September is National Recovery Month, Not National Opioid Month As the Numbers Suggest

Every day, 46 Americans die from an overdose of prescription opioid narcotics such as Vicodin, OxyContin, and methadone.

Prescription Opioiod Abuse Alive and Well Along With A National Herioin Crisis:
The rise in heroin use is leading to more drug overdose deaths. In February of this year, SAMHSA issued an alert about a marked upswing in deaths linked to the use of heroin contaminated with the opioid fentanyl. Fentanyl is reported to be about 100 times more potent than morphine, the active ingredient of heroin.


Addressing the Problem:  What is Being Done?  What is NOT being done?
In the last 5 years, arrests of dealers and suppliers of opioids when there has been a death have increased substantially. The idea is to send dealers the message that if they sell people drugs and they die, they may be charged with reckless homicide.
Has this really had an impact???  The laws for possession of Heroin especially with intent to distribute are severe and can often land a dealer in jail for longer than a murder (depending on factors such as location, amount of heroin, etc).

Good Samaritan Laws.  What About “Bad Samaritan Laws”?
Some states have passed Good Samaritan laws. To date, 21 states have this legislation, which encourages those witnessing overdoses to call emergency medical services and exempts them from arrest and prosecution for minor drug and alcohol law violations.

This needs to be spelled out clearly.  Let’s face it, if one is witness to an overdose and might have reluctance in calling 911, because of the potential legal ramifications, odds are, they too are using heroin at that moment.  So, a fellow addict needs to know what is meant by exemption from “minor drug and alcohol law violations.”  Well intended, but again, will this make a difference without an assurance of some kind of immunity?  What about a “Bad Samaritan” Law that punishes those that take no action?

We need to be realistic.  California, Washington, and New York, have passed both Good Samaritan laws and naloxone laws.  Naloxone is a drug that can reverse an overdose and is now carried by a number of professionals including law enforcement, mental health clinics that ordinarily do not stock medicine, and clinicians who do not write prescriptions such as myself.  Naloxone is also being possessed by non-professionals such as loved ones of heroin addicts, and other concerned individuals, such as myself.

Prescriptions Still Flying off Rx Pads Across the Country:
In 2012, healthcare providers wrote 259 million prescriptions for opioids, enough for every American adult to have a bottle of pills.

The number of opioid prescriptions ranged from a low of 52 prescriptions for every 100 people in Hawaii to a high of 143 prescriptions per 100 people in Alabama. Southern states had the most prescriptions per person for opioids and benzodiazepines, especially Alabama, Tennessee, and West Virginia. Opioid prescribing rates correlated with benzodiazepine prescribing rates.

The Northeast, especially Maine and New Hampshire, had the most prescriptions per person for long-acting and high-dose opioids. Of all prescription opioids, state prescribing variation was the highest for oxymorphone. Nearly 22 times as many prescriptions per person were written for oxymorphone in Tennessee as in Minnesota.

This widespread variation among providers, is likely caused by a lack of clear consensus on when to use a certain type of drug. For opioids, high rates might also mean that the state has a large population of people who are addicted to drugs. These patients might get multiple prescriptions for their own use and actively seek out prescriptions for long-acting or high-dose forms of these drugs.

Many states report problems with for-profit, high-volume pain clinics — so-called “pill mills” — that prescribe large quantities of opioids to people who don’t need them for medical reasons, although these pill mills are being shut down in certain states.

Antibiotic prescribing rates are also highest in the South, so it is possible that regional healthcare characteristics and patterns might influence the use of prescription drugs in general. We think it’s important for all states, especially those where prescribing rates are highest, to examine whether the drugs are being used appropriately.

It boggles the mind that states with significant prescription opioiod abuse aren’t making significant efforts to identify opportunities to increase access to substance abuse treatment and consider expanding first-responder access to naloxone, a drug that can reverse overdose as mentioned above.

Migrating to Heroin:  When Best Intentions Cause Collateral Damage:
The route to heroin comes from recreational use of other substances,  progresseing  to trying prescription painkillers before ending with heroin, especially when one is “dope sick” (withdrawing from prescription opioids which are more expensive and more difficult to obtain from drug dealers.

When an individual’s body is screaming for more of a substance causing that individual to be physically ill, mentally desperate and panicked, judgement is significantly impaired.  Polysubstance abuse may be due to the crackdown on prescription opioids and new tamper-resistant technology aimed at decreasing their abuse.  Before, abusers may have been on a single type of molecule, but now that molecule is in a tamper-resistant formulation, so they migrate to other options.  The evidence of migration is seen plain as day in the increase in heroin use.”

