02/10/17

Guns and Needles

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Reporting for The Washington Post, Christopher Ingraham gleaned some grim facts from the recent CDC data on drug and opioid deaths in the U.S. Opioid deaths surpassed 30,000 in 2015; an increase of 5,000 from 2014. Deaths from synthetic opioids like fentanyl rose by over 70% from 2014 to 2015. For the first time since the late 1990s, heroin deaths surpassed traditional opioid painkillers like hydrocodone and oxycodone. The grimmest reality is that more people died in 2015 from heroin-related causes than gun violence. “As recently as 2007, gun homicides outnumbered heroin deaths by more than 5 to 1.”

The above linked Washington Post article graphs and discusses CDC data showing the surge in opioid deaths from 8,280 in 1999 to 33,092 in 2015. You will also find graphs of the death rate increases by three classes of opioids. And there is a graph showing the rapid increase in heroin deaths over the last five years or so to 12,989 in 2015, surpassing gun homicide deaths in 2015 by 10 (12,979).

The CDC MMWR—Morbidity and Mortality Weekly Report—indicated that the rate of drug overdose deaths increased in 30 states and DC; and remained stable in 19 others. Opioid death rates increased by 15.6% from 2014 to 2015. The report suggested the increase was most likely driven by illicitly manufactured fentanyl. These increases were also concentrated in eight states. According to another CDC MMWR from August 26, 2016, those states were: Massachusetts, Maine, New Hampshire, Ohio, Florida, Kentucky, Maryland and North Carolina.

During 2014 to 2015 death rates increased overall, as well as for both males and females in the three different classes of opioids. The following chart gives the CDC death rates by class of opioid, year, sex and overall population. The opioid classes are: natural and semi-synthetic opioids (codeine, morphine, hydrocodone, hydromorphone, oxycodone, oxymorphone and buprenorphine), synthetic opioids (meperidine and fentanyl) and heroin. Heroin is a semi-synthetic opioid, but was assessed separately by the CDC. Methadone is a synthetic opioid but was also assessed separately. See the CDC MMWR for data on methadone deaths.  The “rate” in the chart is the death rate per 100,000 people.

Characteristic

Natural and semi-synthetic opioids

2014

2015

% change in rate, 2014 to 2015

No. (rate)

No. (rate)

Overall

12,159 (3.8)

12,727 (3.9)

2.6%

Sex

Male

6,732 (4.2)

7,117 (4.4)

4.8%

Female

5,427 (3.3)

5,610 (3.4)

3.0%

Characteristic

Synthetic opioids other than methadone

2014

2015

% change in rate, 2014 to 2015

No. (rate)

No. (rate)

Overall

5,544 (1.8)

9,580 (3.1)

72.2%

Sex

Male

3,465 (2.2)

6,560 (4.2)

90.9%

Female

2,079 (1.3)

3,020 (1.9)

46.2%

Characteristic

Heroin

2014

2015

% change in rate, 2014 to 2015

No. (rate)

No. (rate)

Overall

10,574 (3.4)

12,989 (4.1)

20.6%

Sex

Male

8,160 (5.2)

9,881 (6.3)

21.2%

Female

2,414 (1.6)

3,108 (2.0)

25%

From 2014 to 2015, the combined opioid death rates increased by 15.6%. The most radical increases were with synthetic opioids, overwhelmingly from fentanyl. The overall increase was 72.2%, driven primarily by a 90.9% increase in male deaths. Overall heroin deaths in 2015 were higher than the number of deaths from natural and semi-synthetic opioids in 2015. Death rates from natural and semi-synthetic opioids increased as well, but at a more leisurely rate.

Another Washington Post article by Christopher Ingraham, “Where opiates killed the most people in 2015,” again used CDC data to compose a series of maps. These maps illustrated which states in 2016 had the most opioid deaths overall and also by classes of opioids: heroin, synthetic and natural (natural and semi-synthetic). Nationally, there were roughly 10.4 opioid overdose deaths per 100,000 people. But New England, and the Ohio/Kentucky/West Virginia had the highest rates. Ohio, West Virginia and Connecticut had the highest death rates from heroin overdoses, between 20 and 36.

