July | August 2017




by Debra Miller
Vermont Gov. Peter Shumlin attracted national attention more than two years ago when he spent his entire state-of-the-state speech describing what he called “a full-blown heroin crisis” in his state.
“In every corner of our state, heroin and opiate drug addiction threatens us,” he said. The number of overdose deaths from heroin in Vermont had doubled from the year before. Another indication of trouble in the state, Shumlin said, was the rise in the number of Vermonters in treatment for opiate addictions—up 770 percent since 2000, numbering 4,300 people in 2012.
Fast forward to late March 2016, when President Barack Obama appeared in Atlanta before a national summit of almost 2,000 professionals, advocates and people in recovery to discuss prescription opioid abuse and heroin use. He said 28,000 people in the United States died from opioid drug overdoses in 2014.
“It's important to recognize that today we are seeing more people killed because of opioid overdose than traffic accidents,” Obama said. “This is affecting everybody—young, old, men, women, children, rural, urban, suburban.”
Obama praised the non-partisan and cross-sector action already underway.
“We've got an all-hands-on-deck approach, increasingly, that says we've got to stop those who are trafficking and preying on people, but we also have to make sure that our medical community, that our scientific community, that individuals—all of us are working together in order to address this problem,” Obama said.

Trends Hit the States

“The increasing number of deaths from opioid overdose is alarming,” Dr. Tom Frieden, director of the Centers for Disease Control and Prevention, said in a January 2016 press release about the newest national data.
Driving the upward trajectory of overdose deaths are two interrelated trends, according to the CDC: the 15-year-long increase in deaths related to prescription pain relievers and a recent surge in illicit drugs, largely heroin and, more recently, fentanyl. Fentanyl is the powerful prescription pain reliever recently in the news as the cause of the accidental overdose death of the musician Prince. Counterfeit fentanyl is sold on the black market, often mixed into heroin to increase the high.
From 2000 to 2014, nearly half a million people died from drug overdoses, the CDC reported. Deaths from all drug overdoses numbered over 47,000 in 2014. In 2014, opioids, mainly prescription pain relievers and heroin, accounted for 61 percent of all drug overdose deaths—the 28,000 lost lives the president referred to in Atlanta earlier this year. The national rate of opioid overdoses has tripled since 2000. The other major classes of drugs associated with overdose deaths include stimulants, often used to treat attention deficit hyperactivity disorder, and central nervous system depressants for relieving anxiety, such as Valium.
States’ opioid drug overdose rates vary greatly. In 2014, West Virginia’s rate of opiod overdose deaths—31.6 deaths per 100,000—was nearly ten times that of Nebraska, the state with the lowest rate at 3.2 deaths per 100,000, according to CDC data. Besides West Virginia, the states with the highest drug overdose death rates include New Hampshire (23.4 per 100,000), New Mexico (20.2 per 100,000), Rhode Island (19.8 per 100,000) and Ohio (19.1 per 100,000).
The trend of more overdose deaths seems nearly inescapable for states. When CDC compared 2013 rates to 2014 rates, it found 34 states posted increases (12 of them statistically significant) in the one-year comparison. No state had a statistically significant decline in drug overdose death rates.

A Complex, but Preventable Disease

“Drug addiction is a preventable disease,” according to Nancy Hale, CEO of Operation Unite, a nonprofit organization started in 2003 in Kentucky to rid communities of illegal drug use through law enforcement, treatment and education. Operation Unite sponsored the fifth annual National RxDrug Abuse and Heroin Summit in Atlanta in March featuring Obama.
Hale said the summit emphasized the stigma of words like addiction and drug addict. “We are talking about a complex disease and quitting takes more than good intentions or a strong will.”
According to Hale, the National Institutes of Health have found the brain changes over time because of drugs. The change hampers the ability to resist the impulse to take the drug, despite the consequences of using drugs on the person themselves or their family.
Besides treatment for the chronic disease of drug use, Hale said, a holistic approach, including community education and outreach, is necessary.
“No one policy or program will solve the problem. Everyone is a stakeholder,” she said.
Dr. Matt Rohrbach, a medical doctor who is a member of the West Virginia House of Delegates, said his state cannot move ahead economically unless it turns around its drug abuse numbers. He agreed that the fight against drug abuse must be waged on many fronts.
“Addiction is a medical problem just like diabetes and heart disease,” he said. “Some answers are medical, some are social.”

