05/17/16

Overdosing

© banerwega | stockfresh.com

© banerwega | stockfresh.com

Melanie (not her real name) was one of the first persons I counseled at White Deer Run in the late 1980s. She was 18 at the time, and a heroin addict before it was being called a national epidemic. She completed treatment; relapsed and returned about a year later as an adult patient. I think she even completed treatment that time as well. I can’t tell you much more about her, except that she was from Philly; and she is the first person I worked with who became an overdose statistic. There have been many more since then.

Most of the places I’ve worked as a drug and alcohol counselor have been within Pennsylvania. So when I heard of the study done by Balmert et al. on the accidental poisoning deaths in Pennsylvania from 1979 to 2014, I was interested in reading it. There aren’t too many ways that statistics, especially death statistics, can be interesting reading. But buried within those tables and figures are people I knew.

Within a data set attached to the study, I found the reported deaths by accidental drug poisoning for the years 1987 through 1989.  In 1987, there were 41 individuals between the ages of 15 and 24 who died from accidental poisoning, 6 of whom were female; in 1988 there were 39, 12 of whom were female; in 1989 there were 54, 9 of whom were female. Somewhere in those statistics is Melanie’s overdose.

When I compared those deaths with the last three in the data set, 2012, 2013 and 2014, the stats grew exponentially. In 2012, there were 224 individuals between the ages of 15 and 24 who died from accidental poisoning, 63 of whom were female; in 2013 there were 203, 47 of whom were female; in 2014 there were 277; 70 of whom were female.  That’s a lot of Melanie’s.

The CDC published a data brief indicating drug poisoning became the leading cause of injury-related death in 2008, surpassing deaths from motor vehicle accidents. 90% of those deaths were from drug poisoning. From 1999 to 2008 the number of drug poisoning deaths from opioid analgesics more than tripled. “Of the 36,500 drug poisoning deaths in 2008, more than 40% (14,800) involved opioid analgesics.”

Most of those 14,800 deaths involved natural and semi-synthetic opioid analgesics such as morphine, hydrocodone and oxycodone. The number of drug poisoning deaths from methadone, a synthetic opioid, increased sevenfold from 1999 to 2007. Then it decreased between 2007 and 2008. The age group with the highest death rate from opioid poisonings was between 45 and 54 years of age.

In 2007-2008 48% of Americans reported the use of at least one prescription drug in the past month. Not surprisingly, this was related to increases in drug use, misuse and nonfatal health outcomes. Over 5 million reported using prescription pain relievers nonmedically in the previous month.

In 2012 the CDC looked specifically at drug-poisoning deaths from opioid analgesics and heroin. Their report in Health E-Stats noted that from 1999 to 2012 the drug poisoning deaths from opioid analgesics increased from 1.4 per 100,000 in 1999 to 5.1 in 2012. The death rates from heroin overdoses nearly tripled from .7 per 100,000 in 1999 to 1.9 in 2012. The states with death rates significantly higher than the overall U.S. rate of 13.1 per 100,000 included Pennsylvania, Ohio and West Virginia, which had the highest overall rate at 32.0 per 100,000. See the linked CDC reports for more detailed information.

Returning to the Balmert et al. study on accidental poisoning deaths in Pennsylvania, we can see how the Pennsylvania rates compare to those just reviewed. Table 1 in Balmert et al. indicated the overall death rate for Pennsylvania in 2014 was 29.16 per 100,000. The death rate was highest for the 25-34 age group (39.87), and lowest among the 15-24 age group (16.25). See  Table 1 in the Balmert et al. article.

Examining the mortality patterns by county showed that the highest rates for males from 2010 to 2014 were in the counties of southwestern PA (the Pittsburgh metro area), the counties surrounding Philadelphia and those near Scranton in the Northeast part of the state. The highest rates for females were in the same areas.

The county level findings provide possible avenues for targeting interventions to areas with the highest mortality from accidental poisoning. Counties with the highest 2010–2014 rates in females are primarily in suburban southwest PA. In males, the highest prevalence rates are more widespread and include both southwest and southeast PA, plus the northeast area including Carbon and Susquehanna. These patterns emphasize that, currently, accidental poisoning deaths especially among white females are occurring in suburban and rural areas. Other area-specific analyses should focus on non-urban mortality patterns.

