Pubdate: Mon, 10 Nov 2014
Source: Baltimore Sun (MD)
Copyright: 2014 The Baltimore Sun Company
Author: Robert P. Schwartz
Note: Dr. Robert P. Schwartz is medical director of Friends Research Institute.
Page: 13
Bookmark: (Heroin Overdose)


Once largely relegated to Baltimore City, heroin use and its related 
adverse consequences are spreading to every part of the state, and an 
increasing number of Maryland's citizens are dying of heroin 
overdoses. This shift reflects national trends showing a 74 percent 
increase in heroin use from 2009 to 2012 and a doubling of heroin 
overdose rates in 28 states sampled by the Centers for Disease 
Control. After a sharp reduction in heroin overdose deaths from 2007 
to 2010, Maryland heroin deaths have risen to mirror these increases, 
reaching 464 deaths in 2013. In Baltimore City, conversely, the 
number of heroin overdose deaths had declined from its peak in 1999 
to a low of 76 in 2011 and has not risen as sharply as it has in 
other parts of the state.

This recent statewide rise in overdose deaths appears to be driven by 
two factors: changes in the availability of prescription opioids and 
a decreasing price for heroin.

After more than a decade of increasing misuse of prescription opioid 
analgesics, the supply of such medications is being reduced by law 
enforcement actions and by prescription monitoring programs, which 
alert physicians of patients who are "doctor shopping" for multiple 
prescriptions. As the availability of these medications is reduced, 
some individuals with a proclivity to misuse opiates will move toward 
heroin, which has declined in price in the past few years.

The combination of relatively cheap heroin (which is sometimes laced 
with fentanyl - an opiate 100 times more potent than morphine) and a 
group of individuals with prescription opiate dependence who can no 
longer afford to obtain these medications is a recipe for increased 
overdose deaths.

The response to this increase in overdose deaths must be multifaceted 
and include local prevention messaging, physician training on proper 
prescribing of opioid medications, federal and state law enforcement 
to reduce large-scale heroin trafficking, and efforts to increase the 
availability of treatment for those in need.

Fortunately, there are a number of treatments that can be brought to 
bear. Two effective medications, methadone and buprenorphine, are 
approved by the FDA to treat opioid addiction.

These medications, when taken at the proper dose as part of 
treatment, help patients feel normal (not "high"), block the effects 
of heroin, free patients from the daily grind of heroin use and 
permit them to function in society. A third effective medication, 
called naltrexone, is FDA-approved to prevent relapse.

It is a pure opioid blocker that can be taken daily by mouth or 
monthly by injection.

No single treatment is right for everyone, and therefore these 
effective treatments must be available in the community and in local 
jails to anyone who needs and wants them.

Importantly, there is also an FDA-approved medication called naloxone 
(Narcan) that is an antidote to opioid overdose.

This medication is a short-acting opioid blocker that can revive an 
individual who has overdosed on opioids.

While typically used by paramedics and emergency room staff, 
increasingly naloxone is being made available to non-medical 
personnel to save lives in the community because typically overdoses 
are witnessed by someone who could intervene effectively.

To date, Maryland's response to heroin related problems has been 
robust. In June, the governor issued an executive order to create a 
state-wide Overdose Prevention Council which has brought together key 
state agencies to coordinate the Maryland's response.

The health department has ramped up its prescription monitoring drug 
program and increased the availability of the heroin-antidote 
naloxone, which is being used by law enforcement, first responders, 
and peers and family in Baltimore City. A new Good Samaritan law 
passed this year protects from prosecution individuals who try to 
assist those who have overdosed. Drug abuse treatment is increasingly 
available to indigent patients through the state's expansion of 
Medicaid, and long-standing waiting lists for methadone treatment 
have all but disappeared. Finally, the state's prisons and the 
Baltimore City Detention Center have significantly increased the 
availability of drug abuse treatment.

While governors do not control every factor in their states that 
might influence the availability of heroin and prescription opiates 
and their related consequences, they can make a difference. It will 
be critical for Governor-elect Larry Hogan to continue the efforts 
that are already underway in Maryland and to react quickly to 
changing conditions.
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MAP posted-by: Jay Bergstrom