UNNATURAL CAUSES SICK AND DYING IN SMALL-TOWN AMERICA | Since the turn of this century, death rates have risen for whites in midlife, particularly women. The Washington Post is exploring this trend and the forces driving it. Read part one, part two, part three, part four and part five.
BAKERSFIELD, Calif. — Karen Franklin leans against the sink in the pink-tiled bathroom of her childhood home, counting out pills. There's a purple morphine tablet for chronic back pain, a blue Xanax for anxiety and a white probiotic for her stomach, which aches from all the other pills.
In all, Franklin, 60, takes more than a dozen different prescription drugs, washing them down with tap water and puffing on a Marlboro while she waits for them to kick in.
“They take the edge off, but that’s about it,” Franklin says. So she keeps a bottle of vodka handy for added relief, increasing her risk of joining the legions of American women dying from prescription-drug overdoses.
While death rates are falling for blacks and Hispanics in middle age, whites are dying prematurely in growing numbers, particularly white women. One reason: a big increase in overdoses, primarily from opioids, but also from anti-anxiety drugs, which are often prescribed in tandem.
Between 1999 and 2014, the number of middle-aged white women dying annually from opiate overdoses shot up 400 percent, according to a Washington Post analysis of data from the Centers for Disease Control and Prevention. Anti-anxiety drugs known as benzodiazepines contributed to a growing share of the 54,000 deaths over that period, reaching a third in the past several years, The Post found — though spotty reporting in death records means it is likely that the combination is even more widespread.
Both drugs depress the central nervous system, temporarily easing pain and anxiety while suppressing respiration, heart rate and the gag reflex. Alcohol has the same effect, and combining any of these can be fatal.
“They act like a dimmer switch on the central nervous system,” said Rear Adm. Susan Blumenthal, former U.S. assistant surgeon general and an expert on women’s health issues. “When taken in combination, a person’s breathing and heart will slow down, and can ultimately stop. People can go to sleep and never wake up.”
White women are more likely than women of other races to be prescribed opiates, and far more likely to be prescribed both opiates and anti-anxiety drugs, according to an analysis of middle-aged participants in the latest National Health and Nutrition Examination Survey. White women prescribed opiates are five times as likely as white men to be given that drug combination — helping to explain why white women may be at special risk.
Federal health officials have recognized the danger. This spring, in a guideline that urged doctors to reduce the use of opioids for chronic pain, the CDC warned against prescribing them together with benzodiazepines, except for patients battling fatal diseases such as cancer. At the very least, the CDC urged doctors to warn patients of the risks, especially when the drugs are mixed with alcohol.
On Thursday, the U.S. Food and Drug Administration began requiring warning labels on opioids and benzodiazepines — nearly 400 products in total — with information about the potentially fatal consequences of taking these medications at the same time.
“It is nothing short of a public health crisis when you see a substantial increase of avoidable overdose and death related to two widely used drug classes being taken together,” FDA Commissioner Robert Califf said in a statement. “We implore health care professionals to heed these new warnings and more carefully and thoroughly evaluate, on a patient-by-patient basis, whether the benefits of using opioids and benzodiazepines — or CNS depressants more generally — together outweigh these serious risks.”
Federal officials have no power to mandate a change in doctors’ prescribing habits. Even if they did, a mandate would do little for patients such as Franklin who get their prescriptions from multiple physicians.
“An opioid might be prescribed by a pain specialist while a general practitioner or a psychologist may prescribe the benzodiazepine. They may not know about one another,” said Deborah Dowell, lead author of the CDC’s new opioid guidelines.
Franklin’s struggle began 17 years ago with a single prescription for Vicodin. At the time, she had her own home and managed a grocery store. But the side effects of long-term opioid use soon set in. Mounting anxiety. Sleeplessness. Depression. With each new problem, doctors sent her home with more pills.
Now she lives with her 88-year-old father and spends her days shuffling between the TV, a refrigerator stocked with chocolate Ensure and the bathroom, which relatives call her sanctuary. Armed with a Bible and a carton of Marlboros, she prays for God’s protection, cracking the bathroom window to let the cigarette smoke drift into the back yard.
Lately, Franklin has been blacking out. Her sister found her facedown in a plate of food, and she started using a walker after losing consciousness on her way to the mailbox.
“What is happening right now is a slow suicide,” said her friend Ellen Eggert, a supervisor for the Kern County Mental Health Department. But Franklin is resisting Eggert’s appeals to seek help with her addictions.
