Overdose Deaths Double for Teenagers Amid Fentanyl Surge

By Pat Anson, PNN Editor

Drug deaths among U.S. teenagers have risen sharply in the last two years, according to a new study that found the number of fatal overdoses doubled for adolescents aged 14 to 18 years.

In 2019, there were 492 drug deaths among adolescents. In 2021, there were an estimated 1,146 fatal overdoses, a 133% increase.

The vast majority of adolescent drug deaths last year involved illicit fentanyl (77%), followed by benzodiazepines (13%), methamphetamines (10%) and cocaine (7%). Less than 6% of the overdoses among teens involved a prescription opioid.

The study findings, reported in the journal JAMA, reflect what is happening in the overall U.S. population, with drug overdoses rising to record levels. They also mark the reversal of a decade long trend of fewer overdose deaths among teens, which coincided with declining rates of illicit drug use.

Researchers say adolescents may be unaware or naive about the risks posed by fentanyl, a synthetic opioid up to 100 times more potent than morphine and 50 times stronger than heroin. In a prescription, fentanyl plays a valuable role in treating severe pain, but as a street drug it can be deadly

“Beginning in 2020, adolescents experienced a greater relative increase in overdose mortality than the overall population, attributable in large part to fatalities involving fentanyls,” lead author Joseph Friedman, MPH, University of California, Los Angeles, reported in the journal JAMA.

“In the context of decreasing adolescent drug use rates nationally, these shifts suggest heightened risk from illicit fentanyls, which have variable and high potency. Since 2015, fentanyls have been increasingly added to counterfeit pills resembling prescription opioids, benzodiazepines, and other drugs, which adolescents may not identify as dangerous and which may be playing a key role in these shifts.”

U.S. Adolescent Overdose Deaths

SOURCE: jama

Friedman and his colleagues found the highest overdose rates among Native American, Alaska Native and Latino adolescents, reflecting what they called a “wider pattern of increasing racial and ethnic inequalities” in drug deaths.

Fentanyl is even killing kids who have not reached their teenage years. In California, a boy was recently arrested and charged with murder in the death of 12-year-old Dalilah Guerrero. The 16-year-old suspect allegedly sold a counterfeit pill made with fentanyl to the girl, who overdosed after crushing and snorting the tablet at a party in San Jose.

The spike in adolescent drug deaths comes even as substance abuse by teens fell to record lows. An annual survey by the University of Michigan found significant declines in all types of drug use by adolescents in 2021, with the use of prescription opioids falling to the lowest level in nearly two decades.    

DEA Warns of Fentanyl Mass Overdoses

Public health experts and law enforcement agencies are growing increasingly alarmed by the rising number of fentanyl overdoses. Last week, the DEA warned of a nationwide spike in fentanyl-related mass overdose events, in which three or more overdoses occur in the same location.

In the past three months, at least seven mass overdoses were reported in Florida, Texas, Colorado, Nebraska, Missouri and Washington, DC, resulting in 29 deaths. Three people died in a hotel room in Cortez, Colorado after ingesting what that they thought were 30mg oxycodone pills, but were actually counterfeit pills containing fentanyl.

“Tragic events like these are being driven by fentanyl. Fentanyl is highly-addictive, found in all 50 states, and drug traffickers are increasingly mixing it with other types of drugs — in powder and pill form — in an effort to drive addiction and attract repeat buyers,” DEA Administrator Anne Milgram said in a letter to federal, state and local law enforcement agencies. 

“We recommend that the members of your offices assume that all drugs encountered during enforcement activities now contain fentanyl. Given fentanyl’s extreme toxicity and the increases we are seeing in the distribution of polydrug substances containing fentanyl, please take all the precautions you would take when handling fentanyl whenever you interdict any illicit substance.”

A recent study by the National Institute of Drug Abuse estimated that over 9.6 million counterfeit pills containing fentanyl were seized by U.S. law enforcement agencies last year.

Overdose Crisis Reaches Grim Milestone

By Roger Chriss, PNN Columnist

The CDC announced this week that the U.S. has seen over 100,000 drug overdose deaths in the 12-month period ending May, 2021. This record-high spike in overdoses is thought to be primarily a result of pandemic lockdowns and the continuing spread of illicit fentanyl.

National Institute on Drug Abuse director Nora Volkow, MD, told NPR that the overdoses “are driven both by fentanyl and also by methamphetamines" and predicted that the surge of fatalities would continue because of the spread of more dangerous street drugs.

Connecticut this week warned that fentanyl was found in marijuana and is the suspected cause of several near-fatal overdoses in the state. “This is the first lab-confirmed case of marijuana with fentanyl in Connecticut and possibly the first confirmed case in the United States,” said state public health Commissioner Manisha Juthani, MD.

When asked if there is anything giving hope about the future of the drug crisis, PROP co-founder Andrew Koldony, MD, told Axios, “Uh... not really.”

Public health is often depressing. It is also rarely simple. We are not going to arrest, restrict or treat our way out of the drug crisis. Although harm reduction and improved access to addiction services will help, they will not be sufficient to reverse current trends.

The U.S. does not even have good data on the street drug supply. RAND researcher Bryce Pardo, PhD, looking at better and more current data in Canada, sees designer street drugs becoming even more dangerous.

“There is a recent and alarming trend toward more harmful supply of drugs sold in illegal markets in Canada. Consumers in Ontario, Alberta, and British Columbia buying powder may be at greater risk for exposure to fentanyl mixed with novel benzodiazepines,” Pardo reported in JAMA Psychiatry. “There is a need to improve monitoring and surveillance of drug consumption in the US as markets continue to trend toward more harmful drug mixtures.”

The U.S. also doesn’t have good data on drug deaths. Even the term “overdose” is problematic now. Deaths that are “opioid involved” in toxicological terms are resulting from inadvertent exposure via tainted cocaine and methamphetamine. And although fentanyl and other opioids are still involved in the majority of deaths, there are now more psychostimulant-involved deaths than there were two decades ago.

The U.S. also lacks good data on the people who died, in particular their drug use history, general health status, and other factors thought to affect drug risks and outcomes. It is easy to speculate that the stress and isolation of the pandemic exacerbated existing risks, but it is important to note that suicides did not rise in 2020 when they might have been expected to.

There is no easy policy fix here. Restricting prescription opioids and legalizing cannabis didn’t work. Ideology will not help. Legalizing drugs is a meaningless slogan since neither “drugs” nor “legalization” is well-defined. The same with old narratives and origin stories about the crisis, which may help explain what happened but contribute little about what to do next.

Safe supply is an appealing but problematic notion. There is no obvious way to test illicit substances in human trials. Illicit labs are unlikely to hold back their products any more than illicit cannabis suppliers are going to obey the law. Street drug test kits might help, if only we knew enough about the drugs and their users.

Treatment is similarly challenging. As Kolodny told Axios, “If we really want to see deaths come down in the short run, someone who's opioid addicted has to be able to access treatment more easily than they can buy a bag of heroin or fentanyl.” Though this is an admirable goal, there is no practical way to do it.

And all of this assumes that street users are opioid-addicted. More and more are not, as the increasing levels of death and harm from psychostimulants shows. Further, an increasing number of deaths are “polydrug” deaths involving two or more substances, which makes addressing risks all the more complicated.

