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The US Opioid Crisis, Charts Galore

How many hospital admissions, deaths and addicted babies does it require before the government empowers their federal health agencies to intervene?

The US accounts for 4.4% of our 7.1 billion global population, and consumes nearly 90 percent of the world’s opiate supply.

As we all know by now, this situation spread like pill popping wildfire, and is completely out of hand. Drug overdoses have dramatically increased over the last two decades, with deaths more than tripling between 1999 and 2016. In 2008 overdose was declared the number one cause of accidental death in the states. This is killing more Americans than gun violence and car crashes combined.

In 2016, more than 63,000 people died from drug overdose, approximately 42,249 or 67% involved prescription or illicit opioids.

Synthetic opioids account for the highest number of deaths and belong to the novel psychoactive substances (NPS) drug category. These are man made and similar in action to the naturally occurring opiates, morphine and heroin. They are derived from species of the opium poppy plant and have been used for medicinal and recreational purposes for centuries.

Fentanyl is the most popular synthetic opioid. Fatal overdoses doubled in 2017, to over 19,000. Unlike many other synthetic opioids, fentanyl is available for prescription use. Licensed in the 60’s, it was administered during surgery. Clinical use expanded in the 90’s, when a prolonged-release skin patch was developed for chronic pain.

Fentanyl is estimated, dose for dose, to be 75 times stronger than morphine and is now common in the illicit drugs market. The opioid is reportedly used as a highly dangerous lacing agent of heroin and cocaine.

Associated Complications of Opioid Addiction

There are a host of associated side effects, illnesses and complications, which go hand in hand with opiate abuse. This includes opioid use disorder, hepatitis, HIV and neonatal abstinence syndrome (NAS).

Nearly six out of every 1,000 infants born in the US are now diagnosed with NAS. This number has quadrupled in the last 15 years. The number of effected babies between 1999–2016, in Tennessee alone:-

Trump

The opioid epidemic was declared a public health emergency in October 2017. President Trump issued a Presidential Memorandum:-

“We are already distributing nearly $1 billion in grants for addiction prevention and treatment, and more than $50 million to support law enforcement programs that assist those facing prison and facing addiction,”

In March 2018 Trump announced a three-fold plan. This entails higher penalties for dealing and trafficking, reduction of opioid demand and prescriptions by one third in the next three years, and an increase in harm reduction rehab practices.

Incidentally, in keeping with the usual Trump parlour tricks, the crisis is proving to be a great sensationalist platform. One of the harder hitting controversial clamp downs of his administration, proposes the death penalty for traffickers. When almost half the opioid overdose deaths in 2016 were caused by prescription drugs, I question whose head should be for the chopping block exactly.

The new budget calls for $3 billion in 2018 and $10 billion in 2019 for the Department of Health and Human Services to improve access to treatment, prevention and recovery support (see HHS strategy below). The funds will also contribute to opioid abuse prevention by addressing mental health concerns.

To summarise, the plan is to enhance law enforcement measures to stop illicit drug movement and sales, lower the amount of prescriptions and improve rehab. This will synergistically decrease addiction and lessen opiate demand over time. Makes sense. But.

What will be done to address government responsibility in recognising public health concerns, to prevent such an epidemic happening in the first place, or indeed, again?

When doctors are dishing out prescription opiates and pharma companies are sat rubbing their hands together, eager for their giant pay outs, when does the state step in to say it is not okay to keep killing our citizens for money.

Federal Agency Strategy

Towards the end of last year, the CDC launched the Rx Awareness campaign to encourage people to:-

Prescription Painkiller Impact

According to the FDA, federal agencies such as the Substance Abuse and Mental Health Services Administration (SAMHSA) and CDC, long ago identified trends thought to increase the risk of opioid overdose:-

These include, but are not limited to, the chronic use of higher dose opioids, a current or past opioid use disorder diagnosis or opioid overdose event, or illicit opioid use”.

The greater the frequency and dosage of opioids taken in the past, whether legal or illicit, has been an identified causative link to opioid overdose for several years.

