U.S. Suiting Up to Battle National Heroin Epidemic

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I just returned from a nice relaxing vacation but still thought that it was necessary to cover this very important topic. I have been truly dismayed by the local horrors that the heroin epidemic have wrought upon all of us and even in my small town. It is everywhere and there doesn’t seem to be any answers.

Nina Flanagan wrote in the healthcaredive .com blog that the heroin use in the U.S. is exploding across all demographics with more than 400,000 people treated in emergency rooms last year for a heroin overdose, almost double the number from 2009, according to the Centers for Disease Control and Prevention. Perhaps even more startling is the fact heroin overdose death rates quadrupled between 2002 and 2013, up to 8,200 deaths, and in 2013, more than 500,000 people reported past-year heroin abuse or dependence, up 150% since 2007.

The most recent study on the economic costs of heroin addiction in the U.S. dates back to 1996 by the MEDSTAT Group in the District of Columbia. The authors estimated heroin addiction cost the U.S. economy $21.9 billion overall, $5.2 billion in criminal activity, $11.5 billion in productivity losses and $5 billion in medical care.

However, there haven’t been any recent studies on U.S. heroin addiction costs, but if one calculates the rate of inflation since 1996 at a 2.26% increase annually, that would put today’s heroin addiction costs at more than $33.6 billion.

A link with opioid analgesics

Dr. Nora Volkow, director of the National Institute of Drug Abuse, (NIDA) told the Senate Caucus on International Narcotics Control last year there is “growing evidence to suggest a relationship between increased nonmedical use of opioid analgesics and heroin abuse in the U.S.” This is backed by data from IMS Health’s National Prescription Audit that showed the number of prescriptions for opioids (hydrocodone and oxycodone) have skyrocketed from 76 million in 1991 to 207 million in 2013 with the U.S. being the biggest consumer, accounting for almost 100% of the world total for hydrocodone (Vicodin) and 81% of oxycodone (Percocet).

Emergency department visits for nonmedical use of opioid analgesics topped 300,000 in 2008 and treatment admissions jumped to 5% of all admissions in 2007. Overdose deaths due to prescription opioids have tripled over the past 20 years, reaching more than 16,000 deaths in 2010. According to CDC data, every day 44 people in the U.S. die due to a prescription opioid overdose.

The nonmedical use of opioid pain relievers costs insurance companies up to $72.5 billion annually in healthcare costs.

New federal programs

The heroin crisis has spurred recent action by HHS, which announced a new $133 million initiative in March, funded by President Obama’s FY 2016 budget. The focus will be on three main areas:

  • Training and educational resources, including updated prescriber guidelines;
  • Increased use of naloxone to help reduce deaths from overdose; and
  • Expanding the use of the Medication-Assisted Treatment (MAT), which combines medication with counseling and behavioral therapies.

Sylvia Burwell, HHS Secretary, said in the press release, “We need all stakeholders to come together to fight the opioid epidemic.”

CDC also announced the launch of the Prescription Drug Overdose Prevention for States program last March, which will provide states with resources to advance innovative prevention efforts. Funding will support approximately 16 states with programs to improve safe prescribing practices to “turn the tide on the prescription drug overdose epidemic.” Secretary Burwell included a major expansion of this program in the HHS 2016 budget to include all 50 states.

Working with law enforcement

A new $2.5 million program, the Heroin Response Strategy, pairs healthcare workers with local law enforcement agents in 15 states to focus on heroin treatment instead of punishment, according to a Voice of American news article. The geographical areas of focus are states along the Northeast corridor, which have seen a steep increase in heroin overdoses and deaths. A big concern is the large number of cases where heroin is laced with fentanyl, a prescription opiate used to treat post-surgical pain. Officials hope the new effort will reduce the number of heroin users needing immediate treatment in emergency rooms.

States take their own steps

Some states have been taking action into their own hands to attempt to mitigate the issue.

Maryland reported 464 heroin-related overdose deaths in 2013, 77 more than homicide deaths. In response, the state has formed a new inter-agency and task force to address this crisis. Heroin-related emergency room visits have tripled since 2010, with 1,200 statewide. Gov. Larry Hogan’s efforts will combine experts in drug abuse, law enforcement, public health officials, education experts and first responders, according to Capital News Service. Another part of the initiative will be to distribute an FDA-approved drug, Evzio, that can be administered by anyone through a training program, to prevent fatal heroin overdoses. Gov. Hogan also plans to allocate half a million dollars from federal funds to expand re-entry programs for those leaving prison to reduce recidivism.

New York State introduced a series of bills to address heroin and opioid addiction and treatment last year. The goal was to amend the state’s insurance law to force providers to approve authorization and payment of substance abuse care. It requires every policy that provides medical coverage to include specific coverage for drug and alcohol abuse treatment services deemed necessary by a doctor. Thus, the only prerequisite is a doctor’s referral, preventing insurance companies from denying treatment based on a set of guidelines. Patients now have access to an expedited appeals process and have no interruption in treatment while the appeal process in underway. The bills also provide a new model of care that diverts patients who do not need hospitalization to outpatient treatment.

Indiana has been struggling with growing addiction rates and not enough services. The state Attorney General Greg Zoeller, who also heads the Prescription Drug Abuse Task Force, told the Kokomo Tribune, “One of the largest problems we have in Indiana is that we have much higher rates of addiction than we have services to treat those who are addicted. We are trying to do anything to get people certified for addition services.

