Prescription Opioids Play Minor Role in Massachusetts Overdoses

By Pat Anson, PNN Editor

Two new studies in Massachusetts – one of the states hardest hit by the overdose crisis – highlight the role of multiple substances in most overdose deaths and how limiting the supply of prescription opioids has failed to reduce the number of drug deaths.

Researchers at Boston Medical Center's Grayken Center for Addiction analyzed toxicology reports on nearly 2,250 fatal overdoses involving opioids in Massachusetts between 2014 and 2015. Overdose data in Massachusetts is considered more reliable because it is one of the few states to extensively use toxicology testing.

Only 9 percent of the deaths in Massachusetts involved prescription opioids alone. Most of the overdoses (72%) involved illicit fentanyl or heroin, while one in five (19%) involved a combination of heroin, fentanyl or prescription opioids.

Other substances such as alcohol, marijuana, stimulants (cocaine and methamphetamine) and non-opioid medications (benzodiazepines and gabapentin) were also frequently involved.

“Using multiple substances, in addition to opioids, is the rule rather than the exception for opioid-related deaths,” researchers reported in the journal Drug and Alcohol Dependence.

“Our study draws attention to the heterogeneity of the problem at hand and that there is not a one-size-fits-all approach to addressing the overdose epidemic, which is increasingly driven by polysubstance use.”


Over half of the Massachusetts overdoses involved someone with a diagnosed mental illness. Homelessness and a recent incarceration also raised the risk of a fatal overdose involving both opioids and stimulants.

"As a provider, these findings indicate a pressing need to address and treat not just opioid use disorder, but other substances that patients are misusing," said lead author Joshua Barocas, MD, an infectious disease physician at BMC. "To truly make a difference in reducing opioid overdose deaths, we must tackle issues such as homelessness and access to mental health services. This means not only investing in treatment but also implementing tailored programs that address the specific barriers to accessing care."

Opioid Prescriptions Down 39% since 2015

The number of opioid prescriptions has declined significantly in Massachusetts over the last four years, according to a recent report from the state’s Department of Public Health. In the first quarter of 2019 there were over 518,000 prescriptions filled for Schedule II opioids such as hydrocodone and oxycodone – a 39% decline from the first quarter of 2015.

But the decrease in prescriptions has failed to make much of a dent in Massachusetts’ opioid overdose rate, which peaked in 2016 with 2,100 deaths and remains stubbornly high.  



In 2018, nearly nine out of ten opioid-related deaths (89%) in the state involved illicit fentanyl, with cocaine (39%), heroin (32%), and benzodiazepines (40%) such as Xanax also commonly found.

Only about ten percent of the overdose deaths in the fourth quarter of 2018 involved prescriptions opioids, virtually unchanged from the 2014-2015 study.

Overdoses Soar in 2 States Despite Fewer Rx Opioids

By Pat Anson, PNN Editor

New studies from two of the states hardest hit by the opioid crisis – Massachusetts and Pennsylvania -- are throwing a damper on recent speculation that drug overdoses may have peaked.  

Researchers at Boston Medical Center released a startling study that found nearly 5 percent of people over the age of 11 in Massachusetts have an opioid use disorder.

The Drug Enforcement Administration also admitted in a Joint Intelligence Report that reducing the supply of prescription opioids in Pennsylvania failed to reduce the state’s soaring overdose rate and may have even increased demand for counterfeit painkillers. Pennsylvania had 5,456 fatal overdoses in 2017, a 65% increase from 2015.  


“Implementation of legislation influencing prescription opioid prescribing has resulted in a decrease in availability; however, a corresponding decrease in demand is less certain,” the DEA report found.

“Practitioners may be offering non-opioid alternatives to pain management to their patients, but this is most likely due to increased scrutiny of prescribing habits, as well as legislated changes, not due to requests from patients seeking non-opioid products.”

Prescription opioids were involved in only 20% of Pennsylvania’s overdoses. Most of the deaths involve a combination of illicit drugs such fentanyl, heroin, cocaine and counterfeit medication.

“The increasing presence of counterfeit opioid CPDs (controlled prescription drugs) in Pennsylvania is an indicator of strong demand for opioid CPDs in the illicit market. Traffickers use substances such as heroin, fentanyl, and tramadol to create tablets that look like the opioid CPDs most commonly purchased on the street (e.g., oxycodone 30 milligram tablets). The tablets are often exact replicas with the shape, coloring, and markings consistent with authentic prescription medications,” the report found.

