Overdose Deaths from Opioids, Heroin on the Rise

News Update 7-18-14“Overdose deaths from both prescription opioids and heroin increased in 2011, the most recent year available, according to new data from the U.S. Centers for Disease Control and Prevention.

While prescription opioid deaths followed a more than decade long trend and increased by about 2% from 2010 to 2011, to 16,917; heroin deaths jumped by about 44% in the same span of time to 4,397.

Officials with the CDC said the increase in heroin deaths may be partly due to users having less access to prescription opioids and switching to the illicit drug.

Leonard Paulozzi, a physician and researcher with the CDC, said about 75% of heroin users say they started out by using prescription opioids.

Paulozzi said doctors need to do a better of job of screening for opioid abusers by checking prescription drug monitoring programs in their states for patients who are doctor shopping and using urine screens to detect if they are using illicit drugs.”

http://www.jsonline.com/watchdog/watchdogreports/overdose-deaths-from-opioids-heroin-on-the-rise-b99302962z1-265452991.html

Source: Milwaukee Journal Sentinel – July 2, 2014

Treat Patients with Addiction During, After Hospitalization, Researchers Say

hospital sign purchasedshutterstock_33280960The results of a new study demonstrate that starting hospitalized patients who have an opioid (heroin) addiction on buprenorphine treatment in the hospital and seamlessly connecting them with an outpatient office based treatment program can greatly reduce whether they relapse after they are discharged.

Led by researchers at Boston Medical Center (BMC), the study shows the important role that providers play in offering these patients addiction treatment both while in the hospital and after – even if their primary reason for being in the hospital is not for their addiction.

In this study, 139 hospitalized individuals with opioid addiction who were not already in treatment were randomized into two groups. One group received a tapered dose treatment of buprenorphine for withdrawal and referral information about community treatment programs and the other were initiated on buprenorphine, an opioid substitute proven to treat opioid addiction, along with referral to a primary care office-based buprenorphine treatment program.

Of those in the buprenorphine maintenance group, more than one third (37 percent) reported no illicit opioid/drug use for the month after they left the hospital compared to less than one in ten (nine percent) among the control group. These patients also reported, on average, fewer days of illicit drug use and continued to use less over the following six months. This effect was evident despite the fact that these patients did not initially come to the hospital seeking treatment for their addiction.

“Unfortunately, referral to substance abuse treatment after discharge is often a secondary concern of physicians caring for hospitalized patients,” said Jane Liebschutz, MD, MPH, a physician in general internal medicine at BMC and associate professor of medicine at Boston University School of Medicine, who served as the study’s corresponding author. “However, our results show that we can have a marked impact on patient’s addiction by addressing it during their hospitalization.”

This study is published in JAMA Internal Medicine.

http://medicalxpress.com/news/2014-06-patients-addiction-hospitalization.html

Source: Boston Medical University –  June 30, 2014

How Heroin Baggies are Marketed Like iPhones

“Nine years ago, when Graham MacIndoe was living in New York City and addicted to heroin, he started collecting the small glassine bags that held the drugs he bought. MacIndoe was a commercial photographer, and even in the grip of a years-long addiction that would ultimately leave him broke, imprisoned on Riker’s Island, and facing deportation, he became interested in the baggies on a visual level.

“There was just something about the design, the typography, the branding,” MacIndoe tells Quartz. “And just being around the drug trade myself, the promises that were in the bags—of good times and money, and this elusive lifestyle that you thought drugs would bring you.

MacIndoe found that marketing in the underground economy mirrored the corporate one in other ways. Special offers often accompanied a new drug’s introduction. Popular brands quickly attracted imitators, who adopted the visual look of the packaging but filled it with a lower-quality product. A kind of built-in obsolescence was common too, with suppliers “cutting” (i.e., adulterating) initially potent brands to maximize profits—a pressure to upgrade that MacIndoe compares to Apple’s strategy with the iPhone. “They’re giving you a product that seems really great at the time,” he says, “and then after a little while you realize you’ve got to move on, because they’re telling you something else is better—and they’re making it better intentionally so you’ll move on to a different brand.”

http://qz.com/229470/how-heroin-baggies-are-marketed-like-iphones/

Source: Quartz – July 7, 2014

Across The US, An Explosion of Addiction

heroin and injection“Over the last 18 months, The Cincinnati Enquirer has used a team of reporters to cover the heroin problem locally. We joined with Gannett papers in Arizona, Delaware and Vermont for this series on heroin nationally.”

