In the previous report, we discussed the drastic decrease in mortality seen in South Florida after the establishment of the first needle exchange program in the state.

The very next day, the CDC released preliminary estimates  showing a significant rise in all-cause drug mortality nationwide — and particularly mortality secondary to opioid overdose — for many of the same reasons opioid mortality rose over the past decade in Florida:

• the number of people using opioids has risen
• the drugs themselves are becoming more deadly- that is to say, the active components have changed to powerful synthetic opioids.

Over 72,000 people died as a result of an drug overdose in 2017, up 24,000 from just two years prior.

Opioid Epidemic and Race

A common refrain is that drug addiction does not discriminate. Indeed, as many have pointed out, the opioid epidemic only began to be described as such when White Americans, particularly from suburban and rural areas, began to experience sharp increases in overdose mortality. As German Lopez notes in “When a drug epidemic’s victims are White,”

Because the crisis has disproportionately affected White Americans, white lawmakers — who make up a disproportionate amount of all levels of government — are more likely to come into contact with people afflicted by the opioid epidemic than the disproportionately Black drug users who suffered during the crack cocaine epidemic of the 1980s and ’90s… Is it any wonder, then, that the crack epidemic led to an incredibly punitive “tough on crime” crackdown focused on harsher prison sentences and police tactics, while the current opioid crisis has led more to more compassionate rhetoric and calls for legislation, including a measure Congress passed last year, to focus on treatment instead of incarceration?

The past two decades of CDC mortality statistics identified that White Americans were in fact one of the hardest hit groups. However, while White Americans as a national population are notably the largest consumer base for illicit opioids, in the past year it is, in fact, Black Americans who have seen the highest change in rates of new opioid overdose mortality. Review of the mortality rates demonstrated that Black Americans in urban counties rose by 41% in 2016, markedly outpacing any other racial or ethnic group.

It is hard to say whether the stark rate change in overdose mortality is due to increasing lethality of opioids entering illicit drug markets in which Black Americans are consumers or if there is some intervention that is limiting the danger of an ever more lethal supply for White Americans.  Overdose deaths amongst Black Americans may be related to recently noted phenomena of fentanyl being found in other illicit drugs, and opioid overdose may be underreported as a cause of death amongst Black Americans experiencing polypharmacy because synthetic opioids such as fentanyl and its analogs have not been consistently tested in all municipalities. As Josh Katz and Abby Goodnough emphasize in the New York Times:

Fentanyl-laced cocaine, too, may be playing a role. A study published this month in the journal Annals of Internal Medicine found that cocaine-related overdose deaths were nearly as common among black men between 2012 and 2015 as deaths due to prescription opioids in white men over the same period. Cocaine-related deaths were slightly more common in black women during that period than deaths due to heroin among white women, according to the study. But it also found that the largest recent increases in overdose deaths among blacks were attributed to heroin. One of the researchers, David Thomas of the National Institute on Drug Abuse, said he did not know whether some of the cocaine-attributed deaths in the study involved fentanyl, although he had heard anecdotally of such mixing.

In addition, while the declaration of the Opioid Epidemic came on the heels of various public figures such as Chris Christie naming personal losses due to drug addiction and its sequelae, indigenous communities in the United States have seen epidemic rates of overdose beyond even that of White Americans with an infinitesimal fraction of the media coverage. In fact, as noted by Rear Adm. Michael Toedt, M.D., the Chief Medical Officer of the Indian Health Service, “[American Indians/Alaskan Natives] had the highest drug overdose death rates in 2015 and the largest percentage increase in the number of deaths over time from 1999-2015 compared to other racial and ethnic groups.” The overdose mortality in Indian County is even more striking, particularly given the minimal representation this epidemic has had in public discourse. 

On NPR’s “All Things Considered,” Dr. Ron Shaw,  president of the Association of American Indian Physicians notes that tailoring a public health response to an epidemic requires a culturally competent approach. “Now, the psychosocial treatment of the disease, which has to do with social living skills and having to address historical generational intergenerational trauma, that will be specific for native populations. We’ve always known that culture is prevention when it comes to drug use or drug abuse at an early age, but culture also is treatment. And so implementing treatment specific and culturally relevant treatment items in the treatment curriculum are very important.”

In July 2016, IHS became the first federal medical agency to require providers to check state Prescription Drug Monitoring Program databases prior to prescribing and dispensing opioids for treatment longer than seven days. The agency also requires all prescribers to complete training courses on addiction, which IHS developed in collaboration with the University of New Mexico. To increase access to medication-assisted therapy, IHS physicians have access to online opioid treatment training modules that certify them with buprenorphine prescribing privileges.

Opioid Treatment Options: Buprenorphine

Buprenorphine is a partial agonist at the µ-opioid receptor, the famed site responsible for all of the positive and many of the negative effects of an opioid drug. It is often combined with the opioid antagonist naloxone, in a formulation sold as Suboxone. Buprenorphine is safer and easier to use as outpatient mediation assisted therapy for opioid use disorder versus the longlived standard of methadone, a full agonist for the µ-opioid receptor.  However, there are many barriers to providers prescribing buperenorphine; including a certification process and federal cap of 30 patients per year per provider (that may be waived), resulting in 96% of states (including the District of Columbia) reporting higher rates of opioid abuse or dependence than buprenorphine treatment capacity. Indeed, buprenorphine access too has a racial and economic overtone. As Jose Del Real writes in “Opioid Addiction Knows No Color, but Its Treatment Does”,

For recovering users without money or private health insurance, [methadone] clinics are often the only option [for addicted persons] to get their lives on track, even as less cumbersome alternatives have become available for those who can pay for it.

