POST 194. August 2, 2021. CORONAVIRUS. “Recently-released data is painting a grim picture of the opioid epidemic that has gripped the United States — as the country is still grappling with the coronavirus pandemic that has killed more than half a million Americans. Some people are calling them twin pandemics that have collided”…

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February 20, 2021

“The opioid epidemic has been eclipsed in the public consciousness by Covid-19, but it hasn’t abated. The pandemic has only exacerbated the crisis, piling stress and grief on top of substance-abuse problems and jeopardizing efforts at recovery…

On the campaign trail, Joe Biden proposed a $125 billion investment in prevention of substance abuse, treatment, and recovery, to be paid over 10 years with taxes on the pharmaceutical industry…

Biden called on Congress last month to set aside $4 billion for HHS to expand drug treatment access during the pandemic. And within his first 30 days, he hired six senior staffers for the Office of National Drug Control Policy (ONDCP), which Trump had gutted.

Advocates want to see the office funded at least at pre-Trump levels. Just as critical is how that money will be spent. The drug czar, whom Biden is expected to appoint soon, has budgetary authority over more than a dozen federal agencies in the National Drug Control Program.

“Less than 50% of ONDCP’s annual $25 billion budget is allocated to treatment and prevention,” said Oliva. “The majority of that budget is spent on law enforcement and interdiction. I would urge the new drug czar to reverse these priorities.”

Treatment will be an emphasis, but enforcement will not go away, LaBelle, the acting drug czar, says. “Drug interdiction, international drug trafficking and precursor chemicals, and the future of drug trafficking and the shift toward synthetics is another issue that has to be taken on.”

Frontline workers around the country say they need funding for less visible long-term recovery support systems—such things as housing, therapy, job placement, and peer support. For any of it to work, mental health care and addiction treatment will need to be widely available and cheap or free.

“If we can get someone on the recovery journey and they can sustain that for five years, they have an 85% chance of sustaining that recovery for the rest of their lives,” says Hampton, the Biden campaign adviser, citing findings from a 2016 surgeon general’s report.” (A)

March 25, 2021

“Opioid-related deaths drove these increases, specifically synthetic opioids such as fentanyl. Opioids accounted for around 75 percent of all overdose deaths during the early months of the pandemic; around 80 percent of those included synthetic opioids…

Overdose deaths increased in almost every state; 24 states and the District of Columbia had an estimated increase of at least 30 percent, and the overall U.S. total increased by 33 percent.

States like West Virginia and Kentucky have long been at the heart of the opioid epidemic, and that region is still reporting some of the largest proportional increases. Recent research has also highlighted the growing impact of fentanyl and overdose deaths within states farther West. Arizona, California, Colorado, Illinois, Texas, and Washington all experienced increases above 35 percent during the first eight months of 2020; Colorado recently reported record overdose deaths during full year 2020…

One policy tool that can address multiple objectives is Medicaid expansion. Data continue to show the positive impact of expansion on coverage, MAT access, and mortality outcomes for substance-use patients.

By simply expanding Medicaid, nonexpansion states like Florida, Georgia, Tennessee, and South Carolina could access significant federal financing in their push to help an ever-growing number of people in need. These four states all experienced overdose death increases above 30 percent during the first eight months of 2020.

Utilizing Medicaid also decreases the reliance on annual discretionary funding to support siloed treatment programs, which has proven to be unsustainable in the fight to reduce drug overdoses. Policy experts recently argued for restructured financing of substance-use treatment through “mainstream public and private insurance programs” like Medicaid that allow states to reliably “pull” down funding as their needs increase.

But in the absence of further financing reform, federal discretionary funding has quickly increased to meet the growing crisis. The December 2020 funding package included $4.25 billion in mental health and substance-use emergency funding; the recently passed American Rescue Plan (ARP) will provide an additional $3.5 billion for block grants in these same areas. President Biden recently announced $2.5 billion to further support states.