Part IThe Resurgence Of The Deadly Drug Has Sparked A Flurry Of Action From Governors’ Mansions And Statehouses Across New England And The Midwest To Small-Town Police Stations From Northern Kentucky To Wisconsin

Part II – Heroin’s Hidden Journey – Nearly All Heroin Fueling A U.S. Resurgence Enters Over the 1,933-Mile Mexico Border

Part III – Heroin addicts left trapped; families, heartbroken

Part IV – Scanning the battlefield in war on heroin

Part V – In Vermont, on the front lines of war on heroin

Source: USAToday.com – June 12, 2014

Heroin Users Are 90 Percent White, Living Outside Urban Areas

“The image of the heroin user is changing, according to researchers who say the great majority are now white men and women who mostly live outside the cities.

Their study published in JAMA Psychiatry, tracked data from almost 2,800 heroin users and found that first-time users are now generally older than those who began taking the drug in the 1960s. About 90 percent are white, according to the study, and 75 percent now live in non-urban areas.

The research also confirmed a link between the rise of opioid abuse and the growing use of heroin that had been noted in earlier studies. Heroin use has jumped 80 percent to 669,000 users from 2007 to 2012, according to the National Survey on Drug Use and Health, after being relatively stable since 2000.”

http://washpost.bloomberg.com/Story?docId=1376-N6AV3H6S972C01-71HUL1EQ4U5J4QKSAPSPOBBT5I

See related article  - Opioids leading to new class of heroin abusers, study finds at: http://www.jsonline.com/news/health/opioids-leading-to-new-class-of-heroin-abusers-study-finds-b99278535z1-260996001.html

Source: WashingtonPost.com – May 29, 2014

To Beat Heroin Addiction, A Turn To Coaches

“Recommendations out this week from a task force on opiate abuse include more peer support and home-based counseling. Health insurers and state Medicaid leaders say they will look at funding for recovery coaches, but there is no plan to do so right now.

Across the country, there’s growing interest in using recovery coaches to help heroin users stop, says Robert Lubran, director of the division of pharmacologic therapies at the federal Substance Abuse and Mental Health Services Administration. At least one state, New York, is paying for coaches to help treat addiction through its Medicaid program.

“This is an evolving field,” Lubran says. “[We are] learning more and more about the best ways to treat addiction and certainly the use of peer counselors, or peer coaches, has become more and more widespread.”

http://commonhealth.wbur.org/2014/06/heroin-recovery-coaches

Source: WBUR’s CommonHealth Reform and Community – June 13, 2014

News From the States

Belgium Study Suggests Heroin-Assisted Treatment Superior to Methadone for Heroin Addiction (Free registration required to view article)

“Patients severely addicted to heroin may respond to a treatment practice that incorporates pharmaceutical heroin, a new feasibility study suggests.

An open-label, randomized controlled trial (RCT) of 74 patients showed that significantly more of those who received diacetylmorphine under strict nurse supervision in a specialized center responded at 3, 6, and 9 months after starting treatment than those who received methadone.

http://www.medscape.com/viewarticle/825108

Source:  Medscape.com -May 13, 2014

Other National News of Interest

National Institutes of Health Press Release: HHS Leaders Call For Expanded Use of Medications to Combat Opioid Overdose Epidemic

New England Journal of Medicine commentary describes that vital medications are currently underutilized in addiction treatment services and discusses ongoing efforts by major public health agencies to encourage their use

A national response to the epidemic of prescription opioid overdose deaths was outlined in the New England Journal of Medicine by leaders of agencies in the U.S. Department of Health and Human Services (HHS). The commentary calls upon health care providers to expand their use of medications to treat opioid addiction and reduce overdose deaths, and describes a number of misperceptions that have limited access to these potentially life-saving medications. The commentary also discusses how medications can be used in combination with behavior therapies to help drug users recover and remain drug-free, and use of data-driven tracking to monitor program progress.

