CDC urges providers to consider risks of opioid treatments

Although opioid prescriptions declined for five years since a peak in 2010, the Centers for Disease Control and Prevention (CDC) found that the highest-prescribing counties dispensed six times more opioids per resident in 2015. The CDC urges providers to consider evidence-based guidance for opioid prescriptions and weigh the risks and benefits of such treatment with patients.

Demographics

According to the CDC’s Vital Signs report, a breakdown of the number of opioids prescribed per person in 2015 by county revealed considerable variation, with clusters of high-rate counties located in various places across the country. The CDC believes that the variation reveals inconsistencies among providers who prescribe opioids. Counties with higher prescribing tended to have small cities or large towns, more white residents, more dentists and primary care providers, a higher rate of uninsurance or unemployment, and more people with a chronic condition like diabetes or arthritis, or a disability.

Issues

The CDC identified three specific issues with high prescribing that pose risks for patients. In 2015, there were enough opioids prescribed to keep every American constantly medicated for three weeks. This level of prescription may indicate that providers need to consider more non-opioid treatment options, such as physical therapy and other medications, and only use opioids when the benefits are most likely to outweigh the risks.

Even for those on low doses, taking an opioid for more than three months increases a patient’s risk of addiction 15 fold. When treating acute pain, opioids should only be prescribed for the expected duration of severe pain. In addition, a dose of 50 morphine milligram equivalents (MMEs) or more per day doubles a patient’s risk of overdose death. The CDC believes that the average daily MME per prescription remains too high.

Resources

The CDC recommends continuously balancing risks and benefits throughout opioid treatment, from the starting prescription through dosage increases. The agency’s Guideline for Prescribing Opioids for Chronic Pain outlines when a provider should initiate or continue opioids for chronic pain, treatment options, and risks and harms of opioid use.

Trump administration disperses $485M in opioid fight

The Trump Administration announced $485 million in grants to assist states with combating opioid addiction. The funding is the first part in two rounds of opioid-focused state grants provided for by the 21st Century Cures Act (Cures Act) (P.L. 114-255). The funds will be administered by the Substance Abuse and Mental Health Services Administration (SAMHSA).

The funding will be received by all 50 states, the District of Columbia, American Samoa, Micronesia, Northern Marianas, Palau, Puerto Rico, and the Virgin Islands. The allocation of the $485 million was determined according to need. The largest grants were awarded to states with the highest rates of overdose deaths and unmet need for opioid addiction treatment. Some of the highest awarded states include: California ($44,749,771), Florida ($27,150,403), Ohio ($26,060,502), Pennsylvania ($26,507,559), and Texas ($27,362,357).

In a letter to governors, HHS Secretary Price called the opioid crisis alarming, noting that “opioids were responsible for over 33,000 deaths in 2015.” He also admonished governors that “we cannot continue to lose our nation’s citizens to addiction.” Price cautioned that “while I am releasing the funding for the first year immediately, my intention for the second year is to develop funding allocations and policies that are the most clinically sound, effective and efficient.”

Highlight on Massachusetts: Seeing the opioid crisis differently

Massachusetts, like many states, has an opioid epidemic. The number of individuals experiencing opioid-related overdose and death in Massachusetts was four-times higher in 2015 than it was in 2000. The crisis isn’t new, but state health officials have taken a new step to raise awareness and disseminate information concerning the epidemic. State health officials released an interactive website designed to display information graphically so that it will have a more profound impact.

Chapter 55

As part of an effort to combat the epidemic, Chapter 55 of the Acts of 2015 was signed into law—a piece of state legislation that permitted an analysis of government datasets to achieve better understanding of the opioid crisis. The Massachusetts Department of Public Health (DPH) led the data analysis, which culminated in a report: The Chapter 55 Report. The report identified a number of trends as well as analyzed key factors impacting the crisis, including: costs, growth of addiction, prescriptions, illegal drugs, and demographics.

Crisis

The crisis in Massachusetts is above the national average, due in part to a sharp rise in opioid-related deaths in the last two years. For example, 2014 was the first year since 1999 that the fatal overdose rate in Massachusetts was more than double the national average. Additionally, while, in 2000, about one third of admissions to substance abuse treatment centers were opioid-related, by 2015, opioid-related issues accounted for more than half of admissions. A similar pattern was documented by the Health Policy Commission in terms of emergency department visits and hospitalizations.

