Archive for the ‘Drug Abuse’ Category

Marijuana: A Gray Matter

August 20, 2017
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Marijuana remains a Class I controlled substance in federal law, denoting it as a drug with high abuse potential and no acceptable medical use. However, it is legal for medical use in 29 states and the District of Columbia, and is legal for recreational use as well in 8 states and the District of Columbia. States are under enormous pressure to enact marijuana legalization laws due to widespread public support for the policy change and public disdain for the current federal classification, which is seen as irrational and duplicitous given the much laxer legal status of more dangerous substances such as alcohol and tobacco.

This is not to say that marijuana is not dangerous. As an internist and pediatrician, I am keenly aware of marijuana’s potential negative effects on adolescent and adult health and development, the potential for addiction, and the finding of increased marijuana-related traffic accidents in states with legal recreational use. But it is important to note that, unlike other Schedule I substances, rates of physical addiction are much lower, overdose nearly nonexistent, and no change in rates of fatal traffic accidents has been observed. Marijuana is by no means benign, but it is regulated out of proportion to its potential for harm.

Activists on the marijuana issue used to typically fall into three camps: legalize it, legalize medical use, or keep it banned. But increasingly, the two extreme views are more prominent in the public arena. Marijuana is not a black-and-white issue. It can be beneficial, and it can be harmful. Current federal policy listing marijuana as a substance with no acceptable medical use is not consistent with evidence supporting significant efficacy in pain states, multiple sclerosis, and other conditions. Furthermore, maintaining its illegal status at the federal level does nothing to prevent state legalization, while it does prevent adequate research so that smart, evidence-based policies and regulations can be enacted.

I believe the federal government should reclassify marijuana as a Schedule III substance: a drug with potential for abuse less than the drugs in Schedules I and II, with currently accepted medical use in treatment, and with moderate or low risk of physical dependence but high risk of psychological dependence. This would be consistent with current evidence, would allow research study while continuing regulatory restrictions, and may also reduce pressures on states to legalize recreational use. Marijuana reclassification would allow the federal government to stay engaged and help control the discussion around the benefits and risks of marijuana use, rather than sitting idly by as an unrelenting wave of legalization sweeps across the nation.

A bipartisan bill has been proposed in the House of Representatives calling for marijuana rescheduling. Call your representative to support this evidence-based policy change.

Improving Access to Buprenorphine: A Medication-Assisted Treatment to Address United States’ Opioid Epidemic

August 20, 2017

The United States recently declared the opioid epidemic as a national emergency. Buprenorphine is a prescribed partial agonist used in opioid medication-assisted treatments (MATs); it is particularly unique given that it can be administered in settings outside of opioid treatment programs like physician offices. Alarmingly, a recent study found that nearly 1 million people with opioid addictions in the U.S. could not access MATs due to prescribing capacity constraints, demonstrated in the figure below. Accordingly, it is critical that the U.S. focus on lifting the patient caps for prescribing buprenorphine.

AJPH Graph of Opioid Treatment Access Rates, July 2015

Source: American Journal of Public Health, July 2015

INCREMENTAL POLICY WINS

Per the Drug Addiction Treatment Act of 2000 (DATA), the number of patients that qualified physicians could treat with buprenorphine was capped at 30 patients at once, during the first year, expandable to 100 patients in the second year. The 2016 passage of the United States Code. Section 303(g)(2) of the Controlled Substances Act allows qualified physicians (who have treated 100 patients at once, for at least one year) the ability to apply for the treatment of 275 patients, at once. Key advocates who were successful in increasing the patient caps include the Substance Abuse and Mental Health Services Administration, American Medical Association, American Society of Addiction Medicine (ASAM), and the National Association of County and City Health Officials.

WHY STOP THERE?

A RAND study found that less than 10 percent of waived physicians treated more than 75 patients with buprenorphine, prior to the passage of the 2016 increase in patient caps. There are also great variations in the number of actively prescribing waived physicians in urban and rural communities. Lifting the patient caps for waived physicians is the most immediate and effective method of making buprenorphine available to a greater portion of the population, as it can be administered in any office-based setting; this policy change may also mitigate the “black market” for buprenorphine, which has been perpetuated by its limited access. An important component of the proposed change is that it will maintain the requirement for physician waivers. This will ensure that an appropriate standard of quality is met, and potentially limit the increases in the number of “pill mills” as compared to current trends, since those consumers may gain access to the full treatment through the proposed policy change.

