The July issue of Vital Signs released by the Centers for Disease Control and Prevention (CDC) focuses on the geographic differences in opioid prescribing. Because health issues that cause pain don’t vary from place to place, according to the CDC, epidemiologists wonder why in 2012 physicians in the highest-prescribing state wrote almost three times as many opioid prescriptions per person as those in the lowest-prescribing state. The CDC also points out that higher prescribing is associated with more overdose deaths. States should increase their prescription drug monitoring programs (PDMPs) and regulate pain clinics to eliminate pill mills, the CDC concluded.

Of particular interest is the Florida situation, which was highlighted in the July 4 issue of the CDC’s Morbidity and Mortality Weekly Report (MMWR).

The MMWR article, by CDC and Florida state epidemiologists, shows that Florida’s addition of a PDMP and crackdown on pill mills resulted in a decline in prescription drug overdose deaths in the state.

Leonard Paulozzi, M.D., medical director with the CDC and a co-author of the article, told ADAW that the supply-side methods — law enforcement and regulations — clearly worked.

Background

Drug overdose deaths in Florida increased by 61 percent from 2003 to 2009, mainly due to oxycodone and alprazolam, a benzodiazepine. During 2010 to 2012, the number of drug overdose deaths in the state decreased more than 16 percent, from 3,201 to 2,666. Death rates for prescription drugs overall decreased by more than 23 percent, with a 52-percent decline in overdose deaths from oxycodone and a more than 35-percent decline in overdose deaths from alprazolam. Legislative and law enforcement actions and the declines in these targeted drugs suggest “that the initiatives in Florida reduced prescription drug overdose fatalities,” the article concluded.

Florida was considered a source for opioids because of the proliferation of pain clinics; it also had 98 of the 100 physicians who dispensed the most oxycodone directly from their offices.

In January 2010, pain clinics were required to register in Florida, and the next month, the federal Drug Enforcement Administration and local and Florida law enforcement initiated an investigation into their operations. That October, regulations of pain clinics were expanded. Operation Pill Nation raids began in February 2011, physician dispensing was banned as of July 2011 and mandatory reporting to the PDMP began in September 2011. In July 2012, wholesale distribution was curtailed.

Heroin

But heroin overdose deaths, which had dropped in Florida as prescription overdose deaths rose, are now on the rise again, according to 2013 data from the Florida Medical Examiners Commission. Still, Paulozzi of the CDC refused to say that there was a link between the supply-side initiatives against prescription opioids and the increase in heroin use and overdoses.

“There is not enough evidence to conclude that the heroin increases are causally related to increased regulation of prescription opioids,” Paulozzi told ADAW via an email that came through the CDC press office. “Nor is there evidence that the heroin increases are related to programs and policies that curb access to painkillers.” For example, in New York City heroin overdoses started increasing in 2011, before the PDMP or opioid prescribing guidelines were implemented, he said.

“However, there is evidence that heroin use follows opioid use, whether or not reductions in opioid access are driving up heroin use,” said Paulozzi. “That relationship demands that we get control of inappropriate opioid prescribing and use so that there are fewer people addicted in the first place and so that our health care system is not contributing to our substance abuse problem in the United States.” Reducing the abuse of prescription opioids will reduce the risk of heroin use, he said. And he noted the following from the Florida MMWR report: “The increase in deaths associated with heroin and hydromorphone and morphine after 2010 might be a sign of a switch to use of alternative opioids. However, the effect of such a switch was limited: 668 fewer opioid analgesic overdose deaths occurred in 2012, compared with 60 more heroin deaths. Heroin deaths fluctuated widely during 2003–2012, so other factors might be involved.”

Florida response to Appalachia

Florida’s response — like the response recommended by the CDC — was primarily a supply-side strategy, said James N. Hall, epidemiologist with the Center for Applied Research on Substance Use and Health Disparities at Nova Southeastern University in Fort Lauderdale. “Cracking down on pill mills, changing the regulations on prescribing and particularly direct dispensing by practitioners, and the reformulation of OxyContin to a tamper-resistant form” were all responsible for the decline in overdose deaths. Florida, which is not generally in favor of regulations, was put on alert to the “extreme nature of the problem” by other states, particularly in Appalachia, where people were traveling to pick up pills and bring them back to use and to sell, he said. Billboards with 800 numbers advertising pain clinics were frequently seen on the two main interstates, but only on the southbound lanes, he said. “You could pay for your winter break by coming down to Florida, enjoying the nice beaches, going to a couple pill mills, maintaining your own habit, and selling the surplus to cover your cost,” Hall said.

Lack of treatment

However, the state has ignored the demand side — the need for treatment, said Hall. Cutting addicts off from their prescription opioids without access to treatment is a prescription for heroin use. “This became a contributing factor to the rising use of heroin, as well as rising deaths due to heroin in Florida.” Hall, who served on the Community Epidemiological Work Group (CEWG), noted that new heroin epidemics breaking out in smaller cities and rural counties is a national problem, and that Florida traditionally has not had as large a heroin problem as some other states, particularly in the Northeast.

“Heroin is the mother of all addictions,” said Hall. “Opioids are what defined addiction in the first place.” Epidemiologists are more scared of opioids and, in particular, heroin than any other drug, he said.

“What we’re seeing in Florida in terms of heroin is part of the national phenomenon,” said Hall. “If we had not cut back on the illicit supply, the heroin problem would be still increasing.” And while the heroin numbers are relatively low in Florida, the rapid escalation is what makes it an epidemic, he said. “The heroin epidemic is going to continue, because we have not yet increased the treatment side of the issue.” Florida is also slow to making naloxone available, said Hall.

Paulozzi of the CDC admitted that getting more people into treatment would help but said that is the province of the Substance Abuse and Mental Health Services Administration, not the CDC. “If we can reduce the number of people who begin using prescription opioids nonmedically today and get more people into treatment, we will have fewer heavy prescription opioid users using heroin in the future,” he said. “In the short term, people injecting OxyContin do report turning to heroin once OxyContin became more difficult to crush, but our long-term goal is to reduce the number of people injecting drugs such as OxyContin in the first place.”