How West Virginia Became the Epicenter of the Opioid Crisis

By Douglas Hughes, Guest Columnist 

Aggressive promotion by the distributors of OxyContin, the best pain medication ever formulated (when properly used), led to excessive prescribing by West Virginia doctors. 

This caused a methamphetamine drug problem in the state to morph into a prescription opioid epidemic, mostly due to unused opioids squirreled away in medicine cabinets.  Adolescents ignored by their guardians had complementary party favors of these excess opioids. This is why so many families were affected. 

After a few years of this, once the addiction problems were exposed, the excess prescribing stopped. Those desiring to misuse OxyContin went to pain clinics and lied to receive more.  Since we don’t have tachometers on our foreheads to gauge real subjective pain, lying to doctors was effective for many to get drugs to abuse.  

Not wanting to assist pain specialists and willing to deny legitimate intractable pain treatment, the West Virginia legislature passed the “Chronic Pain Clinic Licensing Act.”

When implemented on January 1, 2015, the goal to deny licenses to a dozen new and existing pain clinics was achieved. This left only pills being hoarded in medicine cabinets, which were quickly depleted.  

OxyContin distribution was suspended to pharmacies in most of West Virginia in 2015. 

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These two efforts stopped most OxyContin prescribing and decimated legitimate disabled intractable pain sufferers in West Virginia, the state with the highest incidence of industrial and worker compensation injury cases. 

For the sake of argument, let’s estimate pain clinic patients were 50% legitimate pain sufferers and 50% abusers lying in order to get opioids.  Each of those twelve pain clinic closures turned a thousand or more patients onto the streets.  Some wanted to abuse, while others desperately sought to replace critical pain treatment denied to them by state law.  Some turned to street drugs as their answer. 

In 2015, West Virginia police departments reported that pain pills seized from drug arrests fell a remarkable 89 percent. The opioid crisis was shifting rapidly to heroin, as the drug sub-culture always does when a drug source changes. The prescription opioid epidemic in West Virginia essentially ended in 2015.  There was no memo from the CDC.

Those thousands of good and bad patients from pain clinics were both naive to the strength and use of heroin.  Dosing, once regulated by prescription, now was more lethal. Learning how to prepare and inject heroin without becoming infected, overdosing and dying was problematic. There were record overdose deaths in 2015, even though there were fewer pain pills. 

Counterfeit medication and heroin laced with illicit fentanyl appeared and record overdose deaths continued in 2016 and 2017 because there were so many inexperienced street drug users.  

Since 2015, West Virginia has wasted millions of dollars annually chasing imaginary diversion and investigating and prosecuting good physicians. This satisfied everyone except legitimate pain patients, who were left suffering and dying in their beds.  A suicide epidemic ensued.

West Virginia lacks a prevention component to their drug crisis response, which insured the re-occurrence of another epidemic. Apparently, we are satisfied with this catastrophe. May we have another?   

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Douglas Hughes is a disabled coal miner and retired environmental permit writer in West Virginia.

Do you have a story you want to share on PNN? Send it to: editor@painnewsnetwork.org.

The information in this column should not be considered as professional medical advice, diagnosis or treatment. It is for informational purposes only and represents the author’s opinions alone. It does not inherently express or reflect the views, opinions and/or positions of Pain News Network.

Study Debunks Myths About Origins of Opioid Abuse

By Pat Anson, PNN Editor

It’s become a popular myth – and for some, a propaganda tool – to claim that opioid pain medication is a gateway drug to heroin and other street drugs.

An opioid education campaign called The Truth About Opioids – funded with taxpayer dollars from the White House Office of National Drug Control Policy — declares in big bold letters on its website that “80% of heroin users started with a prescription painkiller.”

The 80% figure stems from a 2013 study that found four out of five new heroin users had previously abused prescription opioids by using them non-medically.

Importantly, the heroin users were not asked if they had a valid prescription for opioids or even where they got them – but that doesn’t stop federal agencies from citing the study as proof that illegal drug use often starts with a legal opioid prescription.

The Drug Enforcement Administration last year used the 80% figure to justify steep cuts in the supply of prescription opioids, claiming in the Federal Register that addicts often get hooked “after first obtaining these drugs from their health care providers.”

