{"id":5254,"date":"2016-09-02T12:19:49","date_gmt":"2016-09-02T16:19:49","guid":{"rendered":"http:\/\/www.khpi.org\/blog\/?p=5254"},"modified":"2017-02-13T14:07:10","modified_gmt":"2017-02-13T19:07:10","slug":"a-batch-of-bad-heroin-arrives-in-louisville","status":"publish","type":"post","link":"http:\/\/www.khpi.org\/blog\/a-batch-of-bad-heroin-arrives-in-louisville\/","title":{"rendered":"A Batch of Bad Heroin Arrives in Louisville."},"content":{"rendered":"

\"top-1000-map\"<\/a>Bad heroin is an oxymoron, but over the past week, several dozen opioid overdoses<\/a> appeared in local emergency rooms or were rescued by emergency medical technicians.\u00a0 At least one died.\u00a0 It is being reported that some 300 overdose cases were reported in our region.\u00a0 Since these patients responded to the opioid-specific rescue drug, naloxone, it is assumed they overdosed on one opioid or another.\u00a0 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.\u00a0 For decades, heroin available to end-users has been cut, or diluted with a variety of non-opioid substances \u2013 some more benign than others.\u00a0 In recent years, the availability of higher quality heroin from Mexico has both driven down the price and increased the potency of street heroin.\u00a0 Presumably both sellers and users have been adjusting their practices to account for the greater potency.\u00a0 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.\u00a0 This of course did not protect them from an accompanying epidemic of HIV infection and viral hepatitis.<\/p>\n

Really-bad heroin.<\/strong>
\nFor reasons not fully known to me, for the past year or more, heroin preparations used by addicted individuals have been shown to contain fentanyl.\u00a0 It is apparent that these augmented preparations can catch whole communities of users by surprise.\u00a0 The arrival of heroin with augmented lethality is signaled by an increase in overdoses and deaths within a confined geographic area.\u00a0 While I was there in the summer of 2015, such an outbreak of heroin-associated deaths occurred in Washington County, Pennsylvania.<\/p>\n

Whether the offending additive was fentanyl or its cousin carfentanil is relevant not just to law enforcement, but for the rescue community. \u00a0Unexpectedly high doses of naloxone are required to wake up individuals who have ingested these super-opioids.\u00a0 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.\u00a0 I take that to be the message for us in Louisville.<\/p>\n

Connection with prescription opioids.<\/strong>
\nThe overdoses here in Louisville and elsewhere are being caused by the illegal opioid heroin augmented with fentanyl, a legal drug illegally used.\u00a0 It is generally accepted that a large portion, if not the majority of heroin users start down that path of addiction using prescription opioids.\u00a0 Certainly here in Kentucky and adjacent states with major opioid addiction problems, the extent of heroin use and the volume of prescription opioids to the general public usually go hand-in-hand.\u00a0 It is not a good omen that in Kentucky we are exposed to an inundation of prescription opioids of diluvial proportion.\u00a0 It is therefore not a surprise that we also lead the nation in newly reported cases of Hepatitis-C<\/a>, and are right up there in accidental deaths associated with drug overdose.\u00a0 Based on Medicare, Medicaid, and KASPER databases, I have written about the abundant availability of prescription opioids in Kentucky and adjacent states.\u00a0 The pill mills that openly gave away opioids as fast as they could be handed out are being shut down, but the variation in the willingness of physicians and other medical providers to prescribed opioids remains\u00a0frankly stunning.\u00a0 Understanding whether these differences can be justified medically will be a difficult yet essential undertaking for the nation.<\/p>\n

Super-prescribers.<\/strong>
\nAs I began to tackle the 2014 Medicare-Part-D drug utilization and cost database released earlier this month, I was both surprised and disappointed to learn that of the top 20 most frequent prescribers of opioids to Medicare patients nationally, four practiced in Kentucky.\u00a0 On further review, five of the top 30, and seven of the top 40 practice in the Commonwealth!\u00a0 In the four highest volume opioid-prescribing specialties, and in the two main pain management specialties, Kentucky\u2019s healthcare providers prescribed opioids more often<\/a> than their national colleagues.\u00a0 I prepared an interactive\u00a0chart<\/a> and a US map<\/a> identifying the states where the 1000 most frequent prescribers of opioids to Medicare Part-D patients practice. [Note that Medicare uses a broad\u00a0definition of “opioid” that includes drugs like tramadol, methadone, and buprenorphine.]<\/p>\n

\"top-1000-bar-chart\"<\/a><\/p>\n

Some numbers.<\/strong>
\nIn 2014 there were 503,804 Medicare prescribers who wrote more than 10 prescriptions or refills for opioids.\u00a0 The most frequent prescriber wrote 26,449 prescriptions.\u00a0 I calculated that based on a five-day work week with no vacation this came out to 102 prescriptions per day for Medicare patients alone.\u00a0 The range of prescription count for the top thousand most frequent prescribers spanned 3393 to 26,449.\u00a0 Kentucky had 44 of the top thousand.\u00a0 Only six states had more.\u00a0 We might predict that as a matter of chance, states with large populations might have higher numbers of volume prescribers.\u00a0 Nonetheless, the distribution of the states with the largest numbers of super-prescribers largely overlays a map of states with larger numbers of opioid prescriptions<\/a> overall, large numbers of accidental deaths, opioid addiction, or hepatitis cases<\/a>. Florida and Texas \u2013 you must have a real problem!<\/p>\n

