Over the past few years, media reports have sounded the alarm that an opioid epidemic is sweeping the country, killing thousands of our citizens. And now new research findings reveal that the problem may be even more widespread than we had thought.
In 2015 it was reported that 33,000 people died from an opioid overdose — a historic high. However, researchers now tell us that number should have been even higher, as it is likely that thousands more opioid overdose cases went unreported due to problems with how the “cause of death” is reported in the U.S.
A new study from the U.S. Centers for Disease Control and Prevention (CDC) uncovered the fact that toxic levels of opioids had contributed to numerous deaths where infectious diseases like pneumonia were listed as the only cause of death. The misreporting is partly due to a lack of codes available for listing opioids as a causal factor on death records from state to state. The coding issue and other problems in the reporting system limit coroners from accurately recording cause-of-death details — a procedural hitch that spans the nation.
This discovery by CDC researchers indicates that the opioid epidemic is even more dire than we realized.
Drastic situations require drastic measures. A new federally backed program may give us the opportunity we need to put those measures in place.
Help From High Places: Working Together Nationwide to Save Lives
Through the Department of Health and Human Services (HHS), the Trump Administration recently issued a press release announcing it had established the President’s Commission on Combating Drug Addiction and the Opioid Crisis. With money made available through the 21st Century Cures Act, which President Obama signed in December 2016, the commission is allocating federal funding to all 50 states and the U.S. territories to ramp up addiction prevention, treatment and recovery services.
Faulty cause-of-death reporting systems notwithstanding, funding amounts for these grants were based on each state’s rate of overdose deaths and unmet need for opioid addiction treatment. Administered by the Substance Abuse and Mental Health Services Administration, every state and territory will receive funding, with the largest grants going to California ($44,749,771), Texas ($27,362,357), Florida ($27,150,403), Pennsylvania ($26,507,559), Ohio ($26,060,502), New York ($25,260,676), Michigan ($16,372,680) and North Carolina ($15,586,724).
HHS Secretary Tom Price, MD, reports that the HHS is working to ensure the funds and any new policies will support “clinically sound, effective and efficient programs.” The HHS aims to work with states to improve strategies that strengthen public health surveillance, advance the practice of pain management, improve access to treatment and recovery services, target availability and distribution of overdose-reversing drugs, and support research. In a letter to state governors, Dr. Price made an appeal for assistance in identifying best practices and key strategies that will help stem this public health crisis.
Based on recent information on the opioid crisis and my own experience in the addiction field, I propose several practices and strategies that I believe will help.
9 Things We Need to Do Now to End the Opioid Epidemic.
#1 Write only short-term prescriptions. It should be a medical standard nationwide to prescribe opioid painkillers for only three to seven days or fewer. Short-course treatment helps prevent addiction in the person who receives the pain pill prescription, and also keeps any oversupply out of home medicine cabinets — which is where kids/teens are finding them. Most youngsters with addiction say they were first introduced to opioids at home. Studies show that opioid pain pills are often the gateway to heroin addiction. Many heroin addicts have reported that once the home supply of opioid pain pills ran out and they couldn’t get more prescriptions, they sought heroin to feed their addiction to an opiate-fueled high.
#2 Prescribe only low doses, and establish a standard maximum dose for all patients. Since we know that patients receiving higher-dose prescriptions can become dependent in only two days, it makes sense to lower the dosing guidelines and cap the maximum dose … and always prescribe the lowest possible dose for pain management. In 2016, the CDC established new opioid prescription guidelines, which provide a safer template for prescribing doctors to follow.
#3 Require that all doctors check a prescription monitoring database to ensure that patients don’t doctor-shop for opioids. New Jersey and 28 other states have established laws that require doctors to consult an electronic state-managed prescription drug monitoring program (PDMP) before prescribing opioid painkillers or other controlled substances. Not all states have such laws, and sharing this information among states can be problematic. Let’s establish these laws in every state and optimize doctor access to prescription databases so the information can be shared among prescribers in different states, enabling them to grab nationwide information more efficiently.
