Oregon Medical Board Has ‘No Limits’ on Prescription Opioids

By Pat Anson, PNN Editor

The Oregon Medical Board has come full circle in its regulation and enforcement of pain management guidelines. After years of taking disciplinary action against doctors for prescribing high dose opioids without a “legitimate medical purpose,” the board has acknowledged that its policies had a chilling effect on doctors who no longer felt safe treating chronic pain with opioids.

“The Board is well aware some number of clinicians have shied away from long-term pain management in part or in whole for fear of Board sanctions. We wish it weren’t so, and the Board is hopeful the realignment in prescribing guidance will provide reassurance to those licensees caring for patients with long-term pain,” David Farris, MD, Medical Director of the Oregon Medical Board (OMB), recently wrote in the board’s newsletter.

The board’s “realignment” came a year after the Centers for Disease Control and Prevention revised its own opioid guideline to give doctors more flexibility in treating pain patients.

In 2016, the CDC initially recommended that daily opioid dosages not exceed 90 MME (morphine milligram equivalents), which was widely seen as a mandatory dose limit.

But after numerous reports of patients being rapidly tapered, going into withdrawal and dying by suicide, the CDC guidance was revised in 2022 to eliminate any dose thresholds. Physicians were instead urged to prescribe opioids cautiously at the “lowest possible effective dose.”   

“There are no set regulatory limits on the daily dosage of opioids that can be prescribed in Oregon. There is also not a requirement to rapidly taper or discontinue opioids for patients.”

— Oregon Medical Board

In a “Statement of Philosophy” adopted in January, the OMB urged doctors to read the CDC guideline and heed its advice about treating patients individually and to allow “shared decision making” about their treatment.

“In alignment with this statement and CDC guidelines, there are no set regulatory limits on the daily dosage of opioids that can be prescribed in Oregon. There is also not a requirement to rapidly taper or discontinue opioids for patients on existing opioid doses. The Board wants to ensure licensees accepting new patients on existing chronic opioid therapy do not feel pressured to rapidly change a patient’s current opioid dose,” the OMB said.

‘More Harm Than Good’

Opioids have been a contentious issue in Oregon for several years. In 2018, the state considered rule changes to its Medicaid program that would have limited coverage of opioids to just 90 days for patients with neck or back pain. The proposal, which would have forcibly tapered thousands of patients on long-term opioid therapy, was supported by Physicians for Responsible Opioid Prescribing (PROP), an anti-opioid activist group.     

The plan was scrapped after pain management experts signed a joint letter warning that Oregon’s tapering plan was unsupported by treatment guidelines and would do “substantially more harm than good.”

The Medical Board’s decision to give more leeway to doctors reflects a growing awareness that the crackdown on opioids is harming pain patients and may be worsening the drug crisis.    

“The Board wishes to reassure and encourage licensees to assume the prescribing responsibilities for such patients, regardless of MME level, at least temporarily, in order to avoid patients going into withdrawal or turning to illicit sources,” Farris wrote.

“It is gratifying to see the OMB finally recognize that their arbitrary opioid dosing policies harmed people with chronic pain and the providers caring for them. It seems as though the Board may have been adversely affected by advice received from home state clinicians aligned with PROP, and, inevitably, the chickens have come home to roost in that regard,” said Bob Twillman, PhD, former Executive Director of the Association of Integrative Pain Management, who signed the 2018 joint letter.

“I hope this change in stated policy will be reflected in changes to Board investigations and to the state-developed CME (Continuing Medical Education) program on pain management that is mandated for all prescribers in the state. It's going to take years to repair the damage done so far, but I'm hoping the pendulum can finally come to rest somewhere near the midpoint of the extremes we've seen over the last 30 years.”

Opioid prescribing in Oregon has been falling for nearly a decade – as it has nationwide – but overdose deaths in the state keep rising. According to CDC data, Oregon has one of the lowest rates of fatal overdoses involving prescription opioids in the country. Deaths linked to illicit fentanyl, stimulants, methamphetamine and heroin are far more common in Oregon.  

Stimulants Involved in Growing Number of Fentanyl Overdoses

By Pat Anson, PNN Editor

The number of drug deaths involving both fentanyl and stimulants has soared in recent years, according to a new UCLA study that highlights the complex and changing nature of the U.S. overdose crisis.

Stimulants such as cocaine and methamphetamine are now involved in nearly a third of fentanyl-related overdoses, the most of any other drug class. Fentanyl is a synthetic opioid up to 100 times more potent than morphine and 50 times as potent as heroin.

In 2010, researchers say there were only 235 fatal overdoses in the U.S. involving illicit fentanyl and stimulants. In 2021, there were 34,429 drug deaths linked to fentanyl and stimulants, a 14,550% increase in a little over a decade.

"We're now seeing that the use of fentanyl together with stimulants is rapidly becoming the dominant force in the US overdose crisis," said lead author Joseph Friedman, PhD, an addiction researcher at the David Geffen School of Medicine at UCLA. "Fentanyl has ushered in a polysubstance overdose crisis, meaning that people are mixing fentanyl with other drugs, like stimulants, but also countless other synthetic substances. This poses many health risks and new challenges for health care providers.

“We have data and medical expertise about treating opioid use disorders, but comparatively little experience with the combination of opioids and stimulants together, or opioids mixed with other drugs. This makes it hard to stabilize people medically who are withdrawing from polysubstance use."

People who overdose on stimulants and other non-opioid substances mixed with fentanyl may not be as responsive to naloxone, which only works as an antidote to opioids.

The study findings, published in the journal Addiction, highlight the four “waves” of the overdose crisis, which began with an increase in deaths from prescription opioids (Wave 1) in the early 2000s, followed by a rise in heroin deaths (Wave 2) in 2010, and fentanyl-related overdoses in 2013 (Wave 3). The fourth wave — overdoses from fentanyl and stimulants — began in 2015 and continues to escalate.

The Four Waves of Overdose Crisis

SOURCE: ADDICTION

Since cocaine, methamphetamine and other stimulants are not opioids, the findings undercut the long-held theory that the overdose crisis started with prescription opioids and is still being fueled by people addicted to them. Deaths involving prescription opioids and heroin have been in decline for several years.

Researchers found that fentanyl/stimulant deaths disproportionately affect African Americans and Native Americans. There are also geographical patterns to fentanyl/stimulant use. In the northeast US, fentanyl is usually combined with cocaine, while in the south and western US, fentanyl is most commonly found with methamphetamine.

"We suspect this pattern reflects the rising availability of, and preference for, low-cost, high-purity methamphetamine throughout the US, and the fact that the Northeast has a well-entrenched pattern of illicit cocaine use that has so far resisted the complete takeover by methamphetamine seen elsewhere in the country," Friedman said.

