Opioids, Heroin and Public Health

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Source: The Dana Foundation

The Opioid Epidemic

“We’ve moved from an epidemic to a crisis” in opioid abuse in the United States, said Daniel Ciccarone, M.D., MPH, during a panel discussion at AAAS in Washington, DC, this week. Ciccarone, a doctor at University of California, San Francisco, who treats addicted people and does research, described a pattern of intertwined waves involving abuse of prescription pills, heroin, and synthetic opioids like fentanyl.

For example, while overdose deaths due to prescription pill use are spread relatively evenly across the country, “this is not true for heroin,” Ciccarone said. The Northeast has had troubles with opioid abuse for a generation, while in the Midwest, numbers have jumped just recently. And while older folks (50-64) are using pills in greater numbers, it’s younger people (20-35) driving heroin use.
“Heroin itself is becoming more and more dangerous,” he said, especially when it is laced with synthetic drugs like fentanyl and carfentanil (used to tranquilize elephants). People who stop breathing after using these stronger concoctions often don’t respond to emergency treatments like naloxone.


The latest epidemic came about in large part out of doctors’ good intentions, said Nora Volkow, M.D., director of the National Institute on Drug Abuse, part of NIH. Starting in the late 1990s, doctors increasingly prescribed opioids to young and old for acute (sudden onset) and chronic pain (pain that is regular and has lasted for months). They were responding to a call to better help people who were in severe pain, and they thought that while the patient was experiencing pain, they would not be likely to become addicted to the drug.

“The epidemic really started from our over-prescription,” said Volkow, a member of the Dana Alliance for Brain Initiatives. For example, in 2013, the number of total pills prescribed in this country was the equivalent of a 1 month supply for every adult in the US, she said. Over the past 15 years, “the whole United States appeared to become infected,” she said.

Opioids are very effective for acute pain. Volkow described her own experience taking them after she was in a car accident: “It was amazing, not just because the pain was gone but because of that great sense of well-being.” But many people grow more tolerant of the drug the longer they use it, and need ever-increasing doses to find relief. This can lead to over-use, and to people transitioning from pills to black-market drugs like heroin and fentanyl. “80 percent of new cases of heroin are actually emerging from individuals who became addicted to prescription opioids,” she said; because prescription drugs are expensive and difficult to get, while heroin has gotten cheaper, they make the switch. (The other 20 percent of new users are mainly younger people, who started directly with heroin as a recreational drug.)

This is dire news, but we have experienced waves of other deadly maladies and overcome them before. “When we had the HIV epidemic, when we had the Ebola epidemic, we addressed it using science,” Volkow said. “Scientific solutions can provide us means to control these problems, and it’s not any different for the opioid crisis”

For example, Karen Drexler, M.D., an addiction psychiatrist and program director for addictive disorders at the Veterans Healthcare Administration (VA), described the success of Dr. John Snow in solving a cholera epidemic in 1854 London. While others blamed bad air for the outbreak, Snow looked at this map showing where the sickened people lived, and asked what they had in common. It turned out they all obtained water from one local pump. Snow stopped the outbreak by taking the handle off the pump. People obtained their water from elsewhere, and stopped getting sick.

Map of opioid prescriptions and overdoses. Data source: National Vital Statistics, 2013 Source: State of Maryland

Looking at “our ‘map of London’ for the opioid epidemic,” Drexler said, it was clear that the most overdoses were where there were the most over-prescriptions. For opioids, “taking the handle off the pump” means reducing the number of prescriptions and changing prescription advice to use the lowest effective dose for the shortest amount of time so people have the least risk of becoming addicted. “Prevention is best,” she said.

The VA is applying a series of evidence-based actions to reduce prescriptions, including more-closely monitoring people who are taking opioids, advising doctors not to prescribe opioids for chronic pain, and suggesting alternative drugs and counseling.

Volkow described three areas NIH and others are working on: developing better, safer treatments for chronic pain; designing better strategies to help addicted people come off the drugs; and finding more direct opioid-blocking drug interventions like methadone, naloxone, and buprenorphine. The latter are proven to help, but “they are not being used. Less than 15 percent of people who would benefit from these are getting them,” she said, because of stigma, lack of doctor training, and lack of insurance reimbursement. In addition, “with science, of course we look for transformation,” she said, including looking for a potential vaccine against fentanyl.

Drexler described several current models of treatment that have evidence of success, including brief one-on-one counseling, which “is sufficient for many with opioid-use disorder,” she said. Other methods include the Massachusetts model of buprenorphine maintenance, Project Echo in New Mexico, and a method mirroring the alcohol care management model.

“I’m very hopeful that we’ll be able to disseminate these models out,” she said, perhaps by using marketing methods similar to those drug companies use. Still, “we need more help for newer, better treatments as well as how to implement the ones we have.”

“We need to treat this as a poisoning epidemic, not a drug epidemic,” Ciccarone said, including boosting programs that do “harm reduction,” caring for people who are engaging in risky behavior. “We tend to think of harm reduction as ‘aiding and abetting drug users,’ in the political sphere, but harm reduction saves lives,” it’s cost-effective, and it can bring people into treatment, he said. “Stop treating the drugs as sort of the special privilege of the criminal justice folks and the injured bodies as only public health.”