Study Finds Dentists Overprescribe Opioids

By Pat Anson, PNN Editor

Over half of the opioid prescriptions written by dentists in the United States exceed the 3-day supply recommended by pain management guidelines, according to a large new study that also found a stronger dose than necessary was prescribed nearly a third of the time.

The findings, published in the American Journal of Preventive Medicine, are important because dentists are responsible for about 10% of the opioids prescribed in the U.S.

“Dental procedures like extractions can leave patients with a lot of pain that needs to be managed, and many dentists are doing a wonderful job of managing their patients’ pain appropriately and responsibly,” said Jessina McGregor, a researcher in the Oregon State University College of Pharmacy. “But our findings suggest that there’s room for improvement among some dentists, improvement that could make a huge difference in our society as we try to combat the opioid crisis.”

McGregor and her colleagues reviewed insurance records from over half a million dental visits from 2011 to 2015. The study period was before the CDC released its controversial opioid guideline in 2016, so the findings may not reflect current practices in dental pain management.

Nevertheless, the study is the largest to date of dental visits in the U.S. that resulted in an opioid prescription.

Fifty-three percent of the time, patients were given more than the 3-day supply of opioids recommended by the CDC for most types of acute, short-term pain. Some dental associations recommend no more than two days’ supply – even for dental procedures associated with the severe pain.

In addition to the excess number of pills, researchers say the dose of opioids prescribed by dentists was stronger than what was medically necessary 29% of the time.

Men, young adults aged 18-34, and people living in the South were most likely to be prescribed opioids that were stronger than needed.

“One large potential area for improvement is the almost 30% percent of opioids that were prescribed following procedures where the pain intensity was expected to be mild and manageable by non-opioid analgesics like ibuprofen or acetaminophen,” said McGregor.

“Our statistical models suggest that even something as simple and straightforward as substituting a lower-potency opioid like hydrocodone for oxycodone could make an enormous reduction in overprescribing, as much as a 20% reduction.”

Researchers say prescribing guidelines tailored to dentists and oral pain are urgently needed to reduce excess prescribing . A small 2016 study of patients who had their wisdom teeth removed found that over half the opioids prescribed went unused. That suggests as many as 100 million excess pain pills are prescribed annually by dentists.

Anti-opioid activists have long claimed that young people can easily became addicted to opioids after dental surgery. But a large 2018 study found that the risk of long-term opioid use after wisdom tooth removal is relatively rare. The study of over 70,000 teens and young adults found that only 1.3% were still being prescribed opioids months after their initial prescription.

Is It Too Early to Declare Victory in the Opioid Crisis?

By Pat Anson, PNN Editor

Wisconsin’s two U.S. Attorneys are taking a victory lap on the one-year anniversary of threatening letters they sent to 180 doctors, physician assistants and nurse practitioners in the state. The letters warned the providers that if they continue to prescribe “relatively high levels” of opioid medication — above doses recommended by the CDC — they could face civil or criminal prosecution.

In a joint news release this week, Scott Blader and Matthew Krueger, U.S. Attorneys for the Western and Eastern Districts of Wisconsin, said there has been “a substantial decrease in opioid prescribing” among providers who received the warning letters.

“Thanks partly to this initiative and the consistent efforts by the Wisconsin medical community to stem over-prescribing, Wisconsin has seen substantial progress in the fight against opioid abuse,” the news release claimed. “Total opioid prescriptions in Wisconsin have declined by 30 percent between 2016 and 2019, according to data from the Wisconsin Prescription Drug Monitoring Program. The letters sent by the United States Attorneys appear to have amplified this downward trend.” 

The release did not indicate if any provider who received the warning letter had been charged with a crime or if any of their patients has been harmed by their prescribing. The two U.S. Attorneys’ offices did not respond to a request for further information.

President Trump also claimed progress was being made in the overdose crisis during his State of the Union address on Tuesday.

“We are curbing the opioid epidemic, Drug overdose deaths declined for the first time in nearly 30 years. Among the states hardest hit, Ohio is down 22 percent, Pennsylvania is down 18 percent, Wisconsin is down 10 percent — and we will not quit until we have beaten the opioid epidemic once and for all,” Trump said.

Fentanyl Deaths Increasing

A closer look at the overdose numbers shows that it’s way too early to declare victory. A CDC report last week found that drug deaths declined over 4% in 2018, led by a significant drop in overdoses involving hydrocodone, oxycodone and other painkillers. But deaths linked to illicit fentanyl and other street drugs are surging – threatening to reverse the overall trend.

“One thing that we’re seeing is that the decline doesn’t appear to be continuing in 2019. It appears rather flat, maybe actually increasing a little bit,” said Robert Anderson, PhD, Chief of the Mortality Statistics Branch, National Center for Health Statistics. “We do know that deaths due to synthetic opioids like fentanyl are continuing to increase into 2019 and we’re seeing increases similarly with cocaine and psychostimulants with abuse potential, the methamphetamine deaths."

The most recent overdose stats from Wisconsin are also revealing, as the following two charts will show. While deaths in the state involving prescription opioids began declining in October 2017 -- over a year before the U.S. Attorneys even sent their warning letters – overdoses linked to fentanyl and other synthetic opioids are rising.

SOURCE: WISCONSIN DEPARTMENT OF HEALTH SERVICES

Nearly twice as many Wisconsinites are dying from heroin and fentanyl overdoses than from prescription opioids – a fact that is omitted in the news release from the U.S. Attorneys.

The only mention of fentanyl was the kind available by prescription. Prosecutors took credit for a Wausau physician being sentenced to three months in prison for writing “fraudulent fentanyl prescriptions” to six patients.  

A better representation of what’s happening in Wisconsin – and around the nation – is last month’s arrests of over three dozen people accused of trafficking illicit fentanyl, heroin and cocaine in Milwaukee. The drugs were allegedly shipped from Puerto Rico and Mexico, meaning drug cartels thousands of miles away recognize that there’s a demand for street drugs in Wisconsin’s largest city.

In 2019, 370 people died of drug overdoses in Milwaukee County. It was iIlicit fentanyl — not prescription opioids — that was the leading cause of death.

That doesn’t deserve a victory lap.

DEA: Fentanyl 'Primary Driver' of Overdose Crisis

By Pat Anson, PNN Editor

The U.S. Drug Enforcement Administration has released the 2019 National Drug Threat Assessment, a comprehensive report that outlines the threats posed to the nation by drug traffickers and the abuse of illicit drugs.