In addition to its low cost, drug users say methamphetamine helps prolong fentanyl’s “high” and delays the onset of withdrawal symptoms.  

Counterfeit pills laced with fentanyl – which are frequently made to look like oxycodone or alprazolam (Xanax) – represent about a quarter of all illicit fentanyl seizures. Researchers say it is difficult to track deaths involving counterfeit pills because they are often mistaken for legitimate medication, so the data is not completely reliable.

In its most recent update on the overdose crisis, the CDC estimates there were a record 111,355 drug deaths in the 12-month period ending April 2023 -- about a thousand more deaths than the year before. Fentanyl and its analogues were involved in nearly 70% of the overdoses, stimulants were linked to about a third of them, and cocaine was involved in about a quarter of the drug deaths.

CDC Report ‘Likely Underestimated’ Deaths Linked to Counterfeit Drugs

By Pat Anson, PNN Editor

A new report from the Centers for Disease Control and Prevention found that fatal overdoses in the U.S. from counterfeit medication more than doubled in recent years, with 93% of those deaths involving illicit fentanyl.

Deaths from counterfeit pills rose from 2% of all overdoses in the third quarter of 2019 to 4.7% of drug deaths in the last quarter of 2021, according to the CDC’s Morbidity and Mortality Weekly Report (MMWR). The overdose rate from fake medication was three times higher in western U.S. states (14.7%). 

However, due the unreliability of death certificates, witnesses and coroner investigations, as well as other flaws in the study’s methodology, the MMWR report acknowledges that the number of deaths involving counterfeit medication is “likely underestimated.”

CDC researchers only looked at overdose data from 34 states and the District of Columbia, identifying 2,437 deaths linked to counterfeit pills during the 30-month study period.

Nearly 106,700 people in the U.S. died from drug overdoses in 2021, so if the 4.7% death rate was applied to that year alone, that would suggest there were over 5,000 deaths nationwide involving counterfeit medication.

Even that estimate is probably on the low end, because CDC researchers focused on counterfeit pills made to look like oxycodone and the anti-anxiety drug alprazolam (Xanax).

While “Mexican Oxy” – blue tablets that look like 30mg oxycodone – are favored by counterfeiters, fake pills are also designed to look like Vicodin, Norco, Adderall, and many other medications. Deaths from those pills were not counted.  

Importantly, whether a death was even linked to fake medication “depended largely on scene or witness evidence of pill use” and other anecdotal evidence, rather than toxicology tests on the pills or the actual people who died.

And while pills are obviously designed to be taken orally, the MMWR report only includes “noningestion routes of drug use,” such as smoking, snorting or injection, which require the pills to be ground into powder or liquefied. CDC researchers considered data on the oral ingestion of counterfeit pills so unreliable, “that information is not presented” in the report.

Many of these details on the study’s strange methodology are buried in the footnotes of the MMWR report, which a casual reader could easily miss. 

Not surprisingly, given the limitations on data, smoking was found to have an outsized role in overdose deaths. According to the MMWR, nearly 40% of the deaths linked to counterfeit medication involved smoking – a misleading statistic, given the study’s flaws. But that didn’t stop researchers from drawing conclusions or recommending “safer smoking practices.”

“The higher percentage of deaths with evidence of drug use by smoking might reflect recent general shifts from injecting drugs to smoking them in western states or could be specific to counterfeit pill use methods,” wrote lead author Julie O’Donnell, PhD, an epidemiologist at the CDC’s National Center for Injury Prevention and Control.

“Harm reduction services that expand outreach to persons using drugs by methods other than injection, such as smoking, and provide education about safer smoking practices and risks related to smoking, might be most successful at addressing diverse drug use patterns.”

There’s a safer way to smoke illicit fentanyl?

This is the CDC’s first MMWR report to look exclusively at deaths caused by fake pills, a public health crisis that the agency has been slow to acknowledge. The DEA started warning about a “fentanyl crisis” as far back as 2016, a time when the CDC was preoccupied with its guideline to reduce opioid prescribing.

There were major flaws in CDC research even back then. The agency eventually admitted that thousands of overdose deaths linked to illicit fentanyl and other street drugs were misclassified as deaths caused by prescription opioids. Some deaths that involved more than one drug were counted multiple times.

Restoring Safe Supply of Rx Opioids Would Reduce Overdoses

By Pat Anson, PNN Editor

A decade long effort to reduce the supply of opioid pain medication in the U.S. has contributed to a surge in overdose deaths and made the illicit drug supply more toxic, according to a new study.

“A big reason that we have such a problem with addiction in this country is because people can't access legitimate pain medication,” said lead author Grant Victor, PhD, an assistant professor at Rutgers University School of Social Work. “Our findings support a change in policy.”

Victor and his colleagues analyzed toxicology data from nearly 2,700 accidental overdose deaths in the Indianapolis metropolitan area (Marion County, Indiana) from 2016 to 2021, comparing them to patient records in the state’s prescription drug monitoring program (PDMP).

Their findings, published in the Journal of Substance Use and Addiction Treatment, show that less than half the people who overdosed (43.3%) had any kind of PDMP record, meaning they were never prescribed an opioid pain reliever or buprenorphine (Suboxone), a medication used to treat opioid use disorder.

Most of the decedents who did have a prescription for an opioid analgesic or buprenorphine had not filled one in the 30 days prior to their deaths, indicating that prescription opioids are not driving overdose deaths in Marion County. Overdoses there increasingly involve illicit fentanyl, a synthetic opioid 100 times more potent than morphine, which accounts for nearly 90% of the county’s overdoses.  

There were 637 drug deaths in Marion County in 2021, nearly twice the number that died in 2016. During that period, opioid prescriptions in the county fell by nearly a third.

MARION COUNTY PUBLIC HEALTH DEPT.

Toxic Drug Market

Victor says many of the overdose deaths could have been prevented if a safer supply of prescription opioids was still accessible – both to legitimate patients and those who misuse the drugs.

“There was a wave of policy initiatives that effectively tamped down on the diversion of prescription opioids, but did so primarily by increasing surveillance of prescribing practices for opioids. And through a number of mechanisms, that made it more difficult for individuals with legitimate pain concerns to access these types of medications,” Victor told PNN.

“When you remove a certain class of drugs that is federally regulated and can be monitored and dosed appropriately, it leaves folks with few options. Options that are currently available are illicit and the potency of these drugs is highly variable. The drug market in general, as we know it today, is very toxic and that is one of the main drivers in the overdose crisis.”

Victor says some of his own family members have chronic pain and after years of taking opioids safely, they’ve been cutoff and told to take Tylenol. He said it’s rare for a pain patient to die from an overdose and few meet the diagnostic criteria for substance use disorder.   