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“The 80% statistic is misleading and encourages faulty assumptions about the overdose crisis and medical care,” Roger Chriss explained in a PNN column last year.

A new study by researchers at Penn State University debunks the myth that the opioid crisis was driven primarily by doctors’ prescriptions. The researchers conducted a series of surveys and in-depth interviews with opioid abusers in southwestern Pennsylvania -- a region hard hit by opioid addiction -- asking detailed questions about their drug use.

The study was small – 125 people were surveyed and 30 of them were interviewed – but the findings provide a an important new insight into the origins of opioid abuse and the role played by painkillers.

"What emerged from our study -- and really emerged because we decided to do these qualitative interviews in addition to a survey component -- was a pretty different narrative than the national one,” said lead author Ashton Verdery, PhD, an assistant professor of sociology, demography and social data analytics at Penn State. "There's a lot about that narrative that I think is an overly simplistic way of thinking about this."

‘Opioids Were Never the First Drug’

Verdery and his colleagues found that over two-thirds of those interviewed (66.7%) first abused a prescription opioid that was given, bought or stolen from a friend or family member. Another 7% purchased the drugs from a stranger or dealer. Only one in four (26%) started by abusing opioid medication that was prescribed to them by a doctor.

“We found that most people initiated through a pattern of recreational use because of people around them. They got them from either siblings, friends or romantic partners," said Verdery. “Participants repeatedly reported having a peer or caregiver in their childhood who had a substance use problem. Stories from childhood of witnessing one of these people selling, preparing, or using drugs were very common. Being exposed to others’ substance use at an early age was often cited as a turning point for OMI (opioid misuse) and of drug use in general.”

And prescription opioids were not the gateway drugs they are often portrayed to be. Polysubstance abuse was common and usually began with drugs such as alcohol, marijuana, cocaine, methamphetamine, prescription sedatives and prescription stimulants.

“It is important to note that interviewees universally reported initiating OMI only after previously starting their substance use career with another drug (e.g., alcohol, marijuana, cocaine). Opioids were never the first drug used, suggesting that OMI is likely associated with being further along in one’s drug using career,” Verdery reported in the Journal of Addictive Studies.

Verdery says additional studies are needed on the origins of drug abuse and that researchers should focus on the role that other substances play in opioid addiction. Only then can proper steps be taken to prevent abuse and addiction before they start.

"We think that understanding this mechanism as a potential pathway is worth further consideration," said Verdery. "It's not just that people were prescribed painkillers from a doctor for a legitimate reason and, if we just crack down on the doctors who are prescribing in these borderline cases we can reduce the epidemic.”

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.”

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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.  

SOURCE: MASSACHUSETTS DEPARTMENT OF PUBLIC HEALTH

SOURCE: MASSACHUSETTS DEPARTMENT OF PUBLIC HEALTH

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.

A Pain Poem: What I Wouldn't Do

“What I Wouldn’t Do”

By Serina Mikunda

What would I do just to feel okay?
To feel less pain, for only a day?
I would hope and wish and pray
But what would I not do?

We would do most anything to quell desperation
To feel like more than an aberration
To achieve more than adaptation
But our laser tight focus can lead us askew

Would you take meds from a loved one's drawer?
Cause suffering to someone you say you adore?
Turn into someone you would abhor?
Changing from the person you once knew?

Would you use heroin you got off the street?
Would you lie, or would you cheat?
Dig in deeper to a life of deceit?
Justifying that relief was long overdue?

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I know you are feeling a lot of abandonment
Not getting much help from the medical establishment
I offer only my view, no judgement
I know you are doing the best you can do

I know what is asked of you is crazy
I know people think that you're just lazy
And your ability to see beauty is getting hazy
These urges are getting hard to subdue

Think long-term, join us in the fight
Help us shoot sparks until something ignites
We will all warm ourselves by the firelight
Warming others by the light of our virtue

Because we have all walked through the fire
And we know all too well the situation is dire
But you have the chance to lead, to inspire
Whether it happens is all up to you

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Serina Mikunda is an author and activist in St. Louis, Missouri. Serina lives with Ehlers-Danlos syndrome.

Pain News Network invites other readers to share their stories (and poems). Send them to:  editor@PainNewsNetwork.org

The information in this column should not be considered as professional medical advice, diagnosis or treatment. It is for informational purposes only and represents the author’s opinions alone. It does not inherently express or reflect the views, opinions and/or positions of Pain News Network.