The commentary was authored by leaders of the National Institute on Drug Abuse (NIDA) within the National Institutes of Health, the Centers for Disease Control and Prevention, the Substance Abuse and Mental Health Services Administration (SAMHSA), and the Centers for Medicare and Medicaid Services (CMS).

“When prescribed and monitored properly, medications such as methadone, buprenorphine, or naltrexone are safe and cost-effective components of opioid addiction treatment,” said lead author and NIDA Director Nora D. Volkow, M.D. “These medications can improve lives and reduce the risk of overdose, yet medication-assisted therapies are markedly underutilized.”

Research has led to several medications that can be used to help treat opioid addiction, including methadone, usually administered in clinics; buprenorphine, which can be given by qualifying doctors; and naltrexone, now available in a once-a-month injectable, long-acting form. The authors stress the value of these medications and describe reasons why treatment services have been slow to utilize them. The reasons include inadequate provider education and misunderstandings about addiction medications by the public, health care providers, insurers, and patients. For example, one common, long-held misperception is that medication-assisted therapies merely replace one addiction for another – an attitude that is not backed by the science. The authors also discuss the importance of naloxone, a potentially life-saving medication that blocks the effects of opioids as a person first shows symptoms of an overdose.

The article describes how HHS agencies are collaborating with public and private stakeholders to expand access to and improve utilization of medication-assisted therapies, in tandem with other targeted approaches to reducing opioid overdoses.  For example, NIDA is funding research to improve access to medication-assisted therapies, develop new medications for opioid addiction, and expand access to naloxone by exploring more user-friendly delivery systems (for example, nasal sprays). CDC is working with states to implement comprehensive strategies for overdose prevention that include medication-assisted therapies, as well as enhanced surveillance of prescriptions and clinical practices. CDC is also establishing statewide norms to provide better tools for the medical community in making prescription decisions.

Charged with providing access to treatment programs, SAMHSA is encouraging medication-assisted therapy through the Substance Abuse Prevention and Treatment Block Grant as well as regulatory oversight of medications used to treat opioid addiction. SAMHSA has also developed an Opioid Overdose Toolkit  to educate first responders in the use of naloxone to prevent overdose deaths. The toolkit includes easy-to-understand information about recognizing and responding appropriately to overdose, specific drug-use behaviors to avoid, and the role of naloxone in preventing fatal overdose.

“SAMHSA’s Opioid Overdose Toolkit is the first federal resource to provide safety and prevention information for those at risk for overdose and for their loved ones,” said co-author and SAMHSA Administrator Pamela S. Hyde, J.D. “It also gives local governments the information they need to develop policies and practices to help prevent and respond appropriately to opioid-related overdose.”

CMS is working to enhance access to medication-assisted therapies through a more comprehensive benefit design, as well as a more robust application of the Mental Health Parity and Addiction Equity Act.

“Appropriate access to medication-assisted therapies under Medicaid is a key piece of the strategy to address the rising rate of death from overdoses of prescription opioids,” said co-author Stephen Cha, M.D., M.H.S., chief medical officer for the Center for Medicaid and CHIP [Children’s Health Insurance Program] Services at CMS. “CMS is collaborating closely with partners across the country, inside and outside government, to improve care to address this widespread problem.”

However, the authors point out that success of these strategies requires engagement and participation of the medical community.

The growing availability of prescription opioids has increased risks for people undergoing treatment for pain and created an environment and marketplace of diversion, where people who are not seeking these medications for medical reasons abuse and sell the drugs because they can produce a high.

The press release can be accessed at: http://www.nih.gov/news/health/apr2014/nida-24.htm

The New England Journal of Medicine article can be accessed at: http://www.nejm.org/doi/full/10.1056/NEJMp1402780?query=featured_home

Source: National Institutes of Health – April 24, 2014

Heroin a Growing Threat Across USA, Police Say

heroin and injection“Between 2009 and 2013, according to the assessment produced by the government’s National Drug Intelligence Center, heroin seizures increased 87%. The average size of those seizures increased 81% during the same time.”