“There are a number of researchers who are trying to drive this point home and hope to reverse some of the policy initiatives that have unfolded over the last few years that have been perhaps unintentionally harmful to public health and to chronic pain patients,” he said.

“We've been swept up in this kind of frenzy about prescription opioids. They're still making movies about the Sackler’s (owners of Purdue Pharma). My opinion of them is not all that high, but I think it is a convenient kind of scapegoat to portray pharmaceutical companies as the evil here, when they’re not a primary concern. When you're looking at public health and what's currently driving overdose deaths, it’s not prescription opioids.”

Few previous studies have compared overdose deaths directly to prescription drug data, which would seem to be an obvious way to get to the bottom of what’s causing the overdose crisis.  One such study looked at opioid overdoses in Massachusetts, finding that only 1.3% of those who died had an active prescription for opioids.

CDC Study Shows Oxycodone Plays Minor Role in Overdose Crisis

By Pat Anson, PNN Editor

A new study by the CDC highlights the sharply rising death toll in the U.S. caused by illicit fentanyl, while at the same time revealing the minor role played by oxycodone in the nation’s overdose crisis.

The study, released this week by the CDC’s National Center for Health Statistics, looked at overdose death rates from 2016 to 2021. Deaths involving fentanyl more than tripled during that period, rising from 5.7 deaths per 100,000 people in 2016 to 21.6 deaths per 100,000 in 2021. Drug deaths involving methamphetamine and cocaine also rose sharply, while fatal overdoses involving heroin declined.

And what about oxycodone, the most commonly prescribed opioid pain medication? It turns out oxycodone has always played a relatively minor role in the overdose crisis, although regulators and public health officials said otherwise in a concerted campaign against all prescription opioids.

“Overprescribing opioids – largely for chronic pain – is a key driver of America’s drug overdose epidemic,” then-CDC director Dr. Thomas Frieden said in a 2016 news release.

But the facts don’t support Frieden’s claim. In 2016, the year the CDC released its controversial opioid prescribing guideline, there were only 1.9 deaths per 100,000 people that involved oxycodone. By 2021, the rate had fallen 21% to 1.5 deaths -- well below the death rates of fentanyl, methamphetamine, cocaine and heroin.   

Drug Overdose Deaths in U.S. (2016-2021)

SOURCE: CDC

CDC researchers used an unusual method to conduct this study. Instead of relying on medical ICD-10 codes in death certificates, which lump drugs together into broad categories, the CDC used a “literal text” analysis.

“To address the limitations of ICD–10- coded mortality data, the National Center for Health Statistics has developed a method that searches the literal text of death certificates to identify mentions of specific drugs and other substances involved in the death. Death certificate literal text is the written information provided by the medical certifier, usually a medical examiner or coroner for drug overdose deaths, that describes the causes, manner, and circumstances contributing to the death,” the researchers explained.

Flawed Data

The literal text method is not foolproof, but it’s an improvement over the ICD-10 codes, which the CDC admitted in 2018 “significantly inflate” the number of deaths involving prescription opioids — flawed data that Frieden used to make his “key driver” of the epidemic claim in 2016.

How inflated were the overdose numbers back then?  Using the old ICD-10 method, which counted illicit fentanyl as a prescription opioid, Frieden’s CDC estimated that nearly 32,500 Americans died from overdoses of opioid medication in 2016. The death toll was later revised downward to about 17,000 overdoses after the CDC came clean about its flawed methodology.

Patient advocate Richard “Red” Lawhern has long been suspicious of CDC data, including studies that use literal text analysis.  

“CDC suggests an incidence of drug overdose deaths ‘involving’ oxycodone at only 1.5 per 100,000.  But they neatly avoid telling us that such a rate is so low that it confounds the non-uniformity of reporting from county to county, creating such statistical noise that the contribution of this agent (oxycodone) to overdose mortality is too small to accurately measure or report,” Lawhern said.  

Another problem is the qualifications of county coroners and medical examiners varies. Some are elected to their positions without any medical training or experience. The death certificates they fill out usually don’t say if a prescription drug was obtained legally or illicitly, or what specific drug or combination of substances caused the death. That is determined later by a toxicology test. As a result, a drug may be “involved” in a death and be listed on the death certificate, but have little or nothing to do with someone’s demise.

“It is startling that CDC has so consistently and deliberately conspired to disguise the fact that oxycodone really isn't significant in drug overdose mortality, and probably never has been,” Lawhern told PNN. 

Of course, every death is a tragedy in some way, regardless of the cause or substance involved. The graphic below helps bring oxycodone’s role into more context – comparing the five leading causes of death in 2021 to those involving fentanyl, oxycodone and the other drugs.

SOURCE: CDC

Despite the minor role played by oxycodone in 2021 deaths, efforts continue to restrict its availability. This year the Drug Enforcement Administration reduced the supply of oxycodone for the seventh consecutive year. Since their peak in 2013, DEA production quotas for oxycodone have fallen by 65 percent. The tightened supply has resulted in recent reports of oxycodone shortages and patients unable to get their prescriptions filled.

The DEA justifies the cuts by saying it is concerned about diversion and abuse, but the agency’s own data shows that less than one percent of legally prescribed oxycodone (0.3%) is diverted to someone it was not intended for.

U.S. Prescription Opioid Use Fell 7.4% in 2022

By Pat Anson, PNN Editor

The amount of prescription opioids sold in the United States fell another 7.4% last year, according to a new report by the IQVIA Institute, a healthcare data tracking firm.

Since their peak in 2011, per capita use of prescription opioids by Americans has declined 64 percent, falling to levels last seen in the year 2000. Despite that historic decline, fatal overdoses in the U.S. have climbed to record levels, fueled primarily by illicit fentanyl and other street drugs.

“The greatest reductions in prescription opioid volume — measured in morphine milligram equivalents (MME) — have been in higher-risk segments receiving greater than 90 MMEs per day,” the IQVIA report found. “Despite significant progress in reducing opioid prescriptions to combat the opioid overdose epidemic, overdose deaths have been rising, primarily due to illicit synthetic opioids.”

The CDC estimates there were 108,712 overdose deaths in the 12-month period ending in November, 2022. About 72,000 of those deaths involved heroin or synthetic opioids such as fentanyl.

By comparison, drug deaths involving legal prescription opioids have remained relatively flat, averaging about 16,000 a year since 2017. They ticked upwards in 2020 and 2021, but appear have trended downward again in 2022, according to the IQVIA.