Not surprisingly, the annual report found that illicit fentanyl is the “primary driver” behind the overdose crisis, with fentanyl and its analogs involved in more overdose deaths than any other illicit drug. Fentanyl is a synthethic opioid 50 to 100 times more potent than morphine. The drug is prescribed legally to treat severe pain, but illicit versions of fentanyl have flooded the black market.

Of growing concern to the DEA is the appearance of illegal pill press operations in the U.S. that are manufacturing millions of counterfeit painkillers and other medications, using fentanyl powder smuggled in from China and Mexico.

“Fentanyl will remain a serious threat to the United States as record numbers of individuals suffer fatal overdoses from illicit fentanyl sourced to foreign clandestine production,” the report warns.

“Clandestine fentanyl pill pressing operations will likely increase as DTOs (drug trafficking organizations) seek to appeal to the large pill abuser population in the United States, with counterfeit fentanyl-containing pills continuing to be associated with clusters of overdoses and deaths due to inconsistent mixing and often unexpectedly high potency.”

With China cracking down on illicit fentanyl laboratories, the DEA expects the primary source of fentanyl production to shift to Mexico and India.  

Fewest Prescription Opioids Since 2006

One bright spot in the DEA report is the continuing decline in overdoses involving prescription opioids. As PNN reported, overdose deaths involving natural and semisynthetic opioids, which include painkillers such as oxycodone and hydrocodone, were 3.8% lower in 2018 than in 2017.   

The DEA said the supply of prescription opioids is now at its lowest level since 2006. DEA production quotas for hydrocodone and oxycodone have been cut nearly in half since 2016, with further cuts proposed for 2020.

But while the retail supply of opioid medication has fallen dramatically, the diversion of opioids and other controlled drugs by medical professionals and wholesale distributors – so-called “lost in transit” diversion – has soared. There were 18,604 lost in transit reports filed in 2018, nearly six times the number reported in 2010.

“It is unclear if these dosage units are being diverted, destroyed, or truly lost. Although representative of only a small number of DEA registrants, diversion by physicians, nurses, and other medical professionals and their staff remains a threat to communities across the United States,” the report warns.

The DEA predicts “a steady decrease” in the supply of opioids over the next several years and that prescription drug abusers “may shift to abusing heroin, illicitly produced synthetic opioids, and methamphetamine to obtain similar effects, which may further increase overdose deaths through at least 2020.”

The DEA said the threat posed by psychostimulants such as methamphetamine and cocaine is “worsening and becoming more widespread.” While most cocaine users prefer to snort or inject the drugs, law enforcement agencies are starting to find cocaine in tablet or pill form.

“Whether these instances are harbingers of a new trend, an experiment, or simply the result of accidental contamination within poly-drug operations remains to be seen. Tableting and capsulizing cocaine may allow traffickers to capitalize on the considerably larger CPD user market with a different version of cocaine, further maximizing profits,” the DEA said.

Finally, while the DEA officially considers the herbal supplement kratom a “drug of concern” and once tried to ban it, there is once again no mention of kratom in its annual drug threat assessment.

Drug Overdose Deaths Fell 4% in 2018

By Pat Anson, PNN Editor

Drug overdose deaths in the United States dropped in 2018 for the first time in nearly three decades, according to a new CDC report that highlights the rapidly changing nature of the overdose crisis. While deaths linked to many prescription opioids declined, overdoses involving illicit fentanyl, cocaine and psychostimulants rose.

There were 67,367 drug overdose deaths in the U.S. in 2018, a 4.1% decline from 2017 when there were 70,237 fatal overdoses.

The rate of overdose deaths involving natural and semisynthetic opioids, which includes painkillers such as oxycodone and hydrocodone, was 3.8% lower. There were nearly 2,000 fewer deaths linked to painkillers in 2018 than there was the year before.

However, the decline in deaths involving opioid medication was more than offset by a continuing spike in overdoses linked to synthetic opioids other than methadone, which primarily involves illicit fentanyl and fentanyl analogs. The death rate in that category rose 9% from 2017 to 2018.

SOURCE: CDC

While the overall trend is encouraging, a top CDC official was cautious about preliminary data for drug deaths in 2019.

“One thing that we’re seeing is that the decline doesn’t appear to be continuing in 2019. It appears rather flat, maybe actually increasing a little bit,” said Robert Anderson, PhD, Chief of the Mortality Statistics Branch, National Center for Health Statistics.

“We do know that deaths due to synthetic opioids like fentanyl are continuing to increase into 2019 and we’re seeing increases similarly with cocaine and psychostimulants with abuse potential, the methamphetamine deaths."

Overdose deaths often involve multiple drugs, so a single death might be included in more than one category and be counted multiple times. A death that involved both fentanyl and cocaine, for example, would be classified by CDC researchers as an overdose involving both synthetic opioids and cocaine.

“There’s a lot of overlap between these categories and so a death may be actually counted in multiple categories, in two or more in many instances, making it difficult to partition the decline,” said Anderson. “We really don’t have a good handle on how best to do that.”  

Opioid Prescriptions Decline Significantly

A second CDC study on opioid prescribing shows that prescriptions have declined significantly in 11 states with prescription drug monitoring programs (PDMPs) that participate in the Prescription Behavior Surveillance System (PBSS). The 11 states include California, Ohio, Texas and Florida, and represent over a third of the U.S. population.

The decline in opioid prescriptions in the states ranged from 14.9% to 33% from 2010 to 2016, indicating that prescriptions were falling long before the CDC released its controversial opioid guideline in March, 2016. Significant declines were also noted in high dose opioid prescriptions, the average daily dose and in prescriptions obtained from multiple providers.

Despite the nearly decade-long decline in prescriptions, CDC researchers continue to blame opioid medication for the ongoing overdose crisis, offering little evidence to support that view.

“PDMP data collected by PBSS indicate that steady progress is being made in reducing the use and possible misuse of prescription-controlled substances in the United States. However, some persons who were misusing prescription opioids might have transitioned to heroin or illicitly manufactured fentanyl, a change that has made the drug overdose epidemic and associated overdose rates more complex,” researchers said.

“Because the opioid overdose epidemic began with increased deaths and treatment admissions related to opioid analgesics in the late 1990s, initiatives to address overprescribing might eventually result in fewer persons misusing either prescription or illicit drugs. Reduction in overprescribing opioids might lead ultimately to a decrease in overall overdose deaths.”