\"top-1000-map\"<\/a><\/p>\n

Who is writing all these prescriptions?<\/strong>
\nIt used to be that the identity of physicians prescribing any drug was largely a secret from the public.\u00a0 However, with the advent of Medicare’s publication of its Part-D utilization database, individual prescribers of drugs from Tylenol thru fentanyl are now identified by name.\u00a0 I am in hopes that this knowledge will allow prescribers to compare themselves to their peers and reconsider their practice habits, or will identify individuals or regions deserving of attention from professional and standard-setting organizations.\u00a0 It is my professional opinion that the disparities in rates of prescription are not defensible medically.\u00a0 Sadly, in Kentucky, individuals responsible for oversight of opioid prescribing standards have set the bar very very<\/u> low.\u00a0 A continuing medical education session sponsored by the Kentucky Medical Association that I attended a few years ago focused largely on how to structure the medical record to survive an outside audit rather than whether or not opioids are appropriate for a given condition.\u00a0 The Kentucky Board of Medical Licensure provided names<\/a> for nominations to the Governor\u2019s Kasper Advisory Council leading to the appointment of one of Kentucky’s highest opioid prescribers to that standard-setting supervisory body. Here is a list of the top 1000 Medicare prescribers of opioids<\/a> in 2014.<\/p>\n

It is my belief that only by decreasing the number of opioid first-doses that will we even begin to grapple with this terrible problem.\u00a0 National organizations such as the CDC have acknowledged this. It is my understanding that the Surgeon General sent every physician<\/a> in the nation a mailing from that organization asking them to think twice before prescribing opioids for nonmalignant or terminal conditions. \u00a0Here is a\u00a0copy<\/a>. \u00a0\u00a0An surge of deaths from individuals being prescribed both opioids and benzodiazepam sedatives like Valium just prompted the FDA to issue its highest level of warning against that practice<\/a> \u2013 the dreaded black box that appears in package inserts and advertisements.\u00a0 This warning should not have been necessary but sadly, many prescribers apparently still needed to hear that message. (I will query the database in this regard.)<\/p>\n

Controlling our opioid-abuse epidemic will be enormously difficult. \u00a0Experience with other substance addictions such as to tobacco and alcohol suggests that problems with opioid addiction will never go away.\u00a0 It was experience with the opioid group of drugs that essentially defined the science and language of addiction.\u00a0 Although the aggregate cost to society of opioid addiction is probably not as great as either tobacco or alcohol, its effects are similarly broad.\u00a0 Is not just the user and their loved ones who pay the price.\u00a0 To fund their habit, users disrupt the lives of all of us.\u00a0 One can only speculate how many robberies, murders, or organized crime activities are consequent to putting illegal opioids into the hands of those whose craving is not to be denied.<\/p>\n

Why go halfway?<\/strong>
\nIn the spirit of suggesting that outside-the-box solutions must be considered, I offer this one again.\u00a0 What would happen if the personal use of heroin or nonmedical use of prescription opioids was decriminalized?\u00a0 Why not provide opioids of predictable and safe quality to individuals who are addicted, along with syringes in a safe place to use?\u00a0 For many, these safe alternatives would be part of a medication assisted treatment program.\u00a0 For others it would provide access to whatever other effective treatment is available, or offer a holding pattern that is at least no worse than the nightmare world where we allow addicts to flounder.\u00a0Why\u00a0would this not be\u00a0a lot safer and a lot less expensive for all of us, user and non-user alike? \u00a0What would happen to the number of home break-ins?\u00a0 What would happen to the number of drug-related murders?<\/p>\n

The major fear of course is that making nonmedical opioid use safer and available might lead to more opioid addicts.\u00a0 I do not know if that would be the case.\u00a0 Certainly the punitive and moralistic approaches we are taking now have proven themselves to be abundantly ineffective.\u00a0 It seems to me as a society that we have already made the decision to try to help opioid-addicted individuals by structuring a response revolving around keeping them\u00a0alive with the rescue drug naloxone. \u00a0Is it not logical then to take the next step and keep them safe, and to make it at least possible for them to live a more productive and healthier life?\u00a0 It is my belief, that opioid addiction is a fellow traveler with despair, with poverty, with unemployment, and with many of the other non-medical determinants of health. \u00a0\u00a0If we are truly serious about dealing with opioid addiction and the social disruption that accompanies it, we will have to confront a very broad range of issues.\u00a0 We should be doing that anyway.<\/p>\n

I have made a \u00a0suggestion.\u00a0 What is yours?<\/p>\n

Peter Hasselbacher, MD
\nPresident KHPI.
\nEmeritus Professor of Medicine, UofL
\n1 September 2016<\/p>\n

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