Prescription Opioid Use and Opioid Overdose Deaths

It appears likely that prescription opioid use will fall again in 2023, due in part to further cuts in opioid production quotas imposed on drug makers by the Drug Enforcement Administration. The DEA says the opioid supply will still be “sufficient to meet all legitimate needs,” but as PNN has reported, some manufacturers are currently reporting shortages of oxycodone and hydrocodone.      

Pain patients have complained for years about chain pharmacies being unable or unwilling to fill their opioid prescriptions, but the problem seems to have grown worse in recent months, particularly at CVS.

“Every month I have to spend hours on the phone trying to find a location that has them in stock,” a CVS customer in Indiana told us. “We should not have to be subjected to this every month!” 

“Some pharmacists are anti opiate. No matter what. She was rude and she is the manager. While it’s hard every month to fill, this time her rude attitude was over the top,” said another CVS customer in Colorado.

Medication Costs Declining 

There is some good news in the IQVIA report: medications are getting cheaper. The average amount paid out-of-pocket for a retail prescription fell from $10.15 in 2017 to $9.38 in 2022. Uninsured patients who pay the full amount in cash have also seen their drug costs decline slightly.

The use of manufacturer copay assistance programs and coupons is growing, collectively saving patients about $19 billion in 2022.

Over the next five years, growth in the use of biosimilar drugs to treat autoimmune conditions, diabetes and cancer is expected to save consumers over $180 billion. Like generic drugs, biosimilars are medications that can replace more expensive biologics such as Humira, which are losing patient protection.

Altogether, spending on medicines for the next five years is expected to be flat, according to the IQVIA, with rising costs in some drug classes offset by declines in others.

Study Links Rx Opioids to Higher Suicide Risk

By Pat Anson, PNN Editor

Suicide is an all-too-common experience in the pain community. About one in every ten suicides in the U.S. involves chronic pain, and in a PNN survey of nearly 6,000 pain sufferers, an astounding 49% told us they thought about suicide because their pain was so poorly treated.

Many of those patients lost access to opioid pain medication after the CDC released its opioid guideline in 2016. The resulting backlash against opioids by regulators and law enforcement had predictable results on people in pain, resulting in an untold number of suicides by mothers, husbands, veterans, advocates and others – that the CDC didn’t even bother to track.

Just a few months ago, a Georgia man and his wife died by suicide after the doctor who was treating the husband had his license to prescribe opioids suspended by the DEA.

A new study is now casting doubt on the association between suicide and cutbacks in opioid prescribing. Researchers at Columbia University Mailman School of Public Health looked at U.S. prescription data from 2009 to 2017 and found the suicide rate was significantly higher in census regions where there was more high-dose, long-term opioid prescribing.

“The relationship between opioid prescribing and suicide risk is a complex one. This is particularly the case when people have their opioids tapered,” said Mark Olfson, MD, professor of epidemiology at Columbia School of Public Health.

“People can become desperate if their pain is not well controlled. Yet opioids also pose a greater risk of overdose than any other drug class and approximately 40 percent of overdose suicide deaths in the U.S. involve opioids. At a population-level, the national decline in opioid prescribing over last several years appears to have reduced the number of people who died of suicide.”

The study findings, published in the American Journal of Psychiatry, are surprising because they cover a period when the U.S. suicide rate was steadily rising, fueled by factors such as mental illness, substance abuse, economic hardship and social isolation. The study ignores those societal issues and focuses solely on opioid medication as the driving force behind suicides.   

Olfson and his colleagues found that geographic regions with the biggest declines in opioid prescriptions tended to have the largest declines in suicide deaths, including suicide overdoses that involved opioids. If the national decline in opioid prescribing had not occurred, they estimate there would have been 3% more suicide deaths overall, and 10.5% more suicide deaths involving opioids.

“It is not surprising that regional declines in opioid prescribing were found to ameliorate local trends in suicide deaths. These findings reinforce the importance of safe opioid prescribing practices and proper disposal of unused opioids,” they reported. “While some patients with pain need and benefit from opioids without risk, those for whom opioids are prescribed should be evaluated and, if necessary, treated for co-occurring mental health disorders that might otherwise increase their risk of suicide.”

‘Confusing and Contradictory’ Findings

The new study is at odds with recent research in British Columbia, which found that tapering or stopping opioid therapy significantly raises the risk of a patient dying from an accidental or intentional overdose. A large 2021 study of U.S. patients on long-term opioid therapy also found that tapering raises the risk of a non-fatal overdose and attempted suicide.

There are “serious methodological problems” with the Columbia study, according to Stefan Kertesz, MD, an associate professor at the University of Alabama at Birmingham, who is leading a federally funded study of pain patient suicides. Kertesz says the study’s reliance on prescription data overlooks all the other issues in a community that may contribute to suicide.

“Let’s use common sense: If communities can change their level of opioid prescriptions, then surely they can change in countless other ways that might bear on community-level suicide risk. Some communities might have a decline in economic well-being. Others might invest in crisis centers,” Kertesz told PNN by email. “However, this paper’s statistical choices require us to assume that none of the 886 regions changed in any respect that would affect suicide, other than the number of opioid prescriptions.”

Kertesz is concerned the study findings could be used to justify further cuts in opioid prescribing.

“Unfortunately the paper offers a confusing, unnecessary and internally contradictory message about the application of its findings to individual patients, one that distracts from the work of the authors and is likely to be misapplied in ways that put patient safety at risk,” he said.

The study was funded by the National Institute on Drug Abuse.

Studying suicides is difficult for researchers because many suicide deaths are misreported as accidental or of undetermined cause, making much of the data unreliable. Drug experts say up to 30% of opioid overdose deaths listed as accidental may have been intentional.

Limiting Supply of Rx Opioids Fails to Achieve Goals

By Pat Anson, PNN Editor

Limiting initial prescriptions for opioid pain medication to 5-days’ supply did not reduce the rate at which patients in New Jersey transitioned to long-term opioid use, according to a new study at Rutgers University.

In 2017, New Jersey became one of the first states in the country to impose a mandatory 5-day limit on initial opioid prescriptions for acute pain. If a patient needed more, their doctor would have to write a new prescription, enroll them in a pain management program, and counsel them on the risks of opioid addiction.

At least 38 other states adopted similar laws, with the goal of reducing opioid diversion, misuse and overdose. Six years later, there is little evidence that New Jersey’s 5-day limit saved lives or accomplished any of its goals.

“This policy’s apparent failure to achieve its goals illustrates the extreme difficulty of solving healthcare problems by dictating physician behavior,” said senior author Stephen Crystal, PhD, director of the Rutgers Center for Health Services Research.

