By Dr. Geoffrey Modest
The CDC just published their report tracking drug and opioid-involved overdose deaths in the United States from 2010 to 2015 (see https://www.cdc.gov/mmwr/volumes/65/wr/mm655051e1.htm?s_cid=mm655051e1_x ).
- Background: from 1999 to 2014 there was a tripling of drug overdose deaths, with 47,055 total drug deaths in 2014, and 60.9% involved an opioid. During 2013-2014, deaths from natural/semisynthetic prescribed opioids [this class includes natural opioids (morphine and codeine), and semisynthetic opioids (oxycodone, hydrocodone, hydromorphone, and oxymorphone)] increased slightly, but there was a rapid increase in deaths from heroin and “synthetic opioids other than methadone” (including tramadol, fentanyl).
- In 2015, there were 52,404 drug overdose deaths including 33,091 (63.1%) involving an opioid. This death rate calculates to 16.3/100000 population (it was 12.3/100000 population in 2010, a 33% increase)
- From 2014 to 2015 the death rate from “synthetic opioids other than methadone”, which includes fentanyl, increased by 72.2%, and heroin death rates increased by 20.6%. Natural/semisynthetic opioid death rates increased by 2.6%, but methadone death rates decreased by 9.1%
- The rates of death involving heroin and “synthetic opioids other than methadone” increased among all demographic groups, regions, and most states (Florida and South Carolina had both decreasing and then increasing trends during this time: Florida decreased from 2010 to 2013 and then increased til 2015; South Carolina decreased from 2010 to 2012 and then increased til 2015)
- The largest absolute rate increases in deaths from “synthetic opioids other than methadone” occurred in Massachusetts, New Hampshire, Ohio, Rhode Island, and West Virginia. The largest percent increases in rates occurred in New York (135.7%), Connecticut (125.9%) and Illinois (120%). The largest absolute rate increases in heroin deaths were in Connecticut, Massachusetts, Ohio, and West Virginia, and the largest percentage increases were in South Carolina (57.1%), North Carolina 46.4%, and Tennessee (43.5 percent)
- The above includes 28 states with high quality reporting on death certificates, including specific drugs involved in overdoses. [Seems like all states should be tracking this. And this is why our national statistics and epidemiologic studies pale in comparison to western European countries, where they have large and inclusive national registries. Would be great to fix this…. much better data to act on]
- Deaths from illicitly-manufactured fentanyl were probably largely responsible for the increase in deaths attributed to “synthetic opioids other than methadone” and were largely concentrated in eight of the 27 states examined. Actual fentanyl prescribing rates did not change during this time [confirming that this was likely illicitly-manufactured]
- Factors likely involved in these changes include:
- My guess is that the decrease in overdoses due to methadone is related to more vigorous efforts by the federal and state governments to limit its use in chronic pain. This shows that targeted strategies seem to work.
- The smaller increase in natural/semisynthetic opioid deaths may also be related to changes in policies/education, use of the prescription drug monitoring program, and legislative changes in naloxone prescription and distribution.
- The implementation of harm reduction strategies, including syringe exchange programs, increased access to naloxone, more available medication assisted treatments, strategies to reduce the transmission for hepatitis C and HIV, etc., are likely very important in decreasing the extremely important sequelae of drug use
- But, ironically, it seems that as there is less availability of prescription opioids in opioid prescribing, many patients are taking some more dangerous but now much cheaper drugs such as heroin, which may well be laced with fentanyl (i.e., these opioid substitutes may be being used more, and these may even be more fatal, such as by the increase in fentanyl-related deaths).
- So, the bottom line here for me is that single targeted measures (decreasing methadone prescribing) can lead to shifts in drug usage with potentially even worse clinical outcomes. Which really speaks to the need to deal with the underlying problems of poverty, lack of hope/avenues to advancement felt by many young (and old) people, lack of positive social supports, poor quality education for many, increasing income inequalities, etc. etc. etc.
- As I have mentioned in several blogs, including one which evaluated/critiqued the CDC guideline for prescribing opioids for chronic pain (see past blogs below), the issue of chronic pain control is often one of the most difficult clinical issues we encounter in primary care. There are very clear examples (at least to me) of patients who need chronic opioids to function and lead reasonably normal lives. And several need very high doses (for a multitude of reasons, likely including genetic differences in mu receptors). There also are pretty clear examples of clinicians overprescribing opioids, from surgeons/emergency rooms as well as from primary care, and these can have profound social sequelae, such as drug diversion and opioid-related deaths. And, there are whole group of people in the middle, where it is not entirely clear and is a judgment call by the treating clinicians. The first two groups are easier to deal with; this middle group where there is more uncertainty about the need for opiates is quite challenging clinically and more socially concerning given the reality of the explosion of illicit drug use and deaths.
- I would also like to mention again a prior blog finding that 12th graders prescribed opioids by clinicians (e.g. for surgery) but were considered beforehand to have a very low likelihood of using illicit drugs in the future per a standardized and validated questionnaire, had a much higher rate of opioid abuse at age 23 than a similar group who were not prescribed these opioids (see below).
http://blogs.bmj.com/bmjebmspotlight/category/pain/ for the array of blogs on opiates and chronic pain
http://blogs.bmj.com/bmjebmspotlight/2016/03/25/primary-care-corner-with-geoffrey-modest-md-new-cdc-guidelines-for-opiate-prescribing/ for a critique of the CDC guidelines
http://blogs.bmj.com/bmjebmspotlight/2015/11/10/primary-care-corner-with-geoffrey-modest-md-prescribed-opioids-and-future-prescription-opioid-misuse-in-teens/ for the blog on 12th graders at low risk of addiction by a validated questionnaire, then getting prescribed opiates, finding that by age 23, there was a 33% increased risk of opioid misuse