Pubdate: Mon, 02 May 2016
Source: Boston Globe (MA)
Copyright: 2016 Globe Newspaper Company
Contact: http://services.bostonglobe.com/news/opeds/letter.aspx?id=6340
Website: http://bostonglobe.com/
Details: http://www.mapinc.org/media/52
Author: Evan Horowitz

US FACING NOT ONE, BUT TWO OPIOID EPIDEMICS

The headlines have become grimly familiar: "More than 20 overdose 
deaths hit Middlesex in 3 weeks," "Opioid overdoses kill 10 people in 
12 days in Sacramento area," "Opioid abuse has death grip on Tennessee."

But there's a problem with this umbrella term "opioids." It hides the 
fact that Americans are actually dying from two separate scourges: 
some are succumbing to heroin, others to prescriptions drugs like 
OxyContin, Percocet, and Vicodin.

Reacting to these very different epidemics with a set of policies 
focused on "opioids" may ultimately prove inadequate, even 
counterproductive. Because heroin and prescription opioids are 
killing different people, in different ways, across different parts 
of the country.

Heroin deaths are largely concentrated across New England and the 
Midwest, and heroin victims tend to be young men in their 20s and 
early 30s. By contrast, prescription opioids are killing people all 
across the country, especially people aged 45-54 and including a 
substantial number of women.

Perhaps most critical, a Globe anaylsis of death certificates 
compiled by the Centers for Disease Control shows a marked shift 
towards heroin, which once contibuted to less than 15 percent of 
opioid overdose deaths and now accounts for nearly 40 percent.

Reports from the front lines suggest that heroin overdoses may still 
be spreading. In the worst case scenario, if the death rate in 
heroin-afflicted New England became a national norm, nationwide 
heroin deaths would double.

Two opioid epidemics

The last fifteen years have seen a terrifying increase in the number 
of opioid deaths - counting both prescription drugs and heroin.

To understand this explosion in opioid abuse, it helps to break this 
story into two phases:

1999-2010

During this first phase, the overdose rate from prescription opioids 
increased by roughly 300 percent. That alarming growth was driven by 
newly-popular prescription drugs like OxyContin, which flooded the 
market before spilling into the streets, where they found a ready 
market of users.

The impact was sudden and widespread, breaking across regional 
boundaries and claiming lives all across the country.

Throughout these years, heroin deaths remained muted. In 1999, there 
were about .7 heroin overdoses for every 100,000 people in the US. In 
2010, that numbers was 1.0, a slight increase but nothing to match 
the trauma of prescriptions drugs.

2010-2014

The years since 2010 have seen a tripling in heroin deaths, partly a 
result of growing popularity and partly from the deadly kick which 
comes from the widening practice of lacing heroin with fentanyl.

And as heroin deaths have soared, prescription drug overdoses have 
largely plateaued, though an uptick in 2014 has raised concern of a comeback.

One key feature of the heroin surge is that it's been fairly 
localized. Across New England and parts of the Midwest, heroin 
contributes to about half of all opioid-related deaths. In 
Connecticut, 59 percent of opioid-related deaths involve heroin. In 
Illinois, it's 64 percent.

A slightly less virulent heroin crisis is affecting the borderlands 
of the southwest as well as the Pacific northwest.

Yet, across the great plains and much of the southeastern United 
States, heroin deaths remain far more rare. In Oklahoma and Kansas, 
Idaho and Wyoming, less than one in five opioid-related deaths stem 
from heroin.

The CDC cautions against putting too much weight on these state 
numbers, because some of the variations may stem from the fact that 
states report deaths in different ways. But their own research 
confirms the regional pattern, and detailed survey data from the 
Substance Abuse and Mental Health Services Administration tell a similar story.

Different drugs, victims

Heroin and prescription drugs aren't just spreading through different 
regions; they're also affecting different types of people, whether 
you look at age or gender.

