Colleges can’t be bystanders on opioids

THE OPIOID CRISIS, rooted in the overprescribing of painkillers, has seized the attention of public officials from Beacon Hill to Capitol Hill. So, too, has the inadequacy of mental health services on college campuses become well documented. But so far, neither policymakers nor college administrators have connected the dots between the painkiller epidemic and the crisis of young people on campus with more access to narcotics than to care, although the connections are right before their eyes.

The dots were connected for me and my husband Larry a decade ago, in the most horrible way possible.

Our son Jeremy was 21 years old and a junior at Indiana University in 2007 when he fatally overdosed. Jeremy was found in his apartment, rushed to the hospital, and pronounced dead. The coroner’s report claimed cardiac arrest due to an overdose. Toxicology studies found high levels of hydrocodone and cannabis. Where did the drugs come from? How long had Jeremy been taking them?

It would be 13 months before Larry and I knew how unmonitored pain medication, following a back injury at school a year earlier and complicated by alcohol use ignored by the clinicians treating him, led to his death.

Getting answers was not easy. We started at the university, meeting with two deans and the newly appointed associate provost. Jeremy’s professors reported he had been showing up to class and keeping up with assignments and quizzes, though it was only a month into the term. As that was all the information these administrators had, the meeting was short. Jeremy lived off campus—less than a mile from school—which made investigating his death a matter for the local police. That was a relief to the university, I suspect.

That same afternoon, we met with the chief of the Bloomington Police Department and a detective. The chief let loose with a mini-tirade about drug addicts, and the detective asked about hydrocodone, which confused us. We had not yet seen the coroner’s toxicology report, but in retrospect, it was clear that he had. We were urged to keep in close contact, and the detective said that he would do the same.

Yet, for weeks, we heard nothing. The police department ignored phone calls and emails. Just before Thanksgiving, we FedExed letters to the university, the police, and the mayor of Bloomington. Our complaints got the case assigned to a new detective, but she made little headway. She interviewed some of Jeremy’s friends and focused in on a young man who had spent time with Jeremy before he died, but she could not track him down. She tried to locate him on campus, but the dean of students refused to provide information as to his whereabouts and couldn’t say why. Neither could the associate provost. We asked the detective why a university official wouldn’t cooperate. “Sometimes they do, and sometimes they don’t,” she said.

Access to information about college students is covered by the federal Family Education Rights and Privacy Act of 1984, or FERPA. The FERPA law, which applies to institutions of higher education receiving federal funding (they all do), protects students’ educational and personal information from disclosure without prior consent. It also guarantees confidentiality of student medical records, as most university health services neither maintain electronic records nor rely upon third party payments, and therefore are not governed by the Health Insurance Portability and Accountability Act, or HIPAA.

In the event of health emergencies and campus drug and alcohol violations, which may be considered matters of public safety, the law permits institutions of higher education to contact parents of a student until he or she is 21 years of age and/or if he or she is claimed as a dependent on parental income tax. Universities vary, however, in how they interpret the law, and integrate federal and state law into school policy. Some schools telephone parents as soon as there is any violation or health emergency. Others call only if, beforehand, parents and students sign a waiver requesting notification. To do nothing and/or just wait is also not unusual.

LEARNING WHAT HAPPENED

It was more than a year before we gained access to Jeremy’s medical records. In October 2006, while at school, Jeremy was diagnosed with a herniated disk. Hanging out with friends, he had fallen off a barstool—which should have been a bright red flag. As a teenager, Jeremy had had a problem with alcohol, but he and we thought that was behind him. In his Brookline High School graduation speech in 2005, he spoke proudly of having overcome his “inner demons.”

Jeremy’s back injury was followed by numbing down his left leg. He called home worried and we urged him to see a doctor, which he did, readily granting us permission to consult with health care providers. No surgery was necessary, we were told, by a doctor there. Outpatient treatment would include epidurals, massages, and some medication.