In 2010 and 2011, Florida regulated pain clinics and stopped healthcare providers from dispensing prescription opioids from their offices. By 2012, oxycodone prescribing had dropped by a quarter and oxycodone overdose deaths had dropped by half.  What I don’t know off hand is if Florida has experienced a significant increase in heroin use as opioid addicts (prescription) who can no longer obtain these drugs make up the majority of new heroin users as the governments crackdown on prescription opioids created a significant increase in demand for heroin.

In Nassau County, NY, where I live and practice, heroin use is at an all time high and the cost is at an all time low. Not a good combination.


Opioid Use Crosses All Demographic Boundaries.  ADDICTION DOES NOT DISCRIMINATE:
Although the biggest segment (41%) of opioid abusers lives in large urban areas, followed by smaller urban centers and then rural area, the abuse rate per person is higher in rural areas.  The days of the heroin addict as being a title reserved for the section of society living in urban, low-socioeconomic areas, unemployed, college students, or in the music industry are over.  The image of the opioid addict as a young person is fast becoming outdated, a new study suggests. These days, someone abusing opioids could be a working mom, or even a senior, a new review suggests.
AGE:  Seniors Addicted to Opiates At An All Time High & Growing:
According to various sources, Americans aged 50 to 69 years represent the fastest growing population of opioid addicts, and the number of people aged 65 years and over who have at some point abused opioids increased by 34% from 2011 to 2012.  There are lot of people who are inappropriately using opioids at any age, and that includes senior citizens,  Fifteen to 20 years ago, there were not many people over the age of 50 who were abusing opioids.  Exposure to these substances drive abuse and addiction along with environment and accessibility to more and more people “trying” these drugs not just socially, but as an increase continues to exist for prescribing opiates for legitimate reasons, but without consideration for alternative treatments .  If the individual is genetically susceptible to addiction than potential addicts are now more than ever being exposed to these drugs where perhaps several years ago, they might not ever encounter such substances.

Young people are still at high risk and comprise a large portion of the population, while the number of older addicts is growing.  Adolescents (those aged 12 to 17 years) still composes a large proportion — about 26% — of the total population of those with opioid addiction.  The research shows that opioid addiction is a growing problem….DUH!

Eduction Level Of Addicts – Also At an All-Time High:
Some 24 million Americans (9.2% of the population) used an illicit drug in 2012, which was an increase from 8.1% in 2008, and the numbers are expected to continue to rise.  Today’s drug addicts are quite educated. About 47% of heroin users and 45% of prescription drug abusers are high school graduates, and 22% and 30%, respectively, have completed some college.  These more sophisticated addicts may want pharmaceutical grade instead of street grade drugs.  It’s been speculated, that these individuals may think the price is the same and there are risks for both, so why not get the pharmaceutical grade.
As for heroin addicts, most (90%) are white and their mean age is 22.9 years. Women are just as likely to be heroin addicts as men.  Research also uncovered a possible problem with polysubstance abuse.

Of 22.2 million substance abusers in 2012, 4.5 million used a drug but not alcohol, 14.9 million abused alcohol but not drugs, and 2.8 million abused both drugs and alcohol

The evolving demographics for opiod addiction no longer has a verifiable bio-marker for clinicians to utilize when considering screening for opioid addiction.  More effective precautions include examining personal and family history of mental health disorders, abuse of other chemicals besides opioids.

Physician Responsibility:
Best practice guidelines for those who write scripts for opioids have an obligation to their patients can use prescription drug monitoring programs to find patients who might be misusing their prescription drugs, putting them at risk for fatal overdose. If a patient has a substance abuse problem, you can help find effective treatments such as methadone or buprenorphine. You can also discuss the risks and the benefits of pain treatment options with your patients, including options that don’t involve prescription opioids.

If opioids are to be dispensed as part of the course of treatment precautions must be taken.  This includes screening for substance abuse and mental health problems, avoiding combinations of prescription opioids and sedatives unless there is a specific medical indication, and prescribing the lowest effective dose and only the quantity needed, depending on the expected duration of pain.

These physicians know that these medications are dangerous – They are dangerous because they are addictive and because they can kill through respiratory suppression. The risks and the benefits need to be carefully balanced, and for the great majority of patients with chronic non-cancer pain, the risks associated with prescription opioids may well outweigh the benefits.

The Substance Abuse and Mental Health Services Administration (SAMHSA) is the agency within the U.S. Department of Health and Human Services that leads public health efforts to advance the behavioral health of the nation. SAMHSA’s mission is to reduce the impact of substance abuse and mental illness on America’s communities.

SAMHSA has made their new (updated for 2014) Opidiod Overdose Prevention Toolkit free and downloadable.  It contains information anyone can benefit from.  You can download this free and invaluable resource from SAMHSA here.

Feel free to contact me with comments / questions and/or more.

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