Dr. Kelly Clark, president of ASAM, was succinct in her argument against patient caps: “This medication [buprenorphine] and this specialty of addiction medicine represent the only areas in medicine in which physicians are shackled and have a maximum number of patients that we can treat with an evidence-based medication…These limits are not evidence-based or clinically based.” It is critical that health care and public health professionals leverage their networks and join the fight to advocate for increased access to buprenorphine by lifting the patient caps for qualified physicians. The U.S. must take imminent action to provide an appropriate treatment response to the growing opioid epidemic.

Supervised Injection Facilities to Mitigate Rhode Island’s Overdose Crisis

August 20, 2017

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https://www.shutterstock.com/search/overdose

Rhode Island, the smallest state in the United States, had 336 overdose-related deaths in 2016, double the number of deaths in 2010. Since 2011, illicit drug overdose deaths increased 250% with the crisis expanding to include a 15-fold increase in fentanyl-related deaths.

In August 2015, Governor Gina Raimondo signed an executive order, directing the Department of Health and Department of Behavioral Healthcare, Developmental Disabilities and Hospitals to co-convene an Overdose Prevention and Intervention Task Force with community and stakeholder participation. The Task Force developed an action plan aiming to reduce overdose deaths by one third by 2018.

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Source: Rhode Island Department of Health

Because the number of deaths continued to climb, a second executive order was signed in July 2017, calling for community and school-based prevention education, and a directive to explore “a comprehensive harm reduction strategy for intravenous drug users to decrease risk of overdose, infection, and assault.”  

Harm reduction strategies include distribution of clean needles, outreach, peer support, naloxone training, substitution therapy, and supervised injection facilities.  These approaches mitigate the adverse effects of high-risk behaviors associated with drug use by reducing stigma, and legal and social barriers to care.

Vancouver SIF

Source: The Stranger

Supervised injection facilities (SIFs) are an effective public health strategy because their impact is multi-faceted and based in harm reduction. SIFs reduce death from overdose, increase access to services for healthcare and recovery, and improve community safety.

With good results in Canada and campaigns for SIFs in New York and other US locations, Rhode Island is not alone in this crisis. Supervised injection facilities can help stem the exponential increase in deaths and unbearable toll this overdose crisis is taking on individuals, families, and the state.  It is crucial that the Overdose Task Force and Governor Raimondo support local implementation of this evidence-based life-saving strategy.

When fixing the opioid crisis, please don’t block access to those that actually need them

August 20, 2017

Opioids contribute to the 142 people that die each day in America of drug overdose. The President has claimed that he plans to declare a state of emergency, an unprecedented move, typically reserved for natural disasters and disease outbreaks that are more acute in nature, which has the potential to unleash access to beneficial solutions such as addiction treatment.

There are 2 ways to declare a state of emergency: via the Stafford Act, which is typically reserved for natural disasters like hurricanes and tornadoes, and the Public Health Service Act, which is focused on medical issues.  Both would unlock resources for proposed solutions – the former focused on law enforcement and measures further limiting access while the latter, coming from the secretary of health and human services, focused more on comprehensive medical measures. Please choose carefully.

The figure is a line chart showing drug overdose deaths involving opioids, by type of opioid, in the United States during 2000-2014.

Rates of opioid-related overdose by type of opioid taken from Centers for Disease Control and Prevention.

The CDC breaks that number down. More than half of overdose deaths involve opioids, either prescription opioids or heroin. Overall rates of overdose have dramatically increased between 2000 and 2014.  However, death rate increases since 2010 have been driven by heroin while rates from prescription opioids have plateaued or decreased, indicating that recent policy focused on blocking access may be simply shifting the small proportion that actually become addicts toward a more dangerous, means of getting high.

Few treatment options exist for people that live with chronic, severe pain. The nation needs non-opioid medicines that are effective at relieving severe pain, but that are safe and not potentially abusive. Until then, adequate management is complex and requires a balance of pharmacological and non-pharmacological approaches, which requires provider education and provider time with patients.

 

Further exacerbating the issue, prescribers and pharmacist, fearful of litigation and criminalization, withhold prescription opioids from those that legitimately need it. Inadequate pain management impacts not only quality of life, but deteriorates activities of daily living and leads to depression, anxiety, and “self-medication” with more harmful substances such as alcohol.