When I asked a nurse for additional details about the injury, she was evasive. She never mentioned he might have blacked out, which I only learned afterward from his medical records. These same documents confirmed that Jeremy told his doctors about the alcohol he consumed at college, including that night, in addition to Adderall, prescribed for attention deficit disorder since he was in middle school. There was ample reason for a cautious approach to treatment, and close monitoring. But that is not what Jeremy got.

During the first 12 days of treatment, the Indiana University Health Service prescribed 70 doses of narcotic painkillers, including hydrocodone and propoxyphene, in addition to 30 prednisone (steroid), 20 Skelaxin (muscle relaxant), and 20 Naproxen (anti-inflammatory)—a total of 140 pills in less than two weeks. Within a month, the campus health service referred Jeremy to a physiatrist at Indiana Rehabilitation Associates in Bloomington, where the narcotic regimen continued for seven months. All prescriptions were filled at the Indiana University pharmacy.

Jeremy returned home in May 2007. The year had not been easy. It showed. Irritable and frustrated because his grades had dropped, he worried about getting himself back on track academically. MRI in hand, he consulted a specialist in spinal and back injury at Brigham and Women’s Hospital in Boston. The doctor prescribed anti-inflammatory medication and muscle relaxants, but no narcotic painkillers.

The summer went well. Jeremy was invigorated, calmer, and eager to return to school, which he did on August 20. He was supposed to join us in New York City on October 6 to celebrate Larry’s 60th birthday. But in mid-September, he telephoned, asking to come home sooner, insisting it was important. We made an airline reservation at once. But on the morning of September 19 Jeremy overslept and missed his flight—in retrospect, another red flag. That week he missed two doctors’ appointments. Eight days later he overdosed and died. He should have told us about all the narcotics prescriptions; it cost him his life.

A CAMPUS CRISIS 

Drug overdoses are the leading cause of accidental death in the United States. Since 1999, fatal overdoses have in-creased 167 percent for the population at large and 224 percent among young adults aged 18 to 24. These appalling rates are traceable to the opioid epidemic, fueled by the overprescribing of opioid analgesics and the recent availability of cheaper heroin and illegally produced fentanyl, according to the Centers for Disease Control and Prevention.

According to the federal Substance Abuse and Mental Health Services Administration (SAMSHA), in 2014 18-to-25 year-olds used more prescription medications—psychotherapeutics, pain relievers, sedatives, tranquilizers and stimulants—than other cohorts, older or younger. For every overdose death in this age group, there were 119 emergency room visits and 22 treatment admissions associated with these medications. SAMSHA also found 18-to-25 year-olds were less compliant with doctor’s instructions than other age groups, misusing medication for pain relief, relaxation, sleep improvement and enhanced concentration.

The situation appears worse on residential college campuses. Research comparing college-enrolled 18-to-24 year-olds to peers not in college has found rates of binge drinking, intoxication, and misuse of stimulants significantly higher among those in college. Stimulants such as Vyanese, Adderall, and Ritalin—sometimes referred to as “study drugs”—are passed around freely, with ample supplies due to overprescribing. (Overdose deaths caused by stimulants, prescription and non-prescription, have doubled since 2010.) The chemical culture of alcohol, drugs, and prescription medication on campus and in the doctor’s office are colliding, leaving in their wake a trail of pain and undue harm.

In the midst of this growing crisis, colleges and universities do almost nothing. The federal Clery Act requires campuses to log alleged crimes. The Safe and Drug Free Schools and Communities Act of 1997 targets unlawful possession, use, or distribution of drugs and alcohol. Good Samaritan laws encourage students to call 911 in the case of a medical emergency by granting immunity for illegal possession. But none of these legal measures requires, or even inspires, these institutions to keep track of, let alone act on, the deadly mix of chemicals in circulation among their students.

Institutions of higher education provide little education and guidance to families and young adults about public health and health care services at their institutions for students living either on or off campus. Families are kept in the dark about overdose deaths, ER visits, and prescribing laws and practices in the states where institutions are located. They’re also often given no details about the availability of medical professionals for students, access to pharmacies and standards of care, and university laws and policies, including waivers of federal privacy rules under FERPA so that parents can be informed about what happens to their child.