Combined with ARP’s significant financial assistance for state and local governments, the targeted substance-use funding will likely be critical for struggling addiction-treatment providers and government agencies that account for a significant percentage of overall substance-use treatment funding. Many have had to contend with tighter budgets related to the pandemic’s economic impact.”  (B)

May 3, 2021

“Recently-released data is painting a grim picture of the opioid epidemic that has gripped the United States — as the country is still grappling with the coronavirus pandemic that has killed more than half a million Americans.

“Some people are calling them twin pandemics that have collided,” Harvard researcher Michael Barnett, Ph.D., said on CBSN Monday.

The Centers for Disease Control and Prevention estimates that 90,237 people in the U.S. died of opioid overdoses between October 2019 and September 2020. The figure is the highest ever recorded since the opioid crisis began in the late 1990s.

“This is an incredibly important public health crisis that has come along with COVID,” Barnett said. “Before 2020, we went into the COVID pandemic with an out-of-control public health crisis of addiction.”

Barnett, who serves as an assistant professor of health policy and management at the Harvard T. H. Chan School of Public Health, pointed out that 2019 had been the worst year on record in terms of opioid-related deaths before this latest figure and said 2020 “would have been terrible as well” with or without the pandemic.

“However during the pandemic, as all of us have experienced, add the stress of the pandemic, extreme isolation, job loss, and you really have a perfect storm for addiction to flourish,” he

The number of American adults who reported symptoms of anxiety or depression between April 2020 and February 2021 rose by 27% over the previous year, also according to CDC data. Emergency room visits for drug overdoses increased by 36% in the same period.

Overall stress due to the pandemic’s impact on health and the economy as well as increased isolation have been described as the main drivers behind the spike in mental health problems.

Barnett warned, “All of these are issues that can either lead people to addiction or worsen addiction in those who may be predisposed.” (C)

June 14, 2021

“Pennsylvania has been among the states hardest hit by the opioid epidemic. It had one of the highest rates of death due to drug overdose in 2018, with 65%, a total of 2,866 fatalities, involving opioids.

The state’s stay-at-home order, implemented on April 1, 2020, mandated that residents stay within their homes whenever possible, practice social distancing and wear masks when outside the home. All schools shifted to remote learning, and most businesses were required to operate remotely or close. Only essential services were allowed to continue operating in person.

In the following months, the public’s overall cooperation with these mandates contributed to measurable declines in coronavirus infection rates. To learn how these mandates also affected people’s use of opioids, we assessed data from the Pennsylvania Overdose Information Network for changes in monthly incidents of opioid-related overdose before and after April 1, 2020. We also examined the change by gender, age, race, drug class and doses of naloxone administered. (Naloxone is a drug widely used to reverse the effects of overdose.)

Our analysis of both fatal and nonfatal cases of opioid-related overdose from January 2019 through July 2020 revealed statistically significant increases in overdose incidents for both men and women, among whites and Blacks, and across several age groups, most notably the 30-39 and 40-49 groups, following April 1. This means there was an acceleration of overdoses within some of the populations most affected by opioids prior to the COVID-19 pandemic. But there were also uneven increases among other groups, such as Black people…

Pennsylvania’s pandemic shutdown has reduced access for recovering opioid users to some of their usual sources of in-person support, like counseling and support groups. Brian King, Author provided (no reuse)

We found statistically significant increases in overdoses involving heroin, fentanyl, fentanyl analogs or other synthetic opioids, pharmaceutical opioids and carfentanil. This is consistent with previous research on the main opioid classes contributing to increases in drug overdose and death. The results also affirm that heroin and synthetic opioids such as fentanyl are now the major threats in the epidemic…

People in the early stages of treatment or recovery from opioid addiction may be particularly vulnerable to relapse, suggested one of our public health partners. “They might be working in industries that are closed down, so they have financial problems … [and] they have their addiction issues on top of that, and now they can’t like go to meetings, and they can’t make those connections.” (Under our clearance with Penn State for doing research with human subjects, our public health informants are kept anonymous.)…”  (D)

July 23, 2021

“The COVID-19 pandemic has exacerbated the many challenges people with any substance use disorder face, not just opioids. Most distressing is that overdose deaths have skyrocketed…

Vulnerable and marginalized patients experiencing homelessness were particularly hit hard and are those I worry most about. Early on, shelters and social service agencies shut down or limited their hours and numbers of people they could serve. Also, public bathrooms to wash hands closed, and it’s almost impossible to maintain social distancing and good hygiene if you’re surviving on the street with other people in the same situation.