PDMP data for the CDC study came from the PBSS monitoring program at Brandeis University, where Dr. Andrew Kolodny is Co-Director of the Opioid Policy Research Collaborative. Kolodny is the founder and Executive Director of Physicians for Responsible Opioid Prescribing (PROP), an activist group that has long been critical of opioid prescribing.

Healthcare Technology Vendor Took Kickbacks to Promote Rx Opioids

By Pat Anson, PNN Editor

A decade ago, electronic health records (EHRs) were touted as a major innovation that would allow doctors to maintain a digital record of their patients’ medical history, diagnoses, prescriptions and insurance claims. A 2009 federal law encouraged doctors and hospitals to adopt EHRs with over $19 billion in funding to upgrade their information technology.

It didn’t take long for someone to game the system and use EHRs to commit fraud on a massive scale.

Practice Fusion, a San Francisco health information technology developer, agreed this week to pay $145 million to resolve criminal and civil allegations that it took kickbacks from drug companies to promote their products to physicians using its EHR software.

Federal prosecutors didn’t release the names of the drug companies, but according to Reuters, Practice Fusion solicited and received $1 million in kickbacks from OxyContin maker Purdue Pharma.

In return, Practice Fusion created an EHR alert advising physicians to switch new pain patients from immediate-released opioids to extended release opioids like OxyContin. From 2016 to 2019, the alert was triggered 230 million times, according to prosecutors.

“Practice Fusion’s conduct is abhorrent.  During the height of the opioid crisis, the company took a million-dollar kickback to allow an opioid company to inject itself in the sacred doctor-patient relationship so that it could peddle even more of its highly addictive and dangerous opioids,” Christina Nolan, U.S. Attorney for the District of Vermont, said in a statement. 

“The companies illegally conspired to allow the drug company to have its thumb on the scale at precisely the moment a doctor was making incredibly intimate, personal, and important decisions about a patient’s medical care, including the need for pain medication and prescription amounts.”

Prosecutors say Practice Fusion took kickbacks from more than a dozen pharmaceutical companies, allowing them to design the phony alerts and determine when a healthcare provider received them. “Numerous prescriptions” were written as a result. The federal case is the first criminal action against a vendor of electronic health records.

“Across the country, physicians rely on electronic health records software to provide vital patient data and unbiased medical information during critical encounters with patients,” said Ethan Davis, Principal Deputy Assistant Attorney General.

“Kickbacks from drug companies to software vendors that are designed to improperly influence the physician-patient relationship are unacceptable.  When a software vendor claims to be providing unbiased medical information – especially information relating to the prescription of opioids – we expect honesty and candor to the physicians making treatment decisions based on that information.”

Practice Fusion offers free EHR software to smaller, independent physician practices. The software is used by 112,000 health care providers who see 5 million patient visits each month. Practice Fusion was purchased in 2018 by Chicago-based Allscripts for $100 million in cash.

“Since learning of this matter we have further strengthened Practice Fusion’s compliance program. Allscripts recognizes the devastating impact that opioids have had on communities nationwide, and we are using our technology to fight this epidemic,” an Allscripts spokesman said.

Arizona Drug Bust Shows Fentanyl Crisis Growing

By Pat Anson, PNN Editor

In one of the largest fentanyl busts in state history, nearly 170,000 counterfeit pills made with illicit fentanyl have been seized in Phoenix, Arizona. A DEA task force and Phoenix police seized the pills during a traffic stop on January 22, arresting two suspects who were under surveillance.

The blue pills were stamped with an “M” and a “30” – distinctive markings for 30mg fake oxycodone tablets known on the street as “Mexican Oxy” or “M30.” The total street value of the drugs was estimated at $3 million.

"These 169,000 pills, it can have a varying amount of fentanyl. They have no quality control, and what makes them that much more deadly is they look like legitimate oxycodone pills. They don't contain an active ingredient. It is just fentanyl with other ingredients," said DEA Spokesperson Erica Curry. 

"We are talking about a very deadly substance in such small quantities it can be lethal to anyone who doesn't have an opioid tolerance built up."

DEA PHOTO

Fentanyl is a synthetic opioid 50 to 100 times more potent than morphine. Counterfeit pills laced with illicit fentanyl have been appearing around the country and are linked to thousands of overdose deaths. In 2019, law enforcement agencies seized over 1.4 million fentanyl pills in Arizona alone.

According to a recent DEA analysis, about one in every four counterfeit pills have a potentially lethal dose of fentanyl.

Street Drug Users Aware of Fentanyl

Who would be foolish or desperate enough to take a street drug that might kill them? Do overdose victims even know the fake pills they’re buying contain fentanyl?

The answer in many cases is yes, according to a new study of street drug users in Vancouver, British Columbia – the first major North American city to see an influx of illicit fentanyl.  

The study drew on data collected from over 300 people recruited at drug treatment sites in 2018. The participants completed a brief survey on their drug use and provided a urine sample that researchers tested for fentanyl and other substances.

About 60 percent of those tested had fentanyl detected in their urine. Of those, nearly two-thirds (64%) knew they had taken fentanyl.

"This research shows the majority of people who use fentanyl know they're doing so," says Dr. Jane Buxton, an epidemiologist and professor at the University of British Columbia, who is corresponding author of the study published in the International Journal of Drug Policy.

"Making people who use drugs aware of the presence of fentanyl in the drug supply isn't enough; we need harm reduction services, substance use treatment, overdose prevention resources, and pharmaceutical alternatives to the toxic drug supply to reduce the devastating impact of fentanyl and its analogues on our communities."

The fentanyl crisis in British Columbia is growing worse by the year.  A similar study in 2015 found only 29% of participants tested positive for fentanyl, with only 27% aware that they'd used it.

When fentanyl first appeared in the illicit drug supply, many users took fentanyl unknowingly because dealers secretly added it to heroin, counterfeit pills and other street drugs. It’s no secret today. According to preliminary data from the BC Coroner, fentanyl or its analogues were found in 85 percent of fatal overdoses in 2019.

Researchers do not fully understand the reasons people knowingly take fentanyl. Some users are aware it is present in the illicit supply of opioids and have no other choice, while others may prefer the experience of taking fentanyl.

"This research lays groundwork that will help us learn more about why fentanyl use is increasing," said lead author Mohammad Karamouzian, a PhD student at UBC's School of Population and Public Health. "These findings will also contribute to more effective messaging campaigns and harm reduction strategies to help reduce preventable deaths and support the health of people who use substances, their families, and their communities."