“The consciousness of the nation has not really focused on the problem,” Attorney General Eric Holder told the conference of more than 200 officials organized by the Police Executive Research Forum, a D.C.-based think tank. “People saw this more as a state and local problem. …This is truly a national problem. Standing by itself, the heroin problem is worthy of our national attention.”

http://www.usatoday.com/story/news/nation/2014/04/16/heroin-overdose-addiction-threat/7785549/

Source: USAToday.com – April 17, 2014

Medication Assisted Treatment: A Standard of Care. An interview with Elinore McCance-Katz, MD, PhD, Chief Medical Officer, SAMHSA

Edit-Dr.M-KNote: This interview was issued by SAMHSA’s HRSA Center for Integrated Health Solutions in their February 2014 eSolutions newsletter.

“We have a huge need in our country to treat mental health and substance use concerns, and we have a chronic shortage of specialty care programs with enough capacity to treat everyone with a substance use concern. It is our responsibility to expand access to this care in a way that allows greater choice of where individuals can receive treatment.

With the Affordable Care Act, the treatment of substance use disorders is now an essential benefit. Individuals with multiple complex healthcare needs, including mental health and substance use concerns, can be seen in integrated care settings and health homes.

We are going to see more and more integrated care. All healthcare providers, whether in primary care, mental health, or substance use treatment, will need to learn how to provide treatment for disorders they may not have historically treated. Providers who are not used to treating patients with certain types of problems may not feel confident about providing care. When that happens, the individual is less likely to get the care they need. Primary care providers especially will need to be ready to assess and provide treatment for clients who present with mental health and substance use concerns.

The Need for Medication Assisted Treatment

Medication assisted treatment (MAT) is a standard of care. There are a variety of medications that have been shown to be effective in treating substance use disorders and that can be used safely. Specifically, there are a number of FDA-approved medications for tobacco, alcohol and opioid abuse treatments.

MAT is an effective form of care, when medication is taken as prescribed, used properly, and the individual is engaged with other supports and services. With opioid use disorders, studies show that clients who get medical detoxification only have a greater than 90% relapse rate.

We have to think about how effective the treatment is, what the alternative is if not treated, and where an individual is in their recovery. Individuals with chronic relapsing diseases should have access to MAT. It’s just the standard of care. We cannot diminish the importance of that.

Substance use disorders are not simply treated by taking a medication. In fact, taking medications can be part of the problem. Just giving someone medication is not enough. Psychosocial interventions, counseling, and other services are absolutely necessary and will always be very important.

Integrated care providers are going to have to learn about how to use these medications. Many medications can be used within primary care. We’re going to see a spectrum of severity with clients in primary care. Some may need referral to specialty care and others can be treated at the primary care organization.”

The interview can be accessed at: http://www.atforum.com/addiction-resources/documents/SAMHSA-MAT-A-Standard-of-Care-Feb-2014.pdf

Source: The Substance Abuse Mental Health Services Administration – February 2014

National Institute on Drug Abuse (NIDA) Updated Research Report on Heroin

Message from AATOD Regarding the Death of Philip Seymour Hoffman

AATOD“Philip Seymour Hoffman’s death has attracted national media attention as most celebrity deaths do, especially when they relate to a drug overdose. We have seen this phenomenon shortly after the deaths of Anna Nicole Smith and Michael Jackson. There was an immediate flurry of media attention, and then other stories took center stage.

For many addiction treatment professionals and patient advocates, the issues surrounding celebrity deaths represent the daily struggles that must be confronted by a wary public. A number of issues naturally come to surface during such times about opioid addiction and treatment.”

The AATOD message addresses:

  • Changing Social Attitudes
  • Changing Federal and State Oversight
  • The Opportunity to Educate

“The tragedy of Mr. Hoffman’s death will inevitably be revisited by another celebrity death in the future. We will engage once again in the flurry of media stories which typically have a limited lifespan. Ultimately, we need to work effectively to change America’s perceptions about the safety and danger of prescription opioids, the danger of heroin (which is obviously not an FDA approved drug), and the value of prevention and early intervention in providing access to care. Mr. Hoffman’s death is a stark reminder of the dangers of using heroin. It is not, nor has ever been, a safe drug. The user simply does not know what the drug has been cut with or its potency.