The DEA said heroin and fentanyl could be found in 97% of Pennsylvania’s counties and called the city of Philadelphia a “wholesale market” for illicit drugs from China and Mexico.

Opioid Use Disorder in Massachusetts

Illicit fentanyl is also blamed for a soaring number of fatal overdoses in Massachusetts, where researchers used a new method to estimate how many people have opioid use disorder (OUD).  

Instead of relying on insurance claims for addiction treatment, researchers used a database that links information from 16 state agencies on other forms of healthcare use. Researchers were then able to identify patients who have OUD and estimate those who have the disorder but aren't seeking treatment. Individuals with substance use disorders are often less likely to seek medical care or be insured. Many are also reluctant to admit they have a drug problem.  

"There are many people with opioid use disorder who do not encounter the health care system, which we know is a barrier to understanding the true impact of the opioid epidemic," said Joshua Barocas, MD, an infectious disease physician at Boston Medical Center, who was lead author of the study published in the American Journal of Public Health.

Barocas and his colleagues found the prevalence of opioid use disorder in Massachusetts rose from 2.72% in 2011 to 4.6% in 2015. People between the ages of 11 and 25 experienced the greatest increase in OUD – a demographic much younger than a typical chronic pain sufferer, who is usually middle aged.

In 2012, Massachusetts was one of the first states where insurers and healthcare providers took steps to reduce the supply of prescription opioids – measures that have yet to have any meaningful impact on the state’s overdose rate.  



Massachusetts was also one of the first states to use toxicology screens from coroners and medical examiners to get a more accurate assessment of the drugs involved in overdoses.

According to the most recent report from the first quarter of 2018, nearly 90% of Massachusetts overdoses involve fentanyl, 43% percent involve cocaine, 42% involve benzodiazepines and 34% involve heroin. Prescription opioids were involved in only about 20% of the Massachusetts overdoses, the same rate as Pennsylvania.

Preliminary estimates released by the CDC last week show a modest 2.3% nationwide decline in opioid overdoses from September 2017 to March 2018. Over 48,000 people died from opioid overdoses during that period, with most of those deaths involving illicit fentanyl, heroin and other street drugs.

90% of Massachusetts Overdoses Linked to Fentanyl

By Pat Anson, Editor

Nearly 90 percent of opioid-related overdose deaths in Massachusetts now involve fentanyl, according to a new report that documents the rapidly changing nature of the opioid crisis. Less than 20 percent of drug overdoses in the state were linked to prescription opioids.

In the second quarter of 2018, Massachusetts health officials say 498 people died from an opioid-related overdose – the third straight quarter that opioid deaths have declined.

But the good news was tempered by the rising toll taken by fentanyl -- the synthetic opioid that’s become a deadly scourge on the black market. Fentanyl is often mixed with heroin, cocaine and counterfeit drugs to increase their potency. 

Because Massachusetts was one of the first states to conduct blood toxicology tests in overdose cases, it’s quarterly reports on drug deaths are considered more accurate than federal estimates and more likely to spot emerging trends in drug use. 


"This quarterly report provides a new level of data revealing an unsettling correlation between high levels of synthetic fentanyl present in toxicology reports and overdose death rates. It is critically important that the Commonwealth understand and study this information so we can better respond to this disease and help more people,” Massachusetts Gov. Charlie Baker said in a statement.

Another trend documented in Massachusetts is the increasing role played by cocaine and benzodiazepines --- an anti-anxiety medication – in drug overdoses. In the first quarter of 2018, cocaine (43%) and benzodiazepines (42%) were involved in more overdoses than heroin (34%) and prescription opioids (19%). 



Drug experts say many cocaine users may not realize their drug has been spiked with fentanyl, while many people who buy Xanax or Valium on the black market don’t know they’re getting counterfeit medication laced with fentanyl.

“If you are using illicit drugs in Massachusetts, you really have to be aware that fentanyl is a risk no matter which drug you’re using,” Dr. Monica Bharel, Massachusetts public health commissioner told The Boston Globe. “The increased risk of death related to fentanyl is what’s driving this epidemic.”

Fentanyl is also involved in a growing number of fatal overdoses in Pennsylvania. According to the Drug Enforcement Administration, there were 5,456 overdose deaths in Pennsylvania last year. Of those, over 67% percent involved fentanyl. The presence of fentanyl or its chemical cousins in overdose deaths rose almost 400% in the state from 2015 to 2017.

Most overdoses involve multiple drugs and blood tests alone do not determine a cause of death -- only which drugs were present at the time of death.

