Update on the Opioid Crisis — Still not at the Peak

Today is International Overdose Awareness Day (IOAD) a global event held on or around August 31st of each year which aims to raise awareness of overdose and reduce the stigma of a drug-related death. Unfortunately, 2017 is likely to be the deadliest year yet in the opioid crisis. According to preliminary data from the Centers for Disease Control and Prevention, more than 72,000 people in the US are predicted to have died from a drug overdose in 2017, up from the record number of over 64,000 people in 2016. Sadly, a new record has been set each year the past few years, with no peak in sight. At least two-thirds of drug overdose deaths in 2016 and 2017 were linked to opioids. The overdose death event typically occurs after a gut-wrenching downward spiral and cycles of relapses and near-death experiences that leave families and communities fractured, confused, hurt and struggling. This downward spiral, punctuated by the death of a loved one, loss of hope for recovery and the need to pick up the pieces. At the current rate, 200 families a day are dealing with this final devastating event. Despite the frenetic activity over recent years, the grip of this self-induced crisis continues to tighten.

What is challenging is how the pool of persons with Opioid Use Disorder (OUD), established by misleading pharmaceutical marketing and medical overprescribing of opioids, is evolving their behavior to sustain the demand as access to legal opioids is reduced. It is estimated that 11% of the U.S. population has a problem with chronic pain. This high prevalence of pain cuts across all racial and sociodemographic categories, especially when you include acute pain. That is why the overprescribing of opioids for pain has had such a broad and far-reaching impact, touching families who never thought anything like this could happen to them. Due to the overprescribing of opioids, beginning in the late 1990’s, opioid addiction rates increased and a conditioned population of persons with OUD was created. This population was poised to shift to street drugs as access to legal opioids were cut off or their addiction worsened. In the early years of the epidemic, this meant shifting to street heroin. Heroin is more powerful and cheaper than pills, but introduces the users to the dangers of illicit activity and IV drug use. In the early 2000’s over 75% of new heroin users started by using opioids in pill form, usually legally.

Unfortunately, illicit suppliers recognized this new pool of customers created and began to increase production and innovation to meet this demand. Drug dealers have the resources and will to create ever-evolving products to meet the needs of their market. They have responded to the demand for cheaper and more powerful opioids by increasing the production of fentanyl. Fentanyl, used legally and appropriately in medical care for years, is easy and cheap to manufacture. Unlike heroin, you don’t have the complexity of growing and processing the poppy plant. Fentanyl and related synthetic opioids are 50 to 100 times more potent than heroin. They are often mixed with heroin to give it an extra “kick”, obviously a risky enhancement. When buying on the street, you never know what you are getting, and this game of Russian Roulette is becoming more deadly. Fentanyl has made America’s opioid epidemic, already the deadliest drug overdose crisis in American history, even deadlier. In fact, overdose deaths linked to non-methadone synthetic opioids like fentanyl tripled from over 9,000 in 2015 to more than 29,000 in 2017, surpassing the prior culprits, common opioid painkillers, and heroin. Fentanyl is so powerful, that it is more resistant to an antidote used to reverse opioid overdoses, naloxone. While for a heroin or opioid pill overdose, one dose of naloxone would typically reverse the drug effects, with fentanyl it usually takes multiple doses to save someone’s life, at a point where every minute counts. And it seems there is an insatiable appetite for more potent illicit opioid analogs. We are now seeing analogs like carfentanil in the illicit drug market. Carfentanil is typically used as a sedative for large animals like elephants and is considered too dangerous for any legitimate use in humans. Alarmingly, It has been characterized as a “chemical weapon” because several countries, including the US, have considered its potential use in war.

https://www.drugabuse.gov/related-topics/trends-statistics/overdose-death-rates

Almost like “whack-a-mole”, addressing the many tentacles and forces driving this crisis will not be solved with simple or limited solutions. There is no silver bullet and it will take many broad and coordinated efforts to curtail this epidemic. Like the most effective corporation, the drug dealers have a focused operation aligned around one thing, delivering a product which is very profitable and has insatiable demand with a new large pool of customers. Death of the customer only increases demand because that dealer is seen as having the “good stuff”. The creativity and agility of the suppliers will always overcome the limited resources of law enforcement. In order words, we will not be able to arrest our way out of this crisis.

Because the pathway to addiction for this particular epidemic is so well-defined and predictable, we have the opportunity to attack the pathway at key transition points where people move from one phase to the next. This fact lends itself to applying a public health approach that focuses on preventing people from progressing down the pathway to full-blown addiction and then to illicit drugs. There are three key leverage points: (1) when a person develops an acute or chronic pain condition (2) when the painful condition warrants treatment with opioids and (3) when addiction occurs. The saying really applies here that an ounce of prevention is worth a pound of cure. We still have to manage the large pool of persons with Opioid Use Disorder (OUD) created by prior over-prescribing of opioid pain pills, but we can stem the tide by preventing others from moving down that pathway. You can categorize interventions as primary, secondary and tertiary prevention focused. Primary prevention focuses on more appropriate management of pain. This can be frustrating for patient and provider because pain management can be a trial and error process, especially for chronic pain. However, it is worth the effort, and now that we know, we should never press the “easy button” and automatically prescribe opioids. There are many other options for pain management that are effective and non-addictive. Opioids should be the last resort. Secondary prevention focuses on those cases when opioids are appropriate. In this situation, it is important to adhere to the CDC safe prescribing and management guidelines for opioid therapy. In essence, the guidelines recommend “starting low and going slow” in escalating dosing. There is also no evidence that treating with opioids for more than 6 months is useful. Finally, with tertiary prevention, we are focused on addressing those who are addicted. The goal is to reduce the morbidity, family and community impact and risk of mortality from addiction. The ultimate goal is to support persons with OUD in achieving an effective and lasting recovery. This is resource intensive, difficult and often complicated by frustrating relapses. However, there is evidence that addiction changes the brain and creates, in essence, a chronic condition, like any other chronic condition like diabetes, which requires lifelong treatment and support.

This is the epidemic of our time, more deadly than any other in recent history, and unfortunately, we may not yet have reached the peak. However, through concerted and coordinated efforts focused on prevention and halting the progression down the pathway to addiction, we may be able to turn the tide. Much easier said than done due to the fact that the forces driving people down the pathway into the grip of addiction are so pervasive and committed. However, we have prevailed in the past with other epidemics with public health approaches, and hopefully, this opioid epidemic will not be an exception. On this International Overdose Awareness Day, my thoughts and prayers go out to all those who have lost loved ones to this devastating epidemic.