Heroin and Fentanyl Fueling Veteran Overdoses, Not Rx Opioids

By Pat Anson, PNN Editor

The U.S. Department of Veterans Affairs has taken a number of steps in recent years to reduce opioid prescribing for military veterans and their families. In 2015, the VA adopted the CDC opioid guideline before it was even finalized. Two years later, the agency adopted a clinical practice guideline for VA doctors that strongly recommends against prescribing opioids to patients for more than 90 days.

Both measures were intended to address “mounting concerns about prescription drug abuse and an overdose epidemic among veterans.”

But a new study has found that the “epidemic” of opioid overdoses among veterans is not fueled by prescriptions opioids – but by heroin, illicit fentanyl and other synthetic opioids obtained on the black market.

Researchers at the University of Michigan and VA Ann Arbor Healthcare System reported in the American Journal of Preventive Medicine that overdose deaths from all opioids increased by 65 percent for veterans from 2010 to 2016. But when then looked closer at prescription data on nearly 6,500 veterans who died, they found an unexpected trend.

"The percentage of veterans who had received an opioid pain prescription in the year before their opioid overdose death dropped substantially over this time period," says lead author Allison Lin, MD, an addiction psychiatrist at the VA Ann Arbor.

In 2010, half of the veterans who died of any opioid overdose had filled an opioid prescription in the three months before they died, and two-thirds had filled a prescription in the last year.

But by 2016, only a quarter of those who overdosed had filled an opioid prescription in the last three months, and 41 percent had done so in the past year.

At the same time, the death rate from heroin or from taking multiple opioids nearly quintupled, and the death rate from synthetic opioids such as fentanyl rose more than five-fold.

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“Interventions on opioid overdose prevention have often focused on those receiving opioid prescriptions; if we're only screening for risk in that population, this shows we will miss a lot," said Lin. "We really have to think about opioid overdose prevention and substance use disorder treatment more broadly, to determine where the greatest unmet need is, increase treatment access and accessibility, and improve outcomes."

The VA provides health services to 6 million veterans and their families. Over half the veterans being treated at VA facilities suffer from chronic pain, as well as other conditions that contribute to it, such as depression and post-traumatic stress disorder.

A 2016 study of veterans found a strong link between heroin use and the non-medical use of prescription opioids. Having a long-term prescription for opioids to treat chronic pain was not found to be a significant risk factor for heroin use.

Overdose Crisis Will Worsen, But Not Due to Rx Opioids

By Pat Anson, PNN Editor

The opioid crisis will “substantially worsen” in coming years and could result in the overdose deaths of over a million Americans by 2025, according to an eye-opening new study. Because most of the deaths will involve illicit opioids, researchers say limiting the supply of prescription opioids will have only a “modest” effect in reversing the trend.      

The study, published in JAMA Network Open, is based on mathematical models developed by a team of researchers at Harvard Medical School, Boston University School of Medicine, Pennsylvania State University and other academic institutions.

“Our study also highlights the changing nature of the epidemic. The opioid crisis is expected to worsen in the next decade owing to multiple factors,” said lead author Jagpreet Chhatwal, PhD, a researcher at Massachusetts General Hospital.

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“First, the number of individuals using illicit opioids is expected to increase substantially. Second, unlike historical trends where prescription opioid use has served as a path to heroin use, more people are directly initiating opioid use with illicit opioids. Third, there has been a rapid increase in illicit opioid lethality, likely mainly driven by the infiltration of the heroin supply with the highly potent synthetic opioid fentanyl.”

Under a “base-case” scenario, with the opioid crisis stabilizing by 2020, researchers project that over 700,000 Americans will die from opioid overdoses from 2016 to 2025. Nearly 80 percent of the deaths will involve fentanyl, heroin and other illicit opioids. Overdoses involving prescription opioids would decrease by about 10% during that period.

JAMA NETWORK OPEN

JAMA NETWORK OPEN

A “pessimistic” scenario developed by researchers is even more jaw dropping. If the opioid crisis does not stabilize until 2025, they project over 1.2 million Americans will die from overdoses. Over 88% of the deaths will involve illicit opioids.

