The text message to Mark Bridges, coroner of Newton County, told a story that has become increasingly familiar in Southwest Missouri.
"Mercy ICU just phoned in the brain death of a 42-year-old female. Was homeless, found in a garage. IV meth user. Only family out of state wants nothing to do with it."
Bridges and coroners like him are on the front lines of an expanding medical crisis involving opioids -- pain-relieving medications -- that is transitioning from prescription drugs to heroin, as well as leading to increased use of meth and other drugs.
"Drug overdoses and prescription drug overdoses are definitely at epidemic levels," Bridges told the Joplin Globe. "It is everything that is prescribed for pain, like hydrocodone and oxycontin. And there's meth and other drugs, too."
Bridges estimates there were five or so deaths related in some way to drug overdoses in Newton County in 2014. That number increased to about two per month in 2015.
In Southwest Missouri, heroin also has been confiscated in drug-related arrests, and a methadone clinic in Joplin that treats heroin users has seen an uptick in clients.
The problem has caught the attention of politicians and law enforcement.
U.S. Sen. Claire McCaskill, D-Mo., recently held a hearing in Jefferson City in an effort to bring attention to the increasing use of opioids and heroin.
That's because the use of heroin is tied to the abuse of prescription painkillers. When a bottle of prescription painkillers cannot be obtained, a bag of heroin can be purchased at less cost. In the end, the user gets the same relief.
According to the Centers for Disease Control and Prevention, about 75 percent of new heroin users first became hooked on prescription opiates.
U.S. Rep. Billy Long, R-Mo., also said he recently informally surveyed other members of the House and found that all of them are convinced their district, too, is having problems with opioid and heroin abuse.
"With an average of 51 deaths a day due to addiction to painkillers, America is in a full-blown opioid abuse epidemic," he said.
According to Long, between 2005 and 2014, emergency room visits for opioid overuse in Missouri more than doubled.
The federal Drug Enforcement Administration is enlisting health care providers, civic groups and parents of overdose victims in what it calls its "360 Strategy" to combat heroin and prescription drug abuse and related violent crime. St. Louis is one of four communities nationwide targeted by the new DEA program, along with Pittsburgh, Milwaukee and West Memphis, Arkansas.
"These are our families, our friends, our neighbors and our co-workers," said James Shroba, special agent in charge of the St. Louis DEA office. "We can't arrest our way out of this problem."
Zack Stephens, 23, of rural Joplin, said he has not used heroin, but he understands how a person who is addicted to prescription painkillers can be tempted.
For the past year, Stephens has battled an addiction to Roxicodone, a powerful painkiller, by seeking help from the counselors at the Joplin Treatment Clinic, 2919 E. Fourth St., operated by Behavioral Health Group.
Stephens used methadone from the center to reclaim his life. It's the same drug that is used to help heroin addicts who are trying to detoxify and kick the habit.
"I had a bad back. I was given a script for light painkillers," he said. "That was a good five to six years ago. It was not long after that I started buying really strong painkillers off the street. I was paying $30 a piece. I was spending hundreds of dollars a day -- at least a thousand dollars a week. My house was in foreclosure. I almost lost my family."
Stephens felt powerless because he was afraid of the painful withdrawal he would face to get off the drug.
"It's so scary. It's so bad. It's miserable," he said. "I'm in good shape now. But the withdrawals lasted about a year. My body ached. I would take 15 to 20 hot showers a night to help with the body aches. You have to want to do it.
"Meth is just a nasty drug, but it's not hard to get off. Heroin and painkillers are the two worst drugs out there. That's why they use methadone to treat them. I was not tempted to use heroin, but it does not surprise me that someone would. They are almost the same thing.
"People need to talk about this," he said. "People's lives are being ruined by this. People are dying."
Jason Bowers, program director at the Joplin Treatment Clinic, which is now in its sixth year, said: "Before it was primarily pills, but now heroin has really come into the area. It's cheaper to get and you can get a higher dosage.
"That is how the progression happens," he said. You start abusing a pain medication. You build up a tolerance. You need more and more. Doctors are becoming more aware of that and prescribing less. That's when they turn to heroin.
"Ninety percent of the people or better came to heroin through prescriptions," he said. "This could be a person who has been in a car accident, injured at work or were injured in the tornado. They become addicted and start looking for it on the street. They'll turn to Xanax or meth to reduce the effect when they cannot get an opiate."
The withdrawal period, which is severe, can last up to four months or more. Methadone allows them to not be sick and work through the treatment and the counseling.
"After we admit them as a patient, it takes at least a year. We give them medication that first day. It then goes to six days a week with counseling every week, then four days a week and then three days a week to once a month. They have to stay in treatment for at least a year."
Bowers said the census at the clinic has increased 15 percent over the course of 2015.
"A percentage of those would be heroin patients," he said. "These are new admissions that already are using heroin."
Getting on top of Missouri's abuse of prescription painkillers is made more difficult because Missouri is the only state in the union that does not have a prescription drug monitoring program. Such a program would prevent a person from taking a doctor's prescription for painkillers to more than one pharmacist.
A bill introduced Jan. 20 in the Missouri House of Representatives by Rep. Holly Rehder, R-Sikeston, would correct that by creating a monitoring program, but it could encounter the same headwinds that previous efforts have faced.
Rehder testified that her daughter became addicted to opioids after cutting her thumb at work and was prescribed painkillers. It wasn't hard for her daughter to find more painkillers once she ran out, Rehder said, and her next 13 years were spent in and out of rehabilitation programs and prison.