Despite often erroneously interchanged, there is a distinction between physical dependence and addiction – perhaps the single most important nuance to understand when managing pain and deciding on policy that impacts people with pain. Chronic pain, by definition, does not go away, but the opioid receptors in the brain develop a tolerance, eventually diminishing the pain-relieving effects of opioids at their current dose. This is dependence, and it is normal. Doses need to be incrementally increased over time to provide the same level of relief. Those with very long-standing pain may need very high doses. Policy that is focused on restricting access to high doses seems to not take this into consideration.

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U.S. Department of Health and Human Services strategies for combating the opioid crisis

A decision that emphasizes walled boarders and law enforcement will likely not be effective at reducing overdose and may actually worsen the issue of access further for an often silent, but suffering multitude that are not getting the care that exists, but is increasingly not within their reach. We need policy that pushes people to life-saving measures such as comprehensive pain management, access to addiction treatment without fear or stigma, provider education, and research to enhance our understanding of pain and addiction.

Opioid Taxation: A Call for Support of California Assembly Bill 1512

August 16, 2017

California continues to aggressively fight the U.S. national opioid epidemic, taking active steps to develop hub-and-spoke opioid treatment programs, launching health plans to reduce opioid prescriptions, and enacting tougher laws governing clinical opioid use.

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A new strategy targets drug manufacturers: California Assemblyman Kevin McCarty proposed an amendment to AB 1512 which would enact taxes of $0.01/mg upon the sale of opioid ingredients from manufacturer to wholesaler. Funds collected would then be placed within the bill’s newly created Opioid Prevention and Rehabilitation Program Fund, and distributed to rehabilitation and addiction programs. As physicians and active community members, we strongly support AB 1512.

The bill was amended in the California Assembly on May 9, 2017, is currently in its second hearing within the committee, and its tax-collection component requires 66% approval in both the Senate and Assembly. However, because the proposed tax affects multinational corporations’ financial health and might negatively impact jobs, significant opposition exists against this legislation.

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One vocal opponent to AB 1512 is the California Chamber of Commerce (CalChamber). CalChamber remains the largest organization advocating on behalf of businesses and maintains that AB 1512 is “unfair,” likely to “reduce the workforce” and “increase drug prices for ill patients who need these medications the most.”

In addition to supporting AB 1512, we call on CalChamber to reconsider its negative position and instead influence its constituents to support the legislation. CalChamber’s argument fails to recognize negative externalities and high costs that businesses currently absorb with the opioid epidemic unchecked. CalChamber must recognize that increased opioid pain prescriptions and resultant fatal and non-fatal overdoses lead to overutilization of hospitals and emergency rooms, directly contribute to rising healthcare costs. Moreover, opioids serve as gateway drugs to illicit substances such as heroin, spilling into local communities, further consuming emergency, police, and public and private resources.

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Improved Access to Naloxone in Ontario’s Fight against Opioid Overdoses:

August 11, 2017

LEGAL + AVAILABLE ≠ ACCESSIBLE

Naloxone

Over the past decade Ontario has seen a steady rise in the number of opioid related deaths and narcotic misuse across all socioeconomic groups in the province. Of particular concern is that despite ongoing provincial initiatives little has been accomplished to prevent the rampant abuse and misuse of narcotic pain medications. The opioid epidemic is a public health crisis of epic proportions. Recently it has been estimated that 1 in 8 deaths in Ontario is related to opioid abuse.

The government has rolled out a variety of initiatives to combat the problem. They have stopped paying for higher-strength narcotic pain medications through the provincial drug benefit payment plan in an effort to reduce the abuse of these agents. The provincial government has also increased funding for addiction services, and set out new guidelines for opioid use in chronic pain. (http://nationalpaincentre.mcmaster.ca/guidelines.html)

These recent policy initiatives from the provincial government to combat the provinces growing opioid crisis are welcome news. The problem represents a complex health issue with potentially devastating consequences for individuals, families and the communities they live in. Unfortunately the crisis continues to grow and these efforts do not go far enough to help prevent the senseless deaths that are occurring every day on the streets of our cities from accidental overdoses.

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Ontario opioid toxicity deaths, by drug – 2002-13. Data from Ontario Coroner.