In September of 2014 legislation went into effect allowing first responders to carry naloxone for reversing the effects of an overdose. As of September 1, 2015, 302 overdoses had been reversed with naloxone. The following graphic represents the drug-related overdose deaths by county in Pennsylvania for 2014. See the original here.

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In September of 2015, Tom Wolf, the governor of Pennsylvania, announced that the CDC had granted the Pennsylvania Department of Health $900,000 to prevent overdose deaths related to prescription opioids. Governor Wolf said: “Too many citizens of our commonwealth are dying from drug overdose, and Pennsylvania families in hardworking communities are impacted by prescription drug addiction every day.” The “Prevention for States” grant will support 16 states with annual awards between $750,000 and $1 million over the next four years. The goal is to hopefully turn the tide on the prescription drug overdose epidemic by implementing prevention strategies and improving safe prescribing practices.

On March 18, 2016, the CDC published revised guidelines for primary care physicians when prescribing pain medication. Nearly half of all opioid prescriptions are dispensed by primary care clinicians. An estimated 20% of patients with noncancer pain symptoms or pain-related diagnoses receive an opioid prescription. While evidence supports the short-term efficacy of opioids for reducing pain, few studies have assessed the long-term benefits of opioids for chronic pain. An estimated 9.6 to 11.5 million adults (3% to 4% of the adult U.S. population) were prescribed long-term opioid therapy in 2005.

This guideline is intended to improve communication between clinicians and patients about the risks and benefits of opioid therapy for chronic pain, improve the safety and effectiveness of pain treatment, and reduce the risks associated with long-term opioid therapy, including opioid use disorder, overdose, and death.

The guidelines are not mandatory, but if they are followed, maybe the opioid-related overdose deaths will start to decrease and people like Melanie will live instead of die.

01/29/16

High on Overdoses

© diego_cervo | stockfresh.com

© diego_cervo | stockfresh.com

A recent CDC Morbidity and Mortality Weekly Report indicated that in 2014 more people in the U.S. died from drug overdoses than any other year on record. There were approximately one and a half times more deaths from drug overdoses than from motor vehicle accidents. Sixty-one percent (28,647) of all drug overdose deaths were from opioids; the rate has tripled since 2000. Drug overdose deaths from heroin have more than tripled in 4 years. The overdose death rate involving synthetic opioids almost doubled between 2013 and 2014.

Drug overdose deaths are up for both men and women; in adults of nearly all age groups. The following table presents data for all overdose deaths in 2013 and 2014; by sex; and by age group. The death rates per 100,000 are given, as is the percentage increase from 2013 to 2014.

2013

2014

% change 2013-2014

#

Rate

#

Rate

All

43,982

13.8

47,055

14.7

6.5%

Male

26,799

17.0

28,812

18.3

7.6%

Female

17,183

10.6

18,243

11.1

4.7%

Age Group (yrs)

0-14

105

0.2

109

0.2

0.0%

15-24

3,664

8.3

3,798

8.6

3.6%

25-34

8,947

20.9

10,055

23.1

10.5%

35-44

9,320

23.0

10,134

25.0

8.7%

45-54

12,045

27.5

12,263

28.2

2.5%

55-64

7,551

19.2

8,122

20.3

5.7%

≥65

2,344

5.2

2,568

5.6

7.7%

The authors of the Report said these figures indicate the opioid overdose epidemic is worsening. That almost seems to be an understatement. In a CDC Press Release Tom Frieden, the Director of the CDC, said the increased number of overdose deaths was alarming. “The opioid epidemic is devastating American families and communities. To curb these trends and save lives, we must help prevent addiction and provide support and treatment to those who suffer from opioid use disorders.” He added how important it was for law enforcement to intensify its efforts to reduce the availability of heroin, illegal fentanyl and other illegal opioids.

The 2014 data on overdose deaths showed there were two interrelated trends driving the increase: “a 15-year increase in overdose deaths involving prescription opioid pain relievers and a recent surge in illicit opioid overdose deaths, driven largely by heroin.” Natural and semisynthetic opioids, which include oxycodone and hydrocodone, continued to be the most common type of opioid involved in overdose deaths.

Drug overdose deaths involving heroin continued to climb sharply, with heroin overdoses more than tripling in 4 years. This increase mirrors large increases in heroin use across the country and has been shown to be closely tied to opioid pain reliever misuse and dependence. Past misuse of prescription opioids is the strongest risk factor for heroin initiation and use, specifically among persons who report past-year dependence or abuse. The increased availability of heroin, combined with its relatively low price (compared with diverted prescription opioids) and high purity appear to be major drivers of the upward trend in heroin use and overdose.