Deaths

The website offers novel displays of opioid-related death data, including state maps that demonstrate by county across three blocks of time—2001 to 2005, 2006 to 2010, and 2011 to 2015—the number of individuals, per 100,000 people, who died as the result of opioids. By scrolling over a county, the maps demonstrate the five-year death rate for that county and the death rate per 100,000 people. Some counties have undergone massive increases in their opioid-related death rate. For example, from 2001 to 2005, Eastham County had a five-year death count of zero and a death rate per 100,000 people of zero. In stark contrast, from 2011 to 2015, Eastham County had a five-year death count of nine and a death rate per 100,000 people of 36.3.

Heroin

Another set of maps demonstrates the percentage of patients in treatment who listed heroin as their primary substance of abuse. The four separate maps correspond to the frequency of that designation, by county, in 2000, 2005, 2010, and 2015. In 2000, only about 20 counties were identified as having over 46 percent  of substance abuse treatment patients indicating heroin as their primary substance of abuse—a designation shown as green on the map. The 2000 map is merely speckled with green. By 2015, however, the map is almost entirely green, with the majority of counties marked as having over 46 percent of patients indicating heroin as their primary substance of abuse.

Transition

The website also uses graphics to display the trends related to the transition between prescriptions and illegal opioids.  The graphics demonstrate, based upon specific drugs—heroin, fentanyl, prescription opioids, methadone—the likelihood that an individual had a legal opioid one, three, or six months before death.  For example, in Massachusetts, between 2013 and 2014, 867 individuals who died of an opioid-related overdose had a positive toxicology screen for heroin. Sixty-five percent of those individuals had a legal opioid prescription between 2011 and 2014.

Conclusion

The website offers information about addressing substance abuse and gives examples of steps that can still be taken to expand treatment options, tailor treatment and prevention efforts, and develop post-incarceration treatment plans. The Massachusetts DPH aims to continue to use data as a tool to obtain insight and solutions for the problem.  If nothing else, the agency’s graphic depiction of the Chapter 55 Report is successful in that it is a stark and dramatic way to say: something is wrong.

As naloxone prominence increase in opioid fight, so does price

The price of naloxone, a drug used to reverse the effects of an opioid overdose, has skyrocketed in the past few years. Despite complaints from lawmakers and national advocacy groups such as Harm Reduction Coalition, the price increases have come at a time when public health officials cite the record number of overdose deaths – more than 27,000 in the U.S. in 2014 – with almost 19,000 from prescription opioids and over 10,000 heroin-related, 16 and 28 percent increases from the previous year.

President Obama recently signed a law aimed at addressing the growing opioid crisis in the U.S. and naloxone is at the forefront of the conversation, as it is often the drug of choice to reverse the effects of opioids on the brain and can limit or stops a heroin or prescription opioid overdose. The Comprehensive Addiction and Recovery Act of 2016 increases the availability of naloxone, strengthens prescription drug monitoring programs (PDMPs) by assisting states with monitoring and tracking prescription drug diversion, and expands prevention and educational efforts with teens and other adult populations.

The most common formulation of naloxone used by police departments, hospitals, and addiction advocacy organizations is made by Amphastar Pharmaceuticals, which raised concerns after it increased the list price of 10 injectable naloxone from $120 to $330 in October 2014. In the last decade, Hospira’s injectable dose has gone from 92 cents in 2005 to more than $15 in 2014. Meanwhile, Kaleo Pharma raised the price of its naloxone product, Evzio, several times in since 2015. In November 2015, the price went up to $375, followed by an increase to $1,875 in February 2016; the single-dose auto-injector price is now at $2,250.

According to Truven Health Analytics, the rise in price has been partly driven from the lack of competition. The price hikes jumped in frequency and volume in 2008 after several manufacturers stopped producing the drug, leaving Hospira and Amphastar as the sole manufacturers of naloxone. Mylan and Kaleo only introduced naloxone products in 2014, but only Mylan, Amphastar, and Hospira make the cheaper, injectable versions. Kaleo makes the auto-injector.

The demand for naloxone is not likely to decrease in the near future, as Congress is considering requiring that physicians co-prescribe the drug with every opioid prescription.