In either scenario, efforts to reduce the misuse of opioid medication, such as limiting the dose and supply of prescription opioids, will only reduce the number of overdose deaths by 3 to 5 percent.

“State and local governments have instituted several interventions aimed at preventing individuals from exposure to prescription opioids, including a recently proposed goal to lower opioid prescriptions by one-third in the coming 3 years,” said Chhatwal.

“Our study does not devalue these efforts and it is possible that their effect could improve over time, which may ultimately yield a substantial benefit in the long term. However, given the large number of individuals who have already engaged in prescription opioid misuse or illicit opioid use, our study indicates that prevention efforts, in isolation, are unlikely to have the desired level of effect on opioid overdose deaths the near term.”

The researchers say a strong, multi-pronged approach is needed to reduce overdoses, including greater scrutiny of patients for signs of opioid use disorder (OUD).

"It could include implementation of screening for OUD in all relevant health care settings, improving access to medications for OUD such as methadone and buprenorphine, increasing OUD training programs at medical and nursing schools, improving access to harm-reduction services, and controlling the supply of illicit opioids,” they concluded.

Another recent study also predicts that reducing the supply of prescription opioids will have little effect on the overdose rate and could lead to increased use of heroin.   

Fentanyl and Heroin Linked to 70% of Overdoses

By Pat Anson, PNN Editor

The Centers for Disease Control and Prevention released another report today documenting the changing nature of the overdose crisis and the decreased role that prescription opioids have in drug deaths.  About 70% of fatal overdoses in 2016 involved either illicit fentanyl or heroin.

CDC researchers used “literal text analysis” to study death certificates from 2011 to 2016, looking for drugs listed as the cause of death, significant conditions contributing to that death, and a description of how the death occurred.  Alcohol, nicotine and other non-drug substances were not included in the analysis.

Researchers found that the opioid painkiller oxycodone was the most frequently mentioned drug involved in 2011 overdoses, but by 2016 oxycodone had fallen to 6th place, behind fentanyl, heroin, cocaine, methamphetamine and the anti-anxiety drug alprazolam (Xanax).

TOP 10 DRUGS MENTIONED IN 2016 OVERDOSE DEATHS

Source: CDC

CDC researchers noted that many overdose deaths involve multiple drugs.

“We’ve had a tendency to think of these drugs in isolation. It’s not really what’s happening,”  lead author Holly Hedegaard, PhD, told the Huffington Post.

For example, fentanyl and cocaine were mentioned in nearly 4,600 deaths, while oxycodone and alprazolam were mentioned in more than 1,500 deaths. 

The CDC has already released a preliminary estimate on overdoses for 2017 using a different form of analysis. But the results are largely the same. Over 70,200 people died of a drug overdose in 2017 – the highest number on record. Deaths involving fentanyl and other synthetic, mostly black market opioids surged 45 percent, while deaths involving natural or semisynthetic opioids, mostly painkillers such as oxycodone and hydrocodone, remained flat.      

The number of opioid prescriptions in the United States has been falling since 2011, but opioid medication remains a favorite target for regulators. The DEA has proposed another round of cuts in the supply of opioid pain medication – a 10% reduction in manufacturing quotas in 2019 for oxycodone, hydrocodone, morphine and three other opioids. Some of the medications are already in short supply, forcing hospitals to use other pain relievers to treat surgery and trauma patients.

The Trump Administration says opioid pain relievers are “frequently misused” and that reducing their supply will help prevent addiction, abuse and overdoses. There is little or no evidence that is true.

Do Drug Addicts Really Shoot Kratom?

By Pat Anson, PNN Editor

Our story last week about drug addicts in Ohio allegedly shooting kratom to get a “heroin-like high” angered many people who use the herbal supplement to treat chronic pain and other medical conditions.

“Who the hell is injecting kratom? These people are out of their minds,” wrote one reader.

“No one and I mean no one has ever injected kratom. Kratom is a wonderous, natural plant with many positive effects,” said Erik.

“It’s pathetic that lies like this are being spread about a natural leaf that helps with pain,” wrote Jennifer Greenwood. “Nobody buys kratom from heroin dealers.”

But that’s exactly what the Ohio Substance Abuse Monitoring Network (OSAM) reported earlier this year in its statewide assessment of drug abuse trends. OSAM called a kratom “a psychoactive plant” and claimed drug users in northeast Ohio were buying kratom from heroin dealers and then injecting it.

