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Thursday, July 30, 2015

Fighting Drug Overdoses Now

Overdosing is now the leading cause of accidental death in the United States, accounting for more deaths than traffic fatalities or gun homicides and suicides. Statistically speaking, the American death toll to overdose averages over 120 people a day.

Keith Humphreys, professor of psychiatry at Stanford University and former senior policy adviser at the White House Office of National Control Policy, says ...

"In drug policy, we have so much culture war screaming that it's very hard to address issues like overdose that take some planning, thought, and reflective approaches to public policy…. The polarized and uncivil atmosphere in drug policy  generates much heat but very little light regarding what we should do to address this problem. Evidence is often left aside as people start screaming at each other. Overdose is a public health problem and everyone should be working together to save lives."


Many people now focus on the return of heroin and say, "It's all the fault of criminals." Humphreys states:

"You've got to remember, 4 in 5 of people today who start using heroin began their opioid addiction on  prescription opioids. The responsibility doesn't start today with the stereotypical criminal street dealer. We basically created this problem with legally manufactured drugs that were legally prescribed."

Key factors leading to this epidemic include:

1) Changes in clinical pain management guidelines in the late 1990s (i.e., Federation of State Medical Boards releases Model Guidelines for the Use of Controlled Substances for the Treatment of Pain; Ohio Revised Code 4731.21 Drug Treatment of Intractable Pain) 

2) Aggressive marketing by pharmaceutical companies of new, extended-release prescription opioids to physicians. These factors initially led to rapidly increasing use of prescription opioids.

(FDA Warning Letters)

From 1997 to 2011, there was a 643 percent increase in the amount of prescription opioid grams per 100,000 population distributed to retail pharmacies in Ohio (Source: DEA ARCOS). And, in 2012, there was an average of 67 doses of opioids dispensed for every Ohio resident.

(Ohio Board of Pharmacy, Ohio Automated Rx Reporting System)

Additional societal and medical trends that contributed to this complex problem include marketing of
medications directly to consumers, over-prescribing, substance abuse, widespread diversion of medications, deception of providers including doctor shopping and prescription fraud, illegal online “pharmacies,” unscrupulous providers (e.g., “pill mills”), overmedication and mixing medications, and improper storage and disposal of excess medications.

Contributing factors to the recent rise in heroin-related overdose in Ohio include a growing opioid-addicted population, shutdown of southern Ohio’s pill mills, additional recent scrutiny around prescribed opioids, tamper-resistant prescription opioid formulations, increasing quantity and purity of heroin and decreasing cost of heroin compared to prescription opioids.


44,000 people died from drug overdoses in 2013. 38,329 people died from a drug overdose in the United States in 2010 when overdose deaths increased for the 11th consecutive year, up from 37,004 deaths in 2009, according to an analysis from the Centers for Disease Control and Prevention.

Overdose deaths involving opioid pain medications have shown a similar increase.  Starting with 4,030 deaths in 1999, the number of deaths increased to 15,597 in 2009 and 16,651 in 2010.

1. The quantity of prescription painkillers sold to pharmacies, hospitals, and doctors’ offices was four times larger in 2010 than in 1999.

(Jones C, Mack K, Paulozzi L. Pharmaceutical Overdose Deaths, United States, 2010. JAMA. 2013;309(7):657-659.)

2. Enough prescription opioids were prescribed in 2010 to medicate every American adult around-the-clock for a month.

(Centers for Disease Control and Prevention. Vital Signs: Prescription Painkiller Overdoses in the US. November 2011.)

What Can We Do About the Heroin Overdose Epidemic?

Dr. Nora Volkow, director of the National Institute on Drug Abuse, explains ... 

"NIDA has actively pushed research on an easy-to-use intranasal formulation of naloxone, a drug that can save lives in the event of opioid overdose. We have also taken various measures to improve the education of clinicians in pain treatment and opioid prescribing and created resources (NIDAMED) to guide doctors in detecting and addressing prescription opioid abuse in their patients.

"But we and other government agencies must do much more to address one of the major drivers of the overdose epidemic: underlying opioid use disorders. Particularly, we must push for wider adoption and implementation of existing medication-assisted treatments (MATs) for opioid addiction."

(Dr. Nora Volkow. "What Can We Do About the Heroin Overdose Epidemic?" National Institute on Drug Abuse. June 24, 2014.)

Volkow says research has shown ...

"The opioid antagonist naltrexone and maintenance therapies using the agonists buprenorphine or methadone have proven effective at helping patients recover from opioid addiction and at reducing overdoses. 

"Moreover, all three treatments have been shown to improve social functioning, reduce criminal activity, and lessen the risk of transmitting infectious diseases like HIV. They are also cost-effective.

"But less than half of private-sector treatment programs have adopted MATs, and even in programs that offer them, only 34.4% of patients receive medications. Policy-related hindrances and limitations in the area of insurance coverage are among the barriers to wider MAT adoption, as is a shortage of physicians trained and qualified to deliver these medications.

"But another major barrier is attitudinal—namely, lingering beliefs (even among some staff and managers at opioid treatment clinics) that maintenance treatments simply replace one addiction with another. When maintenance treatment is offered, it is often at an insufficient dose or duration, leading to treatment failure and reinforcing the erroneous belief that medication is a poor approach.

"Implementation of the Affordable Care Act (ACA) will help with some of the insurance coverage issues, but only by transcending old prejudices and misconceptions about opioid treatment (often rooted in stigma) can we ensure they are used and used effectively. We will not reduce the unacceptable numbers of overdose deaths from prescription opioids and, increasingly, heroin, without realizing that addiction—and failure to treat it—lies at the heart of the problem."

(Nora D. Volkow, M.D., Thomas R. Frieden, M.D., M.P.H., Pamela S. Hyde, J.D., and Stephen S. Cha, M.D. "Medication-Assisted Therapies — Tackling the Opioid-Overdose Epidemic." N Engl J Med 2014; 370:2063-2066. May 29, 2014)

We, as caring citizens who wish to fight drug overdose deaths, must support proven strategies and new research. Most importantly, we must free ourselves from stigmas about abuse and addiction and open our minds to help discover solutions and to help save lives.

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