Tag: overdoses

10/15/24

Is There a Better Way to Prevent Overdose Deaths?

© Gill Thompson | Dreamstime.com

The CDC released provisional data suggesting opioid overdose deaths dropped to the lowest level in three years. The newest CDC update indicated the provisional decline reflects data through April of 2024. An Associated Press report said experts reacted cautiously to the reported drop. It was only the second annual decline in more than 30 years, and it was also relatively small. One expert thought it should be understood more as a leveling off; another observed the previous decrease in 2018 was followed by an increase afterwards.

Nevertheless, the CDC Chief Medical Officer thought the dip was “heartening news,” but “there are still families and friends losing their loved ones to drug overdoses at staggering numbers.” A study reported in May of 2024 in JAMA Psychiatry found that an estimated 321,566 children lost a parent to drug overdose in the US from 2011 to 2021. The rate of children who lost a parent to drug overdose per 100,000 children increased from 27.0 per 100,000 to 63.1 per 100,000 in 2021. There were significant differences across racial and ethnic groups, with the highest rates among children of non-Hispanic American Indian or Alaska Native individuals, who had a rate of 187.1 per 100,000 in 2021. This was more than double the rate among children of non-Hispanic White individuals (76.5 per 100,000) and non-Hispanic Black individuals (73.2 per 100,000).

Given the potential short- and long-term negative impact of parental loss, program and policy planning should ensure that responses to the overdose crisis account for the full burden of drug overdose on families and children, including addressing the economic, social, educational, and health care needs of children who have lost parents to overdose.

According to the CDC, around 107,500 people died of overdoses in the U.S. in 2023, which was down 3% from 2022 when there were an estimated 111,000 such deaths. There have been more than 1 million drug overdose deaths since 1999. An August 14th CDC update of that data had a graph that showed the 2018 leveling off was followed by a dramatic increase after the COVID-19 pandemic began in March 2020. See the following figure taken from the CDC update.

The update reported the overall decrease of overdose deaths in the U.S. was 12.2%. Yet the interactive maps indicated several Western states had overdose rates that were as high or higher than reported previously. Alaska (41.82%), Oregon (15.11%), Nevada (13.33%), and Washington (10.03%) all reported double digit increases. Utah, Wyoming, Colorado, Hawaii, and Iowa also reported increases. Nebraska (29.95%) and North Carolina (41.81%) had significant decreases. However, the “reported provisional counts may not include all deaths that occurred during a given time period.” These delays are because they require lengthy investigation, including toxicology testing.

Commenting on the same CDC update, CBS News reported at its peak last summer, the U.S. had more than 86,000 estimated deaths. This compared to the CDC estimate of 75,091 opioid overdose deaths for the year ending in April 2024. “The pace of opioid overdose deaths still remains far worse than before the pandemic, when there were fewer than 50,000 fatal overdoses a year.” Fatal overdoses from drugs other than opioids have been decreasing as well. But the individuals who overdosed aren’t the only victims.

Campaigning on Overdoses

Not surprisingly, CBS News noted how overdose deaths became part of the 2024 presidential campaign rhetoric. Former president Trump said overdoses were lower during his term. Technically, he was correct. The figures were lower during his tenure as the 45th president of the United States from January 2017 to January 2021 than they are currently. But according to CDC data, the overdose increases began around March of 2019. During the Trump presidency, overdose deaths grew from 66,571 in the twelve months before January 2017 to 94,788 in the twelve months before January 2021, an increase of 29.8%.

The former president said he wanted to work with states to force homeless addicts into treatment and punish drug dealers with the death penalty. Both Trump and Harris have tied curbing drug overdoses to immigration and border issues. But Trump incorrectly claimed overdose deaths were up 18% “under Kamala.” Assuming he meant during the tenure for Joe Biden who became president in January of 2021, overdose deaths were reported to be 94,778 in January of 2021, and 97,309 in April of 2024, a 2.6% increase.

Notice that there was an effect of when the reported CDC data on overdose deaths was collected after the COVID-19 pandemic began. For example, at the time the WHO reported the beginning of the COVID-19 pandemic in March of 2020, there had been 74,679 overdose deaths in the previous 12 months. In March of 2021, there were 98,211 reported overdose deaths, an increase of 24% in the first year of the pandemic. This dramatic increase of overdose deaths in the first year of the pandemic occurred during the last year of Trump’s presidency.

