ACOPC_Conference_2014_Adam_Gordon_MD (1)

Overdose in Allegheny County: 2014 updates

Overdose deaths in Allegheny County may have peaked in 2012, said County Medical Examiner Karl Williams, M.D. at the Allegheny County Overdose Prevention Coalition (ACOPC) conference in Pittsburgh last month.  Allegheny County lost 278 citizens to drug overdose in 2013, as compared to 288 in 2012. However, 2014 began with a rash of drug overdose deaths related to a dangerous heroin/fentanyl combination that emerged suddenly in the American northeast.  Although it’s not clear whether 2014 is on pace to surpass the previous few years or not, real-time Allegheny County overdose data will soon be available due a grant-funded initiative to create an online repository with information and resources on overdose at a local level.

This was some of the more optimistic news that Dr. Williams conveyed during his presentation on a generally grim topic, “The Overdose Problem in Allegheny County.”

More than one speaker commented that Allegheny County is “ahead” in terms of overdose response.  For one thing, our Office of the Medical Examiner has the unusual capacity to do toxicological analysis in-house. As a result, according to Williams, during the outbreak of overdose deaths in early 2014, “we were able to realize within days that the offending drug was a unique mixture of manufactured heroin and fentanyl.” If they’d had to send samples to off-site toxicology labs and await results, like many county examiners do, it would have taken weeks to recognize the dangerous batch of heroin and take appropriate public health measures.

Williams also pointed out that the real-time data and resource website, set to launch later this summer, will put Allegheny County ahead of the game.

However, here in Allegheny County, we are also facing a serious heroin problem, a fact underscored by data showing that just under half of our 288 overdose deaths in 2012 involved heroin and emphasized by Keynote Speaker Melinda Campopiano von Klimo, MD, Medical Officer at the National Center for Substance Abuse Treatment.

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For the third year in a row, the ACOPC held its annual conference at the University of Pittsburgh to share local data, offer national perspective, and facilitate cooperative efforts to address overdose among county stakeholders.  This year’s theme was “Permeating Borders,” a gesture toward the importance of multidisciplinary approaches to curb overdose death.  Intriguingly, the afternoon program in this day-long conference agenda focused specifically on permeating borders in two key areas: a) between harm reduction and abstinence-based recovery and b) between physical healthcare and overdose prevention.

Before the afternoon speakers, however, Campopiano von Klimo’s presentation included discussion of a very fuzzy border: the one that exists in our imagination between prescription drug use and heroin use. In reality, these drugs are profoundly intertwined.

“There is overlap,” she remarked.  “People use both.  When we’re talking about prescription drug misuse, we’re also talking about heroin.”

The blurry border between heroin and prescription drugs

Although research is scant on the transition from non-medical pain reliever to heroin use, a 2013 analysis of SAMHSA’s National Survey on Drug Use and Health data showed that among people 12-49, if a person used heroin within the last year, he or she was 19 times more likely to have used pain relievers non-medically than someone who had not used heroin within the last year.  While it’s clear that most non-medical pain reliever (NMPR) users do not progress to heroin use, the data indicate that NMPR use is a common step on the pathway to heroin initiation.

The SAMHSA analysis also points out that the vast expansion of prescription drug misuse, particularly among young people, may not only explain but also foretell a significant increase in heroin users.  That is, although we have already seen the number of heroin initiates, heroin-related emergency room visits, and heroin-related overdoses rise in the last few years, these trends may be the tip of the iceberg.

People use both. When we’re talking about prescription drug misuse, we’re also talking about heroin.

Over the 10-year period between 2002 and 2012, there were more than 20 million NMPR initiates aged 12 to 49.  A Yale research team estimated that 1 in 15 recreational prescription drug users will try heroin within ten years.  Their analysis also showed that the percentage of NMPR who move on to try heroin has been growing; from 5 percent in 2004 to 14 percent in 2010.  This seems to have the makings of a growing population of heroin initiates, users, and (without proactive interventions), overdose deaths.

Although we don’t know the extent to which these predictions will be borne out, we do know that heroin initiation, use, and dependence have all increased in the last ten years.  We know that treatment systems have seen a 5-fold increase in admissions for prescription drug abuse since 2001. And we know that prescription drugs are the 2nd most used illicit drug among persons 12 and older after marijuana.

However, states have been slow to recognize and act on the connection between heroin and prescription opioid use.  According to a 2014 survey of state substance abuse agencies, while 35 states reported that their strategic plan explicitly addresses prescription drug abuse, only 12 of these states reported that their plan “explicitly addresses heroin abuse.”  Only seven states reported that they have data providing evidence that users in their state are transitioning from prescription drugs to heroin abuse, although “a number of States responding ‘no’ or ‘unsure’ said they had anecdotal evidence of such a transition.”

Recommended overdose prevention strategies

Overdose prevention efforts ought to be sensitive to the association between heroin and prescription drug use and account for users of both types of drugs.  Some prevention measures (such as naloxone distribution and expanding access to medication-assisted treatment) have the potential to save the lives of prescription opioid and heroin users. Others, such as prescription drug monitoring databases, only impact prescription drug consumption and could have the unintended consequence of shifting drug users toward heroin.