Crystal and his colleagues analyzed pharmacy data for over 130,000 New Jersey Medicaid patients who were prescribed opioids for the first time between 2014 to 2019. Their findings, recently published in the Journal of General Internal Medicine, show that new opioid prescriptions fell at a monthly rate of less than one percent (0.76%) after the 5-day limit was imposed, a decline that was about half the monthly rate (1.62%) prescriptions were falling before the limit took effect.

Doctors were writing fewer prescriptions for opioids in New Jersey and other states long before limits on the supply were even passed. Opioid prescriptions nationally are now at their lowest level in over 20 years.

“Opioid prescribing was already decreasing before this policy went into effect,” said lead author Peter Treitler, a research project manager at the Rutgers Institute for Health, Health Care Policy and Aging Research. “And so, by the time this New Jersey policy went into effect, it really didn’t change prescribing practices very much, at least in the New Jersey Medicaid population.”

An earlier study by the Rutgers research team found that medically treated overdoses in the Medicaid population tripled in New Jersey after the 5-day limit was imposed. Most of the overdoses involved illicit fentanyl and other street drugs, not prescription opioids.

Less than a third of New Jersey’s overdose survivors were even diagnosed with a chronic pain condition, suggesting the state’s focus on limiting pain medication was misdirected. Most people who overdose suffer from substance abuse disorder, depression or other mental health issues. And most overdoses involve illicit fentanyl and other street drugs, not prescribed medication.

In 2022, there were nearly 2,900 drug deaths in New Jersey – about 30% more than the number that overdosed in 2016, the year before the state’s 5-day limit became law.  

DEA Warns About Fentanyl As It Draws Criticism for Crackdown on Doctors

By Pat Anson, PNN Editor

The Drug Enforcement Administration has issued another public warning about the growing risk of counterfeit opioids and other medications made with illicit fentanyl. Over two-thirds of the drug deaths in the U.S. involve synthetic opioids like fentanyl, which is 50 to 100 times more potent that morphine.

Last year the DEA seized over 50 million counterfeit pills laced with fentanyl and more than 10,000 pounds of fentanyl powder. The seizures represent more than 379 million potentially deadly doses of fentanyl, according to the DEA, enough to kill every man, woman and child in the United States.

Over 56,000 American deaths last year involved fentanyl, nearly the number that died in the Vietnam War, and the crisis appears to be escalating. In 2021, a DEA laboratory analysis estimated that 4 out of 10 counterfeit pills laced with fentanyl contained a potentially lethal dose. The DEA now estimates that six out of ten fake pills contain a deadly dose of fentanyl. Just two milligrams of fentanyl, enough to fit on the tip of a pencil, is considered a potentially lethal dose.

“More than half of the fentanyl-laced fake prescription pills being trafficked in communities across the country now contain a potentially deadly dose of fentanyl. This marks a dramatic increase – from four out of ten to six out of ten – in the number of pills that can kill,” DEA Administrator Anne Milgram said in a public safety alert. “Never take a pill that wasn’t prescribed directly to you. Never take a pill from a friend. Never take a pill bought on social media. Just one pill is dangerous and one pill can kill.”

In an effort to bring more public attention to the fentanyl crisis, the DEA launched its One Pill Can Kill campaign, which highlights the similarities between real medications like oxycodone and alprazolam and their fake counterparts. The counterfeit pills are mass produced by drug traffickers in the U.S. and Mexico, using chemicals largely sourced from China.

Backlash Against DEA

As the DEA grapples with the fentanyl crisis, it’s coming under growing criticism about its efforts to reduce the supply of legal prescription opioids. Recent articles in USA Today, The New York Times, Los Angeles Times and VICE News – many based on stories that first appeared on PNN – suggest that the mainstream media is slowly coming to recognize the harm caused to pain patients by the DEA’s enforcement actions against doctors who prescribe opioids.

“Law enforcement agencies, especially the Drug Enforcement Administration, are out of control, with the DEA routinely caught releasing ‘safety plans’ for the patients of arrested physicians that simply direct pain patients to the nearest emergency room,” wrote Peter Pischke, a disabled freelance journalist, in a USA Today op/ed.

“American medicine and law enforcement continue to fight the last war. Policymakers still operate under the assumption that too many opioids are being prescribed. Overdose deaths — including those among adolescents — are now overwhelmingly caused by street fentanyl, not prescription medications,” Maia Szalavitz wrote in The New York Times.

The backlash against the DEA produced a backlash of its own in Newsweek, in an op/ed by a former deputy chief of staff at the DEA. Rather than doing fewer enforcement actions against doctors, Jim Crotty believes there should be more.

“With the U.S. drug crisis reaching unprecedented levels, and many opioid use disorders starting with prescription drugs, now is not the time to increase their availability,” wrote Crotty, who said the recent deaths of patients who lost access to opioids when their doctor’s license was suspended do not justify a change in DEA policy.

“These isolated incidents, however tragic, should not be used to upend otherwise sound drug policies designed to protect the American public from drug addiction and abuse,” said Crotty. “The U.S. is making slow but steady progress in rolling back the opioid crisis, but there is much work to be done. The threat of prescription opioids still looms large and requires continued vigilance from DEA and its partners to protect Americans' health and safety. We should be asking them to do more, not less.”

Crotty said over 13,000 Americans have died from overdoses involving prescription opioids in the last 12 months – a fraction of the number dying from fentanyl -- and repeated the old saw about the U.S. being “the world's largest consumer of prescription opioids.” That may have been true a decade ago, but no longer is. The U.S. now ranks 8th in per capita opioid consumption, behind Canada, Australia and several European countries

Fentanyl Linked to 94% of Overdose Deaths in Massachusetts

By Pat Anson, PNN Editor

There’s good and bad news in the latest report on overdose deaths in Massachusetts. State health officials say drug deaths were down slightly in the first nine months of 2022, compared to the same period last year. But deaths involving fentanyl – most likely illicit fentanyl -- rose to 94% of opioid-related overdoses, a record high.

Massachusetts was one of the first states in the U.S. to expand the use of toxicology tests to look for the presence of certain drugs involved in opioid overdoses, instead of just relying on death certificates and coroner reports. That makes its overdose data more accurate.

In the first nine months of 2022, there were 1,340 confirmed opioid-related overdose deaths in Massachusetts, and officials expect that to reach about 1,696 deaths by the end of the year. That’s 25 fewer deaths than in 2021, a decrease of 1.5 percent.

Nationally, drug overdose deaths also appear to be slowing. The CDC estimates there were 107,735 U.S. overdose deaths in the 12-month period ending in July 2022, down from over 110,000 deaths in the 12-month period that ended in March, 2022. Illicit fentanyl, a synthetic opioid about 50 to 100 times more potent than morphine, is involved in the vast majority of those deaths.