Another key finding of the study was that people who used fentanyl were more likely to have also recently used heroin or crystal meth.  Those who used cannabis were less likely to use fentanyl.

Surgery Patients Given Tylenol for Post-Operative Pain

By Pat Anson, PNN Editor

Another hospital is touting the benefits of not giving opioid analgesics to patients after minimally invasive surgeries.

Surgeons at Houston Methodist Hospital say they were able to significantly reduce opioid prescriptions given to patients recovering from hernia repair, reflux surgery and other minimally invasive GI-related procedures by treating them with acetaminophen (Tylenol) for post-operative pain.

In a study involving over 400 surgery patients reported in the Journal of Thoracic and Cardiovascular Surgery, Houston Methodist surgeons compared patients treated with acetaminophen to a control group of patients given opioids.

Patients who were treated with acetaminophen had fewer post-operative complications (3%) than those given hydrocodone or tramadol (15%).  They were also significantly less likely to be discharged from the hospital with an opioid prescription than patients in the control group (10% vs. 87%).  

"Just a decade ago we routinely prescribed narcotics to treat pain at home after surgery," said lead author Min Kim, MD, head of the division of thoracic surgery at Houston Methodist Hospital. "We wanted to determine if we could manage pain at home after surgery with over-the-counter pain medication. We developed and implemented the pre-emptive pain control program, which led to excellent pain control at home without requiring prescription narcotics."

Patients in the pre-emptive pain management group received long-acting local anesthetics at each incision. They were also given scheduled doses of acetaminophen or naproxen in the hospital and at home.

"This study provides us with a strategy to successfully manage pain after surgery using over-the-counter pain medication. This led to fewer narcotic prescriptions which proactively decreases the chance of patients becoming addicted to narcotics," Kim said.

Opioid Addiction Rare After Surgery

Few patients actually become addicted after surgery. A 2016 Canadian study, for example, found that long term opioid use after surgery is rare, with less than one percent of older adults still taking opioids a year after major elective surgery.

Another large study in the British Medical Journal found only 0.2% of patients who were prescribed opioids for post-surgical pain were later diagnosed with opioid dependence, abuse or experienced a non-fatal overdose.

Nevertheless, many hospitals have reduced their use of opioids or stopped giving them to patients altogether.

A statewide effort in Michigan reduced the number of opioid pills given to patients after common operations from an average of 26 pills per patient to 18. The surgeries included minor hernia repair, appendix and gallbladder removal, and hysterectomies. Most were minimally invasive laparoscopic surgeries.

In Ohio, patients at Akron General Hospital are getting acetaminophen, gabapentin and non-steroidal anti-inflammatory drugs (NSAIDs) to manage their pain after elective colorectal operations. Surgeons say over 75 percent of them are sent home without an opioid prescription.

And in Vermont, a 2017 state law requires doctors to use non-opioid pain relievers as first-line treatments for post-operative plan. If they are prescribed opioids, patients are initially limited to no more than 10 pills.

Houston Methodist Hospital is expanding its pre-emptive pain management program to include patients recovering from pulmonary surgery.

Production of Two Excedrin Brands Halted

By Pat Anson, PNN Editor

Spot shortages of Excedrin are being reported after a pharmaceutical company halted production of two leading brands of the pain reliever due to “inconsistencies” in their ingredients.

GlaxoSmithKline (GSK) says consumers are not at risk, but as a precaution it has indefinitely suspended all production and distribution of Excedrin Extra Strength and Excedrin Migraine.

“Through routine quality control and assurance measures, we discovered inconsistencies in how we transfer and weigh ingredients for Excedrin Extra Strength Caplets and Geltabs and Excedrin Migraine Caplets and Geltabs,” GlaxoSmithKline said in a statement.

“Based on the available data, GSK believes that the product does not pose a safety risk to consumers. However, as a precautionary measure, GSK Consumer Healthcare has voluntarily implemented a discontinuation of production and distribution.”

Some drug stores in upstate New York have already run out of Excedrin Extra Strength and Excedrin Migraine. GSK said other Excedrin products are still available and urged consumers to ask their pharmacist for advice on alternative pain relievers.

“We are working hard to resolve the issue as quickly as possible, but at this point in time cannot confirm a definite date as to when supply will resume,” the company said.

In 2012, an Excedrin manufacturing plant in Lincoln, Nebraska was shut down for several months after Excedrin bottles were found to contain broken tablets and stray tablets for other medications. That led to a recall and shortages of Excedrin products around the world.

At the time, the Excedrin brand was owned by Novartis. An FDA investigation found that Novartis failed to adequately investigate hundreds of consumer complaints of foreign products found in over-the-counter drugs produced at the Nebraska plant. Novartis spent millions of dollars re-tooling the plant and shifted some production to third-party manufacturers.

GSK now holds majority ownership of Excedrin through a joint venture with Novartis. GSK did not say where the new production problems originated.

FDA Approves Cocaine Nasal Spray

By Pat Anson, PNN Editor

FDA advisory committees have taken a dim view of opioid medications recently, soundly rejecting new drug applications for the “opioid of the future” oxycodegol and a new extended-release version of oxycodone.

There was also a split 13-13 vote on a relatively mild opioid painkiller – a combination of tramadol and the anti-inflammatory drug Celebrex..

Advisory committee recommendations are not binding on the FDA, but the votes reflect a growing reluctance to approve any new medication that may worsen the so-called opioid epidemic.

"We can't approve a drug in the midst of a public health crisis," said advisory committee member Steve Meisel, PharmD, who voted no on oxycodegol.

FDA advisors may be rejecting opioids out of hand, but cocaine is a different story. The agency this month quietly approved a nasal solution containing cocaine hydrochloride (HCI) for use as a local anesthetic. The nasal spray, made by the Lannet Company, is intended to relieve pain in mucous membranes during surgeries and procedures in the nasal cavities of adults.

"The FDA's approval of our Cocaine HCl product, the first NDA approval to include full clinical trials in the company's history, marks a major milestone in Lannett's 70+ years of operations," said Tim Crew, chief executive officer of Lannett in a news release.

"We believe the product has the potential to be an excellent option for the labeled indication. We expect to launch the product shortly, under the brand name Numbrino."

Numb-rino. Get it?

While cocaine is well-known as a drug of abuse, it is classified by the DEA as a Schedule II controlled substance, alongside hydrocodone and oxycodone. Cocaine’s use in medicine is not unheard of. It was commonly used as an alternative to morphine in the last half of the 19th Century until it fell out favor because of high rates of addiction.