McCaskill held her Jefferson City hearing this month in part to draw attention to Rehder's bill.
"We get it through the House every year, but the hangup is in the Senate where they are concerned about privacy," she said. "On the House side, I'm concerned about privacy issues. However, what I think they fail to understand is that a prescription drug monitoring program -- a PDMP -- is no different than electronic medical records.
"The privacy concern is a red herring," she said. "This is an additional tool for medical providers to prevent people from going to multiple doctors to get narcotics. Without this program in place, your population is being harmed and it's harming the populations of other states. They come to Missouri to get narcotics that cannot be traced in Missouri."
Rehder tells the story of a Tennessee physician who had prescribed a painkiller to a patient. He checked that state's PDMP and found that his patient had got a narcotic two weeks before from a VA doctor.
"That helped this doctor address this young man's real problem -- an addiction to narcotics," she said. "That's when you want to recognize the situation in its early stage. Because if you don't, it's a natural progression to go from prescription pills to heroin."
When that progression starts, she said, "Heroin is the boogieman. Nobody wants to do that. But when their body increasingly needs that euphoric feeling, heroin is not the boogieman anymore. They have to do something to stop the withdrawals."
Research, she said, shows that PDMPs decrease the number of overdoses.
"This is a lifesaving tool. They're collecting less information than in your electronic records," she said. "This is a medical process that we should be ashamed in Missouri that we have held it up."
State Sen. David Sater, R-Cassvile, a pharmacist, has tried and failed to get a similar measure through the Senate.
"We're going to let Holly Rehder pass it out of the House first. We think we will have a better chance of getting it through the Senate if that happens," he said. "The people who are opposed to it are afraid the data system would be hacked. It has never been hacked in the other states that have this system.
"This all has to do with the conceal-and-carry database from Missouri that got sent to a federal agency. That left a bad taste in the mouths of a lot legislators."
Some lawmakers became enraged in 2013 when they learned that Missouri's database of concealed-weapons permits had been given to federal authorities investigating Social Security disability fraud.
State Sen. Rob Schaaf, R-St. Joseph, said that legislating a PDMP without voter approval is inappropriate.
"This is private medical information: the people of Missouri are not going to want to have everyone with a password to this program have eyes on that," Schaaf said.
Schaaf, who is a doctor, called a monitoring program a "severe intrusion" of privacy. He said the more he talked to other legislators, the less he found them supporting the program.
State Sen. Eric Schmitt, R-St. Louis County, said that with the prevalence of hacking, he can't support the idea of collecting private, important medical information.
"Data breaches have become so routine, we are numb to it," Schmitt said.
Instead of a PDMP, Schmitt said increased treatment programs and drug courts would be a better answer to opioid and heroin addiction.
"People believe this thing is a panacea," Schmitt said of the PDMP. "It's not."
Tim Mitchell, the owner of three drug stores in Neosho, said he has been advocating for the database for years because "there are individuals trying to get medications by pharmacy hopping and doctor shopping. If they are from out of town and they want to fill a prescription for a narcotic, it immediately throws up a red flag."
The personal information of customers, he said, will be safe.
"We're required to protect those records; if someone wanted something, I would have to have a medical release," he said. "It's not a privacy issue. It's bigger than that. We have to be able to have a common platform to communicate about patients. We have to know what people are being prescribed for safety purposes. People are overdosing. We've got deaths occurring."
The opioid problem is so serious in Missouri that six of the state's leading health care provider organizations recently took a stand on the problem. They urged the adoption of a core set of actions to reduce variation in opioid-prescribing practices to reduce opioid painkiller abuse.
State-specific research released earlier this year found that hospital treatment for commonly prescribed opioid painkillers -- where overuse is a primary or contributing factor for inpatient or emergency care -- increased 137 percent in Missouri between 2005 and 2015. Additionally, separate research suggested a strong link in opioid abuse and heroin addiction. The research found that as many as three out of four prescription opioid abusers would eventually use heroin as a less expensive source of opioids.
The recommendations are backed by the Missouri Academy of Family Physicians, Missouri Association of Osteopathic Physicians and Surgeons, Missouri College of Emergency Physicians, Missouri Dental Association, Missouri Hospital Association and Missouri State Medical Association.
"Missouri doesn't have a comprehensive policy to address opioid misuse and abuse," said Christopher D. Howard, president of hospital operations at SSM Health in St. Louis, and board chairman of the Missouri Hospital Association, in a statement. "There are limited options available to identify inappropriate use of these necessary but powerful painkillers."
Having a prescription drug monitoring program could become a key element in curbing the proliferation of heroin in Missouri, according to the CDC, because prescription drug abuse is "the strongest risk factor for heroin addiction."
From about 2000 to 2013, the number of people using heroin rose 150 percent nationwide, according to the CDC.
Last year, the Ozark Drug Enforcement Team, which covers 20 communities in a four-county area in Southwest Missouri, seized 19,000 grams of meth, which was a record, 65,000 grams or 144 pounds of marijuana, and 20 grams of heroin, said Chad Allison, spokesman for the team.
Twenty grams might not seem like a lot, but a one-inch by one-inch square bag holds a quarter of a gram of heroin.
"If you had a gram, you would be distributing," Allison said.
He added: "This is the way the drug world works in our area. It starts in St. Louis and spreads down the Interstate 44 corridor to Springfield and then to Joplin. Springfield is just now starting to see heroin. We are at the beginning stages of something. Of course, any amount of heroin is alarming."
