Regional Trends in Overdose Deaths Reveal Multiple Opioid Epidemics, According to New Study

The United States is suffering from several different simultaneous opioid epidemics, rather than just a single crisis, according to an academic study of deaths caused by drug overdoses.

David Peters, an associate professor of sociology at Iowa State University, co-authored the study, which appeared in the academic journal Rural Sociology. Peters and his co-authors conducted a county-level analysis of death certificates from across the country that noted opioid overdoses as the cause of death. The study found regional differences in the kind of opioids that cause the most overdose deaths, and these differences should lead to policymakers considering varying strategies to address the epidemics, Peters said.

“Our results show that it’s more helpful to think of the problem as several epidemics occurring at the same time rather than just one,” Peters said. “And they occur in different regions of the country, so there’s no single policy response that’s going to address all of these epidemics. There needs to be multiple sets of policies to address these distinct challenges.”

Multiple epidemics

The study describes three different opioid epidemics in the United States, as well as a syndemic, or a single population experiencing more than one epidemic:

— A prescription drug epidemic persists in rural southern states where access to opioids centers on local pharmacies. Overdose deaths linked to pharmaceuticals peaked nationwide in 2013 and have fallen in the years since. However, some rural counties continue to struggle with prescription drugs, according to the study.
— A heroin epidemic has taken root in states out west and in the Midwest, especially in urban areas near major interstates that experience heavy drug trafficking. The study found overdose deaths related to heroin clustered along two major corridors, one linking El Paso to Denver and another linking Texas and Chicago. Peters said those findings correspond with known routes used by cartels smuggling heroin into the United States from Mexico.
— An epidemic of synthetic opioids, such as fentanyl, has grown as a major concern in urban centers in the northeastern United States. Often these synthetic drugs are mixed with heroin or cocaine and made to resemble prescription medications. These counterfeit street mixes are highly potent and deadly.
— A syndemic involving multiple simultaneous opioid epidemics exists in counties where the opioid crisis first erupted, particularly in mid-size cities in Kentucky, Ohio and West Virginia that have experienced steep job losses in manufacturing and mining.

Peters said roughly a quarter of all counties in the United States fall into one of the epidemic categories noted in the study.

The study was funded by a grant from the U.S. Department of Agriculture’s National Institute of Food and Agriculture. The data used in the study came from the Centers for Disease Control and Prevention.

How To Win America’s Fight Against The Opioid Epidemic

Every day, an astonishing 115 Americans die from opioid overdoses, according to a 2017 report from the Center for Disease Control and Prevention. Approximately half of these deaths are due to the misuse or abuse of prescription opioid painkillers (such as Vicodin, Oxycontin, and morphine). Beyond that, increasingly, deaths come from overdoses of the illicit drugs heroin and fentanyl, which are often used after people become addicted to or misuse prescription opioids.

Each day, more than 1000 people are sent to the emergency room for prescription opioid misuse. In many of these cases, opioids were used along with alcohol or medications meant to treat anxiety or seizures (such as Xanax, Ativan, and Valium). When people ingest such mixtures, they face a heightened risk of injury or death as their breathing slows or stops.

Effective treatments exist. But as treatment for over-dosing is increasingly available, treatment for addiction is still not accessible to many of those who need it. Access to effective treatments for opioid addiction is the missing piece in America’s unsteady fight against the opioid epidemic.

Success in Fighting the Opioid Epidemic

Gains in the fight against the opioid epidemic have been made on several fronts. The physicians and nurse practitioners who prescribe America’s medications are being trained to be more judicious in their use of opioids to treat pain. They are also learning to consider, whenever possible, non-opioid medications and other treatments that don’t come from a pharmacy at all. National guidelines have been established for methods of relieving surgical, cancer-related, and chronic pain without opioids. Taken together, all these efforts are saving lives and reducing the volume of prescription opioids that can be diverted to illicit uses.

Similarly, emergency first responders and trained laypeople now have tools to help prevent deaths from opioid overdoses. Lives have been saved in many communities by the administration of naloxone – a medication which blocks the effects of opioids on breathing centers and reverses overdoses.