The 2014 rates were highest in these five states: West Virginia, New Mexico, New Hampshire, Kentucky and Ohio.  There were statistically significant increases in overdose deaths for fourteen states: Alabama, Georgia, Illinois, Indiana, Maine, Maryland, Massachusetts, Michigan, New Hampshire, New Mexico, North Dakota, Ohio, Pennsylvania and Virginia. Here is an interactive CDC map with this data.

Supporting these findings by the CDC, the National Institute on Drug Abuse (NIDA) reported in “Overdose Death Rates” that there was a 3.4-fold increase in the total number of overdose deaths from opioid pain relievers and a six-fold increase in the total number of overdose deaths from heroin from 2001 to 2014. The following charts are from the NIDA report.

prescription overdoses

heroin overdosesThe CDC pointed to four ways to prevent overdose deaths:

  • Limit initiation into opioid misuse and addiction. Opioid pain reliever prescribing has quadrupled since 1999. Providing health care professionals with additional tools and information—including safer guidelines for prescribing these drugs—can help them make more informed prescribing decisions.
  • Expand access to evidence-based substance use disorder treatment—including Medication-Assisted Treatment—for people who suffer from opioid use disorder.
  • Protect people with opioid use disorder by expanding access and use of naloxone—a critical drug that can reverse the symptoms of an opioid overdose and save lives.
  • State and local public health agencies, medical examiners and coroners, and law enforcement agencies must work together to improve detection of and response to illicit opioid overdose outbreaks to address this emerging threat to public health and safety.

Overdoses are not just a U.S. problem. The World Health Organization (WHO) estimated that globally 69,000 people die from opioid overdose each year. The World Drug Report 2014 estimated thee were 183,000 drug-related deaths worldwide in 2012. The main type of drug implicated in those deaths is opioids.

International Overdose Awareness Day reported that like the U.S. both the UK and Australia have had more deaths due to overdose than road fatalities. Nearly four Australians die each day from overdoses. Ontario, Canada had a 242% increase in fatal opioid overdoses between 1991 and 2010. European Union nations reported 6,100 overdose deaths in 2012. “It is estimated that more than 70,000 lives were lost to drug overdoses in European union countries in the first decade of the 21st Century.”

The CDC recommendations, for the most part, are ones I’d endorse. But like riders attached to big spending bills that have to be passed by Congress, the little phrase in the second recommendation “including Medication-Assisted Treatment” isn’t necessary. Medications like naloxone and naltrexone have a place in the expansion of substance use disorder treatment. But the phrase “medication-assisted treatment” refers to these medications as well as two opioids—methadone and buprenorphine—used in opioid substitution therapy. There is proposed legislation to expand the availability of buprenorphine, the Recovery for Addiction Treatment Act, in committee.

My objection is simple. You don’t “treat” an opioid use disorder with another opioid. You simply substitute dependence on one opioid for another.

I’ve regularly voiced concern over the treatment of opioid dependency with methadone and buprenorphine. Stop and think for a minute. Isn’t it reasonable to find that an individual who was physically addicted to heroin or prescription opioids would improve when they substitute ingesting enough methadone (a Schedule II controlled substance) or buprenorphine (a Schedule III controlled substance) to neutralize their physical withdrawal symptoms? The positive evidence base for opioid substitution treatment is based upon medically assisting an addict to begin using another opioid.

The “evidence-based” effectiveness of opioid “maintenance” treatment involves using these acknowledged addictive substances (methadone and burprenorphine) for weeks and even years to manage or stabilize an addiction to other opioids. There is more information on this issue in other articles I’ve written: “The Seduction of Opioid Substitution,” “Another Head for the Hydra,” and “A Double-Edged Drug.”

Another one of the drug types showing an increase in overdose deaths since 2001 in NIDA’s “Overdose Death Rates” was benzodiazepines. There has been a five-fold increase in the total number of deaths related to benzodiazepines. “Benzos” combined with opioids like methadone and buprenorphine have a synergistic effect and will give the person a heroin-like euphoria with the right drug cocktail. They also contribute to the higher rates of accidental overdose deaths. Expect the opioid overdose death rates to continue to rise even if the expansion of opioid substitution curtails overdose deaths from heroin.