Age

Prescription drug overdoses are most common among middle-aged 
Americans, 45-54, who account for about 25 percent of all 
prescription opioid deaths. When you add in 55-64 year olds, you 
capture nearly half of all overdoses from prescription drugs.

With heroin, the situation is reversed. It's the 25-34 year olds who 
suffer most, with an overdose rate vastly higher than any other age cohort.

This complicates the familiar story of opioid abuse, where people get 
hooked on prescription drugs before shifting to heroin.

For young people, this may indeed be a real risk. One 2012 study 
suggested that 3-4 percent of opioid addicts do make the switch to heroin.

But this doesn't seem to be happening among older Americans. For that 
age group, the prescription drugs themselves are the big risk.

Gender

Heroin chiefly afflicts men, but prescription drugs are a more 
equal-opportunity killer.

Nationwide, more than two of every five prescription opioid deaths 
involves women. In a few places, women are an outright majority of 
victims - including in Washington, Oregon, Nevada, and Idaho.

With heroin, nearly 80 percent of all deaths across the US involve men.

A worrisome future

The fact that heroin deaths remain concentrated in a few geographic 
regions suggests a real risk of further spread. In fact, that spread 
may already be happening, hiding in plain sight simply because the 
death certificate data only extend through 2014.

One way to check is to talk to advocates, treatment experts, and 
public health officials working in places like Virginia, Iowa, and 
Minnesota - states that border heroin-plagued neighbors but where 
heroin wasn't yet the dominant killer in 2014.

When you do, tales range from slight alarm to full-blown panic.

Kevin Gabbert, from the opioid treatment authority at the Iowa 
Department of Public Health, said that heroin deaths "may not be as 
significant as what you're seeing in the eastern part of the country, 
but the rate of increase has been substantial," adding "In the course 
of five days in early April, there were five overdose deaths in the 
eastern part of the state, and heroin is among the drugs suspected to 
be involved."

More distressed was Carol Falkowski, once Minnesota's drug abuse 
strategy officer and founder of the education group Drug Abuse 
Dialogues. "It's just a matter of time until heroin overtakes 
prescription drugs in Minnesota," she said. "Already, 16 percent of 
the people entering treatment in the Twin Cities are coming in for 
heroin, and it's never been that high."

 From Richmond Virginia, Honesty Liller painted a similar picture. 
Liller is the CEO of the McShin Foundation, which provides a host of 
addiction-recovery services, and when asked if the tide was turning 
toward heroin, she replied: "Heck yeah. Within the recovery 
community, we've seen a huge rise in heroin overdoses and deaths, 
particularly this year."

If these perspectives bear out, the 2015 and 2016 maps of heroin 
overdose deaths may include a lot more dark territory, fueling a 
further rise in the opioid death rate.

Two epidemics

Recognizing the current suffering and future risk, the federal 
government has been working with a variety of states to address the 
threat posed by opioid overdose in the United States.

Among the initiatives are increased funding for drug treatment 
programs, steps to block drug trafficking, and easier access to drugs 
that ease the path from heroin to sobriety.

But in this effort, there is no one-size-fits-all solution, and even 
well-meaning efforts can end up exacerbating the problem.

Here's one example. In recent decades, virtually every state has 
passed laws to crack down on opioid prescriptions, shutting down 
"pill mills" and creating prescription monitoring programs to keep 
track of which doctors might be over-prescribing.

More recently, the CDC has tightened its own guidelines to ensure 
these highly-addictive drugs are only made available to patients who 
really need them.

But what if this crackdown on prescription opioids actually pushes 
more people towards heroin?

This may already be part of the reason young men have started dying 
from heroin in greater numbers. And if prescriptions get even harder 
to find, more women and older Americans may look to heroin as a way 
to soothe their pain, and their addiction.

This is the kind of risk that's hard to foresee, unless you 
distinguish between America's two crises, one involving heroin, the 
other prescription drugs.
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MAP posted-by: Jay Bergstrom