But despair is not the appropriate response. The U.S. was facing rapidly rising rates of tobacco-related illness and death for much of the 20th century. But a combination of public health measures has cut the mortality rate from smoking in half since 1990. These measures include stricter laws and regulations, increased costs, and in an unexpected irony, stigmatization of smoking.

Many of the proposed solutions to the drug crisis have been based more on intuition than data. At this point we simply do not know which public health measures are working or how to improve them. What little data we have is often imprecise and years old, and as the crisis accelerates, the importance of granular and timely data grows. Moreover, the measures to date have often been applied piecemeal for short periods, so their real efficacy remains to be determined.

The tragedy of drug deaths cannot be understated, and the potential for far more drug deaths cannot be underestimated. But if the U.S. can improve its understanding of drugs and its response to risks and harms, we needn’t see so many more deaths moving forward.

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. 

Focus on Opioid Crisis Overlooks Rise in Stimulant Deaths

By Pat Anson, PNN Editor

While much of the nation was focused on the opioid crisis, new research shows that another drug epidemic was taking the lives of U.S. military veterans.

University of Michigan researchers say the rate of veteran overdose deaths involving cocaine, methamphetamine and other stimulants tripled from 2012 to 2018. Most of the veterans did not receive any substance abuse treatment in the year before they died.

“We have been so focused on opioids that we are missing the tremendous increase in people who are using multiple substances, as well as those using stimulants only, when we know that many people don’t stick to just one substance,” says lead author Lara Coughlin, PhD, a psychologist and an assistant professor in the U-M Department of Psychiatry. “The fact that so many of those who died of an overdose had not received substance use disorder treatment is especially concerning.”

Coughlin and her colleagues reviewed the medical records of 3,631 veterans who died from overdoses involving stimulants, and found that about two-thirds of the deaths involved cocaine. Over half of the stimulant deaths (54.1%) also involved another substance, usually alcohol or an illicit opioid such as heroin or fentanyl. Prescription opioids were involved in less than 26% of the stimulant-related overdoses.

Researchers called the tripling of stimulant deaths “an escalating public health crisis” that deserves more attention.

“Recent trends show stark increases in stimulant-involved overdoses, with the majority of these overdoses deaths involving multiple classes of substances. These more complex, polysubstance-involved overdose deaths necessitate an expansion from a singular opioid-centric focus to include other substances and consideration of the role of stimulant use on overdose risk to inform effective prevention and treatment efforts,” researchers reported in the journal Addiction.

The authors noted there are few medication-based treatments to help people reduce their use of methamphetamine or cocaine, while multiple medications are available to treat those with opioid or alcohol use disorders.

Better access to treatment was especially needed for veterans in rural areas and those who are homeless. About one-third of all the overdose deaths involving stimulants were in Black veterans, as were two-thirds of the deaths from cocaine alone.

In addition to the risk of overdose, researchers say people who use methamphetamine or cocaine are at greater risk of heart damage. About 62% of the overdoses involving stimulants were among veterans aged 45 to 64.

“We need to build better awareness of the role of stimulants as a risk factor for overdose, and of the need for those who have stimulant use disorders to be referred for treatment, regardless if they are also using opioids,” said Coughlin. “We know that cocaine and methamphetamine are much more likely to be adulterated with fentanyl or other synthetic opioids now, so those who use them need to be equipped with rescue doses of naloxone to use and need to know about the risk for overdose in case they or someone they’re with experiences an unexpected, life-threatening reaction.”

The rise in stimulant deaths has not occurred in a vacuum. In the first half of 2019, data from 24 states and the District of Columbia showed that stimulants were involved in 5 out of 11 fatal overdoses. The CDC issued a Health Alert Network Advisory last year about a record number of overdoses, due in part to an acceleration in stimulant-related deaths.

Is DEA Practicing Medicine Without a License?

By Pat Anson, PNN Editor

Tomorrow the U.S. Drug Enforcement Administration holds another Prescription Drug Take Back Day, a campaign that encourages people to help combat drug addiction and overdoses by disposing of their unneeded medication at thousands of drop-off locations nationwide.

It’s also a day the DEA uses to further stigmatize the prescription drugs that millions of Americans rely on to control their pain and have functional lives.

“The majority of opioid addictions in America start with prescription pills found in medicine cabinets at home. What’s worse, criminal drug networks are exploiting the opioid crisis by making and falsely marketing deadly, fake pills as legitimate prescriptions, which are now flooding U.S. communities,” DEA Administrator Anne Milgram said in a statement. “I urge Americans to do their part to prevent prescription pill misuse: simply take your unneeded medications to a local collection site.”

The DEA’s campaign to reduce the supply of opioid medication goes well beyond drug take back days. In 2022, the agency is planning to cut production quotas for oxycodone, hydrocodone and other widely used opioid pain relievers. If the proposed quotas published this week in the Federal Register are adopted – and past history indicates they will be – it’ll be the sixth consecutive year the DEA has reduced the supply of opioid medication. 

During that period, production quotas have fallen by 63% for oxycodone and 69% for hydrocodone. And opioid prescribing has fallen to levels not seen in 20-years.

But with drug overdoses climbing to record highs, critics say there is no evidence the DEA’s strategy is working. And they are alarmed that a law enforcement agency is setting policies that affect the healthcare choices of Americans -- in effect, practicing medicine without a license.

“I think a very strong argument can be made that DEA is inappropriately exercising medical judgment based on their reasoning for supporting another production reduction for opioid analgesics,” says Dr. Chad Kollas, a palliative care specialist in Florida. “Federal policy has encouraged blind reductions in opioid prescribing, so for DEA to cite that trend as evidence for a reduced need for the medical supply of opioid analgesics is a self-fulfilling prophecy.

“Reduced prescribing has not led to a reduction in overdose deaths involving opioids, but rather has been associated with an increase in overdose deaths and suicides in patients with chronic pain who have been forced off their pain medications. Federal opioid policy calling for non-focused, reduced opioid prescribing has been an abject failure.” 

18.88% Decline in ‘Medical Need’

Under federal law, the DEA is required to annually set production quotas for opioids and other controlled substances. It does so after consulting with the Food and Drug Administration, Centers for Disease Control and Prevention, and other federal agencies to establish the amount of drugs needed for medical, industrial and scientific purposes.  

"The responsibility to provide these estimates of legitimate medical needs resides with FDA. FDA provides DEA with its predicted estimates of medical usage for selected controlled substances based on information available to them at a specific point in time in order to meet statutory requirements,” DEA explained in the Federal Register.

“With regard to medical usage of schedule II opioids, FDA predicts levels of medical need for the United States will decline on average 18.88 percent between calendar years 2021 and 2022. These declines are expected to occur across a variety of schedule II opioids including fentanyl, hydrocodone, hydromorphone, oxycodone, and oxymorphone."

Asked to comment on the DEA’s statement, an FDA spokesperson said the agency sent a letter to the DEA in April 2021 using pharmaceutical sales data from prior years to create “statistical forecasting models to estimate medical need for the next two years.” The FDA letter never actually used the 18.88% estimate, that was a figure apparently calculated by the DEA itself.

“In the letter FDA provided an estimate for need of each individual active ingredient in various opioid medications for 2021 and 2022. It appears the DEA estimated the 18.88% decrease as an average across the list of opioid active ingredients, presumably based on the estimates we provided.  We do not disagree with their forecast for this decreasing trend of opioid need,” the FDA spokesperson wrote in an email to PNN.