The FDA first granted emergency use authorization to the Pfizer-BioNTech COVID vaccine on December 10, 2020, followed by the Moderna vaccine on December 17, 2020, and the Janssen vaccine on February 27, 2021. By April 19, 2021 all U.S. states had opened vaccine eligibility to residents 16 and over. By March of 2022, reported overdose deaths were 108,604 in the 12 previous months, an increase of 9.6%. By March of 2023, the previous 12 months of reported overdose deaths were 110,082, an increase of 1.4%. By March of 2024, reported overdose deaths were 100,518 for the previous 12 months, a decrease of 8.7%.

The variance of the increase in overdose deaths dropped from a high of 24% in the first year of the pandemic, to an increase of only 1.4% in 2023, and was followed by an 8.7% decrease in March of 2024, three years after the availability of the COVID vaccines in the U.S. This suggests it had nothing to do with who was president or vice president; or which political party was in power.

As noted above, there have been over a million overdose deaths since 1999. CDC data indicated there were 47,523 overdose deaths in the 12 months before January 2015, and 72,124 overdose deaths in the 12 months before January 2020, an increase of 34%. So, overdose deaths were a public health problem independent of the pandemic.

Preventing Overdose Deaths Through a Drug-Centered Model of MAT

In order to address this public health problem, the National Institutes of Health launched the HEALing Communities Study (HCS) in 2019. “It was the largest addiction prevention and treatment implementation study ever conducted.” It targeted 67 communities in four states (Kentucky, Massachusetts, New York and Ohio) that had been hit hard by the opioid crisis. The goal was to test the impact of an integrated set of evidence-based interventions for preventing overdose and treating opioid misuse in communities that were highly impacted by the opioid crisis.

The findings of the HCS study were published in the New England Journal of Medicine. The Communities That HEAL (CTH) intervention focused on a harm reduction approach, with education about overdose prevention and naloxone distribution, the use of methadone and buprenorphine to treat opioid use disorder, and safer opioid prescribing, dispensing and disposal practices. Yet, “despite the breadth and depth of the intervention, the risk of opioid-related overdose death was similar in the intervention group and the control group.” In other words, there were no statistically significant differences.

The researchers first said the time frame to implement the various strategies was insufficient. Secondly, they thought the COVID-19 pandemic reduced the capacity of communities to implement the Communities That HEAL (CTH) intervention. Thirdly, changes in the illicit drug market occurred with fentanyl becoming more prevalent, indications that it was used as an adulterant with stimulants and it also began appearing in counterfeit pills. Additionally, there were challenges from the growing use of xylazine in illicit opioids. For more information on xylazine, see “Tranq Dope and Its Consequences” and “Flesh Eating Tranq Dope.”

Attempting to put a positive spin on the disappointing results, a NIH news release from the National Institute on Drug Abuse (NIDA) in June of 2024 said that despite “unforeseen challenges,” the HCS successfully engaged communities to implement hundreds of evidence-based strategies, “demonstrating how leveraging community partnerships and using data to inform public health decisions can effectively support the uptake of evidence-based strategies at the local level.” The NIDA director, Nora Volkow said:

Yet, particularly in the era of fentanyl and its increased mixture with psychostimulant drugs, it’s clear we need to continue developing new tools and approaches for addressing the overdose crisis. Ongoing analyses of the rich data from this study will be critical to guiding our efforts in the future.

Then the leader of SAMHSA (Substance Abuse and Mental Health Services Administration) said:

This study recognizes there is no quick fix to reduce opioid overdose deaths. Saving lives requires ongoing commitment to evidence-based strategies. The HEALing Communities Study facilitated the implementation of 615 evidence-based practice strategies, with the potential to yield lifesaving results in coming years.

However, I believe an additional problem with the results of the HCS study was the various intervention strategies were based on a disease-centered model of drug action. NIDA and SAMHSA need to view MAT and opioid use disorder through the lens of a drug-centered model of medication action and adjust their intervention strategies accordingly.

Joanna Moncrieff describes two different types of drug action, the disease-centered model and the drug-centered model. The disease-centered model underlies the psychopharmacology presumed in current MAT. Its theoretical assumptions about how psychotropic drugs work are rarely discussed explicitly. This assumes psychotropic medications like buprenorphine help to correct a biochemical abnormality. For more on Moncreiff’s models of drug action, see “Rethinking Models of Psychotropic Drug Action.”

William White has tried for years to build bridges between the two philosophically-opposed positions on the use of MAT. In “From Bias to Balance,” he described them as “medication haters” and “medication advocates.” White said medications can play a valuable role in harm reduction, but we do addiction treatment a disservice if we portray medication alone as a panacea for the cure of opioid addiction, which seems to be what the HCS study did. He added:

Medications are best viewed as an integral component of the recovery support menu rather than being THE menu, and their value will depend as much on the quality of the milieus in which they are delivered as any innate healing properties that they possess. If the effectiveness of medication-assisted treatment (MAT) programs is compromised by low retention rates, low rates of post-med. recovery support services, and high rates of post-medication addiction recurrence, as this review suggests, then why are we as recovery advocates not collaborating with MAT patients, their families, and MAT clinicians and program administrators to change these conditions?