Nevertheless, as per the above data, between 1999–2015 prescription opioids sold in the US quadrupled. Federal agencies were continually feeding back these data trends to the government, yet nothing was done. Mass production and distribution by pharma companies as well as over-prescribing by doctors continued to spike, inevitably leading to the rise in opioid overdose deaths. At least half were reported to be caused by prescription drugs.

Where is the gap in communication? Why is the government not actioning public health concerns in a clearly flawed, pain intervention pathway, before it gets uncrontrollable. This cannot be attributed to a lack of funding, when Trump professes to invest a magically materialised $13 billion in the next two years, to try and backtrack the devastation.

There seems to be no clear distinction between the consequences of scoring fentanyl in a back alley from a dealer, and asking a physician to write a prescription for a regulated opioid.

Hippocratic Oath notwithstanding, neither seems to have any regard for quality of life or likelihood of death.

Treatment Options

In March 2018, Trump talked of supporting a wonder vaccine to curb addiction. As is usual with media new fandanglement, this was rather premature. The current data still lies in pre-clinical rodent populations. Also, as forewarned by Dr. John Franklin, from the Department of Psychiatry and Behavioral Sciences, Northwestern, “This is not any kind of magic bullet. This is another tool to give opioid users a chance”. Maybe so, but isn’t it also yet another way for the pharma industry to capitalise on this abhorrent state of affairs?

The licensed prescription drug naloxone (narcan) is commonly used by emergency services to prevent death by opiate overdose. As a narcotic antagonist, naloxone displaces opiates from receptor sites in the brain, crucially reversing respiratory depression, which is the usual cause of death. This is available as an intramuscular injection or nasal spray.

Efficacy of opioid addiction reversal using naloxone is approximately 75–100%. Take home naloxone programs for administration during overdose, prior to reaching hospital, are also very effective in the reduction of opioid mortality.

Naloxone has existed as an approved injectable by the FDA for over 40 years. The table above shows the dramatic price increase the product has undergone, starting at just $20.34 in 2009, reaching as high as $4,500 in 2016. The drug is reportedly extortionate, at a time when drastic methods are vital in attempting to improve mortality rates. This is not a coincidence.

In an effort to lower opioid fatality rates, Kentucky launched a website mapping all pharmacies with an available naloxone supply. I found this equal amounts impressive and harrowing. This is what it has come to.

How Did This Happen?

As far back as 1999 opioids were a recognised public health concern and by 2007, the CDC noticed a steep, difficult to ignore, rise in overdose related deaths over a six year period. An entire nineteen years ago, it was a known fact that the statistics were starting to ramp up for the states shown in dark blue in the map on the left.

The CDC map on the right, shows the prescribing rates of pain killers in 2012. The highest amount of prescriptions are concentrated in many of the same states where the increased number of opioid deaths between 2007–2013 were reported. Regardless of the astronomical rise in opioid mortality, some states continued to maintain the highest prescribing rates. Where addictive substances are concerned, supply really should not continue to increase with demand, certainly not without questions being raised and precautionary measures coming into play. Vital red flags concerning public safety were there, yet they were blatantly ignored.

In 2015 the CDC estimated around half the opiate overdose deaths were caused by prescription pain killers. I’m reiterating, but again, this has been a long-standing known causative link. My question is, if the trends were noticeable such a long time ago, why was the situation left to destructively rampage to the extent of 17,087 deaths in 2016 alone?

At what point is something so widespread, considered a public health concern exactly? How many hospital admissions, deaths, addicts and addicted babies does it require before the government empowers health agencies to intervene?

This Did Not Happen Overnight

As with any sizeable epidemic, pharmaceutical companies have profited hugely from this crisis; firstly from the increase in demand for prescription opiates, and later for the antidote to prevent overdose death. Doctors have abused their position of trust in creating and facilitating opioid addiction across the US.

When the most obvious indicator, in the form of very quanitifable overdose admission rates, saw a steep increase, this could’ve been addressed before it got drastically out of hand. The cause of the problem was identified but left to fester until the consequences became too publically conspicuous to ignore any longer.

If it was a question of money, as to why something wasn’t done earlier, look at the long-term financial implications this has had. In 2015, the economic cost of the opioid crisis was estimated to be $504 billion. Ah, but hindsight is a wonderful thing, I hear you cry.

