't drink and drive. Pills are bad. Before our kids are in the 5th grade.
4. A big fat check for Winnie (Thomas of the Howard Center), for a multidisciplinary single site center to address substance abuse. We are woefully ill equipped to address this problem. We are constantly chasing our tails, playing catch up, and we get together to talk only in response to new bigger crises, or when the Senate Judiciary Committee is coming to town. As a perhaps well intended Pediatrician, I cannot begin to appropriately address the needs of a teenager whose struggles with addiction have repeatedly lead him through the courts and jail. The case management and surveillance piece alone is daunting. I well know that within the world of Pediatrics the algorithms of the UVM ILEHP and VCHIP programs would provide us with the well proven structure for interdisciplinary evidence based Community problem solving process that would make far better use of the energies we are now valiantly expending.

Fred Holmes
December 5, 2008