Infections related to injection use increased because people could not access harm-reduction supplies, like needles or pipes. Before the pandemic we didn’t have adequate harm-reduction measures, and we still don’t. The pandemic further highlighted the dire need to incorporate and offer harm reduction, as well as welcoming safe spaces throughout the continuum of care for people who use drugs, not just in clinics like mine or needle exchanges.

If I have patients who are injecting and are unable to access safer supplies, their drug use doesn’t just stop. They’re going to use and share needles with other people, which puts them more at risk not only of contracting and spreading COVID, but also other blood-borne infections like hepatitis and HIV.

Patients who were taking buprenorphine, life-saving medication for opioid use disorder, had trouble getting their medication. Buprenorphine is a partial opioid agonist medication, which means it activates the same receptors in the brain as other opioids, but only partially. It prevents and treats painful withdrawal, relieves cravings and prevents overdose death. As it restores altered neuropathways that drive ongoing compulsive opioid use, it helps people with opioid misuse disorder regain normal function.

Many patients had a hard time reaching their prescribers when clinics shut down, so we accepted them at our clinic. We’d get calls from the New England area, not just Massachusetts but places like New Hampshire and Maine. People would say, ‘I can’t reach my provider, what should I do?’”  (E)

July 24, 2021

“But the opioid epidemic has not unfolded unchecked. Over the past decade, successful state-level policies have included prescription drug monitoring programmes and increased availability of naloxone to prevent overdose. Endorsement of medication-assisted therapy for treatment of substance abuse and overdose prevention has also increased. In April, 2021, the so-called X-waiver was rolled back by the DHHS, enabling more health-care providers to prescribe buprenorphine for opioid use disorder. But stigma around addiction, and restrictive regulation and persistent reluctance by medical professionals to prescribe medication-assisted therapy have hampered progress.

It is promising, then, that the Biden Administration has nominated Rahul Gupta as head of the Office of National Drug Control Policy. If confirmed, Gupta—former health commissioner of West Virginia—will be the first physician to take the role, signifying less focus on legal and law enforcement approaches to drug policy and an increased emphasis on addiction treatment and expanded health-care services.

His appointment comes at a vital time. The 2020 data suggest that the COVID-19 pandemic has been a potent accelerant of opioid-related overdose deaths. The mechanisms are unclear, but it is likely that disruptions in available treatment services and reduced access to harm reduction practices, such as closures of safe injection sites, will have played a role. The data also highlight important demographic points. West Virginia, the epicentre of the crisis, continues to have the highest number of overdose deaths, but urban areas have overtaken rural areas for age-adjusted death rates. The number of 45–64-year-old non-Hispanic Black people in urban areas dying from synthetic opioid overdose has been rising swiftly, a population who are also at greater risk of dying from COVID-19. Although white, rural, middle-aged people are still severely affected by the opioid crisis, it would be unwise and counterproductive to consider overdose deaths their sole preserve. A major test for Gupta will be how to increase financing of addiction prevention and treatment services within the often fragmented infrastructure funded by public health insurance. He will need to reinforce resources in the regions that have been hardest hit by COVID-19, and equitably target emerging regional and group vulnerabilities to opioid use.”  (F)

August 16, 2021

“In the last week of January 2020, the Seaside Recovery Center, a clinic that uses methadone and other medication to treat people with opioid addiction, opened in the city’s south end…

So the feds began to grant clinics like Seaside Recovery Center the freedom to determine whether patients could be trusted to take medicine home with them — to not sell, abuse or otherwise mishandle it — and how often that person should have to visit the clinic. A patient who had been dropping by daily could now do so weekly.

“We actually got to make those decisions based on what we knew about the patient, and not necessarily just based on what these very old rules told us we had to do,” Noice said.