Many people who have worked in the addiction treatment community for many years know that heroin has been adulterated with all sorts of dangerous chemicals which can lead to death. We need to continually educate the public about these issues and work with patient advocates and public policy officials to ensure that the message is consistent and sticks.”

http://www.aatod.org/news/message-from-aatod-regarding-the-death-of-philip-seymour-hoffman/

Source: The American Association for the Treatment of Opioid Dependence – February 11, 2014

Wider Use of Antidote Could Lower Overdose Deaths by Nearly 50%

“Distributing naloxone and training people to use it can cut the death rates from overdose nearly in half, according to a new study.

The new study, published in the BMJ, followed the expansion of Overdose Education and Naloxone Distribution (OEND) programs in Massachusetts.  The programs were offered at emergency rooms, primary care centers, rehabilitation centers, support groups for families of addicted people and other places that might attract those at risk.

The study involved 2912 people in 19 different Massachusetts communities — each of which had had at least 5 opioid overdose deaths between 2004 and 2006.  The participants were trained to recognize overdose, call 911 and administer naloxone using a nasal inhaler.  If the naloxone didn’t work, they were instructed to try another dose and perform rescue breathing until help arrived.

During that time, 153 naloxone-based rescues were reported for which there was data on outcomes, and in 98% of those cases, the drug revived the victim.

There are still practical barriers however, to widely distributing naloxone and implementing more OEND type programs. Advocates have argued that the medication should be made available over-the-counter since it has little potential for abuse and is nontoxic. The Centers for Disease Control (CDC), the director of the National Institute on Drug Abuse and even the drug czar’s office support making it more widely available, and unlike the case with needle exchange programs, there has been no organized opposition to OEND. But the Food and Drug Administration (FDA) has no precedent for allowing over-the-counter sales of such a drug: naloxone is a generic medication approved in an injectable form. Without a company to submit an application for its use in the intranasal version, the agency isn’t likely to OK over-the-counter sales.”

http://healthland.time.com/2013/02/05/wider-use-of-antidote-could-lower-overdose-deaths-from-by-nearly-50/

Source: HealthlandTime.com – February 5, 2014

Q & A – Methadone or Buprenorphine for Maintenance Therapy of Opioid Addiction: What’s the Right Duration?

question boxQuestion: How long should patients with opioid addiction be treated with methadone or buprenorphine?

Response from Michael G. O’Neil, PharmD Professor, Department of Pharmacy Practice; Consultant, Drug Diversion and Substance Abuse, South College School of Pharmacy, Knoxville, Tennessee

“Data supporting positive long-term outcomes after definitive discontinuation of methadone or buprenorphine in a predetermined time frame for all patients are lacking. Prudent clinical practice dictates that duration of therapy should be individualized by well-trained addiction specialists, taking into account a disease treatment history that includes such factors as relapse, individual patient characteristics, evidence-based literature, patient adherence, socioeconomic characteristics, and environmental considerations until long-term evidence-based studies prove otherwise.

In summary, the complexities of the disease of opioid addiction have created a frustrating situation for practitioners and patients alike. Basic practice principles for chronic diseases, such as hypertension or schizophrenia, should be applied to patients who are unable to stay in recovery using abstinence programs alone. Strict discontinuance of opioid maintenance therapy solely on the basis of duration of treatment is not clinically justifiable at this time. Individualization of treatment for opioid addiction with methadone or buprenorphine by qualified specialists is necessary for many suffering patients, in conjunction with counseling, community support, or behavioral interventions. Treatment cultures for opioid addiction need to continue to evolve, as does education of the general public.”

The article can be accessed at: http://www.medscape.com/viewarticle/819875

Source: www.Medscape.com - February 3, 2014

Genes Play a Large Role in Opioid Dependence

dna“There is reason to think that opioid dependence is at least 60 percent inherited. Now a genomewide association study appears to have led to the identification of major genes contributing to this risk.

Some major genes that contribute to the risk for opioid dependence appear to have been identified. The genes make proteins that influence calcium signaling or potassium signaling within neurons.

The lead scientist, Joel Gelernter, M.D., a professor of psychiatry, genetics, and neurobiology at Yale University, told Psychiatric News that he was surprised by this finding. He had expected genes that code for opioid receptors to turn out to be major contributors, he said. But that was not the case.