Numbrino is not the first nasal spray containing cocaine to be approved by the FDA. In 2017, the agency approved the nasal solution Goprelto, which is also intended for use during surgeries and procedures in nasal cavities. 

Nevertheless, the FDA’s approval of a drug containing cocaine was so unusual that Snopes conducted a fact check to see if it was true. An FDA spokesperson confirmed to Snopes that Numbrino was approved, along with warning labels and other safeguards to discourage its abuse.

“Cocaine hydrochloride nasal solution contains cocaine, a Schedule II substance with a high potential for abuse. However, when used according to the directions provided in the labeling, physical dependence and withdrawal symptoms are unlikely to develop because this drug is for single use during diagnostic procedures and surgeries,” the FDA said.

“To minimize these risks, the labeling suggests that health care facilities using the drug implement effective accounting procedures, in addition to routine procedures for handling controlled substances. Notably, this will be used as an anesthetic by trained health care professionals during diagnostic procedures and surgeries, not by patients directly. It is not available by prescription.”

Numbrino was approved without any of the controversy that surrounds opioid painkillers. In 2018, the FDA’s approval of Dsuvia — a single use opioid intended for severely wounded soldiers and trauma patients — was panned by critics, who called the drug a “dangerously unnecessary opioid medication." Like Numbrino, Dsuvia is not available by prescription and can only be administered by a healthcare professional.

Public Officials Ignorant About Overdose Crisis

By Christopher Piemonte, Guest Columnist

A recent Washington Post article highlights an ongoing debate between the Drug Enforcement Administration and some public officials, who are demanding that DEA further reduce the supply of opioid medication. DEA has responded that, without more precise data, such a reduction would be ineffective and dangerous for Americans that need opioids.

At the center of the debate is the Aggregate Production Quota (APQ) for Schedule I and II opioids and other controlled substances. Every year, the DEA sets the maximum amount for each substance that can be produced. DEA began cutting the opioid supply in 2017 and has proposed further cuts in 2020.  

Congressional lawmakers and state attorneys general argue that the APQ for opioid medication is still too high, and the excess supply leads to overdose deaths. In a recent letter to the Acting Administrator of DEA, six attorneys general claim that the APQ does not account for opioids diverted to the black market, which “factor in a substantial percentage of opioid deaths.”

Citing data from the CDC, they assert that in 2016 “opioids obtained through a prescription were a factor in over 66% of all drug overdose deaths.”

There’s a problem with these claims: They’re wrong.

When asked about the accuracy of the letter, a spokesperson for CDC said prescription opioids were a factor in “approximately 27% of all drug overdose deaths,” a figure nearly 40% lower than that presented in the letter.

It would be one thing if this error were simply a typo or miscalculation. But these state officials, as well as many lawmakers, are insisting on a specific policy response without having made the effort to dig into the data and understand the nature of the problem itself. Specifically, they cite inaccurate data to support the incorrect notion that “prescription opioids have been a dominant driver in the growing crisis.” What’s worse, that false notion is the basis for their intransigent insistence on a blanket reduction in the supply of all prescription opioids.

Experts in law enforcement, medicine and policy agree that the attorneys general made an erroneous factual conclusion, and that an arbitrary opioid quota reduction would be both ill-informed and dangerous.

“There is no question that the DEA, or any agency, attempting to come up with valid quotas for controlled substances will find it difficult if not impossible. One of the problems with interpreting overdose death information is that illicit fentanyl and heroin deaths are frequently lumped together with oxycodone- and hydrocodone-related deaths,” said John Burke, President of the International Health Facility Diversion Association and a former drug investigator for the Cincinnati Police Department.

“The vast majority of people prescribed controlled substances take them as directed. Proposed cuts in quotas will negatively impact Americans who have a legitimate medical need for opioids, causing them even more discomfort and distress. These patients are routinely overlooked when considering the prescribing and dispensing of controlled substances, and it is a tragedy.”

Increased Demand for Street Drugs

Other experts warn that further reducing the supply of opioid medication will lead to drug shortages and increase demand for illicit drugs.   

“On the surface, it appears that limiting the quotas…could, in fact, provide a means to address the overdose crisis,” said Marsha Stanton, a pain management nurse, clinical educator and patient advocate. “That, however, will do nothing more than to minimize or eliminate access to those medications for individuals with legitimate prescriptions. We have already seen the effects of back-ordered medications, which create significant barriers to appropriate patient care.”

“Patients who lose access to prescriptions for opioids, have, in some cases, turned to street drugs as an alternative. This has led to increased morbidity and mortality since street drugs have uncertain content and are often used in a comparatively uncontrolled manner,” said Stuart Gitlow, MD, an addiction psychiatrist and past president of the American Society of Addiction Medicine.

“We, therefore, cannot afford to use a crude blunt instrument such as a quota change to address the drug abuse problem. Rather, we must focus on each patient individually and, through education of clinical professionals, ensure that each patient receives medically reasonable treatment.”

By continually insisting on cuts in opioid production, public officials demonstrate a lack of understanding of America’s overdose crisis. Put simply, they’ve failed to do their homework.

“For more than a decade, experts have urged government officials to focus on much more than reducing the opioid-medication supply. Yet, they remain fixated in intellectual laziness,” said Michael Barnes, Chairman of the Center for U.S. Policy and a former presidential appointee in the Office of National Drug Control Policy.

“Policy makers must reduce demand by prioritizing drug abuse prevention, interventions, and treatment. Prevention is the biggest challenge because it will require public officials to realize and respond to the socioeconomic underpinnings of drug abuse. The time is long overdue for politicians to get serious and do the work necessary to save lives and solve this crisis.”   

The disturbing reality is this: Despite rising death tolls and the shortcomings of recent responses, many officials involved in overdose-response policy misunderstand the complexity of America’s overdose crisis.

Until those individuals are educated about the nuances of the issue, they will continue to demand policy that does not adequately address the problem, and the crisis will carry on. Continued ignorance on the part of government officials would truly be, as Mr. Burke put it, a national tragedy.

Christopher Piemonte is a policy manager for the Center for U.S. Policy (CUSP), a non-profit dedicated to enhancing the health, safety and economic opportunity of all Americans. CUSP is currently focused on identifying and advancing solutions to the nation’s substance abuse, mental health and incarceration crises.

