The Opioid Epidemic

“According the Substance Abuse and Mental Health Services Administration (SAMHSA)’s National Survey on Drug Use and Health (NSDUH), in 2016, over 11 million Americans misused prescription opioids, nearly 1 million used heroin, and 2.1 million had an opioid use disorder due to prescription opioids or heroin….Since 2000, more than 300,000 Americans have died of an opioid overdose.” Between July 2016 and September 2017 emergency room visits for opioid overdoses increased 30% according to the Centers for Disease Control and Prevention. In the Midwest, it jumped 70%.

What is an Opioid?

Opioids are a class of drugs that are depressants. We have natural opioid receptors in our brains, so misuse can start easily and become hard to stop. Medically, opioids are used for moderate to severe pain, often in the form of morphine. Heroin, like morphine, is extracted from the opium poppy and can be injected, snorted or smoked. Hydrocodone, such as Vicodin, is often prescribed for mild to moderate pain and is less potent than morphine. Oxycodone, such as Oxycontin or Percocet, is also prescribed for moderate pain. Fentanyl is a synthetic that comes in a transdermal patch and is prescribed for severe pain. Fentanyl is up to 100 times more potent than morphine and can be 30 to 50 times more powerful than heroin. Prince lost his life to a Fentanyl overdose as have thousands of others.

Some people with an opioid use disorder started with prescription medicine and moved on to heroin. Others started directly with illicit drugs and misused the synthetic fentanyl. Very pure heroin, more often found in the street these days, can be inhaled thus breaking down the needle prohibition.

The Costs of Opioids

The opioid epidemic is costing billions of dollars and taking thousands of lives. In Ohio, for example, a study by the Ohio State University found costs to the state of between $6.6 and $8.8 billion in 2016. That year also saw 4,050 overdose deaths, up 33% from 2015.  There were 64,000 overdose deaths in 2016 in the United States.  States hardest hit by the epidemic are West Virginia, Ohio, Pennsylvania, New Hampshire and Washington, D.C.

West Virginia had the perfect storm for prescription abuse. Industrial injuries in coal mining and manufacturing established the base for prescription opioids to combat chronic pain. The drug companies poured 780 million doses of oxycodone and hydrocodone into that state between 2007 and 2012. The state has a population of 1.8 million people.

On the worse day in Huntington, WV’s history, 26 people overdosed in one day.

What About the Children?

According to “American Addicted,” a special series on PBS News Hour, in West Virginia, one out of five babies are born drug exposed. Although there are proven medical protocols to address this condition (Neonatal Abstinence Syndrome [NAS]), it is heartbreaking to see a newborn withdraw from heroin. Children of all ages are pouring into the foster care system and the number of children in care has risen precipitously. According to the Wall Street Journal, the rate of children in care has risen 40% in Vermont, 24% in Virginia and 19% in Ohio between 2013 and 2016. Numerous children are being orphaned because of parental overdoses and they are being adopted by grandparents, other relatives or foster parents. However, some languish in foster care, especially if they are older. The outlook for those children is grim.

What’s Being Done?

Some states are enacting legislation to limit the amount of medication a doctor may subscribe. Earlier this year, Arizona passed the “Arizona Opioid Epidemic Act” which limits a prescription to 5 days’ worth of medication. It also provided funding for increased treatment.  Doctors are seeking re-education on pain management so that reliance on opioids is reduced.

Another intervention is safe disposal programs for prescription medicine. That prevents having medication that is no longer needed in the house where it may be easily accessible to children and young adults. There is also “Rx Destroyer,” a charcoal activation system that neutralizes drugs.

In 33 states, like Florida, people with substance use disorders are being involuntarily committed to treatment under the Marchman Act.  “Police use the Marchman Act to pick up people without a court order and take them to a designated stabilization and assessment center. Addiction professionals use the law when a patient fails to show up for treatment. Parents and friends use it when they fear a loved one’s life is at risk.”

Criminal justice responses include both pre-charge and diversion programs where, if completed, the defendant has the criminal charges dismissed. The accused is required to participate in treatment, do volunteer work, drug test, and fulfill other conditions to remain free of the charge. Unfortunately, Vermont’s pre-charge program has not been terribly successful due to a variety of reasons.

Drug Treatment Courts have been at the forefront of “treatment-over-incarceration” programs and have proven to be effective in multiple meta analyses. In May of last year, Erie County, NY created the Opiate Crisis Intervention Court, a drug treatment court that provides for immediate 30-day inpatient detox and treatment followed by 30 days of outpatient treatment. Participants are required to come to court every day at 11:00 for a check-in with the judge and they have an 8:00 curfew. They also do group counseling and get drug tested. Although it’s too early for an evaluation, only four out of 140 participants so far have “washed out” in the first five months of the program.

The Federal Response

In April of 2017, the Department of Health and Human Services created its five point Opioid Strategy:

• Improve access to prevention, treatment, and recovery support services to prevent the health, social, and economic consequences associated with opioid addiction and to enable individuals to achieve long-term recovery;
• Target the availability and distribution of overdose-reversing drugs to ensure the broad provision of these drugs to people likely to experience or respond to an overdose, with a particular focus on targeting high-risk populations;
• Strengthen public health data reporting and collection to improve the timeliness and specificity of data and to inform a real-time public health response as the epidemic evolves;
• Support cutting-edge research that advances our understanding of pain and addiction, leads to the development of new treatments, and identifies effective public health interventions to reduce opioid-related health harms; and
• Advance the practice of pain management to enable access to high-quality, evidence-based pain care that reduces the burden of pain for individuals, families, and society while also reducing the inappropriate use of opioids and opioid-related harms.

In October of 2017, President Donald J. Trump declared a Nationwide Public Health Emergency but allocated no added money for treatment.

The opiate epidemic had multiple causes and there is no simple answer. It is clear, however, that we are going to have to beef up treatment that includes medically assisted treatment (MAT) and other evidence-based interventions.

By the Numbers