Synthetic opioid deaths were primarily located along the East Coast. The national death rate from synthetic opioids is 3.1 per 100,000. In Rhode Island it’s 13.2; in Massachusetts it’s 14.4; and in New Hampshire it’s 24.1. Ohio and West Virginia weren’t far behind. Deaths from natural and semi-synthetic opioids were concentrated in West Virginia and Utah. There is also a table of raw data by state in the article.  The following map, taken from the article, is for overall opioid deaths in the U.S. for 2015.

The following chart, taken from the 2016 National Drug Threat Assessment Summary, combines CDC data for deaths by drug poisoning, homicide, firearms and motor vehicle crashes between 1999 and 2014. You can clearly see how overdose deaths have risen, outpacing the other causes of death. The 2016 NDTA Summary said drug overdose deaths are at the highest level ever recorded. “In 2014, approximately 129 people died every day as a result of drug poisoning.” Since 2010, there has been a 248% increase in heroin overdose deaths.

The U.S. has seen a dramatic increase in the availability of heroin in the last ten years, allowing the heroin threat to expand exponentially.  The increases with heroin production in Mexico have guaranteed a steady supply of low-cost heroin, despite the increases in the number of users over the past decade. While heroin from four source areas (Mexico, South America, Southwest Asia, and Southeast Asia) can be found somewhere in the U.S., Mexico is the main source of heroin. South America is the second most common source. Mexican heroin accounted for 79% of the total weight of heroin analyzed by the Heroin Signature Program.

The domestic supply of Mexico-sourced heroin is more than sufficient to satisfy current U.S. market demand. Moreover, Mexican heroin traffickers are able to keep the supply steady and reliable. This is evidenced by high availability levels in U.S. heroin markets and low retail-level prices.

The number of individuals who used heroin in the month prior to a National Survey on Drug Use and Health (NSDUH) increased by 154% between 2007 and 2014. There was a 51% increase in just the last year of the survey; 27% reported lifetime heroin use. “The estimated number of new heroin initiates doubled between 2007 (106,000) and 2014 (212,000).” See the following graph for more information on current heroin users between 2007 and 2014 from the 2016 NDTA Summary.

So far we’ve looked at the opioid epidemic from the perspective of national statistics and surveys. But I want to close with a more up-close-and-personal look at the issue. During the summer of 2016, I read Gun, Needle, Spoon by Patrick O’Neil. Gun is a compelling look at the life of a “current heroin user.” Patrick has over fifteen years clean now, but gives you a clear-eyed, non-blinking look into the abyss of heroin addiction in his memoir. What follows are a couple of paragraphs of life in that nightmare. Read Gun, Needle, Spoon for more.

Technically, kicking heroin takes three days. Every junkie’s kick is slightly different, yet the symptoms are the same. For me it starts out with an unpleasant familiar taste in the back of my throat. My nose begins to run, I sneeze a lot, and my eyes water. Then the aches arrive, followed by vomiting and diarrhea. There’s no sleeping. I’m either cold and shivering or hot and continually sweating. My muscles cramp, my head feels thick, and all I think about is doing more dope in order to not be in such misery. . . .The digital clock on the desk in the living room read 11:55 PM. I light a cigarette and stare at the gun. Before I can really think about it, I pull on a pair of jeans and get dressed. Digging through a pile of dirty clothes, I find a black bandana and tie it loosely around my neck. I slip the gun into my waistband, button my overcoat, and quickly open the front door.

P.S. There is good new here. Patrick just wrote that he received a pardon from the governor of California for his past crimes. You can read about the day he received his pardon here. And take the time to congratulate him, will you?

07/22/16

The Not-So-Golden Years

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© lisafx | stockfresh.com

Dr. Stephen Barnes wrote a thoughtful article on the so-called golden years of adulthood. In case you’re wondering when (or if) you reach said span of time, he said it begins with retirement and ends with the beginning of “age-imposed physical, emotional, and cognitive limitations; roughly between the ages of 65 and 80+. This can be a time of self-fulfillment, with many positive outcomes related to aging. Of course there are some variables to consider: do you have good physical and psychological health; do you have adequate financial resources; do you now have fewer family and career responsibilities.  If you do, then there are opportunities for “self-fulfillment, purposeful engagement, and completion.” However, there is another perspective on the golden years for us to consider—that of Dr Seuss:

The Golden Years have come at last.

I cannot see.

I cannot pee.

I cannot chew.

I cannot screw.

My memory shrinks.

My hearing stinks.

No sense of smell.

I look like hell.

My body is drooping.