The New Face of the Opioid Crisis

By Pat Anson, Editor

Caylee Cresta doesn’t have any illusions about being the next Internet star or YouTube sensation. But the 23-minute video she posted on what it’s like to be a chronic pain patient during an age of opioid hysteria has become a hit in the pain community.

“This video should be made to go viral,” one fan said.

“Caylee you did an amazing, persuasive presentation. Maybe you should be a lobbyist!” another one wrote.

“Single best piece of chronic pain patient advocacy I have ever seen. Absolutely brilliant!” wrote Chuck Malinowski.

Caylee’s video is not addressed to the pain community, but to the public at large. The 26-year old Massachusetts woman with fiery red hair looks directly into the camera and earnestly asks people to set aside their misconceptions about pain, addiction and the opioid crisis.

“I do not suffer from addiction and yet stigma will tell you that I do.  And that is a myth that we are going to change,” she says. “Don’t ever brush off the plight of the chronically ill because your lives can change in an instant, just as ours have.

“The fight against opiates is an uneducated one. This is a movement that lacks understanding in its most basic form. Every lawmaker is taking on this fight without ever consulting even a single chronically ill person. What does that mean? That means that the people who depend on these medications aren’t even being considered when taking them away.”

In her video, Caylee spends little time discussing her own experience as a pain patient. While still in high school, Caylee developed a rare and incurable neurological disorder called Stiff-person syndrome, which is characterized by strong muscle spasms and stiffness. The spams are so severe her lungs have collapsed twice.

“I’ll get such strong spasms in my throat and chest cavity that they create so much air that can’t escape (my lungs) that it just made them literally pop,” she told PNN. “My muscle spasms can break my bones, they’ll get that strong.”

Caylee’s symptoms were usually dismissed by doctors and it took years for her to get a proper diagnosis. Last year, a doctor at a pain clinic dropped her as a patient after getting a warning letter from Medicare that she was prescribing too many opioids. Caylee went without opioids for months, which is when her lungs burst.

Living in Fear

Although Massachusetts has a reputation as having some of the best healthcare in the world, Caylee now drives 3 hours one-way to see a neurologist in Connecticut.

“Any other doctor that I’ve seen over the years has literally looked at me and in one way or another and said, ‘Your prognosis is so dim. It’s so rare.’ They’re not even willing to take me on as a patient. My doctor has stuck by me and tried everything there is to try,” she says. 

Caylee has tried stem cells, chemotherapy and many other treatments. The only thing that works is opioid medication. Although she is once again able to get prescriptions for opioids, she often has trouble getting them filled. She and her husband went to 20 pharmacies one day before finding a pharmacist willing to fill her script.

“You live every single day in fear.  Every time you fill your prescription you go, okay, I’m going to have a life for another month. But you live that whole month with such anxiety and wondering what’s going to happen next,” she said. 

Caylee hopes her YouTube video will help educate the public about the daily challenges of being in pain and give some hope to pain sufferers.

“I want to fight for people going through this. I truly want to fight for them. I just want to let people know that they’re not alone. I want them to know that we’re all in this together,” says Caylee.

“What is probably the most humbling is when I get messages like ‘I would do anything for the world to be able to see this’ or ‘I would do anything for this to go viral and for people to understand what we go through.’ When I get messages like that, that let me know that these people feel like somebody is speaking for them, that touches me in a way that I can’t even explain.”

Florida’s Deadliest Rx Drug is Not a Painkiller

By Pat Anson, Editor

A new report from Florida’s Medical Examiners Commission is debunking a popular myth about the overdose crisis.

The most deadly prescription drugs in the state are not opioid painkillers, but benzodiazepines – a class of anti-anxiety medication that includes Xanax (alprazolam) and Valium (diazepam).  Xanax alone killed more Floridians last year (813) than oxycodone (723).

The medical examiners analyzed toxicology and autopsy results for 11,910 people who died in Florida in 2016, noting not only what drugs were present at the time of death, but which drug actually caused the deaths.

The distinction is important and more accurate than the death certificate (ICD) codes often used by the CDC, which merely list the drugs that were present. Critics have long contended that CDC researchers cherry pick ICD data to inflate the number of deaths "involving" or "linked" to opioid medication, in some cases counting the same death twice.   


Florida made an effort to get the numbers right.

“Florida’s medical examiners were asked to distinguish between the drugs determined to be the cause of death and those drugs that were present in the body at the time of death. A drug is indicated as the cause of death only when, after examining all evidence, the autopsy, and toxicology results, the medical examiner determines the drug played a causal role in the death,” the report explains.  “A decedent often is found to have multiple drugs listed as present; these are drug occurrences and are not equivalent to deaths.”