‘Opioid of the Future’ Abandoned

By Pat Anson, PNN Editor

A promising new pain medication once touted as the “opioid of the future” because of its low risk of abuse is being abandoned.

Nektar Therapeutics withdrew its new drug application for NKTR-181 (oxycodegol) after two FDA advisory committees voted 27 to 0 against approval of the drug because of lingering concerns about the potential for addiction.

“The Company is disappointed in the Committees' vote regarding oxycodegol and believes it is also disappointing for patients suffering from chronic pain and the physicians that treat those patients who are currently relying on existing opioid therapies,” Nektar said in a statement. “The Company has decided to withdraw the NDA for oxycodegol and to make no further investment into the program.”

The molecular structure of oxycodegol is designed so the drug enters the brain slowly, providing pain relief without the euphoria or “high” that can lead to abuse.

In clinical studies, recreational drug users reported less “drug liking” of oxycodegol compared to oxycodone. Patients with chronic back pain also reported significant pain relief taking the drug twice daily.  

The research was so promising the FDA gave oxycodegol “fast track” designation in 2017 to speed its development.

All that changed, however, when the FDA came under a wave of public and political pressure to tighten its regulation of opioids.  A 60 Minutes report last year claimed the FDA “opened the floodgates” to the opioid crisis by approving the use of OxyContin. The agency also received a petition from Public Citizen calling for a moratorium on new opioid approvals because the agency “can no longer be trusted” due to its “poor record” of regulating opioids.

The FDA advisory committees had concerns about oxycodegol being snorted or injected by drug abusers and its potential for liver toxicity. A staff briefing document also questioned whether Nektar’s clinical studies were adequate.

While the panels’ unanimous recommendation isn’t binding on the FDA, Nektar decided to withdraw its new drug application rather than invest further resources in oxycodegol. That will save the company $75 to $125 million in 2020, according to a news release.

Drug Distributor Stops Opioid Sales

Nektar’s decision came the same day a New York based drug distributor announced it will no longer sell opioid medications. The Rochester Drug Co-Operative (RDC) is the nation’s sixth-largest pharmaceutical wholesaler. It buys medicines directly from drug manufacturers and sells them to 1,300 pharmacies in the Northeast.

"The ever-increasing expenses associated with the legal and regulatory compliance for this segment of drugs are simply not sustainable," RDC said in a statement. "While these specific drugs represent a relatively small percent of total sales, they account for significant legal and compliance expenses." 

Two former RDC executives were charged last year with illegally distributing opioids and conspiring to defraud the government. The company paid a $20 million fine and accepted independent monitoring under a five-year deferred prosecution agreement with the government.

An RDC spokesman said the decision to stop selling opioids was a business decision and not related to the legal case.

Obamacare Prevented Thousands of Opioid Overdose Deaths

By Pat Anson, PNN Editor

The expansion of Medicaid under the Affordable Care Act – widely known as Obamacare -- was associated with a six percent lower rate of opioid overdose deaths, according to a new study that estimates thousands of overdoses may have been prevented by expanding access to healthcare for millions of Americans.

Researchers also found a significant and unexpected increase in overdoses involving methadone, an addiction treatment drug sometimes used to treat chronic pain.

Thirty-two states and the District of Columbia opted to expand Medicaid eligibility under the Affordable Care Act (ACA), providing healthcare coverage to uninsured low-income adults. ACA requires that individuals who receive coverage be provided with mental health and substance use disorder treatment.

Researchers at the NYU Grossman School of Medicine and University of California, Davis looked at death certificate data from 49 states and the District of Columbia between 2001 and 2017— looking for changes in overdose rates in counties that expanded Medicaid under ACA compared to those that did not.

Their findings, published online in JAMA Network Open, suggest that Medicaid expansion prevented between 1,678 and 8,132 opioid overdose deaths from 2015 to 2017.

Overall, there was a 6% lower rate of opioid overdose deaths, an 11% lower rate of heroin overdoses, and a 10% lower rate of death involving fentanyl and synthetic opioids other than methadone in states that adopted the ACA.

"The findings of this study suggest that providing expanded access to health care may be a key policy lever to address the opioid overdose crisis," said senior author Magdalena Cerdá, DrPH, director of the Center for Opioid Epidemiology and Policy in the Department of Population Health at NYU Langone Health.

Methadone Overdoses Rose

Cerdá and her colleagues also found a concerning 11% increase in methadone overdose rates in states that expanded Medicaid under the ACA. Methadone is an opioid that has long been used to treat addiction, but it is also prescribed by some doctors to treat chronic pain.

“Although the rate of methadone-related mortality is relatively low compared with other opioid classes, our finding that Medicaid expansion was associated with increased methadone overdose deaths deserves further investigation,” researchers said.

“Past research has found high rates of methadone use to treat pain among Medicaid beneficiaries and that the drug is disproportionately associated with overdose deaths among individuals in this population, underscoring the importance of ongoing local, state, and federal actions to address safety concerns associated with methadone for pain in tandem with Medicaid expansion.”

In 2014, the methadone prescribing rate among Medicaid patients was nearly twice that of commercially insured patients. Medicaid patients were also slightly more likely to be prescribed methadone for pain (1.1% vs. 0.85%) as opposed to addiction.

Expansion Reduced Opioid Deaths

The ACA became law at a time when opioid overdose deaths were rising sharply. Some critics of Obamacare claimed that expanding access to low-cost opioid pain relievers would create an incentive for low-income Medicaid beneficiaries to sell their drugs.

“It stands to reason that expanding the program — particularly to people most susceptible to abuse — could worsen the problem,” a 2018 report by Sen. Ron Johnson (R-WI) claimed. “The epidemic has indeed spiraled into a national crisis since the Obamacare Medicaid expansion took effect in 2014. Drug overdose deaths have risen rapidly, at a much faster pace than before expansion.”

The NYU and UC Davis study found that theory to be false.

"Past research has found Medicaid expansion is associated with not only large decreases in the number of uninsured Americans, but also considerable increases in access to opioid use disorder treatment and the opioid overdose reversal medication naloxone," said lead author Nicole Kravitz-Wirtz, PhD, an assistant professor in the Department of Emergency Medicine at UC Davis.

"Ours was the first study to investigate the natural follow-up question: Is the expansion associated with reductions in local opioid overdose deaths? On balance, the answer appears to be yes." 

Do Pain Patients Really Get High on Rx Opioids?