Deaths in Massachusetts involving a fentanyl have been rising for over a decade, from nearly 42% of opioid-related overdoses in 2014 to 94% this year. Over that same period, deaths involving prescription opioids such as oxycodone and hydrocodone have steadily declined from about 35% to 11% of overdoses in 2022.

More people are now dying in Massachusetts after ingesting fentanyl, cocaine, alcohol or benzodiazepines such as Xanax than from pain medication. Deaths linked to opioid medication fell by 30% in just one year, which coincides with a steep decline in prescriptions in Massachusetts over the past decade.   

Drugs Involved in Massachusetts Opioid-Related Overdose Deaths

Massachusetts Department of Public Health

“Every life lost to opioid overdose is its own tragedy,” Public Health Commissioner Margret Cooke said in a statement. “With this report, we are encouraged by the decrease, however modest, in opioid-related overdose deaths in Massachusetts so far this year. We will continue to build on our data-driven and equity-based public health approach as we address the impacts of the opioid epidemic and the COVID-19 pandemic, especially among vulnerable populations.”

Health officials say the illicit drug supply in Massachusetts is “heavily contaminated” with illicit fentanyl, which is frequently used in the manufacture of counterfeit medication sold on the street.

Pharmaceutical fentanyl is used as a surgical analgesic and in patches and lozenges to treat severe pain, but only small amounts are diverted for abuse. The DEA estimates that only 0.01% of prescription fentanyl is diverted for use by someone it was not intended for.

It's important to note that the presence of a drug found in a toxicology screen doesn’t mean it was the cause of someone’s death. Multiples substances are frequently involved in opioid overdoses, and the official cause of death is a clinical decision made by coroners and medical examiners.

Toxicology tests alone also don’t reveal if a prescribed drug was intended for the decedent, or if it was bought, stolen or borrowed by them. An earlier study of drug deaths in Massachusetts found that only 1.3% of overdose victims had a prescription for the opioid medication involved in their deaths.

The vast majority of patients prescribed opioids use them responsibly and don’t go doctor shopping. The Massachusetts Department of Public Health estimates that only 0.6% of patients who were prescribed an opioid this year had an “activity of concern,” such as getting prescriptions from multiple providers or having them filled at multiple pharmacies.

Opioid Prescriptions Down Sharply for Medicare Patients

By Pat Anson, PNN Editor

The number of Medicare beneficiaries receiving opioid prescriptions has declined significantly since 2016, according to a new government report that also found steep declines in the number of beneficiaries receiving high doses or who appear to be doctor shopping.

The report by the Department of Health and Human Service’s Office of Inspector General found that over 21 million people -- 23% of Medicare Part D beneficiaries -- received at least one opioid prescription in 2021, down from 33% of beneficiaries in 2016. Over 51 million people are currently enrolled in Part D.

The Centers for Medicare and Medicaid Services (CMS) adopted new safety rules in 2018 that discourage high dose prescribing and limit the initial supply of opioids to 7 days. The rules also allowed pharmacists and insurers to flag Medicare patients deemed to be at high risk, as well as their prescribers.

The rules appear to have had a major impact on prescribing. In 2016, over half a million Medicare beneficiaries received a daily opioid dose of at least 120 MED (morphine milligram equivalent). By 2021, that fell to less than 200,000 patients, a 60 percent decrease in high dose prescribing.   

MEDICARE PATIENTS RECEIVING HIGH DOSE OPIOIDS

HHS Office of Inspector General

Since 2016, the number of Medicare beneficiaries who appeared to be doctor shopping dropped from 22,300 to 1,800; while the number of doctors with “questionable” prescribing patterns fell from 401 to just 98.  Patients were flagged for doctor shopping if they were on high doses and received opioids from four or more prescribers or four or more pharmacists.

“The opioid epidemic continues to grip the nation. There is clearly still cause for concern and vigilance, even as some positive trends emerge,” the OIG report found. “The number of Medicare Part D beneficiaries who received opioids in 2021 decreased to approximately a quarter of a million beneficiaries, extending a downward trend from prior years. Further, fewer Part D beneficiaries were identified as receiving high amounts of opioids or at serious risk of misuse or overdose. The number of prescribers ordering opioids for large numbers of beneficiaries at serious risk was steady.”

But there is little evidence that less prescribing is reducing addiction and overdoses.  The Centers for Disease Control and Prevention estimates there were nearly 81,000 opioid-related deaths in 2021, nearly twice the number reported in 2016, when the CDC’s opioid guideline was released. The vast majority of deaths involved illicit fentanyl and other street drugs, not prescription opioids.

The OIG report found that 50,391 Part D beneficiaries experienced an opioid overdose (either fatal or non-fatal) in 2021, but did not break down how many were linked to illicit or prescription opioids.

Over one million Medicare beneficiaries were diagnosed with opioid use disorder (OUD) last year, but only one in five received a medication like Suboxone or methadone to treat their condition. Medicare patients were far more likely to receive naloxone, an overdose reversal drug. Over 445,000 beneficiaries received a prescription for naloxone, an 18% increase from 2020.

Evidence Used to Justify CDC Opioid Guideline ‘No Longer Present’

By Pat Anson, PNN Editor

Anti-opioid activists and public health officials have long argued that opioid “overprescribing” fueled the overdose crisis in the United States, causing drug deaths to surge to record levels.

“This rise is directly correlated with increased prescribing for chronic pain,” Dr. Jane Ballantyne, then-president of Physicians for Responsible Opioid Prescribing (PROP), wrote in a 2015 letter to the National Institutes of Health.

That claim was repeated the following year by the CDC when the agency released its controversial opioid guideline. “Overprescribing opioids – largely for chronic pain – is a key driver of America’s drug overdose epidemic,” then-CDC director Dr. Thomas Frieden said in a news release.   

But a new analysis debunks the overprescribing myth, finding the “direct correlations” cited by Frieden, Ballantyne and others are no longer valid, if they ever were.

In a study recently published in Frontiers of Pain Research, independent researchers Larry Aubry and B. Thomas Carr examined opioid prescribing trends and overdose deaths from 2010 to 2019, using the same data sources that the CDC guideline is based on.

“The direct correlations used to justify the CDC guideline… are no longer present,” they reported.

Aubry and Carr found that opioid prescribing, when measured in morphine milligram equivalents (MME), was in steep decline years before the guideline was even released. That trend accelerated even further when regulators, insurers and healthcare providers started following the CDC’s recommendations.

If the overprescribing theory were true, you would expect drug deaths to go down as opioid sales did. But in subsequent years, overdoses linked to prescription opioids stayed flat and drug deaths surged even higher. In research terms, that is known as a “negative correlation” -- a trend not supported by facts.