#4 Choose alternative pain medications in every case possible. This should be a required first step before prescribing opioid pain medications. The CDC stipulates that non-opioid treatments are preferred for managing chronic pain, and opioids should be used only when the benefits outweigh the risks. Non-opioid alternatives should always be the first choice to avoid contributing to addiction — even short-acting prescription opioids such as oxycodone and hydrocodone were involved in 24% of all drug overdoses in 2015.
#5 Track and record cause of death data more rigorously. An Unexplained Death surveillance system (UNEX) was rolled out by the CDC in 1995 for use in all states, but only Minnesota maintains it. Intended to help identify cases where there is no clear explanation for death and where more testing may be warranted, UNEX needs to be revived and updated in each state so we can more closely track deaths in which drugs played a role. Further, we need to expand the cause-of-death codes for use on death certificates so that when coroners detect elevated levels of opioids, they can list them as potential contributing factors in death records.
#6 Monitor patients who receive opioid medications throughout the course of treatment (say, three to seven days maximum) via follow-up. Once a short course of opioids is completed, transition these patients to non-opioid pain medication, perhaps combined with another therapy.
#7 Alert the medical community about the addiction risks associated with opioid prescriptions. Disseminate clearer information about opioid pain medication/narcotics to all physicians, healthcare personnel and pharmacists. It has taken recent studies and countless unnecessary deaths to give us a true understanding of how addictive and harmful these medications are, and also to reveal how frequently, and even needlessly, doctors across the U.S. have been writing prescriptions for these drugs. This isn’t necessarily an issue of irresponsibility — much of the problem has been due to a lack of awareness and time to thoroughly weigh all the considerations. We need to get information to the medical community more efficiently, and facilitate ways for doctors and pharmacists to easily share information with patients. Simplified advisories would be particularly useful in clinic settings and big box retail pharmacies where people are rushed and pressed for time. There have to be educational signposts in place to help ensure that patients see, understand, and heed the warnings.
#8 Educate the public — initiate a national public awareness campaign that includes TV, radio, print messages and signage. Did you know that more people die from drug overdoses than from guns or car accidents? In fact, more people die from drug overdoses than from AIDS. This holds true even at the peak of the AIDS epidemic in 1995 when 43,115 people in the United States died from the disease. Compare that to 2015 when 52,404 people lost their lives to drug overdoses with at least 63% of those deaths involving an opioid. Educational messages must also shatter stereotypes about drug addicts. The public needs to understand that a drug addict is not just that poor guy sleeping on the street but also the well-to-do adolescent shooting up heroin in his bedroom. Statistics show that today’s drug addict is often a white, middle-class professional living in the suburbs.
#9 Change public discourse to bring more people to addiction treatment. We need to change how we talk about drug addiction — in the media, in our schools, at home and in the doctor’s office. Unless we change how we discuss drug addiction, people who develop drug dependencies will continue to feel shame, hide their addiction and avoid treatment. We must make it clear that addiction is not a moral choice. It is a disease.
It is going to take a concerted effort, but if every state works to improve each of these areas, we can turn things around.
When you think of a drug overdose victim, chances are you think of someone inexperienced with drug use who takes more than they can handle, or a person who unknowingly takes a purer strain of drug than they’re used to. Those assumptions, however, aren’t reflected in current U.S. statistics. So what is an accurate profile of a drug overdose victim?
WHO: Statistics show that the people most at risk of drug overdose are people you wouldn’t necessarily think of as drug addicts — suburban, middle-aged white men, according to a 2014 study. Although many people picture the young being hardest hit, the Centers for Disease Control and Prevention (CDC) reports that in 2015 alone, the highest death rate from drug overdose occurred in people aged 45 to 54.