In New York City, opioid addiction treatment is sharply segregated by income, according to addiction experts and an analysis of demographic data provided by the city health department. More affluent patients can avoid the methadone clinic entirely, receiving a new treatment directly from a doctor’s office. Many poorer Hispanic and black individuals struggling with drug addiction must rely on these highly regulated clinics, which they must visit daily to receive their plastic cup of methadone.

Many hoped that buprenorphine could mean an end to the daily hurdles to receiving treatment for tens of thousands of patients: no additional commute, no security check, no waiting, no line for the plastic cup.

But today in the city, that is primarily true only for middle-class or upper-middle-class patients seeking help with their addiction.

Public health acolytes will recognize buprenorphine and the more cumbersome methadone approaches as examples of secondary prevention: efforts “to reduce the impact of a disease or injury that has already occurred by detecting and treating disease or injury as soon as possible to halt or slow its progress, encouraging personal strategies to prevent reinjury or recurrence, and implementing programs to return people to their original health and function to prevent long-term problems.” Needle Exchange Programs and other Harm Reduction strategies operate within this same matrix of working to decrease the harm associated with an already-present risky behavior.  This week, Abby Goodnough wrote in the NY Times about another potent example of secondary prevention: This E.R. Treats Opioid Addiction on Demand. That’s Very Rare.

Every year, thousands of people addicted to opioids show up at hospital emergency rooms in withdrawal so agonizing it leaves them moaning and writhing on the floor. Usually, they’re given medicines that help with vomiting or diarrhea and sent on their way, maybe with a few numbers to call about treatment. When Rhonda Hauswirth arrived at the Highland Hospital E.R. here, retching and shaking violently after a day and a half without heroin… she was offered a dose of buprenorphine on the spot. A 2015 study out of Yale-New Haven Hospital found that addicted patients who were given buprenorphine in the emergency room were twice as likely to be in treatment a month later as those who were simply handed an informational pamphlet with phone numbers.

Physicians at Cooper University Hospital in Camden, NJ deployed this model in 2016, opening an outpatient addiction treatment center on the Cooper Hospital campus, a short walk from the ER. Based on the same research out of Yale-New Haven Hospital,  the Cooper University Hospital approach aims to minimize barriers to care. As Fran Krtiz writes for the Opioid Institute, “If patients need a state-issued identification—legally required to receive certain medications—hospital staff help them get it. If patients can’t afford to pay, staff help them seek insurance reimbursement and treat them regardless. Where the law permits, it’s medically appropriate, and the patient agrees, doctors begin providing medication-assisted treatment, or MAT, right in the emergency room.”

Goodnough continues the discussion of low barrier, culturally competent approaches to opioid addiction secondary prevention in “In San Francisco, Opioid Addiction Treatment Offered on the Streets:”

The addiction treatment program at Highland Hospital’s emergency room is only one way that cities and health care providers are connecting with people in unusual settings. Another is in San Francisco, where city health workers are taking to the streets to find homeless people with opioid use disorder and offering them buprenorphine prescriptions on the spot. The city is spending $6 million on the program in the next two years, partly in response to a striking increase in the number of people injecting drugs on sidewalks and in other public areas. Most of the money will go toward hiring 10 new clinicians for the city’s Street Medicine Team, which already provides medical care for the homeless. Members of the team will travel around the city offering buprenorphine prescriptions to addicted homeless people, which they can fill the same day at a city-run pharmacy.

As Goodnough notes, at the end of a recent yearlong pilot, more than 20% of patients were still taking buprenorphine under the care of the street medicine team.

In 2016, Montgomery County, Ohio integrated a similar approach of low barrier naloxone access.  Along with the Greater Miami Valley EMS Council for Fire / EMS, the Dayton & Montgomery County Public Health Department established a protocol to furnish Narcan to the public. A number of municipalities, including the entire state of Pennsylvania, have adopted “Naloxone leave-behind” programs, where persons on the scene of an overdose are provided with naloxone by EMS to use in the case of another overdose event.

While the Highland Hospital ED buprenorphine program and the Montgomery County Naloxone leave-behind programs are impressive examples of public health theory entering emergency department protocol management, as a secondary prevention method, they still do not eliminate the initial events that raise the risk for addiction.

Both inside and out of the emergency department, new addictions occur every day; some of them due to overprescribing in the ED setting. For an example of ED based primary prevention to address epidemic opioid use, Scott Weingart of EMCrit highlighted an approach in 2014 to building an Opioid Free-ED, focusing on a series of protocols researched and trialed by one Dr. Sergey Motov of Maimonides Hospital in NYC. Years before the opioid crisis was named as such, Dr. Motov advocated for the use of low dose ketamine, nerve blocks and other “Channel/Enzyme/Receptor Targeted Analgesia.”

Increased criminalization of opioids has borne out worse outcomes for communities facing high rates of addiction. Not every state is responding to the opioid epidemic with just public health policies. As seen in Florida in 2011, criminal justice crackdowns lead to more overdoses, not fewer. Similar laws throughout the country have resulted in worse outcomes for the most vulnerable facing addiction. Meanwhile, a 2016 Surgeon General report identified that only 10% of Americans with a drug use disorder obtain specialty treatment.  As seen with the Miami Dade, San Francisco and Camden examples, the appropriate adaptation of public health theory can limit the negative sequelae of addiction. As the adage goes, an ounce of prevention is worth a pound of cure.

Report by Kasha Bornstein, MSPharm