We could’ve learned from the effect the repercussions of smoking eventually had on global health burden, before letting an even worse public health crisis evolve into something this devastating.

As the timeline shows, a research study in 1950 publicised the link between smoking and lung cancer, causing an increase in legal proceedings against the tobacco industry. Evidence continued to mount for a further four decades, alongside shameless cigarette marketing campaigns. The public were left to carry on consuming just another taxable product, to the detriment of their health, without the government intervening. Mississippi was the first state to sue, but this wasn’t until the mid nineties.

In 1980 the New England Journal of Medicine first condoned the use of opioids for chronic pain, classifying them as “low risk” of addiction. West Virginia and Kentucky sued Purdue pharma for their aggressive marketing strategies of oxycontin in 2001 and 2007 respectively. By 2008 opioids became the number one cause of accidental death. By 2017 Washington, Mississippi, Ohio, Missouri, Oklahoma, New Hampshire, South Carolina and New Mexico, all filed law suits against big pharma. As per the state maps featuring mortality and prescription rates above, these were some of the most prolific opioid prescribing states in the US.

When we had already witnessed the tobacco-induced cancer boom, what was the rate limiting factor involved in the government’s complete disregard of public health this time? How did this persist right the way up to the eleventh hour, when it had become a case of too little too late?

Health agencies now concentrate their efforts on rehab measures, opioid awareness campaigns and individual responsibility. Therein the onus has shifted from the system to the citizen. You are an addict because we failed you, so go ahead and figure out how to fix yourself.

Of course, we are also seeing overt public health initiatives to monitor data more accurately, prescribe responsibly and enhance mental health interventions. These are preventative actions, as a means to decrease the chances of further opioid addiction and related deaths. Governments have a history of looking as though they are doing something, when public outcry reaches an all time fever pitch. This strategy is about twenty years too late.

Backtracking to undo the damage is far more difficult when dealing with addicts. There are reports of doctors being so afraid to prescribe opioids for chronic pain, that it’s leading to patients genuinely suffering and reaching out to unsafe, illegal means of self-medicating. Enter, even greater fentanil demand. Supply increases, and so continues the enduring street presence of a lethal drug, bringing along with it an ever climbing death toll.

Obviously, individual under-prescribing and deliberate misdiagnosis through fear, is not going to retrospectively undo an epidemic caused by a vast collective. This atrocity needs to provoke a new approach to responsible and appropriate prescribing methods, which are closely monitored and regularly assessed as a compulsory measure.

The relationship between the government, private sector and the healthcare system is broken. While preaching about how federal agencies can amplify public health initiatives to firefight the chaos, they ought to be rethinking the dynamic of their collective responsibility in safe-guarding the public. If the government wishes to reverse this situation and prevent it from happening again in the future, no single contributor from any sector, should be left unaccountable.

There has been a considerable increase in law suits by members of the public against the pharma industry, predominantly due to the death of their family members. This is but a quick dying flicker in the public arena, where the reputation of a multinational corporation will remain untarnished. Financially, this is also a mere drop in the ocean to big pharma.

The legislative burden should not lie in the hands of the public to create judicial precedent, robust enough to stand against both medical and corporate negligence. This is now a widespread epidemic. This is going to take drastic government measures to tackle a historically enduring problem, involving the age old, public and private sector corruption debate.

We are talking of a war-like death toll, which is now effecting average life-expectancy in the US. If the protection of the citizen by the state was of the utmost importance, as it should’ve been when opioids became a noticeable problem, the deaths of tens of thousands could’ve been prevented.

This is not just a question of what can be done to repair the damage. This needs to serve as a haunting plea to America, to reinvent doctor, hospital, pharma industry, federal agency and government long-standing relationships, to unanimously harmonise healthcare and wellbeing culture.

This has to be centred around the health and safety of the individual. If the man wants it to remain about money, they need to recognise that in short-sightedly sacrificing the fundamental care ethos, the longer-term financial impact eventually loops back to the state just the same.

Prevention works out a lot cheaper than mopping up the mess.

NAS baby, morphine administration in Neonatal Intensive Care. Source CBS Evening News.
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