Opioid ‘Red Flags’

In its statement in the Federal Register, DEA also said it relies extensively on data from prescription drug monitoring programs (PDMPs) to find “red flags” that may indicate a drug is being abused or diverted. The DEA is particularly concerned about daily opioid doses that exceed 240 morphine milligram equivalents (MME). That’s a very high dose for most people – and well above the CDC opioid guideline’s recommended limit of 90 MME.

“DEA believes that accounting for quantities in excess of 240 MME daily allows for consideration of oncology patients with legitimate medical needs for covered controlled substance prescriptions in excess of 90 MME daily. Higher dosages place individuals at higher risk of overdose and death. Numerous dispensings of prescriptions with dosages exceeding 240 MME daily may indicate diversion such as illegal distribution of controlled substances, or prescribing outside the usual course of professional practice,” the DEA said.

Where does the 240 MME threshold come from? That’s apparently another case of the DEA coming up with its own estimates to determine whether a dose is medical necessary. It certainly doesn’t come from the CDC guideline, which was never meant to include patients suffering from cancer pain or those in palliative care.

“The DEA is misapplying the CDC opioid guidelines, which were explicitly not meant to apply to patients receiving palliative care,” Dr. Kollas told PNN. “Moreover, it’s disingenuous for DEA to infer that patients receiving higher doses of opioid analgesics are diverting them, when the vast majority of opioid overdose deaths arise from illicit fentanyl in counterfeit pills.”

Just how serious is the drug diversion problem? Not so serious at all, according to the DEA’s own National Drug Threat Assessment, an annual report that for years has said that less than 1% of legally prescribed opioids are diverted.  

“The number of opioid dosage units available on the retail market and opioid thefts and losses
reached their lowest levels in nine years,” the DEA’s 2020 report found.

The same report also found that illicit fentanyl, not prescriptions opioids, is “primarily responsible for fueling the ongoing opioid crisis.” That’s a view shared by the American Medical Association, which declared in 2020 that “the nation no longer has a prescription opioid-driven epidemic.”

‘Stop Punishing Pain Patients’

If that makes you wonder why the DEA is so intent on further reducing the supply of opioids, you’re not alone.

“This is pure insanity. The scientific data from the CDC & NIH (National Institutes of Health) show that the overdose crisis is NOT due to prescription opioid analgesics,” wrote Chuck Robertson, one of hundreds who left comments in the Federal Register on the DEA proposal. “We are in the midst of the worst supply chain crisis in modern history, so you want to continue to cut back on production? All this is doing is putting hospitals and pharmacies at risk of being short medications that people need to control pain.”

“Please don’t cut production quotas of the opioids listed. There are hundreds of stories of people who need opioid medication therapy to even live at the most basic of functionality,” said Michelle Stifle, a chronic pain patient for 22 years. “This inhumane treatment is discriminatory. Stop punishing pain patients for the faults of others.” 

“Please do not cut the quotas anymore. My wife has several autoimmune diseases that cause horrible pain. She was completely cut off of her pain meds after almost 20 years of use,” said Jeffrey Smith. “She never took more than prescribed and never abused them. It allowed her to live somewhat normally. Now she suffers every day and has no life. I'm afraid the time is coming she won't be able to take the pain anymore.” 

“I was forced tapered off my pain meds after taking them responsibly for 17 years. I now spend 75 percent of time in bed. I cannot function and am in constant pain,” said Shelly Allen. “I recently tore my rotator cuff and couldn't even get a few days’ worth. Where there may have been overprescribing there is now underprescribing. It's my body, why can't I choose my own pain relief in reasonable doses?”

“We don't need more cuts to the supply of opiates. It doesn't help avoid addiction or address it. All cutting the supply further will do is promote health care rationing,” wrote Amber Smith. “Opiates are necessary for surgery and other medical needs. Would the DEA ever suggest cutting the supply of chemotherapy or insulin? No, yet those are every bit as necessary to patients as opiates are.”

The DEA did not respond to a request for comment on this story. To leave your comment on the DEA’s proposed 2022 production quotas, click here. Public comments must be received by November 17.

Overdoses Tripled in New Jersey Despite Limits on Rx Opioids

By Pat Anson, PNN Editor

In 2017, New Jersey became one of the first states in the country to impose a hard limit on initial opioid prescriptions, with patients allowed only a 5-day supply of opioid pain medication. If they needed more, their doctor would have to write a new prescription, enroll patients in a pain management program, and counsel them about the risks of opioid addiction and overdose.

"We are here today to save lives," then-Governor Chris Christie said after signing the legislation into law. "New Jersey now leads the way first and foremost in recognizing this is a disease."

Four years later, there is little evidence the 5-day limit has reduced opioid addiction or saved lives in New Jersey. In fact, it may have made the overdose crisis worse by forcing some patients to turn to increasingly dangerous street drugs.

A new study at Rutgers University, recently published in The Journal of Substance Abuse Treatment, found that medically treated opioid overdoses among Medicaid patients more than tripled in New Jersey from 2014 to 2019.

Researchers found the overdose rate continued to rise even after the 5-day opioid limit was imposed, with opioid prescription rates nearly cut in half for Medicaid beneficiaries, falling from 23 percent in 2015 to 13 percent in 2019.   

The rising number of overdoses was primarily due to heroin and illicit fentanyl, and often involved alcohol and other drugs. Medicaid patients suffering from alcoholism, benzodiazepine addiction, depression, hepatitis C, heart failure and pneumonia had overdose rates at least 1.5 times higher than other beneficiaries.

“While high rates of opioid prescribing likely contributed to earlier increases in OUD (opioid use disorder), actions to further limit such prescribing alone may do little to reduce opioid overdose in the current environment,” wrote lead author Stephen Crystal, PhD, director of the Rutgers Center for Health Services Research.

“Policies also need to be attentive to the possibility that, if not well managed, reductions in access to prescribed opioids could lead some individuals with pain conditions and other complications, including OUD, to turn to heroin and other illicit drugs, in an increasingly dangerous environment.”

Since their peak in 2015, when over 5,640,000 opioid prescriptions were filled in New Jersey, opioid prescribing has fallen over 35% in the state. That coincided with an alarming increase in overdose deaths as illcit fentanyl began to flood New Jersey.

OPIOID PRESCRIPTIONS DISPENSED IN NEW JERSEY

Source: NJ Cares

NEW JERSEY FATAL DRUG OVERDOSES

Source: NJ Cares

Comorbid Conditions

Rutgers researchers say more attention needs to be paid to people who survive overdoses, who often live with multiple health problems and comorbid conditions. In 2019, over half suffered from major depression (51%), while others had alcohol use disorder (39%), hepatitis C (30%), bipolar disorder (28%), cannabis use disorder (26.5%) sedative/hypnotic use disorder (21%) or schizophrenia (11.5%).  

Notably, less than a third (30.4%) of New Jersey’s overdose survivors were diagnosed with a chronic pain condition, suggesting the state’s focus on limiting pain medication was misdirected at a time when more resources were needed throughout the state’s healthcare system, particularly for mental health.  

“The high level of behavioral health and medical comorbidity that we identified among individuals with overdoses has important implications for interventions in a system in which substance use treatment, mental health care, and primary medical care are often siloed,” Crystal and his colleagues wrote.

