Does Restricting Opioids Lead to More Heroin Overdose Deaths?

Turns out Neonatal Abstinence Syndrome (NAS), a condition suffered by newborn babies of opioid-addicted mothers, isn't the only risk to children in the fight against opioid misuse and abuse.  A JAMA Pediatrics article published yesterday showed a more than 2-fold increase in hospitalizations among children due to opioid poisonings.  While the bulk of these hospitalizations were predictably among older adolescents, the fastest growing cohort of hospitalizations occurred among the youngest children (toddlers and pre-schoolers) who can't tell the difference between candy and OxyContin.  A follow-on piece in the Washington Post fairly equates this public health risk to the gun control debate. Lock up the guns, lock up the drugs - our kids are paying too high a price.  

In other news, this month's Health Affairs contains a really interesting article on the relationship between state laws and opioid / heroin overdose deaths (Health Affairs 35, No. 10 (2016); 1876-1883).  Here are the high level conclusions:

• States that pass laws pertaining to mandatory physician review of PDMP data and the strict licensing of pain clinics reduced opioid amounts prescribed by 8% and opioid overdose death rates by 12%.  
• The study also observed a large (though statistically insignificant) reduction in heroin overdose death rates.  This might be counter-intuitive to you because some believe cutting off the supply of opioids in a community creates risk of increased heroin use.  

The public policy conclusions here are important.  First, if passing these common-sense laws really does lead to decreases in opioid supply and overdose deaths, there isn't any good reason not to implement mandatory PDMP checks and strict pain clinic laws (unless you live in Missouri... in which case irrational concerns over privacy consistently inhibit adoption of sound public health policy). 

Second, the study found "no evidence to support the assertion that policies to curb opioid prescribing are leading to heroin overdoses."  This doesn't mean that heroin overdoses haven't been on the rise; in fact, they've been increasing in virtually every state in the country.  What the study authors are saying is that new opioid restrictions do not appear to be accelerating the rise in heroin overdose deaths.  

Opioid and heroin abuse is clearly a complicated public health problem.  But this data suggests we should avoid the policy trap of using the one (potential heroin overdose deaths) as an excuse to not do the other (restrict the opioid supply through mandatory PDMP checks and strict pain clinic licensing). If there is data out there to the contrary, I'd honestly love to see it.  I think it's important to litigate these studies to ensure we're moving in the right direction.
  

As the devil can cite scripture for his purpose, we all seem able to find anecdotes to support our policy views.  Stories can be powerful illustrators of truth, but let's make sure we use data to guide our public policy discussions. 

Michael 

On Twitter @PRIUM1

Heroin is in Your Community - You Just Don't Know It

The local NBC affiliate here in the Atlanta area, 11-Alive, has just produced an in-depth story about heroin use and overdose deaths.  It's an outstanding series of videos and if you don't have much time on your hands, at least spend 7 minutes watching the first one in the series (after which you'll probably end up watching all of them).  Those of us that follow this public health crisis closely are no longer surprised by these stories, but to have such solid reporting that is so focused on my own community offered me an opportunity to talk about this with others for whom the story might be relatively new.  

Here's what surprises people:

First, this problem is concentrated in the wealthy suburbs of our major cities, not poorer areas with which drugs and related crimes have historically been linked.  The local reporters here in Atlanta discovered a triangle that connects Marietta to the west, Alpharetta to the north, and Johns Creek to the east.  Inside this triangle, you'll find some of the wealthiest ZIP codes in the state (and among the wealthiest ZIP codes in the country, for that matter).  And these reporters also found a heroin overdose death rate inside of this triangle that has skyrocketed nearly 4,000% just since 2010.  

Second, and correlated with the first point, people so closely (and incorrectly) link drugs and crime and poverty that they are completely missing the fact that heroin dealers are making home deliveries all over the north metro Atlanta suburbs.  This is how simple it is now: you text your dealer, you leave $20 under the door mat, the dealer takes the $20 and leaves the heroin.  Done.  No shady street corners, no dark alleys, no dangerous meet ups, no abandoned houses.  It's as easy as ordering a pizza.

Third, it's about as cheap as ordering a pizza, too.  That $20 isn't a made up number - that's what it costs to get secure a supply of heroin that will keep you high for up to several days.  

Fourth, this problem usually doesn't start with other illicit drugs or alcohol (though it certainly can). Heroin addiction most often begins with prescription painkillers.  And while much of the painkiller abuse in high schools is non-prescribed, recreational use, there is a substantial portion of teenage heroin addicts that started out with a legitimate prescription for opioids from a well-intentioned doctor.  Parents I've spoken to routinely miss this critical link.  Otherwise upstanding kids can get addicted to opioids (particularly after a wisdom teeth extraction or a sports injury - see this Sports Illustrated article for a more in-depth view of opioid use among high school athletes).  And when they get hooked and can no longer access painkillers (when doctors cease prescribing them and/or they can't find or afford non-prescribed pills), they're turning to heroin.  

I don't often tell people they're wrong - it's impolite and usually counterproductive.  But... if you don't think this is happening in your community, you're wrong.  If you don't think this is going on in your kid's high school, you're wrong.  If you don't think this could potentially impact you and your family directly, you're wrong.  