But what happens after emergencies – or to prevent them? Treatments for addiction can reduce the likelihood that people addicted to opioids will overdose and die. And such treatments are vital because, like any other chronic illness such as diabetes or heart disease, untreated addiction becomes more severe and resistant to treatment over time.

The Missing Piece – Access

What most of America is sorely missing, however, is sufficient access to the addiction treatments that are the most effective – and not enough efforts are currently underway to increase such access. Currently, the best estimates suggest that only one out of every ten patients seeking drug abuse treatment can actually get into a program. To sharply reduce U.S. opioid deaths, proven forms of treatment should be readily available, on demand, to all who need them. Policymakers, civic leaders, patient advocates, and journalists, should consider the following steps:

  • Treatment and reimbursements should be evidence-based. Research shows that the most effective approach is medication-assisted therapy (MAT), where patients are given methadone, buprenorphine, or naltrexone, alongside therapy to combat addiction. Too many private payers pay for treatments based on mistaken ideas. For example, detoxification is known to be highly ineffective against opioid addiction, yet it is widely practiced and reimbursed.
  • Insurance and other reimbursement systems need to acknowledge that addiction is a chronic disease that almost never goes into remission after a one-time treatment. Treatment for addiction needs to be ongoing and long-term, just like treatments for diabetes or heart disease. But currently most health insurance companies will only cover one treatment episode or a fixed number of treatment days per year.
  • Early, intensive treatment is the most effective and less costly over time. Currently, most insurance companies will only cover outpatient treatment for opioid addiction, and will only reimburse intensive inpatient treatment if the first effort fails. Evidence shows that in many cases, the opposite approach would work better: start with intensive treatment rather than with minor steps that allow time for the disease to progress.
  • Many opioid addicts could be treated within America’s current primary care systems. Two effective medications, buprenorphine and naltrexone, can be prescribed by primary care providers. With appropriate waivers, for instance, a physician can treat up to 100 patients with buprenorphine.
  • Medications need to be supplemented with therapy. Because most primary care clinicians do not have the resources or practice partners to provide the therapies patients need in addition to medications, they often limit the number of addicts they treat or avoid treating them altogether. The answer lies in making behavioral health providers more readily available to work with primary care providers, who could then prescribe effective medications more readily.
  • Patients brought to hospitals for opioid addiction and overdose should be enrolled in therapy and other treatment on the spot. Many patients with opioid addiction end up in hospitals and emergency rooms. The current approach is to stabilize them medically and then tell them, as they are discharged, to seek further treatments. But many do not follow up or have adequate access to the help they need. A better approach would be to start treatment while addicts in crisis are at the hospital – and directly transfer them to an addiction treatment facility upon discharge.
  • Jails and prisons are other places where opioid addicts need treatment. Efforts to bring medication-assisted therapy to the incarcerated could mitigate the larger opioid crisis – and also reduce the rate at which ex-inmates commit new offenses and cycle back to prison.

The bottom line is clear: Increasing access to proven treatments for all addicts who need them would save and improve countless lives, and effectively counter America’s current opioid crisis.

Read more in Peggy Compton and Andrew B. Kanouse, “The Epidemic of Prescription Opioid Abuse, the Subsequent Rising Prevalence of Heroin Use, and the Federal Response” Journal of Pain and Palliative Care Pharmacotherapy 29, no. 2 (2015): 102-114.

Self-Regulation Significant to Overcoming Early Adversity in Drug and Alcohol Abuse

Self-regulation may hold the key to helping young adults overcome their risk for developing alcohol and drug problems, according to recent research from the University of Georgia.

The study looked at 225 non-college-educated adults aged 18-25 from lower socioeconomic backgrounds who grew up in rural areas in Northeast Georgia. Led by Assaf Oshri, an associate professor in the UGA College of Family and Consumer Sciences, the research team found that young adults who experience abuse as children have a higher risk for developing alcohol and drug problems. These same young adults also have a decreased ability to self-regulate, or avoid impulsive decision-making in socially stressful situations.