“Interventions for conditions such as alcohol use disorder, sedative-hypnotic use disorder, and chronic obstructive pulmonary disease could reduce overdose risk. High rates of mental health comorbidity among this population, including major depression, bipolar disorder and schizophrenia, also highlight the need for concomitant mental health treatment.”

New Jersey is not alone in its failed attempt to end the overdose crisis. As PNN has reported, nearly two dozen states have implemented laws limiting the initial supply of opioid medication; 17 states limit prescriptions to 7 days supply, two states cap them at 5 days, and four states limit prescriptions to just 3 days.  

These and other efforts to reduce opioid use, such as prescription drug monitoring programs (PDMPs), have resulted in prescription opioid use falling to 20-year lows in the United States, even while overdose deaths surged to record highs. Over 93,000 Americans died of drug overdoses in 2020, with the vast majority linked to illicit fentanyl and other street drugs.

The trend continues in New Jersey. In the first six months of 2021, the state reported 1,626 fatal overdoses, nearly three dozen more deaths than were recorded during the same period last year. New Jersey is on track to have a record 3,250 fatal overdoses by the end of the year.

Rx Drug Monitoring Programs Are Making Overdose Crisis Worse

By Pat Anson, PNN Editor

Prescription drug monitoring programs (PDMPs) have long been touted as a key weapon in the war on drugs. With the recent addition of Missouri, all 50 U.S. states now have PDMPs, allowing physicians and pharmacists to consult a database to see if patients might be abusing opioid medication or other controlled substances. Law enforcement agencies also use the databases to see if doctors are “overprescribing” opioids. 

But a new study by the Reason Foundation, a libertarian think tank, has found that PDMP’s may be making the opioid crisis worse by forcing patients to turn to street drugs. A record 93,331 Americans died of drug overdoses in 2020, with the vast majority of deaths linked to illicit fentanyl, not prescription opioids.

“This study’s analysis finds that the outcomes of PDMP implementation are far less beneficial than the popular support for this policy suggests,” the report found. “Black market overdoses from heroin and fentanyl dramatically increase following PDMP adoption. It appears that surges in illicit opioid overdose deaths follow PDMP implementation, with no clear reduction in deaths, which is the stated intent of the intervention.”   

Co-authors Jacob James Rich and Robert Capodilupo found that states reduced their opioid prescribing rates by an average of 7.7% after implementing a PDMP. But reduced prescribing had “no consistent effect” on overdose deaths. Instead, the study found strong evidence that PDMPs actually caused opioid death rates to increase by 17.5 percent. Fentanyl, heroin and cocaine overdoses all rose sharply.

“As PDMPs enable doctors to identify patients who may be doctor shopping to acquire opioids for non-medical use, doctors will likely stop prescribing opioids to them. Yet these are the very patients who are likely addicted and who will turn to illicit providers to fuel their habits,” the study found.

Percent Increase In Overdose Rates After PDMP Adoption

SOURCE: REASON FOUNDATION

‘Like Playing Russian Roulette’

A recent PNN survey of over 3,600 pain patients found that it was common for patients to be taken off opioids or tapered to lower doses against their wishes. A small minority of patients – about nine percent -- said they turned to illegal drugs as an alternative to opioid medication.

“Tapering long term higher dose patients is a barbaric practice that causes suffering so great that going to the black market for relief is the only option besides ending one’s life,” one patient told us. “People want to live so they will turn to the streets where they encounter counterfeit pills and/or much cheaper heroin, made with fentanyl. They aren't wanting to die. They are trying to live again.”

“I've had to seek medication from the black market & risk arrest & death just to be able to walk & leave my bed,” another patient wrote. “Perhaps I too will end up dead one day from street pills made from illicit fentanyl since I can't obtain access to a safe supply from a trusted manufacturer.”

“I'm not a criminal by nature, and I know that it's illegal to buy drugs off the street, but when pain gets so bad I can actually feel the desperation take over and seek relief wherever I can find it,” said another patent. “If it gets too bad I do sometimes have to find that guy on the street and purchase a 100mg morphine, or something, and just hope that it's not containing a lethal dose of fentanyl or something else. It's kinda like playing Russian roulette.”

“I couldn't stand the pain level anymore. After 3 years suffering so bad, I tried the streets. Found illegal fentanyl. The dealer said it was heroin but I found out what it really was because I overdosed and almost died,” said another pain sufferer. “I learned my lesson! Never again.”

The Reason Foundation estimates that it costs about $500,000 annually for each state to operate a PDMP. While that’s relatively inexpensive, the report said it was “counterproductive” to spend any money on a program that may actually contribute to more deaths. It recommends that states scrap their PDMPs and spend the money on addiction treatment.

“Millions of taxpayer dollars are spent nationwide on the administration of these ineffective programs each year,” the report found. “After terminating all PDMP policies, the revenue spent currently on prescribing interventions should be reappropriated to subsidizing opioids for proven treatments like medication-assisted treatment (MAT) with drugs like buprenorphine and methadone, and allowing Medicaid to cover addiction treatment services.”

Previous studies have also concluded that PDMPs may be causing more harm than good. A 2018 study found that PDMPs were driving some patients to the black market for cheap drugs like heroin. A 2019 study reached the same conclusion, saying there was a “consistent, positive, and significant association” between PDMPs and heroin overdoses.

PDMP’s are also associated with abrupt opioid discontinuation, according to a recent study in the American Journal of Preventive Medicine. Patients on long-term opioid therapy living in states with robust PDMPs were more likely to have their doses cut without tapering.

Researchers Warn of Deadly New Illicit Opioid

By Pat Anson, PNN Editor

A new illicit opioid that is 20 times more potent than fentanyl has been linked to at least eight fatal overdoses in the U.S. in the last month, according to a public safety alert released by a Pennsylvania research laboratory.

The Center for Forensic Science Research & Education (CFSRE) said its scientists detected N-pyrrolidino etonitazene -- also known as etonitazepyne -- in eight blood samples taken during recent death investigations in West Virginia, Pennsylvania, New York, Florida and Colorado.  Four of the deaths occurred in West Virginia.

“The toxicity of N-pyrrolidino etonitazene has not been examined or reported but recent association with death among people who use drugs leads professionals to believe this synthetic opioid retains the potential to cause widespread harm and is of public health concern. Identifications of N-pyrrolidino etonitazene have also been reported recently from agencies in Europe,” the safety alert said.

Etonitazepyne is a synthetic opioid that is chemically similar to etonitazene, another powerful narcotic that started appearing in illicit drug markets and counterfeit pills in the U.S. and Canada last year.  While etonitazene is classified as an illegal Schedule I controlled substance by the DEA, etonitazepyne has not specifically been scheduled. Several websites even list it for sale for “chemical research.”

"The current drug landscape in the United States is unstable and unpredictable – especially the opioid market – which can ultimately lead to deadly outcomes," said Dr. Alex Krotulski, an associate director at CFSRE. "The purpose of this public alert is to raise awareness about a new and already deadly synthetic opioid so that way people who use drugs are able to modify use patterns and so that laboratories know to test for this new drug in their states or jurisdictions.”

Etonitazepyne may be new to law enforcement, coroners and public health officials, but illicit drug users have been warning each other about the drug for several months in online message boards.