WHAT: What drugs are people in the highest risk groups taking? In a word, painkillers. Prescription opioids like hydrocodone (Vicodin, Lortab) and oxycodone (OxyContin) were responsible for 24% of drug-related deaths in 2015. According to the Office of the Surgeon General, 44% of Americans say they personally know someone who is or was addicted to prescription painkillers, and 78 Americans die every day from an opioid overdose. Prescriptions for opioid medications have quadrupled since 1999.
But the problem doesn’t stop with prescription painkillers. Heroin is another drug contributing to the alarming rise in overdose deaths. In 2015, heroin was responsible for 25% of drug-related deaths. Heroin overdose deaths tripled between 2010 and 2015. The highest recorded death rate from drug overdose in the U.S. occurred in 2014, when there were 47,055 drug overdose deaths, including 28,647 people who died from an overdose involving either a prescription painkiller or heroin.
Trailing close behind heroin and pain pills, at an 18% overdose death rate, are semisynthetic opioids such as fentanyl. Typically used for sedation during medical procedures and to treat cancer pain when other painkillers have failed to provide relief, fentanyl is 50 times stronger than heroin. For illicit use, fentanyl is regularly mixed into other drugs such as heroin and cocaine, often without the user’s knowledge, making it even more dangerous.
WHEN: Many users don’t realize that once they achieve a period of abstinence, either through a drug rehab program or on their own, they are at greatest risk for drug overdose. When they haven’t been using the drug regularly their tolerance drops. If they relapse (as about half of addicts do) and return to their usual dose of the drug, they are at grave risk of overdose.
There is also a risk of overdose when people mix drugs. For example, if a person takes one form of an opiate (such as a pain pill) and within 24 hours takes another type of opiate (such as heroin), they increase the opiate’s effect in their body and, thus, their risk of overdose.
WHERE: Studies also reveal surprising information about where drug overdoses are most likely to take place. A growing number of drug overdoses are occurring not in low-economy urban areas, but in suburban and non-urban settings, and often in affluent neighborhoods. Some of the states with the highest numbers of drug overdose deaths in recent years are New Hampshire, Ohio, West Virginia and Kentucky.
WHY: Addiction to opioid painkiller medications can develop even when people are using them for legitimate medical reasons. In fact, nearly one in four patients receiving long-term opioid pain therapy in a health care setting struggles with addiction. People who struggle with underlying depression, anxiety, trauma or other issues may find that the medication they take for physical pain also helps them cope with their emotional pain. This can contribute to addiction and lead to further problems. For example, since heroin is cheaper and easier to get than prescription opioids, many painkiller addicts turn to heroin when pain pills become difficult to acquire.
Stemming the Tide of Drug Overdose
In an effort to raise public awareness about opioid addiction, the Surgeon General has launched a “Turn the Tide” campaign advising concerned Americans to take active measures to help people in their communities who are struggling with addiction. Some of these include:
- Write to local health care providers encouraging them to treat their patients’ pain appropriately
- Talk to community leaders about the practices that are most effective and the challenges that remain
- Inform policy makers, educators, law enforcement officers and others to help change how they think about substance use disorders and addiction
These measures can help address the problem at the community level, but it is also important to take action at the individual level. If you are seeking medical assistance to manage your pain, ask your doctor questions before taking an opioid prescription. Also consider alternative pain management approaches as well as medications that carry a lower risk for addiction, such as gabapentin (Neurontin, Gralise) and pregabalin (Lyrica). These are FDA-approved for pain and can be combined with other therapies for long-term use.
Finally, if you or someone you know is struggling with opiate addiction, get treatment before you become a statistic, and learn about the powerful anti-overdose tools available to you. Naloxone, a medication that can rapidly reverse opioid overdose, is easy to administer and more readily available than ever. In many states, relatives and friends can obtain prescriptions for an automated injector or nasal spray in case their loved one overdoses and in some states no prescription is required. Drug overdose is a tragedy that can be prevented by knowing who is at greatest risk, and how and when to take action.