“I know it’s not good for me,” Franklin said. “But I would rather say my prayers and take my medication.”
Suicides have doubled
Bakersfield lies in the heart of Kern County, a vast sprawl of lush cropland in California’s Central Valley. Here, accidental overdoses among white women have tripled since 1999, according to federal health data, and suicides have doubled.
The death toll has alarmed health-care workers like Eggert and given rise to a loose network of therapists, nurses, pastors and drug counselors struggling to understand a generation of women overwhelmed by modern life and undone by modern medicine.
Some, like Franklin, begin their descent after an injury. Others seek relief from conditions related to menopause. Middle-aged women also are more likely than men to suffer from a variety of painful conditions, including lupus, migraines and rheumatoid arthritis.
Whatever the complaint, doctors and drug companies have since the late 1990s responded with highly addictive painkillers, many of them central nervous system depressants previously reserved for the terminally ill. The more expansive use of opioids has fed an epidemic of dependency, leading to new prescriptions for anti-anxiety drugs and a rash of fatal overdoses.
These drugs appear to be a factor even among suicides, another major contributor to rising female mortality. According to Kern County coroner records obtained by The Post, 85 white women ages 35 to 60 killed themselves here over the past seven years. About half overdosed on prescription drugs, The Post found, and about half of those — 21 women — had some combination of opioids, benzodiazepines and alcohol in their bloodstreams.
Many of the women who chose other means of suicide, such as gunshot or hanging, also died in a haze of prescription drugs, The Post found. In nearly half of the 28 cases in which a toxicology test was performed, the women had consumed opioids, benzodiazepines or other central nervous system depressants.
When a woman dies in Kern County, it falls to Coroner Manager Dawn Ratliff to determine what happened. Her investigators explore medicine cabinets, flip through journals, scrutinize text messages and interview friends. Repeatedly, a pattern emerges, Ratliff said: A personal crisis leads to prescriptions to soothe the pain. And then they lose control.
“They are worn down. And they can’t rise above it,” said Ratliff, who puts the blame in part on the rise of social media, which can create unrealistic expectations about how life should go.
“Before, if you lived in a rural area, all you knew was your community. You just knew what people in your community looked like, what their lives were like. You didn’t expect to look like a movie star — or live like one,” she said.
Ratliff, 60, works closely with Eggert, 58, who created an outreach team for surviving family members of suicides that has been lauded as a national model. Eggert said she, too, has noticed the weariness and the desire for a quick fix to life’s problems.
“Women have had to be strong for so long. Opioids are a good way out. Benzos are a good way out,” Eggert said. Women “start depending on them to get through. Then, after a while, it’s not getting them through anymore. It’s running their life.”
The autopsy reports are filled with stories of dependency:
Bonnie Jean Marshall, 54, overdosed in 2012 after drinking alcohol and taking three prescription drugs, including the opioid Vicodin and the benzodiazepine Xanax. She lived in Wofford Heights, a village in the southern Sierra Nevada, and suffered from hypertension, pain and anxiety. She left a suicide note: “Sick for months—can’t get well so sorry nana.”
Holi Michele Mitchell, 43, shot herself in 2014 after taking Vicodin and two benzodiazepines — Klonopin and Xanax. She lived in Bodfish, a small town in the Kern River Valley, and struggled with depression after her son died in a car accident. His picture and a broken charm bracelet were found by her body.
Cheryl Moore, 56, left a journal that described two suicide attempts in the weeks before she overdosed on painkillers and alcohol in February 2015. Moore, who lived in Bakersfield, had begun taking opiates 18 months earlier after breaking her ankle. Then her husband, Duane, died of liver cancer, leaving a stockpile of stronger painkillers.
Moore’s brother, Eugene Frey, said he understands why women might turn to suicide, even when, like his sister, they have the means to seek treatment.
“There is an expectation for them to keep it together. People think: ‘Hey, you are white. You are privileged. So why do you have so many problems? Maybe you are the problem,’ ” Frey said. “There isn’t a lot of space for them to be vulnerable.”
Cultural shift
Eggert is part of a network of female health professionals working to understand the increase in white female mortality in Kern County. She said that she believes it is rooted in the cultural shift of the 1960s. As taboos were stripped away, women began drinking, smoking and medicating themselves more like men. As they aged, they began to suffer the effects: Since 1999, the death rate from alcohol abuse has more than doubled among white women ages 45 to 54, according to CDC data, though the rate for white men remains twice as high.