One upshot is that Seaside patients missed out on a key part of their treatment: group counseling. The clinic tried to hold electronic sessions, but individual phone calls between counselors and patients proved more successful.

Addiction treatment relies on peer groups; recovery involves building a network that supports a person’s sobriety, Noice said. For about a month and a half, the few Seaside patients met in the group therapy room, but a strong cohort — the desired number is between 8 and 12, Noice said — couldn’t get established before in-person meetings were discontinued.

The clinic’s doors remained open, medication went to everyone who needed it, new people signed up and care never ceased. Patients still underwent urine analyses, met with counselors — if only briefly — and scheduled longer therapy sessions to take place later by phone or video.

“But we didn’t build a community the way that you normally see a community develop in a clinic like that,” Noice said.

The pandemic has so defined the experience of Seaside’s staff and patients that it is hard to tell whether unforeseen challenges — for instance, the patient population has not increased as fast as CODA had expected — are due to COVID or the newness of the clinic.” (I)

August 25, 2021

“The COVID-19 pandemic forced many of us to spend months or longer isolated in our homes. Throughout 2020, experts warned that the side effects of this necessary but difficult public health emergency would be especially hard for those struggling with behavioral health conditions or a substance use disorder.

Unfortunately, they were right.

Throughout the country, an estimated 93,000 Americans were killed by an accidental overdose last year — a 30% increase from 2019. While we avoided such a spike, and actually saw a reduction, in Camden County, 288 of our friends, family, and neighbors were still lost to this debilitating disease.

While the COVID-19 pandemic still represents the most significant public health crisis of our lifetimes, it took just one year to develop free, safe and effective vaccines for the public that protect against the virus and dramatically reduce the risk of death from contracting COVID-19.

There is no vaccine for overdoses, and none is on the way.

Our best tool in fighting the disease of addiction is openness, empathy and information. If we work together, we can eliminate the scourge of opioid-related deaths from our community, but it is not easy.” (G)

August 26, 2021

“Pennsylvania’s opioid disaster declaration is set to expire at the end of Wednesday after state lawmakers, newly empowered to help manage statewide emergencies, declined the governor’s request for another extension.

Democratic Gov. Tom Wolf first declared a public health emergency in January 2018 after Pennsylvania set a record for opioid deaths, then renewed it more than a dozen times as the state battled an overdose epidemic that has worsened during the coronavirus pandemic.

Wolf had to seek legislative approval for another extension because of a newly approved constitutional amendment limiting a governor’s emergency powers. But the GOP-led General Assembly declined to go along.

“Our fight is not over,” Wolf said in a written statement. “We have an obligation to support individuals desperately in need of substance use disorder services and supports. With or without a disaster declaration, this will remain a top priority of my administration.”

The disaster declaration made it easier for people to get treatment, expanded the state’s prescription drug monitoring program and established an inter-agency opioid “command center” to coordinate the state’s efforts, among other things.

State officials cited progress, with opioid prescribing down by more than 40% and overdose deaths falling by nearly 20% after a record 5,403 people statewide died in 2017.

But overdose deaths have climbed again during the pandemic. More than 5,000 people died of drug overdoses in 2020, according the Wolf administration.” “ (H)

August 31, 2021

“In the wake of the pandemic, the overdose crisis has reached new heights that call for rethinking our response, both nationally and in Florida. In many parts of the country, the year-over-year overdose death rate jumped by more than 50% between 2019 and 2020. The Centers for Disease Control (CDC) calculates the average nationally to reach rates as high as 40%, bringing us over 93,000 overdose deaths nationally in 2020.

We are quite literally at an unheard-of rate of increase — on top of annual increases that had long ago put us at record numbers. The drug overdose death rate suggests a public-health threat of a magnitude that we have never seen in American history. Can you imagine the outcry if we saw that kind of increase in vehicular-accident deaths or gun-related deaths? But drug overdoses? Not so much…

Beyond focusing attention on the crisis, our response needs to be attentive to the fast-moving ways in which the overdose crisis, still mostly fueled by opioids, is shifting. The people distributing and seeking drugs make for an efficient market that responded to the prescription pain medicine crackdown by shifting to illicit fentanyl on the street.