“I got a report about an overdose with only 1 MG of Etonitazepyne (snorted) that caused a pretty high tolerance user to become unconscious and stopped breathing, and he had to be rescued from paramedics,” a poster said on Reddit.

“Everyone needs to be careful with this one. It's not for anyone who has no tolerance to opioids, and can still be dangerous for those who do,” another poster wrote.

Would Drug Legalization Reduce Overdoses?

By Roger Chriss, PNN Columnist

As the overdose crisis worsens, public health data and biostatistics become more important. Debates about opioid prescribing and drug legalization often center on two key concepts: incidence and prevalence as applied to drug use, substance use disorder (SUD) and overdoses.

Brandeis University researcher Andrew Kolodny, MD, recently argued against drug legalization on Twitter.

“Some critics of reducing Rx opioids don't believe that repeated use of highly addictive drugs cause addiction and/or they believe all drugs, including heroin & cocaine should be available over the counter. They don't believe that easy access can increase prevalence of SUD,” said Kolodny, who founded Physicians for Responsible Opioid Prescribing (PROP), an anti-opioid activist group.

Conversely, Columbia University professor Carl Hart, the author of “Drug Use for Grown-Ups,” believes legalizing recreational drugs would help reduce overdoses by making the drug supply safer.

“A large proportion of these deaths are caused by adulterated substances purchased on the illicit market. A regulated market, with uniform quality standards, would virtually put an end to contaminated drug consumption and greatly reduce fatal accidental drug overdoses,” Hart told Columbia Magazine.

Both claims hinge on a proper understanding of incidence and prevalence. In epidemiology, incidence is the rate of new-onset diagnosis of a medical condition. It is measured over a given period of time -- typically a year -- though sometimes the time period is shortened to a week for an urgent problem, such as a viral pathogen like the coronavirus.

By contrast, prevalence measures the total number of people in a population who have a specific medical condition. For prevalence, the duration of the condition is important. For an infectious disease, it may be brief. But for cancer, SUD and many other chronic conditions, it may last a lifetime.

For instance, the incidence of opioid use disorder (OUD) among people who are on long-term opioid therapy is 8-12%, according to the National Institutes of Health. But unlike claims frequently made by PROP, only a small fraction of patients who abuse prescription opioids start using heroin, less than 4% over a five-year period. So, making a clear distinction between OUD involving prescription opioids versus heroin becomes important.

The prevalence of OUD is a cumulative total of all people with OUD over time. This is because OUD and other substance use disorder diagnoses are lifetime diagnoses that remain on a person’s medical records forever. When we count people with OUD, we are counting everyone ever diagnosed with the condition, though in practice sometimes the OUD diagnosis is dropped due to administrative error, poor record-keeping or deliberate obfuscation.

This means that OUD prevalence can go up over time even when the incidence of OUD is going down. In fact, that is what is happening at present.

A recent report from the Substance Abuse and Mental Health Services Association showed modest declines for both prescription opioid misuse and heroin use. This came at a time when U.S. drug deaths were rising, fueled primarily by overdoses involving illicit fentanyl.

These counterintuitive trends make for intense debate about the success or failure of the 2016 CDC opioid guideline and state laws restricting prescription opioid use. A recent study from Indiana University concluded that limits on legal opioid prescribing may have actually driven more people to illicit drugs.

"Our work reveals the unintended and negative consequences of policies designed to reduce the supply of opioids in the population for overdose. We believe that policy goals should be shifted from easy solutions such as dose reduction to more difficult fundamental ones, focusing on improving social conditions that create demand for opioids and other illicit drugs," said co-author Brea Perry, PhD, a professor of sociology at Indiana University.

Even if drug legalization were to reduce drug risks, an increase in the number of drug users could lead to more harms. For instance, if an illicit drug harms 10% of users and there are 1 million users, that results in 100,000 people harmed. If that drug is then legalized and made safer, harming only 1% of users, that seems like an improvement. But if the number of users rises to 15 million, then 150,000 people would be harmed.

Since we don’t know how these numbers would change under a legalized drug regime, any claims about changes in incidence or prevalence are speculative at best.

What is counted and how it is expressed are very important in debates about the role of prescription opioids or drugs in general in SUD and overdose deaths. A failure to be specific about methodology or using data that is not well-founded can result in specious or even deceptive claims. And counterintuitive results are possible, as we are seeing at present in the ever-evolving overdose crisis.

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.

CDC Focused on Rx Opioids While Fentanyl Deaths Soared 1,040%

By Pat Anson, PNN Editor

A new report from the Centers for Disease Control and Prevention documents an alarming increase in overdose deaths and how the agency’s 2016 prescription opioid guideline failed to stop the drug crisis from growing worse.

The study looked at fatal overdoses from 2013 to 2019, a period when U.S. drug deaths rose by over 56 percent, culminating with 70,630 Americans dying from overdoses in 2019.  

Deaths involving prescription opioids remained relatively flat during that period, while overdoses involving other substances rose, led by an astounding 1,040% increase in deaths linked to illicit fentanyl and other synthetic, mostly black market opioids. Overdoses involving heroin, cocaine and stimulants such as methamphetamine also rose.

DRUGS INVOLVED IN U.S. OVERDOSE DEATHS (2013-2019)

“Sharp increases in synthetic opioid- and psychostimulant-involved overdose deaths in 2019 are consistent with recent trends indicating a worsening and expanding drug overdose epidemic. Synthetic opioids, particularly illicitly manufactured fentanyl and fentanyl analogs, are highly potent, increasingly available across the United States, and found in the supplies of other drugs,” researchers reported in the CDC’s Morbidity and Mortality Weekly Report.

“Similarly, psychostimulant-involved deaths are likely rising because of increases in potency, availability, and reduced cost of methamphetamine in recent years. The increase in synthetic-opioid involved deaths in the West and in psychostimulant-involved deaths in the Northeast signal broadened geographic use of these substances.”

The new CDC study adds to a growing body of evidence suggesting that the agency’s controversial opioid guideline has been ineffective and misdirected. While the guideline helped reduce the already shrinking supply of opioid medication – prescription opioid use is now at 20-year lows – drug deaths linked to illicit fentanyl and other substances kept rising. Overdoses hit a record high last spring.

"This represents a worsening of the drug overdose epidemic in the United States and is the largest number of drug overdoses for a 12-month period ever recorded," the CDC said in a recent health advisory.

‘I Don’t Really Want to Die’

Many pain patients – including those who have used opioids safely and responsibly for years – now have difficulty obtaining opioid analgesics and live with untreated or poorly treated pain. A recent study found that nearly half of primary care clinics in the U.S. are unwilling to accept new patients on opioids, because they had either stopped prescribing them or feared scrutiny by law enforcement and regulators if they did.

“Why am I treated like a criminal for needing opioids? For 26 years opioids are the only treatment that allows me to have a life,” a pain patient recently told PNN. 

“My doctor stopped prescribing my pain medication without my consent, leading to rapid tapering and abrupt discontinuation. No medication and haven't heard from her since. She won't return my calls,” another patient said.  

“I'm at a very desperate point in my life,” said a patient with Complex Regional Pain Syndrome (CRPS). “The meds don't address my needs and I'm at my end. If something doesn't give right away, I will be gone! I don't really want to die but I feel that it is the only option left.” 