Looking at data from all 50 states, Aubry and Carr found “significant negative correlation” in 38 states between overdoses and prescription opioids, and a positive correlation in only 2 states. In 10 states, there appeared to be no relationship at all. That calls into question ones of the primary recommendations of the CDC guideline; that daily opioid doses not exceed 90 MME.

“This recommendation is not supported by the available data. Regression analyses of (total opioid deaths, opioid overdose deaths, opioid treatment admissions, and prescription opioid sales) among patients receiving doses of at least 90 MME/day show significant negative relationships, indicating that lower (prescription opioid sales) in this high-dosage cohort do not correspond to lower death rates,” Aubry and Carr reported.

The CDC estimates that over 107,000 people died of overdoses in 2021, well above the 63,600 drug deaths reported in 2016, the year the guideline was released.

Negative Correlation Between Overdoses and Opioid Prescribing

sOURCE: FRONTIERS OF PAIN RESEARCH

Patient Outcomes Not Being Monitored

Even more concerning is that the CDC does not appear to be tracking the impact of its 2016 guideline on pain patients, even as it prepares a long-delayed update to the guideline. As PNN has reported, the CDC ignored warnings from its own consultants that the agency “should consider conducting more research” on patients, many of whom were abruptly tapered or abandoned by their doctors after the guideline’s release.

“Reasonable judgment would dictate tracking and reporting of chronic pain patient outcomes (deaths, suicides, returns in benefits, reported pain, function, etc.) for individuals since the guideline or the guideline update. However, there appears to be no publicly available evidence that a monitoring process is required or is planned to measure and confirm outcomes,” Aubry and Carr wrote.

PROP is not following the data either. In a recent debate, PROP board member Adriane Fugh-Berman claimed that pain patients addicted to prescription opioids were still fueling the overdose epidemic, even though illicit fentanyl and other street drugs are linked to the vast majority of deaths.

“Those patients went to the street. They got addicted to heroin. The reason those deaths went up is because the illicit supply of opioids has become laced with fentanyl and has become highly dangerous,” Fugh-Berman said, without citing any evidence. “It’s not that prescription opioids have nothing to do with it.  Many patients started on prescription opioids ended up on the streets looking for heroin. They’re dying because the illicit opioid products have become extremely dangerous. That’s what’s killing people.”

Fugh-Berman is not an unbiased observer. She and at least five other PROP board members have testified as paid expert witnesses in opioid litigation cases, making as much as $850 an hour for their testimony blaming drug makers for the opioid crisis.

A recent analysis of overdose deaths in 2020 found that prescription opioids ranked well behind illicit fentanyl, alcohol, cocaine, methamphetamine and heroin as the leading cause of drug deaths.   

At least one critic of opioid prescribing feels it’s time to change the focus on why so many Americans are overdosing. Beth Macy, who wrote the best-selling book “Dopesick,” says drug use has changed. 

“At this point, too much attention is focused on stemming the oversupply of prescription opioids. We now have a generation of drug users that started with heroin and fentanyl.”

— Beth Macy, author of "Dopesick"

“At this point, too much attention is focused on stemming the oversupply of prescription opioids,” Macy writes in her new book, ‘Raising Lazarus.’ “We now have a generation of drug users that started with heroin and fentanyl.”

As for the CDC, a spokesperson tells PNN the agency won’t publish its guideline revision until late this year, nearly seven years after the original guideline was released. 

“CDC is currently in the process of revising the draft update to the 2016 Guideline based on comments received during the public comment period and peer review. We anticipate the final Guideline will be released later this year,” the spokesperson said.

Computer Algorithms Improve Timeliness of Overdose Data

By Pat Anson, PNN Editor

An automated process using computer algorithms to analyze death certificates would speed up and improve data collection on drug overdose deaths, according to a new study by UCLA researchers.

The current system used to track U.S. overdose deaths relies on medical examiners and county coroners – including some with little medical training -- to determine the cause of death and drugs involved. Death certificates are then sent to local jurisdictions or the Centers for Disease Control and Prevention, which codes them according to the International Statistical Classification of Diseases and Related Health Problems, Tenth Edition (ICD-10).

The coding process is manual and time consuming, resulting in delays of several months before the deaths are included in CDC overdose data. With drug deaths at record levels and more dangerous substances entering the illicit drug supply, researchers say that antiquated system delays an effective public health response.

"The overdose crisis in America is the number one cause of death in young adults, but we don't know the actual number of overdose deaths until months after the fact," said lead author David Goodman-Meza, MD, assistant professor of medicine in the division of infectious diseases at the David Geffen School of Medicine at UCLA.

"We also don't know the number of overdoses in our communities, as rapidly released data is only available at the state level, at best. We need systems that get this data out fast and at a local level so public health can respond. Machine learning and natural language processing can help bridge this gap."

Goodman-Meza and his colleagues used computer algorithms to analyze the text for keywords in nearly 35,500 death certificates from nine U.S. counties in 2020. The counties include major cities such as Chicago, Los Angeles, San Diego and Milwaukee.

The researchers say their automated system demonstrated “excellent diagnostic performance” in classifying the drugs involved in overdoses.

“We found that for most substances evaluated, the performance of these algorithms was perfect or near perfect. These models could be used to automate classification of unstructured free-text, thus avoiding the manual and time-consuming process of individually reading each entry and classifying them to a specific substance,” researchers reported in JAMA Network Open.

“Excellent performance was shown for multiple substances, including any opioid, heroin, fentanyl, methamphetamine, cocaine, and alcohol using models for general text. Yet for prescription opioids and benzodiazepines, there was a considerable performance gap.”

That “performance gap” is due in part to weaknesses in the drug classification system, which lumps many synthetic opioids under the same ICD-10 code, including fentanyl, fentanyl analogs, tramadol and buprenorphine – a semi-synthetic opioid used in the addiction treatment drug Suboxone.

In the past, CDC has classified all drug deaths using that code as “prescription opioid overdoses” even though the drugs may have been illicit --- which is the case for the vast majority of deaths involving fentanyl. This resulted in government estimates of prescription opioid overdoses being significantly inflated for many years.

Using the computer algorithms developed at UCLA, prescription opioids ranked far behind fentanyl, alcohol and other substances identified as the cause of death in 8,738 overdoses.

Drugs Involved in 2020 Overdose Deaths in 9 U.S. Counties

Source: JAMA Network Open

Until recently, there was a 6-month time lag in drug deaths being counted in the CDC’s monthly Provisional Drug Overdose Death Counts report. The timeliness of the reports were improved earlier this year to a 4-month delay, but Goodman-Meza says they could be improved even more.  

"If these algorithms are embedded within medical examiner's offices, the time could be reduced to as early as toxicology testing is completed, which could be about three weeks after the death," he said.