By Roger Chriss, PNN Columnist

The standard narrative of the opioid crisis is built on the idea that people feel euphoria or get “high” when exposed to opioids and almost immediately become addicted. Some assert that opioid medications should have no role outside of trauma, surgical, palliative and end-of-life care due to their high risk and side effects.

But reality is more complex.

Euphoria is widely believed to be inevitable with opioids, and increases the risk for misuse and addiction. But in fact, euphoria is not common.

"I think that the notion that opioids [always] cause pleasure is a myth," Siri Leknes, principal investigator at the University of Oslo in Norway, told Live Science.  "I think it's especially important to point out that opioids do not reliably cause pleasure or relief of subjective stress and anxiety in the lab or in stressful clinical settings."

Leknes’ research found that patients receiving remifentanil – a potent, short-acting synthetic opioid -- felt high, but the experience was unpleasant.

"Not everyone experiences the same level of euphoria from opioids, and not everyone that uses opioids will develop an addiction or opioid use disorder,” says Brian Kiluk of Yale School of Medicine.

Major cognitive side effects are often thought to be inevitable with opioids. But a review of 10 clinical studies on older adults with chronic pain found that most “demonstrated no effect of opioid use on cognitive domains.” Only at high daily doses did opioids worsen memory, language and other cognitive skills.

In other words, long-term opioid therapy may cause side effects at doses well above what most people ever receive and beyond thresholds recommended by the CDC and state governments.

The risks of overdose are similarly nuanced. For instance, a study on opioids and mortality looked at a nationally representative sample of over 90,000 people, among whom 14% reported at least one opioid prescription. There were 774 deaths during the study period, with the death rate slightly higher among those taking opioid prescriptions.

However, after adjusting for demographics, health status and utilization, the authors concluded there was “no significant association” between opioids and sudden death. “The relationship between prescription opioid use and mortality risk is more complex than previously reported, meriting further examination," they said.

On the efficacy of opioid therapy, a major review in Germany looked at 15 studies with 3,590 patients with low back, osteoarthritis and neuropathic pain. The quality of evidence was low, but the authors concluded long-term opioid use was appropriate for patients who experience “meaningful pain reduction with at least tolerable adverse events."

Pain Patients Used As ‘Guinea Pigs’

Instead, we have an intense focus on prescribing statistics. States like Minnesota tout a 33% decrease in opioid prescribing for Medicare patients, while ignoring how those poor and disabled people are faring.

“My cat gets better pain management than I do after surgery,” one man wrote to state health officials.

In Ohio, opioid prescriptions have declined by 41% since 2012. Some wonder if the cutbacks went too far.

“There needed to be an adjustment and maybe it did go overboard a bit. I feel bad for the people in chronic pain because they're going to be the guinea pigs for how we get it back to the middle," Ernest Boyd, executive director of the Ohio Pharmacists Association, told the Akron Beacon Journal

So the medical needs of people with cancer, sickle cell disease and other chronic painful conditions are going unmet. And some doctors are even avoiding such patients entirely.

Naturally, there is a need to safeguard the entire opioid supply chain, and to carefully screen and monitor people on any form of opioid therapy. But we also need to track the rapidly evolving policy landscape surrounding prescription opioids to make sure that pain patients with chronic medical needs are being not harmed.

Roger Chriss lives with Ehlers Danlos syndrome and is a proud member of the Ehlers-Danlos Society. Roger is a technical consultant in Washington state, where he specializes in mathematics and research.

Pain Relief Hard to Find for Sickle Cell Patients

By Sam Whitehead, WABE

India Hardy has lived with pain since she was a toddler — ranging from dull persistent aches to acute flare-ups that interrupt the flow of her normal life.

The pain is from sickle cell disease, a group of genetic conditions that affect about 100,000 people in the U.S., many of them of African or Hispanic descent.

Sitting in the afternoon heat on her mom’s porch in Athens, Georgia, Hardy recollected how a recent “crisis” derailed her normal morning routine.

“It was time for my daughter to get on the bus, and she’s too young to go on her own,” Hardy recalled. “I was in so much pain I couldn’t walk. So, she missed school that day.”

Sickle cell disease affects red blood cells, which travel throughout the body carrying oxygen to tissues. Healthy red blood cells are shaped like plump and flexible doughnuts, but in people with sickle cell disease, the red blood cells are deformed, forming C-shaped “sickles” that are rigid and sticky.

These sickle-shaped cells can cause blockages in the blood vessels, slowing or even stopping normal blood flow. An episode of blockage is known as a sickle cell “crisis” — tissues and organs can be damaged because of lack of oxygen, and the patient experiences severe spells of pain.

‘It’s Like Torture’

Hardy tries to manage these crises on her own. She’ll take a hot bath or apply heating pads to try to increase her blood flow. Hardy also has a variety of pain medications she can take at home.

When she has exhausted those options, she needs more medical help. Hardy would prefer to go to a specialized clinic for sickle cell patients, but the closest is almost two hours away, and she doesn’t have a car.

So, Hardy often goes to the emergency room at nearby St. Mary’s Hospital for relief. Until recently, the doctors there would give her injections of the opioid hydromorphone, which she says would stop her pain.

Then, some months ago, the emergency room changed its process: “Now they will actually put that shot in a bag which is full of fluids, so it’s like you’re getting small drips of pain medicine,” Hardy said. “It’s like torture.”

INDIA HARDY (JOHNATHON KELSO FOR WABE)

It’s the same for her brother, Rico, who also has sickle cell disease and has sought treatment at St. Mary’s. The diluted medicine doesn’t give the same pain relief as a direct injection, they say.

Concerns About Addiction

St. Mary’s staffers explain that they’re trying to strike a balance with their new treatment protocol between adequate pain treatment and the risk that opioid use can lead to drug dependence.

It’s a local change that reflects a national concern. More than 47,000 Americans died in 2017 from an overdose involving an opioid, according to the Centers for Disease Control and Prevention. Most of those deaths involve an illicit opioid such as heroin, but the rising death toll prompted many hospitals to rethink how they administer opioid medications, including how they treat people, such as Hardy, who suffer from episodes of severe pain.

“We have given sickle cell patients a pass [with the notion that] they don’t get addicted — which is completely false,” said Dr. Troy Johnson, who works in the emergency room at St. Mary’s. “For us to not address that addiction is doing them a disservice.”

Johnson proposed the ER’s shift to intravenous “drip delivery” of opioids for chronic pain patients because of personal experience. His son has sickle cell disease, and Johnson said he has seen firsthand how people with the disease are exposed to opioids when very young.