Harm Reduction

There are a number of harm reduction policies that can reduce the negative consequences of drug use and save lives, Rohrbach said.
In 2015, West Virginia passed a law to provide the overdose antidote naloxone to first responders as well as individuals at risk of overdose and their relatives, friends or caregivers. A followup law passed this year, Rohrbach said, makes naloxone available in West Virginia “behind the counter.” Anyone can ask the pharmacist for naloxone and, after a brief training on administration, take it home. According to the Network for Public Health Law, all but five states—Arizona, Kansas, Missouri, Montana and Wyoming—have laws to improve naloxone access, but West Virginia is only 1 of 12 states that allow possession of naloxone without a prescription.
New Mexico was the first state, in 2007, to adopt a Good Samaritan law that addressed the criminal concerns of a person summoning aid in an overdose situation. Now 34 states and the District of Columbia have laws that prohibit law enforcement action against those seeking help for an overdose.
Needle, or syringe, exchange programs are another harm reduction strategy. The purpose of these programs is to prevent the spread of blood-borne diseases such as hepatitis B, hepatitis C and HIV through needle sharing.
After West Virginia began the state’s first needle-exchange program in Huntington in 2015, Rohrbach said the results were better than expected.
“If you have enough gumption to go to the exchange, you know you have a problem, and you want help,” he said. The exchange, located at the local health department, provided primary care and access to peer counselors, themselves in recovery.
“We found an amazingly high percentage—40 to 50 percent—who started to ask the peer counselors how to get clean,” Rohrbach said “They became willing participants in treatment programs.”

Two states—Florida and Utah—passed laws in 2016 explicitly allowing needle exchanges, bringing the total to 20 states. Another 13 states have changed drug paraphernalia laws to prevent law enforcement action against persons exchanging needles. Five more exchanges have been developed in West Virginia.

Judicial and Policing Policies

Drug courts are in operation in almost every state, but they differ in their design, services and the populations on which they focus. The common denominator is that judges refer defendants to treatment services in lieu of incarceration. The judge, court staff and the defendant’s family and friends provide important support during the treatment process.
“One important benefit of drug court is that the defendant has a second chance for gainful employment without a felony record,” said Rohrbach.
Prescription drug monitoring programs, or PDMPs, began in earnest in the 1990s and now every state but Missouri has one. PDMPs are databases that track prescriptions for controlled substances through entries made by pharmacies and physicians.
Hale, of Operation Unite, recommends mandating physicians to use PDPMs before writing a new prescription. Massachusetts made this change as part of a 2016 comprehensive law on drug abuse.
“Today, the commonwealth [of Massachusetts] stands in solidarity to fight the opioid and heroin epidemic that continues to plague our state and burden countless families and individuals,” Gov. Charlie Baker said when signing the 2016 law. Massachusetts became the first state in the nation to limit first-time opioid prescriptions to seven days. With certain exceptions, prescriptions for minors are limited to seven days. The law also strengthened education for physicians and medical students about prescribing pain relief. The law allocated $250 million for substance use disorder education, treatment and prevention.
But both Hale and Rohrbach said improvements could be made in how PDMPs work across state lines.
Help in eliminating the supply of opiates is coming directly from pharmaceutical manufacturers. Abuse deterrent formulations of major opiates prevent crushing and dissolving pills. The new formulations are more expensive and laws have passed, for instance, in Maryland and Massachusetts to require insurers to cover abuse-deterrent formulations. Hale said in the long run savings would accrue to commercial insurers who will not bear the cost of treating opiate addiction.

Treatment

A growing body of evidence supports medication-assisted treatment for substance use disorders. There are three elements to MAT—medication that reduces drug-seeking behaviors, counseling, and support from family and friends—according to the federal Substance Abuse and Mental Health Services Administration, or SAMHSA. MAT differs from most methadone clinics that often include little or no counseling and from detoxification programs that are short term and don’t use medications to reduce drug cravings.
According to SAMHSA, MAT is greatly underused. SAMHSA data show only 28 percent of heroin admission plans listed MAT therapy in 2010, down from 35 percent in 2000. The reluctance to use MAT treatment may be related to the misconception of substituting one drug for another.
States such as Massachusetts and West Virginia have increased funding for treatment, including MAT, and Obama has requested federal funds. And states that have expanded Medicaid eligibility under the Affordable Care Act have access to new resources to put toward treatment.

Education and Prevention

“The easiest drug addict to treat is the one you prevented,” Rohrbach said, emphasizing the importance of education and prevention activities. He also urged states to develop education programs for health professionals on treatment of chronic pain and opiate prescribing.
“I will be honest, a lot gets back to the fifth vital sign, and how doctors control pain,” he said.
Hale said the National Institute of Drug Addiction has shown that prevention programs are effective and that for each dollar spent on research-based programs, up to $10 can be saved in treatment for alcohol and other substance abuse.
“We can’t arrest our way out of the [drug] problem,” she said. “We can’t treat our way out of the problem. Education holds the key.”