Overdose Crisis Projected to Grow Worse in Canada

By Pat Anson, PNN Editor

Opioid-related deaths reached a record level in Canada last year and are likely to continue rising in 2022, according to a grim new report from the Public Health Agency of Canada (PHAC).

The report estimates that 7,560 people died from opioid-related overdoses in 2021, and projects that number is likely to be surpassed this year. On average, there were 21 drug deaths daily in Canada in 2021, up from eight deaths only five years earlier.

The vast majority of the deaths were linked to illicit fentanyl, a potent synthetic opioid that was often combined with other substances. Men accounted for 74% of the deaths, most them between 20 and 59 years of age.

“For many years, Canada has seen a significant rise in opioid and other substance-related deaths and harms, and this crisis continued to worsen over the course of 2021, in the midst of the COVID-19 pandemic,” Drs. Theresa Tam and Jennifer Russell, co-chairs of a PHAC Special Advisory Committee on Opioid Overdoses, said in a joint statement.

“Additionally, the vast majority of opioid-related deaths continue to be accidental, and more than half also involved the use of a stimulant (e.g., cocaine, methamphetamine), underscoring the polysubstance nature of the overdose crisis.”

Notably, only 19 percent of the deaths involved opioids manufactured by a pharmaceutical company, although the data is not broken to determine if they were bought, stolen or obtained legally through a prescription.    

The latest updated modelling projections from PHAC suggest that opioid-related deaths in Canada are likely to remain high or even increase over the next six months. Under four different scenarios, researchers think the most likely one is “Scenario 2,” in which the level of fentanyl in the drug supply remains the same, contributing to about 4,000 more deaths in the last half of 2022.

Estimated Opioid-Related Deaths in Canada

Public Health Agency of Canada

“The data contained in this release underscore the seriousness of substance-related harms in Canada, and the urgent need to take further action to help prevent them. This includes the critical need to expand access to high quality, evidence-based and innovative care to support people who use drugs,” Tam and Russell said.

Canada recently announced an experimental program that will decriminalize drug possession in British Columbia, the province hardest hit by the overdose crisis. It has also allowed the creation of safe injection sites and made heroin available by prescription.

Like Canada, the U.S. saw a record number of overdoses last year, with nearly 108,000 drug deaths. Researchers at the University of Pittsburgh say overdoses are doubling every 10 years, fueled by multiple drugs, socioeconomic inequality and social isolation.

"There are theories, but nobody has an explanation for why drug overdose deaths so consistently stick to this exponential growth pattern,” said Hawre Jalal, MD, a former professor at Pitt Public Health who is now at the University of Ottawa. "Five years ago, leaders in the drug addiction and policy fields called our findings a coincidence. We need to stop denying that this exponential growth will continue if we don't get at the root causes and fix them."

Overdose Deaths Double for Teenagers Amid Fentanyl Surge

By Pat Anson, PNN Editor

Drug deaths among U.S. teenagers have risen sharply in the last two years, according to a new study that found the number of fatal overdoses doubled for adolescents aged 14 to 18 years.

In 2019, there were 492 drug deaths among adolescents. In 2021, there were an estimated 1,146 fatal overdoses, a 133% increase.

The vast majority of adolescent drug deaths last year involved illicit fentanyl (77%), followed by benzodiazepines (13%), methamphetamines (10%) and cocaine (7%). Less than 6% of the overdoses among teens involved a prescription opioid.

The study findings, reported in the journal JAMA, reflect what is happening in the overall U.S. population, with drug overdoses rising to record levels. They also mark the reversal of a decade long trend of fewer overdose deaths among teens, which coincided with declining rates of illicit drug use.

Researchers say adolescents may be unaware or naive about the risks posed by fentanyl, a synthetic opioid up to 100 times more potent than morphine and 50 times stronger than heroin. In a prescription, fentanyl plays a valuable role in treating severe pain, but as a street drug it can be deadly

“Beginning in 2020, adolescents experienced a greater relative increase in overdose mortality than the overall population, attributable in large part to fatalities involving fentanyls,” lead author Joseph Friedman, MPH, University of California, Los Angeles, reported in the journal JAMA.

“In the context of decreasing adolescent drug use rates nationally, these shifts suggest heightened risk from illicit fentanyls, which have variable and high potency. Since 2015, fentanyls have been increasingly added to counterfeit pills resembling prescription opioids, benzodiazepines, and other drugs, which adolescents may not identify as dangerous and which may be playing a key role in these shifts.”

U.S. Adolescent Overdose Deaths

SOURCE: jama

Friedman and his colleagues found the highest overdose rates among Native American, Alaska Native and Latino adolescents, reflecting what they called a “wider pattern of increasing racial and ethnic inequalities” in drug deaths.

Fentanyl is even killing kids who have not reached their teenage years. In California, a boy was recently arrested and charged with murder in the death of 12-year-old Dalilah Guerrero. The 16-year-old suspect allegedly sold a counterfeit pill made with fentanyl to the girl, who overdosed after crushing and snorting the tablet at a party in San Jose.

The spike in adolescent drug deaths comes even as substance abuse by teens fell to record lows. An annual survey by the University of Michigan found significant declines in all types of drug use by adolescents in 2021, with the use of prescription opioids falling to the lowest level in nearly two decades.    

DEA Warns of Fentanyl Mass Overdoses

Public health experts and law enforcement agencies are growing increasingly alarmed by the rising number of fentanyl overdoses. Last week, the DEA warned of a nationwide spike in fentanyl-related mass overdose events, in which three or more overdoses occur in the same location.

In the past three months, at least seven mass overdoses were reported in Florida, Texas, Colorado, Nebraska, Missouri and Washington, DC, resulting in 29 deaths. Three people died in a hotel room in Cortez, Colorado after ingesting what that they thought were 30mg oxycodone pills, but were actually counterfeit pills containing fentanyl.

“Tragic events like these are being driven by fentanyl. Fentanyl is highly-addictive, found in all 50 states, and drug traffickers are increasingly mixing it with other types of drugs — in powder and pill form — in an effort to drive addiction and attract repeat buyers,” DEA Administrator Anne Milgram said in a letter to federal, state and local law enforcement agencies. 

“We recommend that the members of your offices assume that all drugs encountered during enforcement activities now contain fentanyl. Given fentanyl’s extreme toxicity and the increases we are seeing in the distribution of polydrug substances containing fentanyl, please take all the precautions you would take when handling fentanyl whenever you interdict any illicit substance.”

A recent study by the National Institute of Drug Abuse estimated that over 9.6 million counterfeit pills containing fentanyl were seized by U.S. law enforcement agencies last year.