The five drugs found most frequently in Florida overdoses were alcohol, benzodiazepines, cocaine, cannabinoids and morphine. The medical examiners noted that heroin rapidly metabolizes into morphine, which probably led to a substantial over-reporting of morphine-related deaths, as well as a significant under-reporting of heroin-related deaths.

Benzodiazepines also played a prominent role as the cause of death, finishing second behind cocaine as the drug most likely to kill someone.  Benzodiazepines were responsible for almost twice as many deaths in Florida in 2016 than oxycodone. Like opioids, benzodiazepines can slow respiration and cause someone to stop breathing if they take too many pills.


Source: Florida Medical Examiners Commission

As in other states, deaths caused by cocaine, heroin and illicit fentanyl have soared in Florida in recent years. In just one year, the number of overdose deaths there jumped 22 percent from 2015 to 2016.

"We don't talk about it much now there's the opioid crisis, but cocaine and alcohol are still a huge issue, there are still a lot of deaths due to those things," Florida addiction treatment director Dustin Perry told the Pensacola News Journal.

Florida is not an outlier. Several other states are also using toxicology reports to improve their analysis of drugs involved in overdose deaths and getting similar findings.  In Massachusetts, deaths linked to illicit fentanyl, benzodiazepines, heroin and cocaine vastly outnumber deaths involving opioid medication.  Prescription opioids were present in only 16 percent of the overdose deaths in Massachusetts during the second quarter of 2017.



Although it is becoming clear that many different types of drugs -- opioids and non-opioids -- are fueling the nation’s overdose crisis, politicians, the media and public health officials still insist on calling it an “opioid epidemic” or an “opioid crisis” -- diverting attention and resources away from other drugs that are just as dangerous when abused.  We never hear about a Xanax epidemic or a Valium crisis.

President Trump's opioid commission recognized the need to improve drug overdose data when it released its final report this month.

"The Commission recommends the Federal Government work with the states to develop and implement standardized rigorous drug testing procedures, forensic methods, and use of appropriate toxicology instrumentation in the investigation of drug-related deaths. We do not have sufficiently accurate and systematic data from medical examiners around the country to determine overdose deaths, both in their cause and the actual number of deaths,” the commission found.

Fentanyl Linked to Over Half of Opioid Overdoses

By Pat Anson, Editor

A new report from the Centers for Disease Control and Prevention shows that illicit fentanyl – not prescription pain medication -- was involved in over half of the recent opioid overdoses in ten states.

The report underscores the changing nature of the nation’s overdose crisis and how public health officials have been slow to respond to the growing role of fentanyl and other illegal opioids – focusing instead on limiting access to opioid medication.

CDC researchers say fentanyl or its chemical cousins (known as fentanyl analogs) were detected in 2,903 of 5,152 opioid overdoses (56.3%) during the last six months of 2016.

Their report on overdoses in ten states (Oklahoma, New Mexico, Wisconsin, West Virginia, Ohio, Maine, Missouri, Rhode Island, Massachusetts and New Hampshire) is the first to use toxicological and death scene evidence to characterize opioid overdoses, a method that is far more accurate than other CDC reports that rely on death certificate codes.

source: Centers for disease control and prevention

source: Centers for disease control and prevention

Maine, Massachusetts, New Hampshire, Rhode Island and Missouri reported the highest percentages of deaths involving fentanyl (60-90%), while New Mexico and Oklahoma had the lowest (15-25%). Fentanyl is a potent synthetic opioid that is legally prescribed to treat severe pain. The vast majority of the deaths, however, involve illicit fentanyl that has flooded the black market in recent years. 

“This analysis of opioid overdose deaths in 10 states participating in the ESOOS (Enhanced State Opioid Overdose Surveillance) program found that illicitly manufactured fentanyl is a key factor driving opioid overdose deaths and that fentanyl analogs are increasingly contributing to a complex illicit opioid market with significant public health implications,” the researchers reported.

“Illicitly manufactured fentanyl is now a major driver of opioid overdose deaths in multiple states, with a variety of fentanyl analogs increasingly involved, if not solely implicated, in these deaths. This finding raises concern that in the near future, fentanyl analog overdose deaths might mirror the rapidly rising trajectory of fentanyl overdose deaths that began in 2013 and become a major factor in opioid overdose deaths.”