Campopiano von Klimo offered a tour of SAMHSA’s new Opioid Overdose Prevention Toolkit, released earlier this year, which has lately become the most frequently downloaded product from SAMHSA’s website.  In her presentation, she listed five specific strategies for reducing overdose deaths.

  • Encourage health care professionals, persons at high risk, family members and others to learn how to prevent and respond to opioid overdose
  • Ensure access to treatment for individuals who are misusing or addicted to opioids or who have other substance use disorders
  • Ensure ready access to naloxone
  • Encourage the public to call 911
  • Encourage prescribers to use state Prescription Drug Monitoring Programs (PDMPs)

Campopiano von Klimo’s presentation slideset offers additional details for each one of these strategies.

How to permeate the border between abstinence-based recovery and harm reduction

Two presenters representing different ends of the spectrum–Alice Bell, LCSW, Overdose Prevention Coordinator at Pittsburgh’s needle exchange program, and Neil Capretto, DO, medical director at Gateway Rehabilitation–spoke to the issue of integrating harm reduction principles into traditional abstinence-based treatment programs.

Bell has worked with many professionals in many settings to implement overdose prevention programs.  Traditional addiction treatment programs benefit from the use of overdose prevention strategies, she said, citing three specific value-added areas: improving therapeutic alliances with clients, contributing to a trauma-informed approach to care, and helping to support and retain staff.

Where can overdose prevention strategies be integrated with abstinence-based treatment? Lots of places.

When a counselor provides information about overdose prevention, said Bell, the therapeutic alliance is strengthened because clients feel that their lives and safety are valued, which generates trust.  And because it’s not uncommon for clients to have personal and traumatic experience with overdose, an ongoing open discussion of the issue is an important aspect of acknowledging and helping to address trauma.  Finally, Bell explained, treatment staff can be profoundly affected when a former client dies of a drug overdose.  By arming those clients with tools and information to prevent tragedy, a treatment center is protecting and supporting its staff.

Where can overdose prevention strategies be integrated with abstinence-based treatment?  Lots of places, said Bell. Ideally, throughout the treatment process.  Clients on waiting lists should be given information about naloxone access and how to recognize and address an overdose.  Overdose prevention education should be a component of intake, orientation, and certainly at any point of medication induction.  And finally, education and resources–including naloxone–should be offered to clients moving to another level of care.

For treatment centers (and other health settings) interested in prescribing naloxone directly to clients, Bell recommended the excellent website prescribetoprevent.org.

Capretto, speaking from more than 25 years of experience working in abstinence-based treatment settings, echoed many of Bell’s sentiments.  One important historical note, he told the audience, is that the 12 steps were originally designed for alcohol and not drugs.  The issue of fatal overdose was a less significant consideration for the pioneers of Alcoholics Anonymous, whose approach to managing substance use disorders is a prominent aspect of addiction treatment at Gateway and many other treatment programs throughout the country.

Overdose prevention, including naloxone distribution, saves lives and does not increase risky substance use.  Which is why, said Capretto, Gateway has chosen to pilot a naloxone distribution program among its clientele.

Opioids create a troublesome border between addiction and pain relief

Lots of patients don’t access formal addiction treatment, began Adam Gordon, MD, MPH, in his presentation “Barriers and Opportunities for Physical Health Providers in the Overdose Prevention Equation.”  But those patients often do see primary care providers.  Like SAMHSA’s Campopiano von Klimo, Gordon pointed to the use of  medication-assisted treatment–particularly buprenorphine–as a major opportunity for physical healthcare providers to help patients with opioid use disorders.  “Addictive disorders?  They are treatable!  (by ‘normal’ healthcare providers)” he trumpeted on one of his slides.

And Gordon nudged further, pointing out that not only are physical healthcare providers able to address opioid use, they have a responsibility to do it.  He pointed to the “troublesome nature” of opioids, whereby the DSM-V definition for a mild opioid use disorder, which requires two of a list of 11 possible criteria, are entirely inherent to the use of opioids at all, therapeutic or not.  Those two criteria are withdrawal/physical dependence and tolerance.  Any provider, then, who prescribes opioids, is venturing into territory that could compromise the patient’s health and therefore has a responsibility to address those risks.

And opioid use is associated with a number of co-occurring physical health disorders, said Gordon, which are certainly the domain of the physical healthcare provider.

Near the end of his presentation, Gordon shared a quote from NIDA’s Nora Volkow on the complexity of opioid use and its associated harms, which requires practitioners to actively struggle to strike a difficult balance.

“To address the complex problem of prescription opioid and heroin abuse in this country, we must recognize and consider the special character of this phenomenon, for we are asked not only to confront the negative and growing impact of opioid abuse on health and mortality, but also to preserve the fundamental role played by prescription opioid pain relievers in healing and reducing human suffering. That is, scientific insight must strike the right balance between providing maximum relief from suffering while minimizing associated risks and adverse effects.”

Recommended Resources

ACOPC 2014 Conference presentations online (all available for download)

Opioid Overdose Toolkit, SAMHSA (2014)

Prescribe to Prevent

Associations of Non-Medical Pain Reliever Use and Initiation of Heroin Use in the United States, SAMHSA (2013)

Overdose Awareness Day is August 31, Huffington Post (2014)