Pain prescribing is reaching historic lows. As measured by prescription of morphine milligram equivalents (MMEs), the amount of opioid prescriptions in Florida are down 67% since 2018. The battle to save lives is no longer just in the doctor’s office; it is on our streets and online via apps like OfferUp (the successor to Craigslist) that have taken drug dealing digital.

The crisis is changing quickly in other ways. Though in earlier phases of the opioid crisis, the face of the crisis was rural working-class Americans, today, the most dramatic change has been the rate of overdose increases among Black and Latino Americans. Just as COVID-19 had disproportionate impacts for Black and Latino Americans, so too the opioid crisis is wreaking havoc in communities of color…

While the delta variant has highlighted the extent to which the pandemic demands our attention to preventing unnecessary deaths, it is finally time for leaders to acknowledge that we are simultaneously fighting a second health crisis that also requires urgent attention.

What is clear is that, even though all of us applaud the legal reckoning for drug companies and cheer the much deserved punishment we hope profiteers like the Sacklers receive soon, we can no longer believe that limiting access to prescription opioids is the panacea solution to this crisis we may have once believed it was. Opioid prescribing is at a historic low, yet opioid-related deaths are at a historic high. As one phase of the crisis winds down and another is just beginning, it is time for a new strategy…

I encourage you to ask the tough question: why are we not doing more to prioritize and address this tragedy? We have the ability to address the pandemic and still meet the deep needs of a society battling an unprecedented opioid crisis that has changed before our eyes. This will only happen if and when leaders begin prioritizing this epidemic inside the pandemic to stem the tide of another generation lost to the modern drug crisis.” (J)

September 1, 2021

“Methadone has long been a gold-standard treatment for opioid addiction. But government regulations mean that many patients have to organize their lives around getting and taking it, no matter how well they are doing, a new study has found.

The pandemic made it unsafe for people to queue up daily at methadone clinics, so rules were relaxed to allow patients to take doses home just like other prescriptions. And, advocates say, the change helped people maintain recovery and ought to become permanent.

The new study, published in the Journal of Harm Reduction and conducted by researchers at New York University, Icahn School of Medicine, and the City University of New York, interviewed current and former methadone users, people who used illegal opioids but never methadone, and treatment providers.

“It’s like liquid handcuffs,” one woman, a former methadone patient, told the study authors, using a common euphemism for the treatment. “Say you want to go somewhere for a few days, you need take-homes and if they won’t give them to you, there’s nothing you can do. Everyone has trouble with [take-homes], whether it’s losing their job, or they can’t go out of town, or they’re just late, or sick.”

Methadone staves off the painful withdrawal symptoms that otherwise might send people who use opioids in search of street drugs. Medication-assisted treatments (MAT) such as methadone have repeatedly been shown to produce more durable recovery than 12-step programs alone. It’s possible to take home other types of MAT, but methadone is much cheaper.

Federal regulations require patients to take their methadone under daily supervision at a clinic, largely to prevent street sales and overdoses. Guidelines allow for patients to receive up to two weeks, and, in some cases, a month’s worth of doses to take at home once they’re deemed stable enough. Yet many clinics maintain even stricter rules around take-home doses, and most patients on methadone rarely get more than a few days’ worth of take-home doses, the study authors wrote.

The requirement to show up each day for a single dose of medication makes it hard to find and keep a job, travel, or return to the rhythms of “normal life,” patients said. Several described missing family gatherings, funerals and weddings because they couldn’t get take-home doses, or were forced to juggle work responsibilities with clinic appointments.” (L)

September 2, 2021

“New Jersey experienced a record number of overdose deaths during the first half of this year, according to state data, and could surpass the all-time high number of drug-related fatalities recorded in 2020 if the current pattern holds.