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“Participants reported that the most common route of administration for kratom is intravenous injection (aka “shooting”). Participants in the Akron-Canton region estimated that out of 10 kratom users, seven would shoot the drug and three would orally consume the drug (including drinking it as a tea),” OSAM said.

The OSAM report was cited by the Ohio Board of Pharmacy when it voted last week to classify kratom as a Schedule I controlled substance, alongside heroin, LSD and other dangerous drugs.

The board said kratom can cause hallucinations, psychosis, seizures, weight loss and insomnia, and cited six deaths in Ohio in which kratom was “the primary cause of death.”

The FDA and DEA have made similar claims about the health risks of kratom, but OSAM appears to be the first public agency to allege that kratom is taken intravenously. Repeated calls to OSAM for further information were not returned.    

Kratom comes from the leaves of a tree that grows in southeast Asia, where it has been used for centuries as a pain reliever and stimulant. In recent years, millions of Americans have discovered kratom and started using it as a treatment for pain, addiction, anxiety and depression.

“I don’t think most kratom users are injecting it.  Most users that I’ve ever talked to either mix it with a beverage, ‘toss and swish’, or take capsules,” says Jane Babin, PhD, a molecular biologist and consultant to the American Kratom Association, an organization of kratom vendors and consumers.

While skeptical that anyone would inject kratom, Babin says some addicts are desperate enough to try anything. She thinks the kratom sold by drug dealers in Ohio could be adulterated heroin.

“They describe kratom as a brown substance that resembles heroin.  So I can’t help wondering if what they were using was heroin or at least something other than kratom,” Babin wrote in an email to PNN.

“I can’t imagine that they would be mixing powdered leaf kratom with liquid, heating it and injecting it.  There’s too much insoluble plant matrix/cellulose.  If they did, I would expect problems unless they could filter it… which isn’t likely.  Injecting an ethanol extract directly would likely cause tissue damage, and I have to wonder how sterile any of it is.”

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But there is a case in the medical literature of a 29-year old Rhode Island man doing just that. He started using kratom to treat his opioid addiction, but eventually developed a tolerance for it and needed more.

“He was initially drinking Kratom tea daily, then several times daily, until he found a way to inject it intravenously,” researchers reported last year in the Journal of Toxicology and Pharmacology.

“He began buying Kratom extract in alcohol. He let the alcohol evaporate in a spoon, and then dissolved the remaining resin in water to inject. Subsequently, he began cooking off the alcohol with heat. Finally, the patient said that he was impatient, and began injecting the extract directly. At the time of presentation, he was buying Kratom extract from multiple online vendors, and injecting 1 ml of extract six times daily.”

The man eventually checked himself into an emergency room and sought treatment for kratom addiction.

“This case is an important reminder of the chronic nature of opioid addiction, which has a high rate of relapse. As Kratom becomes more popular in patients seeking abstinence from opiates, including heroin, such intravenous use may also increase,” researchers warned.

Adulterated Kratom

One of the co-authors of that study believes there is another potential risk. Like other food and herbal supplements, kratom products are essentially unregulated and there are little or no quality controls.

“The stuff that’s sold as kratom in the United States cannot be reliably proven to be kratom,” says Edward Boyer, MD, a Professor of Emergency Medicine at Harvard Medical School.   

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“There is evidence to suggest that some of the kratom sold in the United States is adulterated to make it more potent, to make it more powerful.”

Boyer says some kratom supplements have been found to have artificially elevated levels of 7-hydroxymitragynine, one of the naturally occurring alkaloids that make kratom act on opioid receptors in the brain. He suspects opioid drugs are also being used to boost kratom’s potency.

“The fact that a lot of kratom is adulterated is not surprising,” says Jane Babin.  “I suspect it is more prevalent in the stuff that’s being sold at smoke shops and gas stations.  This is a red herring when it comes to kratom, in the same way that Salmonella contamination is.  Both are ‘problems’ with simple solutions through regulation and oversight of kratom identity and purity.”

Instead of banning kratom, Babin says it should be regulated with a standards and certification program that would help keep adulterated products off the market.

