Kentucky’s high rates of opioid prescription must be reduced before even more prescribers are added. National data suggest that adding Physician Assistants to the prescribing mix is unlikely to reduce the number of opioid prescriptions written.
Louisville’s Courier-Journal this week featured an opinion piece by Andrew Rutherford, President of the Kentucky Academy of Physician Assistants, advocating for the passage of Kentucky Senate Bill 55 which would authorize physician assistants in Kentucky to prescribe controlled substances. Emphasizing the stakes involved in the proposal, articles later in the week reported on the latest rash of opioid overdoses in our region– presumably due to the inevitable fentanyl-enhanced “bad batch” of heroin. Several on-line commenters to the second articles suggested that since those who overdosed had made their own risky-decisions, that they should be permitted to suffer the consequences without an intervention of attempted resuscitation. It is suggested that this Darwinian mechanism would ease the opioid abuse problem. Unfortunately however, among the personal choices leading to opioid addiction is the choice to visit a licensed healthcare professional who, with good intentions or not, prescribes opioids. Once an individual becomes addicted, the concept of “choice” become irrelevant. A reasonable question to be asked is, “Do we really need to put more opioids in the hands of Kentuckians? My answer would be an emphatic no. Continue reading “Should Kentucky Physician Assistants Prescribe Controlled Substances?”
Bad heroin is an oxymoron, but over the past week, several dozen opioid overdoses appeared in local emergency rooms or were rescued by emergency medical technicians. At least one died. It is being reported that some 300 overdose cases were reported in our region. Since these patients responded to the opioid-specific rescue drug, naloxone, it is assumed they overdosed on one opioid or another. Toxicology studies are pending, and public health authorities are not overstating what they know, but we can reasonably assume the substances injected or otherwise consumed contained an unexpectedly high amount of heroin; the powerful synthetic opioid fentanyl; or carfentanil, the new-to-the-scene, elephant-strength, fentanyl look-alike. For decades, heroin available to end-users has been cut, or diluted with a variety of non-opioid substances – some more benign than others. In recent years, the availability of higher quality heroin from Mexico has both driven down the price and increased the potency of street heroin. Presumably both sellers and users have been adjusting their practices to account for the greater potency. Uncertainty about the purity or safety of available heroine products is said to be the reason that addicts in southern Indiana chose the prescription drug Opana as their opioid of choice. This of course did not protect them from an accompanying epidemic of HIV infection and viral hepatitis.
For reasons not fully known to me, for the past year or more, heroin preparations used by addicted individuals have been shown to contain fentanyl. It is apparent that these augmented preparations can catch whole communities of users by surprise. The arrival of heroin with augmented lethality is signaled by an increase in overdoses and deaths within a confined geographic area. While I was there in the summer of 2015, such an outbreak of heroin-associated deaths occurred in Washington County, Pennsylvania.
Whether the offending additive was fentanyl or its cousin carfentanil is relevant not just to law enforcement, but for the rescue community. Unexpectedly high doses of naloxone are required to wake up individuals who have ingested these super-opioids. The appearance of such overdose outbreaks caused by more highly purified heroin or other opioids announces to a community that their problem with drug addiction is worse than they thought. I take that to be the message for us in Louisville. Continue reading “A Batch of Bad Heroin Arrives in Louisville.”
I learned today that the Republican-controlled Kentucky Senate passed a bill that would prohibit health facilities that currently run needle-exchange programs from giving out more needles than they receive from the substance-addicted people participating in the program. Only “one-for-one” exchanges would be allowed. The primary goal of any needle-exchange program is to prevent the spread of hepatitis, HIV, or other blood-borne infection that occurs when iv-injecting drug users share their equipment. Whether or not a program is successful is measured by changes in new infection rates. Kentucky could use a little help in that department. As of 2013, for at least the previous 4 years Kentucky led the nation in new reported cases of Hepatitis-C. That is not a place we want to be, including for reasons I will discuss below. The price we pay in gold and human misery is colossal, whether one abuses drugs or not! The 2013 data set from the CDC is the most recent available to me. I must assume that things only got worse since then.
Prohibition and moralizing did not work for alcohol either.
It appears that many if not most of the Senate opponents of needle exchange programs in general are driven by puritanical or judgmental motives. There are certainly valid reasons to try to remove used needles and syringes from public spaces to avoid accidental injury, but that can and should be an independent initiative. The successful needle-exchange program in Louisville has made great progress in approaching a one-for-one exchange rate. The last thing we need in Kentucky is to have any of our towns or cities follow Austin, IN into the HIV and hepatitis blasted Hell out of which it will take several generations to climb.
Kentucky’s sons and daughters of families of all political parties are today sharing needles and other bodily fluids with HIV and hepatitis virus-infected individuals. One need not be a committed substance-injecting addict to be exposed. Healthcare workers are also at risk from needle-sticks. Our goal is to keep as many people healthy as we can through both prevention and treatment. Neither approach is easy, but that is not a reason not to try. Austin had the same warning we are being given now, but did little or nothing effective to stave off disaster. We need to do better. Moralizing will not do the trick. We must allow public health professionals to exercise their professional opinions based on best available evidence. Continue reading “Legislative Tinkering With Needle-Exchange Program: Bad Idea.”
Test of Tabloid Public software.
I am still testing software with the capability to map data geographically. This page may change as I manipulate the page layout.
Below is a map of the number of opioid prescriptions written for Medicare Part-D beneficiaries in 2013 divided by the total general population of each state. This version of “per-capita” adjustment corrects somewhat for the large differences in the population amount the states. I have shown earlier that prescriptions of opioids to Medicare patients correlates well with opioid prescription to the general public. It is disappointing to see Kentucky and our neighboring states stand out as hot-spots of prescription opioid drug use. Hover your cursor over the map to interact with the actual data. Here is a link to a full size version.
Peter Hasselbacher, MD