“It’s become normalized,” Eggert said. “Why does alcohol kill more people than all the other drugs combined? Because it’s acceptable, available, and there’s not a thing wrong with it. Why do women fail to see the danger of taking so many pills? Because it’s legitimate. It comes from a doctor.”
Joan Knowlden, a psychologist in Kern County, said she saw a sharp rise in middle-aged female patients in the early 2000s. Many had turned to alcohol, anti-anxiety drugs and painkillers to “mellow them out.”
Some had delayed childbearing, Knowlden said, and were trying to raise children just as they reached their peak professionally. Many were also entering menopause, which typically causes a drop in serotonin, a chemical that naturally soothes the brain.
“With perimenopause and menopause, you already have anxiety, sleep loss, loss of bladder control and loss of sex drive,” Knowlden said. “It can just become too much.”
Sometimes, Knowlden sends her clients to Sherri Bergamo, a nurse practitioner known as “the Hormone Queen of Bakersfield.” Bergamo noted that the rise of opioid painkillers coincided with a shift in treatment for menopausal women: Doctors stopped prescribing hormone-replacement therapy after studies found it increased the risk of stroke, blood clots and breast cancer.
Forced to "white knuckle" their way through menopause, Bergamo said, many women sought other forms of relief for mood swings and depression. She offers them custom-mixed hormones, which she argues are safer.
“There are some risks, but they are calculated, and they are carefully monitored,” said Bergamo, 74, who has undergone hormone therapy for 26 years. “I believe it saves lives.”
Medicine is coming back around to Bergamo’s point of view. This year, a panel of experts assembled by the North American Menopause Society concluded that hormone replacement is largely safe, especially for women under 60. In October, the society plans to recommend a return to hormone therapy for most healthy women, according to executive director JoAnn Pinkerton, division director of the Midlife Health Center at the University of Virginia Health System.
One thing menopausal women should probably avoid is long-term opioid use, which can further lower hormone levels, said Stanford University professor Beth Darnall, who specializes in pain psychology research.
“When women go through menopause, there are big changes with pain, anxiety and depression. There is a hard body of research on this,” Darnall said. “Opioids, taken long term, reduce the level of hormones in the body. This can lead to a greater sensitivity to pain. And it can feed into this dose-escalation cycle.”
The turning point
The turning point in Franklin’s life came in the late 1990s, when she said her tailbone was fractured during an episode of domestic violence. The pain led her to Vicodin, starting with the lowest dose: tablets containing five milligrams of the opioid hydrocodone.
“It might as well have been baby aspirin,” she says now. “All it did was make me a little sleepy.”
At the time, Franklin was managing a grocery store, a physically demanding job that had her lifting Halloween pumpkins, boxes of Easter candy and endless cases of soda. Within a few months, she persuaded her doctor to double the dose. Then she begged for stronger opiates, cycling through prescriptions for codeine, oxycodone and OxyContin.
Periodically, her doctors cut her off. “They would say, ‘You kind of like this too much,’ ’’ Franklin recalled. So she would call 911 and take a trip to the emergency room, where doctors typically offered a shot of Demerol, another powerful opioid.
In the early 2000s, Franklin’s mother died, her second marriage began to unravel, and she decided to quit working. Doctors added antidepressants, sleeping pills and anti-anxiety medications to her list of prescriptions.
Her world began to narrow. She saw fewer people. Franklin said she became “a hermit.”
Her friend Eggert suggested a psychologist, group therapy, long walks, church, yoga. Franklin rejected each idea. She came to believe she needed surgery. So in 2004, a surgeon implanted metal rods at the base of her spine.
The surgery failed to provide relief, and Franklin filed for disability.
“I was told it would be 80 percent better,” she said, “but instead it was 80 percent worse.”
Franklin keeps an X-ray of her back clipped to her refrigerator. If anyone questions her pain, she points to the X-ray: “They see those plates and they know it’s bad.”
In recent months, her chronic drug use has generated a host of new health problems, including pancreatitis and irritable bowel syndrome. Those conditions led to more doctor visits, which produced more prescriptions, and more pills to shake out of more bottles in her pink-tiled bathroom.
Her bottle of vodka, once stowed under the bathroom sink, now stays out on the floor, within easy reach.
Keating reported from Washington.