Oshri pointed to the results as evidence of the need for family-focused preventive intervention programs for adolescents that target self-regulation, in hopes of better identifying factors that promote resilience among youth.

“If we use delayed gratification, we can do well in life, but it seems like those who have specific early life experiences are less able to perform this optimal decision-making, and that can affect their risk of substance abuse,” said Oshri, who is housed in the department of human development and family science.

Protective factors at the biological and psychosocial levels offer hope that interventions targeting decision-making can help at-risk youth, he explained.

“The goal is to try to identify mechanisms that will help youth who experience adversity in life,” he said

During the study, the young adults were assessed twice over two years. In addition to completing surveys measuring their drug and alcohol use and experiences with child maltreatment, participants completed a decision-making task that evaluated their tendency to make impulsive decisions and ability to self-regulate and delay gratification.

To accomplish this, researchers used a tool called “delayed reward discounting.” The young adults answered questions such as “Would you rather have $14 today or $25 in 19 days?” They also agreed to have their heart rates measured while they completed a series of increasingly difficult math-related tasks in front of an audience of research assistants. These measurements allowed researchers to record stress levels and assess self-regulatory capacities.

Study results found that as participants’ maltreatment experiences as children increased, the higher their inclination toward impulsive decision-making and problems delaying gratification.

The paper, “Child maltreatment, delayed reward discounting and alcohol and other drug use problems: The moderating role of heart rate variability,” was published online in August in the journal Alcoholism: Clinical and Experimental Research.

Co-authors are UGA graduate students Sihong Liu and Erinn Bernstein Duprey and James MacKillop from McMaster University in Canada. The work was supported by the UGA Owens Institute for Behavioral Research and the Sarah H. Moss Fellowship for UGA faculty.

The abstract can be found at https://onlinelibrary.wiley.com/doi/full/10.1111/acer.13858.

Undocumented Immigration Doesn’t Worsen Drug, Alcohol Problems in U.S., Study Indicates

Despite being saddled with many factors associated with drug and alcohol problems, undocumented immigrants are not increasing the prevalence of drug and alcohol crimes and deaths in the United States, according to a new study published in the American Journal of Public Health.

Researchers led by University of Wisconsin–Madison sociology Professor Michael Light used newly developed state-level estimates of the unauthorized immigrant population to examine the relationship between undocumented immigration and drug and alcohol arrests and deaths.

Light says national debate on immigration law spurred him to begin a series of studies on undocumented immigrants and public safety and health.

“This is an area where public and political debates have far outpaced the research,” Light says. “And central to this debate is whether undocumented immigration increases drug and alcohol problems, or crime more generally. There are good theoretical reasons to think it could have increased substance abuse problems in recent decades. But the data just doesn’t show it.”

Light, who was a professor at Purdue University while he conducted the study, along with Purdue sociology Professor Brian Kelly and graduate student Ty Miller, used immigration data from the Center for Migration Studies and the Pew Research Center spanning 1990 to 2014.

They compared undocumented immigration rates to four representative measures of drug and alcohol problems: drug crimes and driving under the influence arrests collected from federal, state and municipal sources in the FBI’s Uniform Crime Reports; and drug overdose deaths and drunken driving fatalities counted by the Centers for Disease Control and Prevention’s Underlying Cause of Death database and the National Highway Traffic Safety Administration’s Fatality Analysis Reporting System.

According to the study, rather than increasing substance abuse problems, a 1 percent increase in the proportion of the population that is undocumented is associated with 22 fewer drug arrests, 42 fewer drunken driving arrests and 0.64 fewer drug overdoses — all per 100,000 people. The frequency of drunken driving fatalities was unaffected by unauthorized immigration rates.

According to Light, one explanation for these findings could be what prior research often calls the “healthy immigrant thesis” or “Latino paradox.”

“When you look at things we think of as predictive of criminal behavior and poor health outcomes — low levels of education, few economic assets — immigrants tend to be engaging in less crime and staying healthier than we would expect,” Light says.