“We start creating people with addiction problems at a very early age in sickle cell disease,” Johnson said.

He brought his concerns to the director of the ER, Dr. Lewis Earnest, and found support for the change. Hospital officials say they also consulted national guidelines for treating sickle cell crises.

“We’re trying to alleviate suffering, but we’re also trying not to create addiction, and so we’re trying to find that balance,” Earnest said. “Some times it’s harder than others.”

St. Mary’s says the new IV-drip protocol is for all patients who come to the emergency room frequently for pain, and most of their sickle cell patients are fine with the change.

Caught in the Crossfire

The national guidelines cited by St. Mary’s also say doctors should reassess patient pain frequently and adjust levels of opioids as needed “until pain is under control per patient report.”

Some people who work closely with sickle cell patients, upon hearing about the new approach to pain management at St. Mary’s, called it “unusual.”

“When individuals living with sickle cell disease go to emergency departments, they are living in extreme amounts of pain,” said Dr. Biree Andemariam, chief medical officer of the Sickle Cell Disease Association of America.

It’s more common for ERs to give those patients direct “pushes” of pain medication via injection, she noted, not slower IV drips.

“If anything, individuals with sickle cell disease in our country have really been caught in the crossfire when it comes to this opioid epidemic.”

— Dr. Biree Andemariam

People with sickle cell disease aren’t fueling the opioid problem, Andemariam said. One study published in 2018 found that opioid use has remained stable among sickle cell patients over time.

“If anything, individuals with sickle cell disease in our country have really been caught in the crossfire when it comes to this opioid epidemic,” Andemariam said.

She suggested that ER doctors and nurses need more education on how to care for people with sickle cell, especially during the painful crisis episodes, which can lead to death.

A study of some 16,000 deaths from 1979 to 2005 related to sickle cell found that men in the group lived to be only 33, on average. Women didn’t fare much better, living to an average age of 37. The same study suggested that a lack of access to quality care is a factor in the short life spans of people with sickle cell disease.

Researchers who study sickle cell say the opioid epidemic has made it harder for patients with the condition to get the pain medication they need. The American College of Emergency Physicians is focusing on the problem, asking federal health officials to speak out about sickle cell pain and fund research on how to treat it without opioids.

“We in the physician community are looking for ways to make sure they get adequate pain relief,” said Dr. Jon Mark Hirshon, vice president of the group. “We recognize that the process is not perfect, but this is what we’re striving for — to make a difference.”

‘They Treat Us Like We’re Not Wanted’

In the meantime, India Hardy said she feels those imperfections in the process every time she suffers a pain crisis, and she’s not alone.

In addition to her brother, Hardy said she has another friend in Athens with sickle cell disease, and that friend has also reported difficulty in finding pain relief at the St. Mary’s emergency room.

“It’s just really frustrating, because you go to the hospital for help — expecting to get equal help, and you don’t,” Hardy said, her voice breaking. “They treat us like we’re not wanted there or that we’re holding their time up or taking up a bed that someone else could be using.”

Hardy filed a complaint with the hospital but said nothing has changed, at least not yet. She still gets pain medication through an IV drip when she goes to the St. Mary’s emergency room.

At this point, she’s considering leaving her relatives and friends behind in Athens to move closer to a sickle cell clinic. She hopes doctors there will do a better job of helping to control her pain.

This story is part of a partnership that includes WABE, NPR and Kaiser Health News, a national health policy news service.

Medical Examiner: ‘I Can’t Remember Last Death From Prescribed Fentanyl’

By Pat Anson, PNN Editor

A recent statement from the San Diego County Medical Examiner’s Office caught our eye – because it offered a rare distinction between prescription fentanyl and counterfeit painkillers made with illicit fentanyl.

It’s an important point for millions of pain patients who use fentanyl responsibly.

“In the last decade when someone overdosed on fentanyl, it was often when someone was prescribed it, and perhaps put on too many fentanyl patches or altered the patches,” said Chief Deputy Medical Examiner Dr. Steven Campman. “I can’t even remember the last time I saw a death from misused prescribed fentanyl.”

Campman was talking about a 68% increase in fentanyl overdose deaths in San Diego. During the first six months of this year, 69 people overdosed on fentanyl -- compared to 41 the year before – and every one of those deaths was attributed to illicit fentanyl.

“Now, in the deaths we see, the fentanyl is illegally obtained as counterfeit oxycodone or alprazolam (Xanax). Illegal drug makers and dealers make pills to look like oxycodone or alprazolam, but the pills have fentanyl in them, and they are deadly,” Campman is quoted in a press release.

Fentanyl is a synthetic opioid 50 to 100 times more potent than morphine that’s been used for decades in palliative care and as an anesthetic during surgery. More recently, fentanyl has been used in transdermal skin patches, oral sprays and lozenges to treat severe pain.

COUNTERFEIT OXYCODONE

“Each of these new uses of fentanyl exposed millions of Americans to the drug without evidence of an inordinate degree of harm if it was used as directed,” Dr. Lynn Webster explained in a recent column.

Only in recent years has illicit fentanyl become a scourge on the black market and given a bad name to a medication that alleviates a lot of suffering. “Mexican Oxy” and other counterfeit pills made with illicit fentanyl have been linked to thousands of overdose deaths around the country. According to a recent analysis by the DEA, one in every four counterfeit pills have a potentially lethal dose of fentanyl.

“The drug isn’t designed to be put in a pill like that, and it takes very little of it to kill someone. And the illicit drug makers don’t have the kind of quality control measures that pharmaceutical companies have either,” Campman added.

Federal prosecutors have called San Diego the “fentanyl gateway” to the U.S. because the city is near ports of entry in southern California that are major transit points for Mexican drug cartels. In July, a drug courier was pulled over by an alert Texas trooper in Amarillo and found to be transporting 73 pounds of illicit fentanyl powder -- enough to kill 10 million people.

The underground fentanyl trade has also given rise to “Breaking Bad” style pill press operations.

In September, DEA agents found five pounds of pure fentanyl in the San Diego apartment of Gregory Bodemer, a former chemistry instructor at the U.S. Naval Academy, who died from an apparent overdose. Also found in the apartment was a pill press, powders, liquids and dyes used in the manufacture of counterfeit drugs.

Bodemer’s death is yet another example of how the opioid crisis has evolved from a prescription drug problem into a fentanyl crisis.

“This is how we are seeing the opioid epidemic here, mostly in the rise in fentanyl deaths,” Campman said.