Kratom is already banned in Alabama, Arkansas, Indiana, Vermont, Wisconsin and the District of Columbia. And there is speculation that the DEA may try again to classify kratom as a federal Schedule I controlled substance, which would make sales and possession of the plant illegal nationwide. The DEA withdrew a plan to ban kratom in 2016 after a public outcry.

Last week’s vote by the Ohio pharmacy board starts a months-long process of drafting new regulations for kratom, so a ban isn’t in effect yet. Public comments will be accepted until October 18. 

“If Ohio does ban kratom (and I hope they don’t), I predict that the already epic opioid overdose problem in that state will get worse,” says Babin. “It would be a shame for Ohio to indirectly prove the value of kratom in combating the opioid crisis when, after it is banned, overdose deaths and suicides increase.”

CDC: Most Overdoses Involve Illicit Opioids

By Pat Anson, Editor

The Centers for Disease Control and Prevention has released a new report further documenting the changing nature of the opioid crisis and the lesser role played by opioid pain medication in drug overdoses.

The report from the CDC’s Enhanced State Opioid Overdose Surveillance (ESOOS) program looked at nearly 12,000 opioid overdose deaths in 11 states from July 2016 to June 2017. 

Nearly 59 percent of the overdose deaths were attributed to illicit opioids like fentanyl and heroin, while 18.5% had both illicit and prescription opioids.

Less than 18% tested positive for prescription opioids only.

Many of the deaths involved someone with a criminal record or a history of substance abuse. Nearly one in ten overdose victims had been released from a prison or jail in the month preceding the overdose.

Evidence of injection drug use was found in about half of the illicit opioid deaths and about 15% had lived through a previous overdose.

OPIOID OVERDOSES (2016-2017)

Source: CDC Enhanced State Opioid Overdose Surveillance

There were also distinct differences in demographics between the illicit and prescription opioid overdoses. The average age of people who died from prescription opioids was 47, while the average age of those who died from illicit opioids was 36. Men were far more likely to overdose on an illicit opioid (73%), while more women (51%) died from a prescription opioid overdose.

“Findings from this analysis indicate that illicit opioids were a major driver of opioid deaths, especially among younger persons, and were detected in approximately three of four deaths overall. Prescription opioids were detected in approximately four of 10 deaths,” CDC researchers reported in the Morbidity and Mortality Weekly Report (MMWR).

Polysubstance Overdoses

Another key finding from the report was the frequent involvement of other drugs in opioid overdoses.

Benzodiazepines – a class of anti-anxiety medication that includes Xanax and Valium – were detected in over half of the prescription opioid deaths and in about one of every four illicit opioid deaths. “Benzos” depress the central nervous system and raise the risk of overdose when used with opioids. 

Gabapentin (Neurontin) – an anti-seizure drug widely prescribed off-label to treat pain -- was detected in over 21% of the prescription opioid deaths and in about 10% of the other overdoses.

“The combined use of gabapentin and opioids might be an indicator of high-risk opioid misuse and requires further study,” researchers said. “Extensive use of cocaine and benzodiazepines among deaths where both prescription and illicit opioids were detected highlights the need for prevention and treatment programs to address polysubstance use.”

Because so many drugs – both legal and illegal -- are often involved in overdoses, the CDC researchers cautioned that efforts to prevent opioid abuse “should not focus exclusively on one opioid type.”

That warning is at odds with the CDC’s own Rx Awareness program, an advertising campaign launched last year that focuses solely on the stories of people “whose lives were torn apart by prescription opioids.”

Fentanyl, heroin and other drugs commonly involved in overdoses are not addressed by the Rx Awareness campaign. 

“Specificity is a best practice in communication, and the Rx Awareness campaign messaging focuses on the critical issue of prescription opioids. Given the broad target audience, focusing on prescription opioids avoids diluting the campaign messaging,” the CDC explained when launching the campaign.

RX AWARENESS AD

RX AWARENESS AD

Earlier this year, CDC researchers acknowledged that they overestimated the number of overdoses involving prescription opioids by combining them with deaths attributed to illicit fentanyl and other synthetic opioids. The ESOOS program was launched, in part, to correct that error.

ESOOS data is considered more reliable because it includes blood toxicology reports, as well as death certificates, medical examiner and coroner reports, death scene investigations, and an overdose victim’s history of substance abuse. A total of 32 states participate in ESOOS.