And yet, undocumented immigration is often stirred into debate of social ills like opioid use. It’s unquestionable that drugs are smuggled across the border between the United States and Mexico, Light says, but this does not mean drug smuggling and unauthorized immigration are one and the same.

“That just doesn’t appear to be the case,” he says. “If you want to fight the opioid epidemic or reduce drunk driving, deporting undocumented immigrants residing in the U.S. is likely not going to be the most effective policy.”

Another Harm Reduction Perspective: An Interview with Walter Cavalieri from the Canadian Harm Reduction Network

The Canadian Harm Reduction Network is a virtual meeting place for individuals and organizations committed to reducing the social, health and economic harms associated with drugs and drug policies. The network was established in 1999 by a group of activists committed to improving the lives of people struggling with drug use, and Walter Cavalieri is the director of the organization.

The Canadian Harm Reduction Network is a virtual meeting place for people to exchange ideas and information. The network has been engaged in recent research, presentations and the media. Essentially the Canadian Harm Reduction Network wants to change the world to make it better, kinder, and a more evidence-based place.

The Canadian Harm Reduction Network has a Facebook page and a Twitter account. The Canadian Harm Reduction Network has also taken part in media studies looking at what harm reduction looks like internationally, rather than only what it looks like in Vancouver, Toronto and Montreal.

Photo-Podcast-16-Walter-Cavalieri
Walter Cavalieri

Walter worked in professional and academic theatre for over 20 years. However, he eventually began to become more in touch with his pursuit to improve individuals’ lives and make the world a better place. Therefore, he began to volunteer at the LGBTTQA counseling centre at the time and his work with the counseling centre became more interesting than any area of theatre work that he engaged in. Walter then went back to school and obtained his Bachelor of Social Work degree and resided in Toronto. During his initial involvement in Toronto, he began to work with children living on the street, that were surviving through drug use.

His initial response to children using drugs was telling them to stop using drugs; however, he began to explore alternatives to this view on drug use. He began to work with the children and discovered the drugs were often used as a coping mechanism for trauma. Walter also began to work with adults and opportunities for a needle exchange were established. He then attended a harm reduction conference in Toronto and realized that harm reduction should be very important in reducing the harm of drug use in Toronto. Thus, Walter helped to establish the Canadian Harm Reduction Network in 1999.

SWH: What does harm reduction mean to you?

Harm reduction means very simply “ending suffering and saving lives”, which is a slogan from Chicago Recovery Alliance. Therefore, whatever harm reduction does, it helps individuals who may be engaging in harmful behaviour move forward and make small incremental changes and improvements in their lives. The client is considered to be the expert and the service provider learns just as much from the client as the client learns from the service provider in order to facilitate less harm in the client’s life.

SWH: How easy is it to get funding for research in harm reduction?

Funding for drug research is very hard to come by. Harm reduction has a very close relationship with AIDS, but drug research needs to be expanded. Much of the funding comes from pharmaceutical companies, as those companies are often interested in drug research. However, it is very difficult to get funding for the health of people on the street or the harm that is coming from injecting. It is also difficult to obtain funding for this research because the government is not interested in harm reduction’s effects on drug use. The government does not like people who take drugs because it isn’t fashionable and does not play to their base.

SWH: Why are harm reduction approaches so controversial?

Harm reduction is done naturally to protect society, children, loved ones, families and communities. For example, children are taught to look both ways before crossing the street. Harm reduction is very intuitive, but keeps humanity’s best interest at heart. The stigma against people who use illicit or licit drugs (ie. prescription or over-the-counter medication) is huge and it’s fostered in official propaganda. Drugs are a dangerous substance to use badly. Instead of raising awareness and educating people to reduce the harm of drug use, the world is trying to induce fear on drug users and potential drug users. However, fear doesn’t always work.

SWH: What is the difference between a harm reduction based program and a 12-step program?

