The federal Centers for Disease Control and Prevention (CDC) in interviews last week with ADAW continued to state that there is no causal connection between the successes in reducing prescribing of prescription opioids and the increase in overdoses with illicit opioids. If there were, some think the federal policies could be implicated, because they had reduced access to prescription opioids — which indeed were responsible for causing overdoses and addiction. However, the increase in heroin and illicit fentanyl overdoses is seen by many local law enforcement and public health officials to be an unintended consequence of the limits on the supply. The main route to reducing misuse of prescription opioids has been prescription drug monitoring programs (PDMPs), which allow doctors to track what other controlled substances a patient has been prescribed or dispensed.
The PDMPs and other prescriber education initiatives have had a chilling effect on the prescribing of opioid analgesics, resulting in fewer of them being available on the street due to diversion.
Last month, the Surgeon General took another step in reducing physician prescribing, warning doctors about overdoses and referring to the CDC’s guide, which also warns about prescribing of opioids (see ADAW, March 28; December 21, 2015).
The CDC denies that the crackdown on prescription opioids, including the shutting down of “pill mills,” has sent people with opioid use disorders into the street to buy illicit fentanyl and heroin, and instead sticks to its main prevention goal of reducing prescription opioids.
“For the majority of heroin users, their first opioid was a prescription opioid,” said Rita Noonan, Ph.D., chief of the health systems and trauma systems branch in the CDC’s Division of Unintentional Injury Prevention. This is why focusing on prescription opioids makes sense “in the long term.”
Noonan also said that geographic areas where opioid prescribing is at high levels are targeted by drug dealers.
She cited a forthcoming study to be published in Health Affairs next month showing that states with pill mill laws and PDMPs were the same states where there was a significant decrease in opioid prescribing. From there, the CDC tried to see if there was also a decrease, or an increase, in heroin death rates, she said.
PDMPs, naloxone and treatment
The federal government has laid out a three-point response to the opioid overdose problem: (1) prescriber education, (2) naloxone provision and (3) treatment with methadone, buprenorphine or naloxone. If a patient is getting prescription opioids and is dependent on them, or is misusing them, or is doctor-shopping, or all three, that person is probably going to end up without refills. He or she will be in withdrawal and need treatment, or will seek out other drugs such as heroin or illicit opioids on the street.
We asked Noonan what the CDC is recommending physicians do about getting treatment for their patients who seem to need it. “We don’t officially work in treatment provision,” she said. “We have told our state grantees to make linkages to treatment, but we don’t fund treatment.” She said that the Substance Abuse and Mental Health Services Administration (SAMHSA) is the agency that is responsible for treatment. President Obama “wanted to spend a lot of money to expand treatment,” she said, referring to the $1 billion proposed by the White House for the FY 2017 budget. She also suggested that the Federally Qualified Health Centers under the Health Resources and Services Administration are also participating in treatment initiatives.
“Scientifically speaking, given the research that we’ve done, there’s no relationship” between the efforts to reduce prescribing of opioids and the increases in heroin and illicit fentanyl overdoses, Noonan said. “Additional research can be done — I don’t want to speculate,” she said. “But what we have right now is evidence that suggests that these policies have had the intended effect, and that they have reduced overdose deaths.”
In fact, almost a year ago the CDC did issue an RFA for research on this subject. From the RFA: “The purpose of this research is twofold: to investigate the patterns of prescription opioid pain reliever (OPR) use and misuse and transitions from OPR misuse to heroin use (Priority # 1); and whether OPR prescribing is a risk factor for heroin overdose, and if policies and strategies aimed at curbing inappropriate prescribing are associated with increased or decreased risk for heroin overdose (Priority # 2). Applicants are expected to submit one application to address either the first or second research priority.” For the RFA, go to http://www.grants.gov/custom/viewOppDetails.jsp?oppId=280151.
Lack of evidence
Still, the main message from the White House has steadfastly been that there is no evidence that people, unable to get prescription opioids from whatever source (doctor, street dealer), are switching to heroin or other illicit opioids, despite anecdotal evidence that this is taking place. A New England Journal of Medicine article from the National Institute on Drug Abuse, the CDC and the Food and Drug Administration in January stated there was no evidence linking the successful crackdown on prescription opioids and increases in heroin (see ADAW, Jan. 18). The main issue is lack of evidence.
“The absence of data is not truth, but a silence that requires rigorous scientific inquiry,” Traci Green, Ph.D., a Brown University researcher on drug abuse epidemiology whose work has been funded by the CDC, told ADAW last spring. “I hope that whatever is found, we are willing to listen objectively to the data and decide on a policy path that is based on evidence.”
Green thought that the NIDA-CDC-FDA article was “premature.” There is “no reason to think that supply crackdowns” would not create unintended consequences, she said. “If we can learn from the past, then maybe we can try to improve the safety of the supply and drug use, reduce the harms of drug use through sensible harm minimization strategies, and quit with incarceration and purely enforcement (supply) based approaches as our sole focus,” she said.
She was particularly concerned about fentanyl, because exposure in the case of a tainted supply is more likely to be fatal than nonfatal, she said. Green is an expert in “counterfeit” prescription pills (see ADAW, June 6).
Four years ago, there was already evidence of a correlation between prescription opioid decreases and heroin increases: in 2012, the National Survey and Drug Use on Health found a heroin increase was correlated with a prescription opioid abuse decrease (see ADAW, Sept. 16, 2013).
Meanwhile, overdoses are going up, with the CDC itself issuing these reports. Last December, the CDC reported that heroin and illicit fentanyl overdoses were increasing (see ADAW, Jan. 11).
A CDC Vital Signs report from Florida in 2014 showed that heroin overdoses were increasing, while prescription opioid overdoses were decreasing (see ADAW, July 14, 2015).
Last year, the CDC’s Leonard J. Paulozzi, M.D., told ADAW that by preventing the initiation of prescription opioid use, there would be fewer heroin overdoses in the future (see ADAW, May 4, 2015). The rationale is that most heroin users say they first took prescription opioids. He admitted, however, that for some people, prevention is too late — they need treatment. “If you have a large cohort of people who are already physiologically dependent on heroin or prescription opioids, those people aren’t going to go away,” he told ADAW then. “They’re going to seek drugs, and they will need to get into treatment. But if we can stop feeding that pool now, it will help.”
Treatment not tracked by the CDC
The CDC has $70 million for funding to states to implement prevention strategies. The next step is to obtain data from those states to better track prescribing practices, morbidity outcomes and mortality outcomes, said Puja Seth, Ph.D., lead for the CDC’s prescription drug overdose epidemiology and surveillance team. The CDC will not track whether patients are referred to treatment, she said. “Treatment is more SAMHSA’s responsibility,” she said. “We want to know whether prescribers are checking the PDMPs before they prescribe.”
Seth added that it’s not possible to have patient-level data regarding who goes to treatment. “We do get some patient-level data on the PDMP form, and we have patient-level data around prescribing practices,” she said. “We can tell if a patient is doctor-shopping.” But the CDC can’t tell which patients are referred to treatment, or whether any physician is actually referring patients to treatment.
The increasing overdoses caused by heroin and illicit fentanyl, and the curbing of prescription opioid availability, are not related, the CDC says, abiding still by its main goals, which are to educate prescribers and encourage PDMPs.