Historically the use of the lifesaving antidote for an opioid overdose, Naloxone was only available to a select group of healthcare providers like physicians and paramedics. Most recently this past year the provincial government reduced the restrictions on this lifesaving medication making it available in local pharmacies to consumers without requiring a prescription.

This is a welcome policy change that will save lives….unless you live in Grassy Narrows, Attawapiskat, Pikangikum, White Dog, or any of the other remote Northern Ontario First Nation reserves where there are no pharmacies or publicly available free Naloxone kits. You may not find these communities listed on the provincial government website ‘Where to get a free naloxone kit’ but deaths from overdoses are happening here at alarming rates.first nation grassy

While there is strong support for this new policy change, simply removing the legal barriers and improving the availability of this life saving intervention may not equal improved accessibility for some residents of Ontario.

LEGAL + AVAILABLE ≠ ACCESSIBLE

Major health disparities exist amongst remote First Nations communities living in Northern Ontario. These populations are socially marginalized and medically underserviced. Access to healthcare for these populations is limited as is the quality, equity and timeliness of the healthcare they do receive. This results in disproportionately high burdens of disease and poor health outcomes. First Nations youth have higher rates of suicide and an increase prevalence of risk taking behaviours which can all lead to higher rates of alcohol and drug abuse and ultimately death from overdose.

Attawapiskat

The government’s expansion of initiatives and services which take aim at combating the opioid epidemic in Canada need to target all Canadians and not just those living in urban centers. If the government is serious about broadening access to initiatives like free Naloxone it needs to couple that with initiatives to ensure these initiatives reach the most vulnerable and disadvantaged members of society like the remote First Nation reserves of Northern Ontario. There needs to be a global expansion of healthcare funding for Aboriginal populations that aims to reduce the health disparities that currently exist in these populations.  Otherwise available does not equal accessible.

 

Skyrocketing price of the “life-saving antidote” for the opioid epidemic in New York State; have the drug companies gone too far?

March 12, 2017

 Figure 3-page-001(https://www1.nyc.gov/site/doh/about/press/pr2016/pr102-16.page)        

Data from the Center for Disease Control (CDC) shows a fourfold rise in overdose deaths related to prescription opioids in the United States since 2000 (figure 1). In New York State (NYS), opioid related hospital admissions peaked in 2014 (figure 2), prompting implementation of policies to address these concerns. One of the major executions by the NYS Department of Health was issuance of a standing order authorizing licensed pharmacists to dispense naloxone, an opioid antidote, to persons without needing a prescription.

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Figure 2

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Source: https://www.osc.state.ny.us/press/releases/june16/heroin_and_opioids.pdf

Naloxone counteracts the dangerous effects of opioids with minimal or no adverse events if mistakenly administered to persons not suffering an overdose. The demand for naloxone has significantly increased now that the State has requested widespread availability for the public to administer naloxone in cases of suspected overdose. However, the rising costs of naloxone have made it difficult to meet these demands. The injectable version of the drug has increased significantly over the past few years. The price for naloxone nasal spray in the CVS chain’s New York stores is up to $110 for people who buy it without a prescription and insurance. An auto-injector version of naloxone called Evzio, that works like Epi-pen, is $2,250 for a single-dose injector.

Increasing access to naloxone for the public is inadequate if prices continue to rise. The State and the manufacturers of these products are our stakeholders. These parties may reduce costs by increasing manufacturers, and offering consistent prices and discounts. Pushback from the manufacturers to lower prices thrives in that they are limited in number and have raised costs to meet rising demand. The community may argue that increasing the availability of antidotes may promote drug overdose. Thus we appeal for an alliance between the state and the manufacturers to reduce prices of these life-saving medications to curtail the opioid epidemic.

Written by Asma Akter, Elan Gorshein, Nidhi Madan

Averting a Crisis: Legalization of Needle Exchange Programs in Virginia

March 12, 2017
ACT UP march for syringe exchange

CREDIT: KAYTEE RIEK VIA FLICKR

In February 2017, Virginia governor Terry McAuliffe signed legislation that legalizes syringe access programs in the state. Needle exchange programs provide anyone needing a clean needle with a place to exchange their used needle for a sterile needle at no cost. These programs can also offer HIV testing and counseling, alcohol swabs, and male and female condoms, among other resources that vary by organization.

According to the approved bill, these programs will only be implemented in regions meeting certain criteria created from information such as overdose rates, number of Hepatitis C cases, and morbidity data. Thanks to several federal and private funds, these programs will not take away from the state’s general funds.