Gelernter and his coworkers conducted a genomewide association study to see whether they could significantly link any gene variants with a risk for opioid dependence. They used a relatively large sample—some 5,700 subjects (over a third with opioid dependence and the rest controls). Afterward they conducted two more studies—one with some 4,000 subjects and the other with some 2,500 ones—to see whether they could replicate their initial findings.

They were able to link variants of a number of genes with a risk for opioid dependence. But the variants that were most strongly associated with opioid dependence risk were those from genes involved in calcium or potassium signaling within neurons.”

http://psychnews.psychiatryonline.org/newsarticle.aspx?articleid=1820456

Source: Psychiatryonline.org – January 28, 2014

Supreme Court: Heroin Dealer Can’t be Given Longer Sentence Because Client Died

Pg8_law“The U.S. Supreme Court unanimously ruled a heroin dealer cannot be held liable for a client’s death and given a longer sentence if heroin only contributed to the death, and was not necessarily the only cause.

The ruling is likely to result in a shorter sentence for Marcus Burrage, who received 20 extra years in prison because of his client’s death, according to USA Today. The decision is also likely to make it more difficult in the future for prosecutors to extend drug sentences, the article notes.”

Beating the Poppy Seed Defense: New Test Can Distinguish Heroin Use from Seed Ingestion

“Heroin is one of the most widely used illegal drugs in the world, but drug testing has long been challenged by the difficulty in separating results of illicit heroin users from those who have innocently eaten poppy seeds containing a natural opiate. Research in Drug Testing and Analysis explores a new test which may present a solution to this so-called ‘poppy seed defense.’

The team sought to identify an acetylated derivative which is known to be present in street heroin, but would not be found in either poppy seeds or medicines containing opiates. The authors identified a unique glucuronide metabolite (designated ‘ATM4G’) which could be used as a marker of street heroin use. A high frequency for the presence of ATM4G in urine strongly suggests that detection of this metabolite may offer an important advance in workplace drug testing and forensic toxicology, providing a potential solution to the poppy seed defense.

‘This research report addresses a longstanding analytical problem in forensic toxicology and workplace drug testing, by identifying a urinary marker that differentiates street heroin users from those whom have ingested morphine present in poppy seeds’ said Dr. Andrew Kicman, from the Department of Forensic and Analytical Science at King’s College, London.”

http://www.eurekalert.org/pub_releases/2014-01/w-btp010714.php

Source:  Eurekalert.org – January 7, 2014

Monitoring the Future Results Released

In mid-December, The National Institute on Drug Abuse (NIDA) announced the results of its 2013 Monitoring the Future (MTF) survey. The survey, conducted earlier in the year by scientists at the University of Michigan, tracks annual drug abuse trends of eighth, 10th, and 12th-grade students. NIDA is a component of the National Institutes of Health (NIH).

MTF is one of three major survey instruments the Department of Health and Human Services uses to monitor the nation’s substance abuse patterns among teens.

This year’s announcement focused on attitudes about and prevalence of marijuana use, as well as abuse of synthetic drugs, prescription medications, and tobacco.

Prescription Medications – There was mixed news regarding abuse of prescription medications. The survey shows continued abuse of Adderall, commonly used to treat attention deficit hyperactivity disorder, or ADHD, with 7.4 percent of seniors reporting taking it for non-medical reasons in the past year. However, only 2.3 percent of seniors report abuse of Ritalin, another ADHD medication. Abuse of the pain reliever Vicodin has shown a marked decrease in the last 10 years, now measured at 5.3 percent for high school seniors, compared to 10.5 percent in 2003.

Heroin – For cocaine and heroin, while there was no significant change from the 2012 rates, there continues to be a gradual decline in use, with both drugs at historic lows in all three grades. The 2013 rate for high school seniors for past year cocaine use is 2.6 percent, compared to a peak of 6.2 percent in 1999. Similarly, the reported use of heroin by 12th-graders is 0.6 percent this year, compared to a peak of 1.5 percent in 2000.

http://www.drugabuse.gov/related-topics/trends-statistics/monitoring-future

Source: National Institute on Drug Abuse – December 16, 2013

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