Some anti-opioid activists have turned a blind eye to pleas from patients and want opioid prescriptions reduced even further.

“Opioid scrips have been trending in a more cautious direction, (though we still have a very long way to go) while opioid OD deaths have soared. Some see this as a policy failure. They may not realize the main goal of more cautious Rx opioid use is to reduce incidence of OUD,” Dr. Andrew Kolodny, founder of Physicians for Responsible Opioid Prescribing (PROP), wrote in a recent Tweet.

But when asked by another poster if there have been declines in OUD — opioid use disorder — because fewer opioids are being prescribed, Kolodny said he didn’t know.

“OUD incidence isn't tracked. We're 25 years into an epidemic of OUD but still have lousy surveillance. So no hard data but if fewer people are exposed to a highly addictive drug, it's a safe bet that fewer people will become addicted,” Kolodny replied.

The CDC is currently working on an update and possible expansion of its opioid guideline – with the goal of releasing a revised guideline late this year. The agency’s Board of Scientific Counselors is holding a public hearing this Tuesday, February 16th to get an update from an “Opioid Workgroup” that is considering changes to the guideline. People interested in listening to the meeting online can register clicking here.

Are Cannabis Dispensaries Really Associated with Fewer Opioid Overdoses?

By Roger Chriss, PNN Columnist

A new study published in The BMJ claims that U.S. counties with medical and recreational cannabis dispensaries have fewer opioid-related deaths.

Researchers at Yale and University of California at Davis found that an increase of just one or two storefront dispensaries in a county was associated with a 17% reduction in all-opioid mortality rates. Deaths involving illicit fentanyl and other synthetic opioids fell by 21 percent.

Although the researchers cautioned that “the associations documented cannot be assumed to be causal,” cannabis supporters were quick to praise the findings.

“The data to date is consistent and persuasive: For many pain patients, cannabis offers a viable alternative to opioids, potentially improving their quality of life while possessing a superior safety profile,” said Paul Armentano, Deputy Director of NORML, a marijuana advocacy group.

While the study findings are interesting, they highlight the importance of considering the complex supply side of legal and illegal drug markets, and how it shapes opioid use and misuse. The study looked at data from over 800 counties with legal dispensaries, and compared them to counts of fatal overdoses between 2015 and 2018.

It turns out many of these counties were on the West Coast, where illicit fentanyl had yet to became as pervasive on the black market as it had in other parts of the country. Since 2018, deaths involving fentanyl have soared on the West Coast. 

“If you were to do the same study with current data, you’d find something different because of the way both opioid deaths and cannabis dispensaries have shifted since then,” Chelsea Shover, PhD, an assistant professor at UCLA School of Medicine told Healthline. 

In general, the opioid overdose crisis has gotten worse in the past couple of years. The CDC recently reported that in the 12 months ending in May 2020, ten western states reported a nearly 100 percent increase in deaths involving illicit fentanyl and other synthetic opioids. The increase was particularly sharp in states that legalized recreational cannabis.  

This is the problem with ecological data and associational findings. If you pick the right time or place, you can get an appealing result. And you may ignore other important issues.  

States that legalized cannabis tend to have better public health and more addiction treatment services. They generally have adopted the Affordable Care Act and Medicaid expansion, and have stronger social safety nets. All of these factors are believed to contribute to rates of substance use disorders and overdose risk.

Ecological data alone never proves anything. It merely suggests associations. If the association holds up over time, then researchers can look into a possible causal relation. If however, the association does not hold up, then claims about causality are pointless.

At this point cannabis does not seem to reliably reduce opioid overdose deaths. Further research will be needed to tease out the effects of cannabis legalization amid all the other factors involved in the overdose crisis.

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.

California Doctor Reluctantly Agrees to Probation for Opioid Prescribing

By Pat Anson, PNN Editor

After a two-year battle with the state medical board, a northern California doctor accused of overprescribing opioid pain medication has agreed to a settlement that allows her to continue practicing while under probation for the next 35 months.

“I settled because I could not afford the legal fees to fight it further and because I was offered a deal that allowed me to continue to prescribe as I see fit, so that no one would get cut off their meds suddenly,” says Corinne (Connie) Basch, MD, a primary care physician in Arcata, a small city in rural Humboldt county.

“I was afraid if I went to a hearing and tried to appear pro se (without an attorney) and somehow pissed off the judge I might wind up with a settlement that prohibited prescribing for a year, which was their initial proposal, and that there might be preventable deaths in my patient population as a result.”

If Basch’s medical license was suspended or revoked, all 1,500 of her patients would have to find new doctors, not a simple task in a remote community where healthcare choices are already limited, especially for pain patients.

The 2019 complaint against Basch by the Medical Board of California centered on her treatment of five patients on relatively high doses of opioids and benzodiazepines, an anti-anxiety medication.

Although Basch tried to taper the patients to lower doses, the complaint alleges their dosages were still excessive and placed them at risk of overdose. No allegations were made that any of Basch’s patients were harmed while under her care.

DR. CORINNE BASCH

“I have a number of people who have been absolutely unsuccessful with every attempt to taper, for whom I was afraid,” Basch wrote in an email to PNN. “I also read some old decisions, basically convictions of doctors in my region. I read how the judges made their decisions: basically going completely on the credibility of this or that expert witness, imputing expertise on state expert witnesses who had not seen any patients for multiple years. 

“It was becoming increasingly clear to me that nobody was going to actually read any of the medical literature that objects to forced tapers and so on — that this whole thing was not going to be argued on its merits, that I was going to be perceived as a defensive miscreant, not as someone bound by conscience to make a different choice.”

Under the strict terms of her settlement, which takes effect today, Basch is required to keep detailed records of all controlled substances she prescribes, which must be “available for immediate inspection and copying” by board investigators. She must also take a series of educational classes on safe prescribing and medical record keeping, and have her practice monitored by another physician throughout her probation – all at her own expense.

Basch is worried about how she will pay for it all -- her entire income last year was $50,000 – but feels obligated to her patients to keep practicing.

“I have some guilt about caving, and also some fear about whether I can actually survive the financial costs of the probation, particularly in the middle of this pandemic which has been so incredibly expensive and challenging for my practice already, but ultimately I felt that I was going to be best able to protect my patients with this choice,” she said.

“As you can tell, I am still incredibly angry about the whole thing, and I feel that the medical board is actually contributing to increased deaths in California, as well as tragically harming our profession.” 

Doctors Shamed for Prescribing Opioids

The California medical board has come under fire in recent years for its controversial “Death Certificate Project,” which resulted in threats of disciplinary action against hundreds of doctors who wrote opioid prescriptions for patients who fatally overdosed, sometimes years later.

The goal was to shame doctors to reduce opioid prescribing, but a recent study found that overdose deaths actually increased in the state after the project was launched. Many of the deaths involved street drugs, not prescription opioids.

Critics say the Death Certificate Project and other enforcement actions have had a chilling effect on doctors statewide.

“I am still incredibly angry about the whole thing, and I feel that the medical board is actually contributing to increased deaths in California, as well as tragically harming our profession.”

— Dr. Corinne Basch

“Through your project, you have attacked many prominent, respected physicians, publicly shaming them as careless prescribers and threatening any doctors who had ever prescribed opioid pain medications for someone who ultimately died. This ‘witch hunt’ has caused many deaths and much suffering,” Kristen Ogden and other patient advocates with Families for Intractable Pain Relief wrote in a recent letter to the medical board.