The CDC recently expanded the ESOOS program to 32 states and the District of Columbia. Additional funding was also provided to improve toxicology testing for a wider range of fentanyl analogs such as carfentanil, which is estimated to be 10,000 times more potent than morphine.

The new CDC report did not detail how many of the overdose deaths involved prescription opioids. A recent report from Massachusetts  estimated that prescription opioids were involved in only about 15% of overdoses in that state, ranking well behind cocaine, benzodiazepines, heroin and fentanyl.

source: massachusetts department of public health

source: massachusetts department of public health

Although opioid prescribing has been in decline for years, public health efforts remain focused on limiting access to pain medication. As PNN has reported, the CDC recently launched a new advertising campaign that focuses exclusively on raising awareness about the risks of prescription opioids, while ignoring the role of fentanyl and heroin in the overdose crisis.

The CDC’s Rx Awareness campaign will initially run in four states -- including Massachusetts and Ohio, two of the states where fentanyl overdoses vastly outnumber those involving pain medication.

Insurer Reports Soaring Rates of Opioid Addiction

By Pat Anson, Editor

The number of Blue Cross and Blue Shield (BCBS) customers diagnosed with opioid addiction has soared by nearly 500 percent in recent years, according to a new report that found only about a third of the addicted patients were getting medication assisted treatment.

The Health of America Report analyzed prescription data for over 30 million BCBS customers from 2010 to 2016. The report focused mainly on patients who use legally prescribed painkillers, while virtually ignoring addicts who use heroin, illicit fentanyl and other illegal opioids, who are now the driving force behind the nation’s opioid crisis.

"Opioid use disorder is a complex issue, and there is no single approach to solving it," said Trent Haywood, MD, senior vice president and chief medical officer for the Blue Cross Blue Shield Association, which represents 36 independent insurers that provide health coverage to over 100 million Americans.

“Opioid use disorder” is a broad and somewhat misleading term that includes illegal drug addicts, as well as chronic pain patients who take opioids responsibly, and develop a tolerance or dependence on them.

The BCBS report found that patients who filled prescriptions for high doses of opioids had much higher rates of opioid use disorder than those on lower doses. Women aged 45 and older had higher rates of the disorder than men. Women of all ages were also more likely to fill an opioid prescription.

The BCBS report found that patients who filled prescriptions for high doses of opioids had much higher rates of opioid use disorder. Women aged 45 and older had higher rates of the disorder than men. Women of all ages were also more likely to fill an opioid prescription.

Less than one percent of BCBC customers (0.83%) were diagnosed with opioid use disorder in 2016, a rate much higher than in 2010 (0.14%). The rise was attributed to “an increased awareness of the disorder,” suggesting that doctors were simply more likely to diagnose opioid addiction then they were in 2010.    

While the diagnosis of opioid use disorder rose by 493 percent during the study period, there was only a 65 percent increase in the number of BCBS customers who were prescribed addiction treatment drugs such as Suboxone (buprenorphine).

BCBS customers in the South were more likely to be diagnosed with opioid use disorder. Alabama led the nation with a diagnosis rate of over 1.6 percent, twice the national average.

The report noted that New England leads the nation in the use of medication-assisted treatments, even though the region has lower levels of opioid use disorder than other parts of the country. In Massachusetts, 84% of BCBS customers diagnosed with addiction were getting treatment with medication.

That prompted Blue Cross Blue Shield Association of Massachusetts to issue a press release claiming the state was “ahead of the nation when it comes to combating the opioid epidemic.” The insurer was one of the first in the country to take steps to significantly reduce access to opioids by its customers. As a result, only 2% of Blue Cross Blue Shield members in Massachusetts are receiving high doses of opioids, far less than the national average of 8.3 percent.

However, restricting access to pain medication has failed to stop a surge in opioid overdoses in Massachusetts, most of which are now caused by illicit fentanyl.  Over 2,000 people died of opioid overdoses in Massachusetts last year, almost three times the number of deaths in 2012, when Blue Cross Blue Shield began restricting access to painkillers.



Prescription opioids were involved in only 9% of the overdose deaths in Massachusetts at the end of 2016. In addition, the most recent report from the state's prescription drug monitoring program identified only 264 of the 288,519 people receiving Schedule II opioids as having “activity of concern” that could indicate they were misusing the drugs. That minuscule rate of 0.0915% hardly suggests that legitimate pain patients are the source of Massachusetts’s drug problem.

This week the largest health insurer in the Philadelphia area, Independence Blue Cross, announced plans to limit the prescribing of opioids in its network to just five days for acute pain -- making it one of the first insurers in the country to adopt such a strict limit.