The 11 states participating in the current report include: Oklahoma, New Mexico, Maine, Massachusetts, New Hampshire, Rhode Island, Missouri, Ohio, West Virginia, Wisconsin and Kentucky.

Addiction to Rx Opioids Falling

By Pat Anson, Editor

A new report from health insurance giant Blue Cross Blue Shield highlights a little-known and rarely reported aspect of the opioid crisis: Addiction to opioid pain medication is declining, not increasing.

Blue Cross Blue Shield (BCBS) said 241,900 of its members were diagnosed with opioid use disorder (OUD) in 2017, a rate of 6.2 for every 1,000 BCBS members. The rate fell to 5.9 in 1,000 members in 2017, a decline of nearly 5 percent. The insurer said it was the first drop in the eight years BCBS has tracked diagnoses of OUD.

"We are encouraged by these findings, but we remain vigilant," said Trent Haywood, MD, senior vice president and chief medical officer for BCBS said in a statement.

"More work is needed to better evaluate the effectiveness of treatment options and ensure access to care for those suffering from opioid use disorder."

BCBS attributes much of the decline to a 29% drop in opioid prescriptions for its members since 2013.  A longtime critic of opioid prescribing hailed the findings as a sign of change.

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"It means that there's light at the end of the tunnel," psychiatrist Andrew Kolodny, MD, the founder and executive director of Physicians for Responsible Opioid Prescribing (PROP) told BuzzFeed.

"Unfortunately though, the genie is out of the bottle," said Kolodny, a former medical director of the addiction treatment chain Phoenix House. "Millions of Americans are now struggling with opioid addiction. Unless we do a better job of increasing access to effective treatment, overdose deaths will remain at record high levels and we'll have to wait for this generation to die off before the crisis comes to an end."

Admissions for Addiction Treatment

The BCBS numbers should be taken with a grain of salt, since they include all types of opioid addiction, including those linked to heroin, illicit fentanyl and prescription opioids. A more accurate way to track addiction to opioid medication would be admissions to publicly-funded treatment facilities for “non-heroin opiates/synthetic abuse” – a category that excludes heroin, but includes hydrocodone, oxycodone, fentanyl and other painkillers.

A database maintained by the Substances Abuse and Mental Health Services Administration (SAMHSA) shows that treatment admissions for prescription opioids peaked in 2011 at 193,552 admissions and fell to 121,363 by 2015 – a significant decline of over 37 percent. It seems likely that admissions for painkiller abuse have fallen even further since 2015, as opioid prescriptions have continued to plummet, and more pain patients are abandoned or denied treatment.

The SAMHSA data also reveals another trend: While the number of people seeking treatment for painkiller, alcohol and marijuana abuse has declined, admissions to treatment facilities for heroin addiction have soared. In 2010, there were 270,564 admissions in which heroin was identified as the primary substance of abuse. By 2015, that number had grown to 401,743 admissions – an increase of nearly a third.

ADMISSIONS TO ADDICTION TREATMENT FACILITIES

SOURCE: SAMHSA

Admissions for heroin addiction now surpass those for other substances, yet much of the nation’s spending and law enforcement resources remain targeted on opioid prescriptions. Many public health officials also cling to the myth the heroin epidemic was triggered by opioid overprescribing, even though heroin admissions outnumber painkiller admissions by a 3 to 1 margin.

“Epidemiological data show that as widely prescribed opioids became less accessible due to supply side interventions, heroin use skyrocketed,“ psychiatrist Nora Volkow, MD, director of the National Institute on Drug Abuse, recently told OpioidWatch.  Volkow was an early supporter of the CDC opioid guideline, one of the first supply side interventions, a strategy that she now characterizes as "naive."

“Expecting that declines in rates of prescribed opioids could, by themselves, stem the tide of the opioid crisis is naïve and an oversimplification of the complex nature of the crisis," Volkow said. "Legitimate questions have been raised about whether some pain patients might now be undertreated, and whether tightened prescribing practices over the last few years has contributed to the surge in overdose deaths from heroin and especially fentanyl.”

A recent study by SAMHSA found that deaths linked to illicit fentanyl and other synthetic opioids surpassed overdoses involving pain medication in 2016.  The study also found that drugs used to treat depression and anxiety are involved in more overdoses than any other class of medication.