I have trouble pooping.

The Golden Years have come at last.

The Golden Years … can kiss my ass.

There was a study done by Gray et al. published in JAMA Internal Medicine for March of 2015 that caught some media attention. It looked at the cumulative use of anticholinergics and dementia. This class of drugs blocks a neurotransmitter called acetylcholine (ACh), which is found throughout the body. Dr. Sandra Steingard noted: “It is involved in gut motility, visual acuity, heart rate, and secretions. In the brain, its activity is linked to memory and movements.” There are a wide variety of drugs with an anticholinergic effect, from antihistamines like Chlor-Trimeton, Unisom (diphenhydramine), Vistaril and Benedryl to antidepressants like Paxil, antipsychotics like Seroquel and Zyprexa, and even Detrol (oxybutinin).

Anticholinergics often cause dry mouth, constipation, rapid pulse, urinary retention, blurred vision and impaired memory. Notice how they correspond to four of Seuss’ complaints. Dr. Steingard also commented on the Gray et al. study and said there were two major findings of the study. “The first is that total exposure to anticholinergic drugs increases the risk of developing dementia. But of further concern, these effects were seen even if the drugs had been stopped years before the onset of dementia.” The study found a dose response risk for developing dementia—a greater exposure to anticholinergics meant a greater risk.

Steingard thought the study was carefully done. Her one complaint was it didn’t have a very complete list of anticholinergic drugs. She provided a link to a chart on AgingBrainCare.org with a more complete listing. As a psychiatrist, she thought the study had particular implications for psychiatry since many psychiatric drugs have anticholinergic effects. Several antipsychotics were in the most severe category.

Many people are now being exposed to psychiatric drugs at very young ages, and are taking them for many years. “We need to use these drugs with caution. Dose matters. Length of time a person is on them matters. Polypharmacy matters.”

The Gray et al. study concluded that there was an increased risk for dementia in people with higher use of anticholinergics. The findings suggested that someone taking even one such drug for more than three years “would have a greater risk for dementia.”

Prescribers should be aware of this potential association when considering anticholinergics for their older patients and should consider alternatives when possible. For conditions with no therapeutic alternatives, prescribers should use the lowest effective dose and discontinue therapy if ineffective. These findings also have public health implications for the education of older adults about potential safety risks because some anticholinergics are available as over-the-counter products. Given the devastating consequences of dementia, informing older adults about this potentially modifiable risk would allow them to choose alternative products and collaborate with their health care professionals to minimize overall anticholinergic use.

Another area of concern within the so-called golden years is substance abuse. Ironically, the initial step into the golden years via retirement is seen as a contributing factor into senior substance abuse. Paul Gaita, writing for The Fix, indicated several aspects of retirement could lead to greater drug and alcohol use among seniors. The circumstances leading to retirement as well as the economic and social nature of retirement are two possible features. A substance abuse counselor added: “In retirement, there can be depression, divorce, death of a spouse, moving from a big residence into a small residence.”

There are issues of loneliness, anxiety and boredom to consider. Then there is the reality of the increased likelihood of medical issues and the death of family or friends who are older. And don’t forget changes in body metabolism. The liver slows down as does kidney filtration. Both of these factors lead to alcohol and drugs staying active in the body for longer periods of time. Then there are medical issues like menopause, limited mobility, sleeping problems and chronic pain.

SAMHSA publishes a free volume in its Treatment Improvement Protocol (TIP) Series entitled: “Substance Abuse Among Older Adults” (TIP 26). It contains chapters on alcohol use and abuse, prescription and over-the-counter drug use and abuse, referral and treatment approaches, as well as appendixes of assessment tools. Here I will highlight the Executive Summary and chapter 1, “Substance Abuse Among Older Adults: An Invisible Epidemic.”

TIP 26 also noted that physiological change and changes in kinds of responsibilities and activities pursued are factors in substance abuse with older adults. Individuals 65 and over consume more prescribed and over-the-counter medications than any other age group in the U.S. Concerns with benzodiazepine use and sleep aides were noted. Limited use of both drug classes was given. Antihistimines and anticholinergics were highlighted as well.

Older persons appear to be more susceptible to adverse anticholinergic effects from antihistamines and are at increased risk for orthostatic hypotension and central nervous system depression or confusion. In addition, antihistamines and alcohol potentiate one another, further exacerbating the above conditions as well as any problems with balance. Because tolerance also develops within days or weeks, (bold the remaining) the Panel recommends that older persons who live alone do not take antihistamines.