According to White, the addiction treatment field has yet to reach consensus on what is the optimal duration of medical support in the treatment of opioid use disorder. I think this impasse partly reflects the unacknowledged presumption of Moncrieff’s disease-centered model of drug action among medication advocates. The disease-centered model is itself a product of what is called the medical model, which sees psychopathology as the result of biology; a physical/organic problem in brain structures, neurotransmitters, etc. The over reliance on the medical model perspective (and the disease-centered model of drug action) in addiction treatment leads to an imperfect conception of substance use and a distorted understanding of the risks and benefits of buprenorphine and methadone when they are used to treat opioid use disorder.

There is no pharmacological difference between drugs used for psychiatric purposes and other recreational or psychoactive drugs. They all act on the nervous system to produce a state of altered consciousness, a state that is distinct from the normal undrugged state; a drug is a drug, is a drug. We need to develop a better way to prevent overdose deaths. The evidence-based interventions of HCS need to see their prevention attempts with MAT through the lens of a drug-centered model of drug action.

For more information on William White and the disease-centered versus the drug-centered models of drug action, see: “The Complexities and Limitations of Buprenorphine” Parts 1 and 2.

11/28/23

Counterfeit Pills, Snapchat and Overdose Deaths

Image by Hasty Words from Pixabay

WPVI-TV, channel 6 in Philadelphia told a story about a new legal battle over drugs available on social media. More than 60 families are suing Snapchat, arguing the overdose deaths of their children were due to the social media app. They are demanding changes to protect their children, claiming they died after buying illegal drugs sold by dealers on the app. One parent said, “Snapchat is the largest open-air drug market we have in the United States when it comes to our kids.”

CNN reported the number of drug overdose deaths is still increasing, but seems to be slowing. New estimates from the CDC estimates were 112,024 people died from a drug overdose in the 12-month period ending in May of 2023. This was a 2.5% increase over the 12-month period ending in May of 2022 (109,261). Dr. Katherine Keyes, a professor of epidemiology, said, “There were extraordinary increases in 2020 and 2021 that have started to flatten out in 2022 – now going into 2023. They’re not declining yet. But the pace of the increase is certainly slowing.”

However, certain states have seen steep increases in overdose deaths in comparison to national totals. For example, overdose deaths in Washington increased more than 37%, from 2,373 to 3,254. Fentanyl and other synthetic opioids were involved in most overdose deaths, followed by psychostimulants like methamphetamine. Washington’s dramatic increase in overdose deaths may have been fueled by the availability of counterfeit pills, which we will look at below.

A CDC report said more than 1 million people died between 1999 from and 2021 of a drug overdose. Synthetic opioids other than methadone seem to be the main driver of drug overdose deaths. “Nearly 88% of opioid-involved overdose deaths involved synthetic opioids.” Opioid were involved in 75.4% of all drug overdose deaths.

A NCHS data brief released in December of 2022 indicated drug overdose deaths were stable from 2006 through 2013, but then increased from 13.8 per 100,000 in 2013 to 32.4 in 2021. From 2020 to 2021, the rate increased 14% from 28.3 to 32.4 per 100,000. For each year from 2001 through 2021, the rate for males was higher than females. Notice from the following figure the dramatic increase in overdose deaths that begins in 2019, the year before the COVID pandemic.

Despite the concerns of parents with Snapchat making it easy for dealers to connect with teenagers seeking drugs, there were four other age groups with higher rates of overdose deaths.  Among adults aged 25 and older, the rate of drug overdose deaths was higher in 2021 compared to 2020. The rates were highest for adults aged 35-44 (53.4 and 62.0 per 100,000 respectively) and lowest for people 65 and older. See Figure 2 below.

The drug overdose deaths involving synthetic opioids other than methadone (fentanyl, fentanyl analogs, and tramadol) increased at different rates from 2001 through 2021. Natural and semisynthetic opioid overdose deaths (i.e., oxycodone and hydrocodone) increased from 1.2 to 3.5 per 100,000 in 2010 and then leveled off, reaching 4.0 per 100,000 in 2020 and 2021. The rate of overdose death involving methadone increased from 0.5 in 2001 to 1.8 in 2006. Then it decreased through 2019 to 0.8, and remained stable through 2021 (1.1). “Of the drugs examined, only drug overdose deaths involving heroin had a lower rate in 2021 than in 2020 (2.8 and 4.1, respectively).” See figure 4 below.