Between January and the end of June, 1,626 New Jerseyans lost their lives to an overdose, the state Attorney General’s office reports, nearly three dozen more deaths than were recorded by that point last year. If this pace continues through the fall, more than 3,250 people would die in this manner during 2021 — an increase of more than 6% over the 2020 total, an NJ Spotlight News analysis found.

Overdose deaths have been on the rise for more than a decade in New Jersey before they appeared to peak in 2018, when some 3,118 residents lost their lives in this way. The tally declined to 3,021 in 2019, before creeping up again to 3,046 last year.

Experts say the recent increase reflects the impact of the ongoing pandemic, which has led a growing number of people to turn to drugs and alcohol to cope with the isolation, fear and economic- and health-related stress. Gov. Phil Murphy’s administration has continued to invest tens of millions of dollars annually in efforts to expand access to treatment and other social services for those with substance use disorders.

But support for these programs is not universal. In July, Atlantic City voted to close a harm-reduction center because of concerns about its impact on the resort’s tourist district. It was one of six facilities statewide that offered free clean needles and other assistance to IV drug users, a proven way to combat overdoses and the spread of infection. State officials later offered their support for a bill by Sen. Joe Vitale (D-Middlesex) that would give the state Department of Health power in deciding where harm-reduction programs should be located, instead of local governments.” (K)

September 3, 2021

“Faced with a novel health crisis, researchers are collecting data on the long-term impact of using opioids to treat COVID-19 pain…

According to Yashar Eshraghi, MD, the medical director of pain research at Ochsner Health in New Orleans, who led the study, current data on the risk for chronic opioid use after short-term use is both unclear and nuanced. Some research does suggest that under certain circumstances, short-term opioid use does not increase a patient’s risk for chronic use or abuse, while other studies have found the opposite to be true….

According to Eshraghi, the new research addresses the nuances needed to properly assess the cost versus benefit of treating a patient’s pain with opioids.” (N)

POSTSCRIPT – September 1, 2021

“Purdue Pharma, the maker of the highly addictive painkiller OxyContin, was dissolved on Wednesday in a wide-ranging bankruptcy settlement that will require the company’s owners, members of the Sackler family, to turn over billions of dollars of their fortune to address the deadly opioid epidemic.

But the agreement includes a much-disputed condition: It largely absolves the Sacklers of Purdue’s opioid-related liability. And as such, they will remain among the richest families in the country.

Judge Robert Drain of the U.S. Bankruptcy Court in White Plains, N.Y., approved the settlement, saying he wanted modest adjustments. The painstakingly negotiated plan will end thousands of lawsuits brought by state and local governments, tribes, hospitals and individuals to address a public health crisis that led to the deaths of more than 500,000 people nationwide.

The settlement terms have been harshly criticized for shielding the Sacklers. They are receiving protections that are typically given to companies that emerge from bankruptcy, but not necessarily to owners who, like the Sacklers, do not themselves file for bankruptcy.

Several states, including Connecticut and Washington State, have already said they intend to appeal the judge’s ruling.

In exchange for the protections, the Sacklers agreed to turn over $4.5 billion, including federal settlement fees, paid in installments over roughly nine years. Those payments, and the profits of a new drug company rising from Purdue’s ashes with no ties to the Sackler family, will mainly go to addiction treatment and prevention programs across the country.

Judge Drain delivered his ruling orally from the bench in a marathon session that ran to six hours, meticulously working through his reasoning in a case he called the most complex he had ever faced. “This is a bitter result,” he said. “B-I-T-T-E-R,” he spelled out, explaining that he was frustrated that so much Sackler money was parked in offshore accounts. He said he had expected and wished for a higher settlement.

But the costs of further delay, he said, and the benefits of an agreement he described as “remarkable” in its ability to help abate the epidemic, tilted toward approval.

While the settlement serves as a benchmark in the nationwide opioid litigation aimed at covering governments’ costs and compensating families, it also means that a full accounting of Purdue’s role in the epidemic will never unfold in open court. Purdue pleaded guilty to federal criminal charges for drastically downplaying OxyContin’s addictive properties and, years later, for soliciting high-volume prescribers.” (M)

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