“When you consider how many California physicians have left the practice of pain care, only a small percentage of the patients harmed have managed to continue to receive pain care at all. Most have not found any pain care, and are suffering agonizing lives for no reason. A few patients we knew have committed suicide because they did not find adequate care and were unable to live with the agony of untreated severe, constant intractable pain.”

The Death Certificate Project is now under review by the medical board and has been given the less inflammatory name of “Prescription Review Program.”

Basch was not targeted under program, but believes the board’s disciplinary actions against her and other doctors have only made the opioid crisis worse.  

“I feel there is a significant parallel to the medical board claiming to ‘do something about the opioid crisis’ and in fact doing the exact wrong thing, taking stable patients off of predictable prescribed medications and throwing them out to street supply which is increasingly adulterated and hazardous. This triumph of appearance over substance is at the root of so many wrongs in our current system,” Basch said.

“I do feel that the medical board should in some way be held accountable for their own negligence, for making policies and not monitoring the outcome, for doubling down on these policies even when the error has been pointed out to them. I am not sure how to get politicians interested in the situation, because it implies understanding the situation with enough depth to see that ‘opioids – bad’ is not a well- conceived policy.”

Opioid Prescribing Limits Failed to Reduce Overdoses in British Columbia

By Pat Anson, PNN Editor

British Columbia’s opioid guideline failed to have any significant impact on overdoses, hospital admissions or deaths in the year after it was adopted, according to new research published in CMAJ Open. The study is the latest to show that opioid prescribing limits have been misdirected and ineffective in slowing North America’s opioid crisis.

The College of Physicians and Surgeons of British Columbia released strict professional guidelines for the “safe prescribing” of opioids and sedatives in 2016, after the Canadian province was hit by a wave of overdoses and deaths. The BC guidelines, which are similar to the CDC’s opioid guideline in the United States, warn doctors to be cautious about opioid prescribing and to avoid increasing doses over 90 morphine milligram equivalents (MME) per day.

Researchers at the University of British Columbia wanted to see how effective the BC guideline was in reducing overdoses, so they analyzed health data on over 68,000 patients on long term opioid therapy. A previous study by the same research team found a “modest” reduction in opioid use in the 10 months after the guideline was introduced, as well as more tapering.

Did the reduced prescribing result in fewer overdoses?  No.

Researchers found no significant change in opioid overdose hospital admissions, opioid overdose mortality, all-cause emergency department visits, all-cause mortality, or all-cause hospital admissions after the BC guideline was adopted. They also found no evidence that pain patients turned to street drugs after their opioid prescriptions were reduced or stopped.

“Concern has been expressed that policies focused on reducing prescribing of opioid analgesics could increase opioid-related deaths if patients unable to access prescription opioids for adequate pain relief turned to street drugs and were exposed to dangerously high levels of synthetic opioids. Our study did not find evidence that the standards and guidelines had the unintended consequence of increasing opioid overdose hospital admissions or opioid overdose mortality,” wrote lead author Richard Morrow, a senior research analyst at UBC.

Critics say the lack of evidence is proof that opioid prescribing has little to do with British Columbia’s overdose crisis.   

“The results are not unexpected and demonstrate the folly of limiting opioids to pain patients in a futile attempt to deal with overdoses from illicit street drugs. The policy has created considerable pain and anxiety along with a worsening quality of life for nothing,” said Marvin Ross, a patient advocate with the Chronic Pain Association of Canada. 

British Columbia’s Coroners Office expects 2020 to be a record breaking year for overdoses in the province, with about five drug deaths every day. A recent study found that the vast majority of BC’s overdoses involved illicit fentanyl and other street drugs. Only 2.4% of the nearly 1,800 fatal overdoses in BC from 2015 to 2017 involved opioid medication alone.

Stricter opioid prescribing policies have also been ineffective in slowing the overdose crisis in the United States. Prescription opioid use in the U.S. is at its lowest level in 20 years, while more Americans are dying from overdoses than ever before.

Prescription Opioid Use at 20-Year Lows

By Pat Anson, PNN Editor

Prescription opioid use in the United States is expected to decline for the ninth consecutive year in 2020, with per capita consumption of opioid medication falling to its lowest level in two decades, according to a new report by the IQVIA Institute, a data analytics firm.

Although fewer opioids are being prescribed, U.S. drug overdose deaths have reached record levels, driven largely by illicit fentanyl and other streets drugs, not pain medication.

In the past year alone, IQVIA estimates there was a 17 percent decline in the amount of prescription opioids dispensed in morphine milligram equivalent (MME) units. The decrease is being driven by changes in prescribing policy, government regulation and insurance reimbursement policies, as well as disruptions in healthcare caused by the COVID-19 pandemic.

In the early stages of the pandemic, IQVIA researchers say there was a 44% decline in the number of new patients prescribed opioids, likely the result of providers and patients canceling non-emergency visits, dental appointments and elective surgeries. As the economy reopened in early summer and healthcare visits resumed, opioid prescribing for pain returned to baseline levels, as did prescriptions for addiction treatment drugs.

“The opioid epidemic has captivated the country for a decade, although it lost attention this year in the face of the COVID-19 pandemic. Patients with chronic pain and addiction have also been affected by disruptions to life and healthcare during COVID, when hospitals, doctors’ offices, and drug treatment facilities were closed,” Murray Aitken, Executive Director IQVIA Institute for Human Data Science, said in a statement.

“While the human toll of the opioid epidemic is being addressed differently across the country, efforts in managing prescription opioids and in supporting medication-assisted treatment are showing measurable progress in many states.”

Prescription opioid use peaked in 2011 and has been in steep decline ever since. By the end of 2020, IQVIA projects per capita annual opioid consumption to fall to 298 MME, nearing a level last seen in 2000.

SOURCE: iqvia iNSTITUTE

“Based on usage in the mid-1990s, it may be difficult to reduce current prescription opioid levels further, as pain medications are necessary for some patients, including cancer patients, until other non-addictive or disease-modifying treatments are available,” the IQVIA report found.

Over the past decade, the greatest decline in prescription opioid use has been in the highest risk categories. Prescriptions written for 90 MME or more per day – a level considered risky by the CDC – have fallen by 70 percent since 2011.

Co-prescribing of opioids with benzodiazepines – an anti-anxiety medication – is also falling rapidly. The number of patients taking both drugs has declined from 86 million in 2016 to less than 60 million in 2020. Opioids and benzodiazepines both slow respiration, and patients who take them in combination are believed to be at higher risk of an overdose.

Overdoses Still Rising

Despite the historic decline in prescription opioid use, U.S. overdose deaths hit a record high last spring, according to a new report from the CDC.  For the 12 months ending in May 2020, over 81,000 people died of a drug overdose.

"This represents a worsening of the drug overdose epidemic in the United States and is the largest number of drug overdoses for a 12-month period ever recorded," the CDC said in a health advisory, adding that the deaths were largely driven by illicit fentanyl, heroin, cocaine and psychostimulants such as methamphetamine. Opioid pain medication is not even mentioned in the CDC report.

“The disruption to daily life due to the Covid-19 pandemic has hit those with substance use disorder hard,” CDC director Robert Redfield said in a statement. “As we continue the fight to end this pandemic, it’s important to not lose sight of different groups being affected in other ways. We need to take care of people suffering from unintended consequences.”

