There’s an innovation of sorts going on in the federal approach to opioid overdoses; a year ago, they were still saying that the best way to deal with the problem was to reduce access to prescription opioids, and that these cutbacks were not driving people to illicit opioids (see ADAW, Sept. 16, 2016). The tone has changed. Now that fentanyl, and not prescription opioids, is leading overdose deaths, the federal Centers for Disease Control and Prevention (CDC) is starting to change its approach. A strategy aimed at reducing opioid prescriptions, with the hope that this would translate to a reduction in opioid use disorders and overdoses, has not worked. In a Viewpoint published online Oct. 11 in the Journal of the American Medical Association, CDC authors write about their provisional data showing that the greatest increases are for overdoses related to illicit fentanyl, which have doubled. Illicit fentanyl now accounts for almost the entire increase in drug overdose deaths from 2015 to 2016, they write.

Another study, by Theodore J. Cicero, Ph.D., and colleagues, found that heroin now tops the list of the first opioid of use (see ADAW, Oct. 16). The CDC has repeatedly said that most heroin users started with prescription opioids. The Cicero study used data from a treatment center component of the Researched Abuse, Diversion and Addiction-Related Surveillance (RADARS) System, a pharmaceutical industry–supported initiative that analyzes postmarketing data on abuse and diversion of prescription opioids and heroin.

We talked to Rita K. Noonan, Ph.D., one of the authors of the Oct. 11 Viewpoint in JAMA, about whether the CDC is changing its approach based on the fact that illicit, not prescription, opioids are now the problem. 

“It’s not either-or,” said Noonan. “There’s no one way to address this.”

There used to be one way: cut back on prescribing of opioids. Prescription opioids were the main focus when people were snorting and chewing OxyContin and prescription opioids were being sold in pill mills. The CDC effectively cut back on many of these prescriptions — but not enough, Noonan said. “We still have a lot of work to do focusing on the supply,” she said.

But illicit fentanyl has changed that. It is driving the entire increase in overdoses, according to the JAMA Oct. 11 study by Noonan and others at the CDC. People may die before someone can even reach them with naloxone, the drug is so potent.

  • Drug overdose deaths in 2015: 52,898; from illicit fentanyl less than 10,000.
  • Drug overdose deaths in 2016: 64,070; from illicit fentanyl more than 20,000.

Source: “Underlying Factors in Drug Overdose Deaths,” JAMA, Oct. 11, Dowell et al.

Opioid prescribing is still three times higher than it was in 1999, said Noonan. But now, perhaps because prescription opioids are less available, people are starting with heroin, according to the RADARS article, and more are dying from illicit fentanyl, according to the CDC. “Now there is a population that has shifted to the illicit or started with the illicits,” she said. “You need very good naloxone distribution, and treatment, and linkages between systems.”

As for heroin being the first opioid of use, “there are other studies from various surveillance systems,” said Noonan. “But we can agree that the numbers we’ve been citing — that three out of four heroin users used prescription opioids first — are changing,” she said. “So we’re not surprised” to see the RADARS report, she said.

“We also know that heroin showed up; it’s cheap and potent,” said Noonan. “Now, it’s illicit fentanyl, often unbeknownst to users and dealers,” she said. “Even experienced heroin users can die from fentanyl.”

Still trying to replace DAWN

Now, the CDC is talking about interventions such as emergency room buprenorphine induction, warm handoffs to treatment for overdose survivors and more.

Simply tracking overdose deaths isn’t going to capture the magnitude of the problem either, because so many people are now rescued by naloxone. “We’re trying to get a better hold on this,” said Noonan.

The demise of the DAWN (Drug Abuse Warning Network) system in 2012 has not been helpful. Run by the Substance Abuse and Mental Health Services Administration (SAMHSA), DAWN, which monitored drug-related emergency department (ED) visits and deaths, was shut down and the work moved to the CDC’s National Center for Health Statistics (NCHS) five years ago (see ADAW, Oct. 8, 2012). The reason was lower costs, less burden on hospitals and adding more information such as patient demographics and the reimbursement source. However, far fewer ED visits were captured by the NCHS program.

The CDC is now phasing in the National Violent Death Reporting System to track overdoses, said Noonan. By next year, 33 states will be included.

DAWN’s last report was on 2011. For six years, the opioid epidemic has been increasing, with the CDC in charge of tracking, and no good system in place yet to replace DAWN.

“We want to better understand who is dying from this,” she said. “When possible, we try to get any of the medical records that might be available.”

“DAWN is gone,” said Noonan. “What we have now is not a full replacement, but we are trying to re-establish a database so we can get a national estimate,” she said. “We’re trying to piece together sources, but the data can be too old,” she said. “In some of those 33 states, they will also be using EMS data.”

Strategy backfired?

Specifically, Noonan and others at the CDC have been looking at this issue. “We asked the question, ‘Are we driving people to the illicits?’” she said. The answer, published in Health Affairs in October 2016, was the same one she gave us in our story that appeared in the Sept. 16, 2016, issue: No. “Despite the potential link, our findings do not support the hypothesis that policies related to opioid prescribing were associated with increased heroin deaths during 2006–13,” that article concluded.

But now, more data is going to be coming in post-2013, and the answer may be quite different. “We’re going to be having informative discussions when the data start rolling in,” said Noonan. The provisional data published in the Oct. 11 Viewpoint show what direction those discussions will take.

Thirty years ago, the crisis was cocaine, then methamphetamine. Will the opioid crisis end, turning into a crisis of another substance? “We created a population that has a taste for opioids,” said Noonan, paraphrasing then-CDC Director Thomas Frieden, M.D. “Pain did not increase, but there was a precipitous increase in prescribing of opioids.” But it’s likely now, because of illicit fentanyl and heroin, that curbing prescriptions is not going to help. “There are people who have been studying drug cycles over many decades and talk about the length of such cycles,” said Noonan. “But it’s hard to tell in this case, because of fentanyl, and because of the nature of how drugs are distributed.” Even the Drug Enforcement Administration (DEA) is stymied, she said. “The DEA will say openly they’re at a loss for how to go after this one,” she said. “They use all their traditional methods, but then you have fentanyl analogs coming through the mail, you have a rogue guy in New Hampshire buying carfentanil on the internet. It’s a new ballgame.” Other dangers go beyond the opioids themselves. “There are lots of drugs and chemicals, pesticides, mixed in with almost anything, sold and distributed, trying to get young people hooked,” she said. “This looks and feels different from previous drug cycles.”

The CDC is still not admitting that their strategy has backfired. “We do get asked the question, ‘Are you forcing people to illicit?’ and the answer is, no, we don’t think so,” said Noonan. “But at the same time we can and should be doing all these other things, like linking to treatment.” And the CDC, which has always said that treatment is the purview of SAMHSA, is now more open to it. “We are very much getting more and more involved in that space,” said Noonan. “We are very much trying to support connection to evidence-based treatment, which is for most people — not all — mainly medication-assisted treatment with methadone and buprenorphine,” she said. “But we’re not abandoning the important work on prescribing.”

For the CDC article, go to https://jamanetwork.com/journals/jama/fullarticle/2657548.

For the RADARS article, go to https://www.ncbi.nlm.nih.gov/pubmed/28582659.

Also see http://www.alcoholismdrugabuseweekly.com/Article-Detail-Print/cdc-no-link-between-rx-opioid-crackdown-and-increase-in-heroinfentanyl-ods.aspx.

Bottom Line…

The CDC is changing its tone, if not its strategy, to focus more on illicit fentanyl and heroin, but is not abandoning its push to cut back on prescribing of opioids.