Overdose deaths from cocaine and stimulants were also on the rise. Cocaine-related overdose deaths was a bit of a roller coaster ride, increasing from 1.3 per 100,000 in 2001 to 2.5 in 2006, then decreasing to 1.5 in 2001, and then increasing to 7.1 in 2021. “The rate in 2021 was 22% higher than in 2020 (6.0).” The rate of overdose deaths involving psychostimulants (i.e., amphetamine, methamphetamine and methylphenidate) increased from 0.2 in 2001 to 0.5 in 2005, remaining stable through 2008. Then it increased from 0.4 in 2008 to 10.0 in 2021. The rate in 2021 was 33% higher than the rate in 2020 (7.5). See Figure 5 below.

Drug overdose deaths have risen fivefold over the past 20 years. The rate for males increased from 39.5 to 45.1 and the rate for females increased from 17.1 to 19.6, from 2020 to 2021. For both sexes, the highest rates were for adult between 35 and 44. The rates of drug overdose deaths involving opioids and stimulants increased from 2020 to 2021.

Counterfeit Pills

One disturbing trend that seems to be driving that increase in overdose deaths is the evidence of counterfeit pill use in the U.S. In a September CDC Morbidity and Mortality Report (MMWR), the CDC said these pills are not manufactured by pharmaceutical companies, but are made to look like legitimate drugs, frequently oxycodone and alprazolam (Xanax). Counterfeit pills often contain illicitly manufactured fentanyls and illicit benzodiazepines like bromazolam, etizolam and fluaprazolam. They increase the risk of overdose by exposing individual users to drugs they did not intend to use and did not know they were in the pills they were buying.

The overall increase of overdose deaths with evidence of counterfeit pill use increased from 2% to 4.7%, driven by an increase from 4.7% to 14.7% in Western states. More than half of overdose deaths with evidence of counterfeit pills (55.8%) occurred in Western states such as Washington. See the following table reproduced from data in Table 1 of the above CDC MMWR report.

The report had these key findings. First, the overall percentage of overdose deaths with evidence of counterfeit pills remained under 6%, but more than doubled from 2.0% in the third quarter of 2019 (July-September) to 4.7% in the fourth quarter of 2021 (October-December). The percentage more than tripled in Western states. Second, the percentage of deaths with evidence of counterfeit pills using illegally manufactured fentanyl (IMF) was more than double the percentage of deaths without evidence of counterfeit pill use.

Evidence of counterfeit pill use more than tripled in western jurisdictions, indicating IMFs, which are frequently present in counterfeit pills, are infiltrating drug markets in western U.S. states. Historically, white-powder IMFs have been less prevalent in western states because of difficulty mixing with predominantly black tar heroin prevalent in that region. The highest percentages of deaths with evidence of counterfeit oxycodone use (both alone and with counterfeit alprazolam) were in western jurisdictions, whereas nearly one half of deaths with evidence of counterfeit alprazolam use only were in southern jurisdictions. This finding suggests that exposure to different types of counterfeit pills and drugs might vary by region. Prevention and education materials that incorporate local drug seizure data and information about regional drug markets might be particularly effective at highlighting relevant counterfeit pill types and reducing deaths.

Those who died from counterfeit pills were significantly younger and more often Hispanic. Counterfeit pills have been marketed towards younger persons, where they may also exhibit more risk-taking behaviors than do older persons. The higher percentage of Hispanic persons could reflect the has implications for access to and use of prevention messaging materials and harm reduction services. “It is important to ensure that prevention messaging and harm reduction outreach are tailored to younger persons and the Hispanic population to address potential engagement, language, or other barriers.”

The DEA reported their lab testing revealed that 4 out of 10 counterfeit pills contain at least 2 mg of fentanyl, a potentially lethal dose. Criminal networks are mass producing counterfeit pills and marketing them as legitimate prescription pills. They’re often sold on social media and e-commerce platforms, which make them widely available to anyone. In 2021, the DEA seized 20 million fake pills, more than the 2 previous years combined. They’ve been identified in all 50 states.

In “Overdosing,” I wrote of the overdose problem as it existed in 2016, before fentanyl, counterfeit pills and Snapchat had become part of the problem. There I referred to “Melanie,” the first person I worked with who eventually became a heroin overdose statistic in the late 1980s. In that article is a map of Pennsylvania showing the drug-related overdose deaths by county in 2014. Philadelphia County even then had the most reported deaths, followed by Allegheny County, where I live. Legislation allowing first responders to carry naloxone to reverse an overdose had just been passed. Let’s continue to fight against the everchanging and adapting drug trade and never forget those who were taken too soon by overdose like Melanie.