Some federal agencies haven’t gotten the message and continue to blame opioid medication and prescribers for the nation’s overdose epidemic.

A new report released this week by the Office of Inspector General (OIG) for Health and Human Services warns that thousands of Medicaid patients in six Appalachian states are being prescribed “harmful amounts” of opioids. The report also identifies 19 physicians with “questionable prescribing practices” and said they will be referred to law enforcement.  

“OIG, along with its law enforcement partners, will review the prescribers with questionable prescribing patterns for possible investigation. OIG will also refer the beneficiaries at serious risk for opioid misuse or overdose to their respective State Medicaid agencies for review and possible followup to ensure that they are receiving appropriate care,” the report states.

“Further, we encourage States to provide greater access to data from prescription drug monitoring programs, including sharing these data with State Medicaid agencies. We also encourage States to analyze data to help identify patients who may be at risk and to promote appropriate opioid prescribing practices.”

AMA ‘Greatly Concerned’ By Rising Number of Opioid Overdoses

By Pat Anson, PNN Editor

The American Medical Association is once again urging states, regulators and policymakers to waive limits and restrictions on prescriptions for opioid medication and other controlled substances during the COVID-19 pandemic.

In a briefing paper released this week, the AMA said it was alarmed by an increasing number of reports of opioid-related overdoses, particularly from illicit fentanyl. The AMA cited recent reports from the Pacific Northwest that thousands of people were unexpectedly dying from causes other than COVID-19, such as fentanyl-laced counterfeit pills and medical conditions aggravated by delays in getting routine healthcare.    

“The AMA is greatly concerned by an increasing number of reports from national, state and local media suggesting increases in opioid-and other drug-related mortality—particularly from illicitly manufactured fentanyl and fentanyl analogs,” the AMA said. “More than 40 states have reported increases in opioid-related mortality as well as ongoing concerns for those with a mental illness or substance use disorder.”

The AMA urged states to adopt new DEA guidance giving more flexibility to physicians treating patients with opioid use disorder (OUD). The DEA has already waived federal requirements for in-person visits before prescribing addiction treatment drugs such as buprenorphine (Suboxone), methadone and naltrexone.

For patients in pain, the AMA recommended that states take a number of steps to make it easier to obtain pain medication during the pandemic:

• Authorize physicians to prescribe opioid medication to existing patients without an in-person visit

• Waive limits on prescriptions for opioids and other controlled substances, including limits on dose, quantity and refills

• Waive requirements on electronic prescribing; authorize prescriptions to be sent to pharmacies via telephone

• Waive drug testing and in-person counseling requirements for opioid refills; allow for telephone counseling

• Enhance home-delivery medication options for patients with chronic pain

The AMA urged many of these same measures be adopted in the early stages of the pandemic.

In a recent letter to the DEA, the AMA strongly recommended that the agency keep its relaxed prescribing guidelines in place indefinitely.

“There is an urgent need to ensure that patients with pain and patients with OUD receive evidence-based care, and this need will not cease with the end of the COVID-19 pandemic,” wrote James Madara, MD, Executive Vice President and CEO of the AMA..

“The AMA strongly recommends, therefore, that all of the flexibilities that have been put in place by DEA during the COVID-19 PHE (public health emergency) be kept in place at a minimum until both the COVID-19 and the opioid public health emergencies come to an end.”

Nearly 85% of U.S. Overdose Deaths Linked to Street Drugs

By Pat Anson, PNN Editor

A new report by the Centers for Disease Control and Prevention shows that the vast majority of drug overdose deaths in the United States involve illicit fentanyl and other street drugs.  

The study, reported in the CDC’s Morbidity and Mortality Weekly Report, analyzed data from 24 states and the District of Columbia enrolled in the State Unintentional Drug Overdose Reporting System (SUDORS) from January to June, 2019. SUDORS captures detailed information from toxicology reports and death scene investigations, and is considered more reliable than overdose data gathered from death certificates.

Among the 16,236 overdose deaths reported by SUDOR during the study period, illicitly manufactured fentanyl (IMF), heroin, cocaine or methamphetamine were involved 83.8% of deaths, either alone or in combination with other drugs. Nearly half of those deaths involved two or more illicit drugs.

About one in five overdoses involved prescription opioids such as hydrocodone, oxycodone, morphine and buprenorphine. The study did not indicate whether the medication was obtained legally or if it was borrowed, stolen or purchased illicitly. What is clear, however, is that street drugs are the primary driver of the U.S. overdose crisis.

% RATE OF DRUGS INVOLVED IN FATAL OVERDOSES (JAN-JUNE, 2019)

SOURCE: CDC

“The finding of this report that nearly 85% of overdose deaths involved IMFs, heroin, cocaine, or methamphetamine reflects rapid and continuing increases in the supply of IMFs and methamphetamine, coupled with illicit co-use of opioids and stimulants,” researchers reported.

More than two thirds (68.5%) of overdose victims were male, and over half (53.3%) were 25 to 44 years of age; demographics that don’t fit the profile of most chronic pain patients, who are generally older and female.

NBER Report Blames Rx Opioids

The new CDC report is at odds with a working paper recently published by the National Bureau of Economic Research (NBER), a non-profit, private think tank. The NBER report largely blames prescription opioids for the U.S. overdose epidemic – not street drugs or so-called “deaths of despair” caused by rising social isolation and economic distress.  

“People have blamed all sorts of things, heroin from Mexico and fentanyl from China and economic decline and so on and so forth,” co-author Janet Currie, PhD, a professor of economics at Princeton University, told Yahoo Finance. “But really the issue is that a whole lot of people got addicted because they were prescribed pain medications which aren’t prescribed in the same way in other countries.”

Currie and co-author Hannes Schwandt, PhD, an economics professor at Northwestern University, say pharmaceutical companies aggressively marketed opioids at a time when doctors were being encouraged to treat pain as “the fifth vital sign.”

“We argue that the development and marketing of a new generation of prescription opioids sparked the epidemic and that provider behavior is still helping to drive it,” the NBER report states. “Prior to the marketing push, most doctors had believed that opioids were too addictive and dangerous for anyone except terminally ill patients. Aggressive marketing by pharmaceutical companies changed those perceptions: Sales of opioid pain killers quadrupled between 1999 and 2013, fueling the rise in overdose deaths.”

What Curry and Schwandt fail to mention is that opioid prescriptions have fallen by nearly 40% since 2013. And their report only briefly mentions the rising toll taken by illicit fentanyl and other street drugs.

Fatal drug overdoses fell in 2018, for the first time in nearly 30 years, but many signs indicate they are rising again and that the COVID-19 pandemic is making the crisis worse in the U.S. and Canada.   

Canada’s Chief Public Health Officer recently warned the pandemic is fueling another surge in drug deaths in Canada.

“Tragically, in many regions of the country, the COVID-19 pandemic is contributing to an increase in drug-related overdoses and deaths,” Dr. Theresa Tam said in a statement. “There are indications that the street drug supply is growing more unpredictable and toxic in some parts of the country, as previous supply chains have been disrupted by travel restrictions and border measures. Public health measures designed to reduce the impact of COVID-19 may increase isolation, stress and anxiety as well as put a strain on the supports for persons who use drugs.”