Strong reasons ought to make for strong actions.  Tell your friends, share the link above with your neighbors, make sure teachers and counselors and pastors are aware.  Above all else, be vigilant.  

Michael

On Twitter @PRIUM1

Drug Abuse and the 2016 Presidential Election

In last week's State of the Union address, President Obama mentioned prescription drug abuse as an issue where he saw opportunity for bipartisan compromise.  Notably, he mentioned this in the first three minutes of the speech.  And not coincidentally, he mentioned it in the same breath as another, related issue that will be a necessary component of prescription drug abuse mitigation: criminal justice reform.

Governor Chris Christie has made prescription drug abuse a centerpiece of his stump speech.  He regularly shares a personal experience of losing a close friend from law school to an overdose.  Just last week, Christie made headlines by shutting down a New Jersey prison in order to convert it to a drug addiction treatment facility.  "The victims of addiction deserve treatment..." he said.

In last night's Democratic primary debate, Secretary Clinton and Senator Sanders both touched on the subject.  After noting that she hears of horrible stories wherever she goes on the campaign trail and after advocating for first responders to carry and be authorized to use Narcan, she closed her comments along the same lines as Governor Christie: "We have to move away from treating the use of drugs as a crime and instead, move it to where it belongs, as a health issue.  And we need to divert more people from the criminal justice system into drug courts, into treatment, and recovery."  Senator Sanders added, after placing at least some of the blame at the feet of the pharmaceutical companies, that "we need a revolution in this country in terms of mental health treatment."

This is clearly going to be a 2016 presidential campaign issue.  Beyond the mere fact that crises often make for strange bedfellows (Clinton and Christie offering nearly interchangeable quotes?!?!), why are we hearing more about prescription drug abuse from candidates now than ever before?

First, New Hampshire.  Everyone knows the Granite State figures prominently as the first primary - on February 9 - in both parties' nomination process (Iowa - on February 1 - is a caucus, not a primary).  What many may fail to recognize is that New Hampshire's citizens have been hit especially hard by the opioid/heroin epidemic over the last several years.  A quarter of New Hampshire voters believe prescription drug and heroin abuse is the single most important issue of the 2016 election, marking the first time in eight years a plurality of voters have ranked any issue more important than jobs and the economy.  If you're going to win the New Hampshire primary - from either party - you better be prepared to address prescription drug misuse and abuse.  

Second, it's not an exaggeration to say that we're losing a material portion of entire generation of Americans to this epidemic.  First, we saw the findings of a recent study from the National Academy of Sciences indicating that the death rate among white, middle-aged Americans has grown over the last two decades while the death rate among almost all other groups has declined.  Now, the New York Times has analyzed nearly 60 million death certificates collected by the CDC and found that the death rate among young, white adults has risen to levels not seen since the AIDS epidemic of the late 1980s and early 1990s.  This generation will be the first since the Vietnam War to experience higher death rates in early adulthood than the generation that preceded it.  The figures indicate that the 2014 death rate from prescription drug and heroin overdose among 25 to 34 year olds was five times its level in 1999.  

We have presidential candidates talking about this issue because it is the preeminent public health issue of our time.  If there's any comfort for us at all, it's that both parties appear to be taking it seriously.  If there's to be a concern, it's that whoever wins will need to make difficult decisions and real progress.  We're losing a generation of Americans.  

Michael
On Twitter @PRIUM1

When Opioids Almost Kill You, Chances Are You'll Get More Opioids

I really wanted the first post of 2016 to be positive, uplifting, inspiring... but a study I read over the break was so unnerving, I had to go and ruin "return to work" day, already a day that lives in infamy, with even more depressing news.

Researchers at Boston Medical Center used a national database of prescription information to assess the likelihood of continued opioid prescriptions after a non-fatal overdose.  They looked at prescription information from 3,000 patients who experienced a non-fatal overdose between 2000 and 2012.  These patients were all prescribed opioids for chronic, non-cancer pain. 

Think about this: These 3,000 patients have already overdosed on prescription opioids. They are lucky to be alive. Surely, their healthcare providers will find another way, another mechanism, another approach to managing their pain. The risk here isn't illness or infection or a change in blood pressure... it's death.  

The bad news:

• Over 90% of these patients continued to receive opioids after their non-fatal overdose event
• 50% of these continued to receive the prescriptions from the same doctor
• 7% of the original group experienced a second overdose
• Two years after the first overdose, those with continuing opioid prescriptions were twice as likely to experience a second overdose event compared to those who were no longer receiving opioids. 

Why is this is happening?  

First, our fragmented healthcare system doesn't make it easy for prescribing physicians to discover the clinical events experienced by their patients outside of their immediate purview.  And patients may not want to disclose an overdose event for fear of having their medications discontinued.  I get that.  And it makes we wonder whether PDMPs should also include the ability for inpatient settings to report both fatal and non-fatal overdose events to the database so doctors can see this information whether its reported by the patient or not.  Linking electronic health records to PDMP systems would be a good start down this path.    