Harm reduction is more than individual treatment. As Dr. Gabor Mate would say, ‘everyone who is addicted to drugs has a history of early trauma’, then we need to address early trauma. However, individuals who have been experiencing life on the street for two to three years are continually being re-traumatized on the street. Many people who live on the street for many years have a limited chance of leading a drug free life because the drugs work for them in hiding the physical and emotional pain and trauma that they must cope with in their lives. What right do we have to say to a person that they cannot take away a painkiller and leave them to suffer, we are not sure that we have that right.

There are many ethical dilemmas in working with people who are struggling with drug and alcohol use that are insoluble. Thus, harm reduction is different than an abstinence-based or 12-step program because there is not one way to reduce harm (ie. remaining abstinent) but many ways. Harm reduction is very much based on an individual’s needs, temperament and goals; therefore, it can include abstinence; however, abstinence does not work for everyone. Harm reduction may not witness the solution as quick; however, the solution will most likely become apparent over time. However, since substances are illegal, it is very difficult to receive support for harm reduction practices. Thus, it is much easier to gain support for moderation management with alcohol and/ or cocaine.

SWH: What stage is Canada at for receiving government support for harm reduction?

The federal government still opposes harm reduction. However, on a province-to-province basis, there is some hope. However, funding is always difficult even for the provinces, but at least the provinces are discussing and brainstorming ideas regarding how harm reduction can be implemented. However, it has become increasingly more difficult to get support for harm reduction at the provincial level as grant funding for harm reduction has become more difficult to acquire. Many organizations have relied on city grants to fund harm reduction outreach programs, which is an integral aspect of harm reduction.

SWH: Do you think Canada is further ahead than the United States in harm reduction?

Canada is ahead of the United States in terms of harm reduction; however, Canada should be much further ahead than it appears to be. If you take a close look at harm reduction in the United States, there are at least 17 states that have Good Samaritan laws. Therefore, in some ways Canada is further behind the United States. Canada has led needle exchange programs and crack kit distribution; however, these programs and resources need to be further administered in both Canada and the United States. In addition, the United States has very solid activist groups that are dedicated to making a difference and advocating for harm reduction, which do not exist in Canada.

For more information please visit the Canadian Harm Reduction Network’s website at .

“Crack Babies” and Poverty: Finding the Right Target

The inspiration for this article is the result of a recently published article: “‘Crack baby’ study ends with unexpected but clear result.” Having worked in child welfare long enough to remember and experience first hand the so-called ‘crack babies’, this caught my attention immediately.

The article is a summary of a study that followed children exposed to cocaine in utero, the ‘crack babies’ as they came to be known, in the late 1980’s and early 1990’s.  I held some of these babies, placed them in foster care, and accompanied them on visits to doctors.

My colleagues and I discussed their future, cautioned foster parents about what to expect, and advised the courts on their progress. I took the calls from distraught foster parents at wits’ end who were struggling to care for infants who would stiffen like a board and whose cries were louder, longer, and much more ‘ear piercing’ than a ‘normal’ baby cry. Thankfully most of these foster parents were completely committed to caring for the children and were calling mainly to vent because confidentiality prevented them from sharing their frustrations with others outside of the child welfare system.

crack cocaineWe told the foster parents what the doctors were telling us, “we don’t know what to expect”. We feared the worst, a lifetime of intellectual delays and medical challenges, and hoped for the best, that they would outgrow the trauma of exposure to cocaine during their early development. Over time, we saw infants grow into toddlers and young children who had some challenges but for the most part, seemed to overcome the early exposure.

The study referenced above sought out evidence, more than the anecdotal evidence such as that my colleagues and I had collected, regarding the future of ‘crack babies’. They found some unanticipated results. Perhaps most significant is summed up in this quote, Poverty is a more powerful influence on the outcome of inner-city children than gestational exposure to cocaine”. Yes, they are suggesting that poverty is more damaging to children than cocaine.

While this is just one study with a moderate sample size (over 200 children were followed), there are compelling reasons to pay attention. This was a longitudinal study spanning 25 years, what many consider the ‘gold standard’ for identifying cause and effect in social science research. The researchers were thorough in examining the many factors that might influence findings.

The most important message here is the influence of poverty on children. This suggests that we should be doing everything possible to address the issue of poverty especially as it impacts children and families.

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