In the years following Jeremy’s death, I spoke with students, faculty, and administrators at numerous high schools and colleges, including Boston University, Dartmouth, Harvard, Stanford, and George Washington University. College administrators were willing to discuss efforts to curb binge drinking on their campuses. But when it came to health and mortality data, they were defensive.

“Families don’t need to be informed, they know about this troubling state of affairs already, it’s all in the newspapers,” one counselor remarked. A campus medical director said sharing data about student deaths from alcohol poisoning and overdoses, and emergency room visits to campus infirmaries and hospitals off-campus would scare parents away.

When I told a prominent college president that a Yale sophomore had recently died from prescription painkillers obtained from an athlete being treated for a sports injury on his floor, his naïve response was “that doesn’t happen here.” He pronounced alcohol the designer drug of choice among college students. Afterwards, the mother of the young man who died at Yale reminded me tragedies like his are often portrayed as random, convincing us that prevention strategies can’t work.

In the midst of this studied ignorance, institutions of higher learning take little responsibility for health and mental health services. The death of seven students in five months from suicide or overdose at Columbia University led senior Jacqueline Basulto last February to initiate a petition calling for improved mental health services at Columbia and 20 other schools. Within two and half months, close to 1,000 signatures were collected across these campuses. The Columbia administration set up a task force to expand services, the only one of the nearly two dozen schools to respond so far.

A recent survey of 50 colleges by STAT found long delays in obtaining initial counseling appointments. Jacqueline Basulto herself was told to wait two weeks at Columbia counseling when she was suicidal, claiming it was the support of her parents nearby and expensive therapy outside the institution that got her through. She attributes student stress to academic pressure and competitiveness and the stigma of needing help. At Indiana University, where Jeremy attended, as well as several other large schools, STAT found one counselor employed for every 1,500 undergraduates.

The National Survey of College Counseling Centers found in a sample of 275 institutions of higher education that just 58 percent have access to on-campus psychiatrists, despite sharp increases in students arriving on campus on medication already and an increase in medication referrals initiated by counseling departments at those schools. Roughly one in four college students who seek mental health services are on medications that need a psychiatrist’s supervision.

Without enough providers, parents may be forced to mail psychiatric medication to their sons and daughters since out-of-state prescriptions for controlled substances such as stimulants are often difficult to fill. Pill shipments contribute to an unmonitored glut of medications which may be shared, bought, and sold on campuses.

A BETTER WAY FORWARD 

It was during my generation in the 1960s that student protests for free speech and civil rights challenged university authority and the presumption that colleges would act in loco parentis. What followed in its place, according to Peter Lake, who directs the Center for Excellence in Higher Education at Stetson University College of Law in Florida, was the “bystander” era, in which universities felt “no duty to respond” to the risks present on their campuses, including the unsupervised use of alcohol and prescription medications.

Lake calls this a broken system, where administrators often feel powerless, young people feel unprotected, and families feel ignored. He thinks we need to steer a different course, using cooperation, compromise, and strategies based upon science (and hopefully neuroscience). That won’t be easy. But certainly American universities have the technological capacity to collect data regarding student deaths, hospitalizations and injuries, analyze the results, and come up with new ideas for better programs and policies.

Today’s students arrive on campuses from all over the country, filled with excitement and enthusiasm about their future, but with no one to monitor medications they may be taking already and with inadequate access to counseling and mental health services. Young scholars who turn their ankles, sprain their wrists, or tear their ACLs find themselves with a bottle of narcotics that turn them into addicts or suppliers of dorm-room drug swaps. Aspiring doctors, lawyers, and entrepreneurs have their lives turned upside down—if not lost forever—by the smorgasbord of drugs in their midst.

A friend once told me that someday I would wake up and my early morning thoughts would not be of Jeremy. I know that will never happen. But I do hope that someday I will awaken and know that young people like Jeremy are having their health, including mental health, nurtured along with their intellects at those ivy-covered institutions their families entrust them to.

In loving memory of Jeremy and all the others. Janie L. Kritzman is a clinical psychologist living in Brookline.