The second phenomenon driving these sorry statistics is that doctors are not comfortable weaning opioid (and other) medications.  No one, least of all me, would ever suggest immediate cessation of opioid therapy in light of a non-fatal overdose.  That's clinically irresponsible and potentially dangerous for the patient.  But the necessary steps forward are complicated: If the patient is on multiple medications that require weaning, which should we weaned first?  What titration steps should be used?  Is medication-assisted-therapy (MAT) an option?  Should I refer the patient or try to handle this myself?  These are hard questions and the primary care community, by far the most frequent prescribers of opioids, is currently ill-equipped to handle them.

Welcome to 2016.  Once more unto the breach, dear friends.  

Michael 

On Twitter @PRIUM1  

A Sad Addition to our Shared Experiences

Think of the number of truly consequential experiences that Americans have in common.  Not the "mom and apple pie" stuff, but experiences that really impact our lives in deep and meaningful ways.  How many of us know someone affected by cancer?  How many of us are products of our public education system?  How many of us have lost a loved one?  

Thanks to the results of the recent Kaiser Health Tracking Poll, we can now add another shared experience among Americans: more than half of us (56%) know someone connected to prescription drug misuse or abuse.  45% of us know someone who has taken a prescription drug not prescribed to them.  39% of us know someone who has been addicted to prescription drugs.  16% of us know someone who has died from an overdose of prescription painkillers.  (56% of those polled answered "yes" to at least one of these questions).  

Interestingly, the poll reveals a demographic and socioeconomic trend around those who answered "yes" to at least one of the questions (know someone who took a drug not prescribed, know someone who has been addicted, or know someone who has died of an overdose).  The top 8 groups, by percentage of those polled answering "yes" at least once:

• 63% of whites
• 63% of those making more than $90k per year 
• 62% of those aged 18-29
• 61% of those aged 30-49
• 61% of those having "some" college education
• 59% of those with a college degree
• 59% with residency in a suburban area
• 59% of males  

That paints a picture of the prescription drug misuse and abuse epidemic.  

And yet, when asked to prioritize public policy goals, reducing drug abuse comes in 6th:

1. Public education
2. Affordable/available healthcare
3. Reducing crime
4. Attracting and retaining businesses and jobs
5. Protecting the environment
6. Reducing drug abuse
7. Reforming the criminal justice system

In studying this list... I wonder if we can't make a significant impact on #6 by tackling #2, #3, and #7. What if we thought differently about mental healthcare?  What if we thought differently about addiction?  What if we didn't treat addicts like criminals?  It's possible - and the regulatory and private enterprise infrastructure to make that happen is actually developing all around us. 

There is hope.   

Michael  

On Twitter @PRIUM1

The Pen, the Price, the Panacea?

The Washington Post attempted to capture America's drug overdose epidemic in four charts/maps. I'm not sure they pulled it off, but I certainly appreciate the attempt to highlight the issue in a way people can easily understand it.

Of the four charts/maps, the last one highlights an issue about which all of us in work comp need to be aware.  This map captures the mix of nalaxone access and "Good Samaritan" laws throughout the country.  Essentially, "Good Samaritan" laws protect drug abusers and those that might assist them (i.e., calling 9-1-1 or driving them to the emergency room in light of an overdose) from criminal prosecution.  All states and local jurisdictions should pass such laws. It makes no sense for people to die because someone else is afraid of getting in trouble.
 



The nalaxone access issue is also important.  But it's more complicated.

Yes, emergency responders and others on the front lines of the drug abuse epidemic should have access to this potentially life-saving drug.  But there are two challenges with respect to nalaxone that we're not openly discussing, mostly because its uncomfortable to do so.  And the two challenges happen to be the critical questions we should ask of any new medication:

1) Cost.  Nalaxone itself is an old drug and long off patent.  A simple syringe filled with a single dose would cost about $3.  But last year, the FDA approved EVZIO, a portable nalaxone injector.  This device is costing payers about $500 for two doses packaged together.  We see EVZIO being paid for in our payer data and we've seen fees closer to $800 for EVZIO.  This drug is a critical public health tool, but does Kaleo Pharma (the makers of EVZIO) deserve patent protection for putting a drug originally approved in 1971 into an injector pen?  Is that really the type of innovation we want our patent system to protect?  

2) Utilization. We just heard from a prescribing physician during a PRIUM follow up call to a peer-to-peer review that he was prescribing EVZIO for the injured worker in question.  We further learned that he was being encouraged by the "drug rep" to prescribe EVZIO to all of his patients being prescribed opioids.  Just in case they overdose.

The answer to the epidemic of opioid misuse and abuse shouldn't be layering on another $800 prescription for a nalaxone injector for every patient on opioids.  Are there instances where such a prescription will make sense?  Certainly.  But why not focus our efforts on eliminating the possibility of overdose completely by focusing on non-pharmacological pain management and non-opioid medications?  We need to focus physician education efforts on the lack of evidence for the effectiveness of opioids among chronic, non-cancer pain patients... and not allow a nalaxone injector to be perceived as the panacea it will never be.

Michael
On Twitter @PRIUM1