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CREDIT: SPENCER PLATT/GETTY IMAGES

There has been controversy regarding whether needle exchange programs are helpful or detrimental. In 2011, Archbishop Francis Chullikat spoke on behalf of the Catholic Church at the United Nations in opposition of harm-reduction programs. The Catholic Church believes that people dealing with drug addictions should be given tools and assistance to break free from their addiction as opposed to measures that allow them to “continue” in their cyclic, addictive behavior. On the other hand, the CDC and NIH both advocate that needle exchange programs play a role in preventing HIV transmission and other health problems among people who inject drugs.

A needle exchange program in Virginia is important for preventing an HIV outbreak, considering an outbreak like this has happened in Indiana and the number of HIV cases rose from a typical 5 cases a year to 200 cases in 2015. It is important for local government officials and residents to voice their support for needle exchange programs to ensure the continuity and growth of such programs. A needle exchange program can be the difference between a public health crisis and a public health victory.

Pushing for the Federal Standardization of Prescription Drug Monitoring Programs

March 11, 2017

In 2012, the Centers for Disease Control and Prevention declared prescription drug abuse an epidemic in the United States as the number of unintentional opioid overdoses had increased by 75% since 1999. These trends went hand in hand with increases in opioid prescriptions. In response, 49 states developed Prescription Drug Monitoring Programs (PDMP) to track prescriptions of regulated substances – databases providers can check before writing prescriptions.

PDMPs have become pillars of the national strategy, but their effectiveness varies by state. These differences highlight the main problem: the features of PDMPs including timeliness of data collection, who has access, requirements for use, interstate operability, and mechanisms to enforce prescriber noncompliance, also vary by state. As PDMPs are evaluated, evidence is amassed about the most effective features and must be translated into policy.

Several players including the National Alliance for Model State Drug Laws and the PDMP Training and Technical Assistance Center have synthesized and spread this information without directly proposing federal standardization. The National Council for Prescription Drug Programs issued technical proposals for the application of best practices; and grassroots NGOs such as Shatterproof have worked with individual states to make PDMPs more effective. As efforts spread, the American Medical Association has reacted against the mandatory use of PDMPs by providers, and the ACLU against the violation of patient privacy.

Another avenue should be pursued. More than half the states use federal funds to support their PDMP, the biggest program being the Harold Rogers PDMP Grant administered by the US Department of Justice’s Bureau of Justice Assistance (BJA). Grassroots NGOs should use their visibility to push the BJA to standardize PDMPs by making the most effective features of PDMPs requirements for the receipt of federal funds. The BJA must encourage states to apply evidence rather than turn their back to it.

A Questionable Solution to Maryland’s Opioid Crisis

March 11, 2017

In 2015, over 1,000 Marylanders died due to opioid-related overdoses. This week, in response to increasing opioid-related deaths, Senate Bill 868 will be heard. This bill increases the scope of the Overdose Response Program (ORP), which provides education and reduces overdose by certifying and training Marylanders to assist overdose victims.

The bill allows healthcare professionals to dispense naloxone to individuals without any of the previously required education. The intent is remove the barrier of attending an educational session for obtaining naloxone, with the hope of curbing the opioid-overdose epidemic.

While naloxone is not difficult to administer, an overdose cannot be treated by just administering naloxone once. Naloxone wears off quickly, and it is critical to call emergency medical services and understand how to initiate CPR. Allowing access to the drug without education may not improve outcomes, and may become a financial burden to those trying to help.

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Image Credit: The Harm Reduction Coalition

While the Department of Hygiene and Mental Health, the Institute for Emergency Medical Services System, and The American Pharmacists Association are invested in this bill, other associations have yet to make formal statements. The American Medical Association has a task force increasing access to naloxone, the American Society of Addiction Medicine, and the Substance Abuse and Mental Health Services Administration recommend and encourage individuals who carry naloxone to receive a comprehensive overdose-related education.

While the bill’s intention is noble, removing education is not the right way forward. There are other possibilities, including requiring healthcare professionals to provide a standardized pamphlet each time they provide or dispense naloxone – which would please all stakeholders.

Nelson Mandela said, “Education is the most powerful weapon which [we] can use to change the world.” In our attempt to save lives, Maryland should be cautious in skipping education.