According to a report by Fox News, the ACA should improve treatment for heroin addicts because up to 5 million people with drug and alcohol problems are eligible for insurance coverage under the overhaul. But, Dr. Tom McLellan, CEO of the nonprofit Treatment Research Institute in Philadelphia, said it will likely take years before insurance companies fully comply with the law. Dr. McLellan’s recent blog in The Philadelphia Inquirer was optimistic with the “all-of-society response” referred to by the CDC’s director, Dr. Tom Frieden.

McLellan said this new approach “to improve opioid prescribing practices to prevent addiction, expand access to effective treatment for those who are addicted, increase use of naloxone to reverse overdoses and work with law enforcement partners like the DEA to reduce the supply of heroin…says a lot to me – particularly that our country has begun to take a full-fledged public health and public safety approach to the epidemic of opioid use problems.”

A decades-long decline in the death rate of middle-aged white Americans has reversed in recent years, according to a surprising new analysis released Monday.

The cause of the reversal remains unclear. Researchers speculate it might be the result of the bad economy fueling a rise in suicides, plus overdoses from prescription painkillers and illegal drugs like heroin, and alcohol abuse.

“That could be just a volatile mix that could set off something like this,” says Angus Deaton, a professor of economics at Princeton University who conducted the research with his wife, Anne Case, another Princeton economist.

Deaton was awarded the 2015 Nobel Prize in Economics for his work on poverty.

Overall, the U.S. mortality rate has been falling by about 2 percent a year since the 1970s.

But the upsurge in suicides and drug overdoses among middle-age whites, among other trends, prompted Deaton and Case to look more closely at this group. They analyzed data from CDC and other sources, including other countries.

Analytics

Higher Death Rates Among Middle-Aged Whites, But Not Blacks Or Hispanics

Among 45-to-54-year-old whites, mortality rates increased by 8.9 percent between 1999 and 2013. Most of the increase came from suicides, drug overdoses and alcoholism. Meanwhile, mortality rates among blacks and Hispanics in the same age group have decreased, largely due to decreases in deaths from illness and other natural causes.

Heroin
Source: Proceedings of the National Academy of Sciences (November 2015)

Credit: Alyson Hurt/NPR

“Pretty quickly we started falling off our chairs because of what we found,” says Deaton, whose findings were published by the Proceedings of the National Academy of Sciences.

The mortality rate among whites ages 45 to 54 had increased by a half-percent a year from 381.5 per 100,000 in 1999 to 415.4 in 2013, the most recent year for which data are available, the researchers found.

Even so, the mortality rate for middle-aged African-Americans was higher: 581.9 per 100,000 in 2013. Hispanics fared better with a mortality rate of 269.6 per 100,000 in the same year.

“There was this extraordinary turnaround” among whites, Deaton says, likening the reversal to a large ship suddenly changing directions.

Based on the findings, Deaton and Case calculated that 488,500 Americans had died during that period who would have been alive if the trend hadn’t reversed.

“We’ve been talking about this at various academic meetings and you look around the room and peoples’ mouths are just hanging open,” Deaton says.

“This is a deeply concerning trend,” says Dr. Thomas Frieden, who heads the Centers for Disease Control and Prevention but wasn’t involved in this research. “We shouldn’t see death rates going up in any group in society.”

The Princeton researchers analyzed data from other Western countries and didn’t see the same trend.

“It’s particularly important that they don’t see it in other countries,” says John Haaga, the acting director of behavioral and social research at the National Institute on Aging, which funded the research. “So something’s clearly going wrong with this age group in America.”

The trend appears to be being driven by increased mortality among those with the least amount of education.

“Those are the people who have really been hammered by the long-term economic malaise,” Deaton says. “Their wages in real terms have been going down. So they get into middle age having their expectations just not met at all.”

It remains unclear why the mortality rate only increased among whites and not African-Americans or Hispanics.

Deaton and others have a theory about the difference for whites.

“One possible explanation is that for whites their parents had done better economically and they had been doing pretty well. Then all of a sudden the financial floor dropped out from underneath them,” says Jon Skinner, a professor of economic and medicine at Dartmouth College who co-authored a commentary accompanying the article. “For African-American and Hispanic households things had never been that optimistic and so perhaps the shock wasn’t quite as great.”

So, what is the solution to this epidemic?

Treating the addictions is reasonable, but there has to be a way to control the ease with which our friends, relatives, loved ones can so easily get these cheap highly addictable drugs. Education, treatment strategies, naloxone, MAT, behavioral modification, etc. are all important but what else needs to be accomplished?

You can’t minimize the severity of sale and distribution of these drugs. Legal action is necessary to prosecute the dealers and distribution, consortiums, cartels, etc.

But physicians also need to take responsibilities inherent in prescribing the narcotics in such high dosages and for all pain. Pain treatment has become a economic win fall. Clinics and major resources have been developed to create a business model with greed as the goal.

Why use oxycodone if Tylenol or Motrin or acupuncture or behavioral modification would be better solutions for the patient?

Our attitudes and approaches have to change or we are going to lose many more patients to this epidemic. We also have to recognize that this epidemic can hijack any of us and our friends and relatives. Get the help that is needed Americans!!!!

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