Substance misuse among adults 60 an older is one of the fastest growing health problems in the country. Yet the situations is underestimated, underidentified and undertreated. “Until relatively recently, alcohol and prescription drug misuse, which affects up to 17 percent of older adults, was not discussed in either the substance abuse or the gerontological literature.” Diagnosis or identification can be difficult because symptoms of substance abuse in older adults will sometimes mimic symptoms of other medical and behavioral concerns such as diabetes, dementia and depression. Adding to this issue is that drug trials of new medications rarely include older adults. So even recognizing the presence of adverse drug reactions with older adults often doesn’t happen until enough adverse events accumulate after the drugs have been approved.

Alcohol abuse can accelerate the normal decline of physiological functioning that happens with aging. There is also the probability of an increased risk of injury, illness and socioeconomic decline. Increased benzodiazepine use with older adults also causes problems. The BMJ indicated that the mass of evidence suggested the benefits of benzodiazepines in older adults rarely outweigh their risks.

Benzodiazepine risks, whether short-term or chronic, include cognitive impairment, delirium, respiratory insufficiency, falls, fall-related injuries such as hip fractures, motor vehicle crashes, and death. Most patients are not warned of these risks before starting these medications. The main risk factor for chronic benzodiazepine use is any previous use, so an intended short-duration prescription of these habit-forming medication is likely to lead to their long-term use. Chronic benzodiazepine users are rarely prompted to discontinue, despite good evidence for the safety and tolerability of tapering protocols.

Ageism also contributes to the problem. “There is an unspoken but pervasive assumption that it’s not worth treating older adults for substance use disorders.” Behaviors that are seen as problematic in younger adults may not inspire the same urgency for treatment with older adults. Also, there can be an attitude that treatment for this population is a waste of health care resources. Attitudes like these are callous and based on misperceptions. For example, most older adults live independently. Only 4.6% of adults over 65 are in nursing homes or personal care facilities.

The reality is that misuse and abuse of alcohol and other drugs take a greater toll on affected older adults than on younger adults. In addition to the psychosocial issues that are unique to older adults, aging also ushers in biomedical changes that influence the effects that alcohol and drugs have on the body.

Health care and social service providers working with older Americans will mainly encounter abuse or misuse of alcohol or prescribed drugs. Although a smaller population, illicit drug users over 60 are increasing. This trend is at least partly due to aging baby boomer whose rates of illicit drug use have historically been higher than previous generations. The following chart from a NIDA report tracks past month use of illicit drugs among adults aged 50 to 64.

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Here is a more intimate and personal look at this issue. Patrick O’Neil, described coping with his 79 year-old mother’s recovery from hip surgery in “I Can’t Watch My Mom Detox.” Incidently, her HMO had been heavily prescribing Vicodin for seven years. Before the surgery. The medical team is considering detoxing her from her dependency on hydrocordone WHILE she’s recuperating from her hip surgery “for her own good.”

A doctor I’ve never met takes me aside and explains the process, how the patient will appear to be suffering but it’s for her own good.

I look at her skeptically. “So you’re going to detox my mom in the middle of her recovering from one of her most painful surgeries ever, because you’re having a knee-jerk reaction to your HMO being at fault for keeping her addicted?”

“It’s a little more complicated than that,” replies the doctor.

“Well, try and explain it then,” I say. “Because it looks exactly like that to me.”

O’Neil is himself a recovering heroin addict and author of his own journey through addiction in Gun, Needle, Spoon. So he really understands what his mother is going through. He suggests they not attempt a detox until after she’s healed from her surgery. It seems they finally agreed.

When I was growing up, my mom never had an obvious substance abuse problem. Even though her father was an alcoholic and addiction is thought to be hereditary, she never exhibited any outright addictive behaviors. And until recently, she hadn’t displayed the sort of desire to overmedicate that I had. Only with age, her retiring, my stepfather dying and close friends passing, she’d lost interest in life. These days she sits at home, alone. Her health, having never been great, is deteriorating even more. When her knee went out, she had it replaced and the doctor prescribed Vicodin. And suddenly, the same monster that lives in me was awakened in my mom and she took to them like they were the solution to all her problems.

“The Golden Years have come at last. The Golden Years … can kiss my ass.”