Heroin and Illicit Fentanyl Drive Death Rates Up, Pose Challenges

Drs. Karen Drexler, Daniel Ciccarone and Nora D. Volkow explored the nature of the opioid epidemic, the science behind it and treatment options during a AAAS symposium. | Stephen Waldron/AAAS

Opioid related deaths contributed to the first increase in the death rate in the United States in more than two decades – an uptick last seen at the height of the HIV/AIDs epidemic in 1993 – and factored into a year-over-year decline in the nation’s life expectancy rate in 2015, according to an expert addressing a congressional briefing and a related presentation on the opioid epidemic at the American Association for the Advancement of Science’s headquarters on May 10.

Center stage on what experts consider to be a worsening opioid crisis are heroin and the synthetic opioid fentanyl – 30 to 40 times more potent than heroin by weight – and fentanyl-related medicines such as carfentanil – 300 to 400 times stronger than heroin by weight, said Dr. Daniel Ciccarone, a professor of family and community medicine at the University of California, San Francisco.

“This is simply not meant for human consumption. It is a large animal pain reliever. And that’s a problem,” said Ciccarone.

Increasingly, such potent opioids are claiming the lives of young adults aged 20-34 and, for the first time, have made opioid-related deaths the leading cause of accidental deaths, surpassing motor vehicle accidents and gun violence, 2015 National Center for Health Statistics data show.

Unlike the illicit use of prescription opioid medicines that spread fairly evenly across the nation, the use of heroin and illicitly-produced fentanyl have become geographically concentrated in the nation’s Northeast and northern Midwest, spreading from Appalachia, to the mid-Atlantic and up through New England, said Ciccarone, adding, “This is an epidemic of crisis proportions.”

In these regions, particularly in seven states with the highest death rates – Maine, West Virginia, Maryland, Kentucky, Ohio, Massachusetts and New Hampshire – heroin is often tainted with illicitly produced fentanyl and fentanyl-related drugs even as users are often unaware of the extraordinary dangers, he added.

Ciccarone has conducted research on opioids for nearly two decades and shared his findings at both sessions. AAAS and the Dana Foundation, a private philanthropic organization that promotes brain research and related educational initiatives, hosted the AAAS symposium and the congressional briefing, which was held in conjunction with the Congressional Neuroscience Caucus, co-chaired by Reps. Cathy McMorris Rodgers, a Washington state Republican, and Earl Blumenauer, an Oregon Democrat.

A 2016 national threat assessment by the Drug Enforcement Agency reported that illicit fentanyl and fentanyl analogues are manufactured in powder and pill form in China and shipped to the United States, Canada and Mexico. In Mexico the drugs are mixed with heroin by the drug cartels who distribute a highly potent and refined power form of fentanyl-laced heroin into the United States.

Data show there are now two paths to heroin use where there had just been one: users either turn to heroin and fentanyl after opioid prescription drugs fail to satiate, or, more recently, users go straight to heroin, said Ciccarone.

“Age and geographic disparities support the notion that heroin is attracting a new population at risk, and, in addition, crucially, heroin has become more deadly,” he added.

In addressing the symposium held in the AAAS Auditorium, Dr. Nora Volkow, director of the National Institutes of Health’s National Institute on Drug Abuse, said the opioid addiction problem “came out of the health care system” after it was determined that opioid prescription medicine was needed to treat chronic pain affecting more than 100 million Americans.

It was not long before data showed dramatic increases in the use prescription opioid medicines by teenagers, Volkow said, and set off alarm bells that “we had a problem with prescription medicines,” a 2003 discovery that was later underscored by a steep increase in overdose deaths among all users.

From 1999 to 2014, for instance, 165,000 people died of overdose from all prescription drugs, an annual rate of 11,000 deaths. Yet by 2014, 47,055 died of prescription drug overdose in a single year and of those 18,893 deaths were attributed to prescription opioid poisoning.

The science behind the epidemic explains the necessity of the multifaceted treatment approaches being taken by the National Institute on Drug Abuse and the Veterans Health Administration to address the growing problem, the speakers said.

Daniel Ciccarone, from left, Jane Bisbee and David Martin discussed the dimensions of the opioid epidemic and its impact on social and judicial services at Capitol Hill briefing. | Anne Q. Hoy/AAAS

Volkow walked through how the analgesic and rewarding effects of opioids are expressed in pain terminals in the spinal cord and in the brain where the drugs impact regions that regulate reward and pleasure. Brain circuits make opioids less effective over time, requiring higher potency levels to achieve equal levels of euphoria, she said. This sets off a spiral of increased cravings, more consumption of ever more potent drugs, behaviors that can lead to death.

The National Institute on Drug Abuse is pursuing a mix of approaches that include developing non-opioid pain medicines, conducting research on vaccines that may blunt the impact of fentanyl and its related offshoots, getting public health organizations to increase the availability and use of medications already available to treat opioid addiction and getting medications such as buprenorphine and naloxone, which suppress withdrawal symptoms and ease cravings, into the hands emergency room doctors dealing with patients with opioid addictions.

Dr. Karen Drexler, director of the Mental Health Program at the Department of Veterans Affairs and a practicing psychiatrist, said the agency has improved treatment by carefully monitoring the progress of patients undergoing long-term opioid therapy at the same time the agency is pressing for non-opioid pain treatment going forward. The VA also has integrated its prescription drug monitoring programs to better enable state-based dispensing pharmacies to share information.

The VA’s stepped approach includes dispensing pain medications to help wean patients off opioids, offering drug counseling, monitoring drug use, tracking medication use, offering outpatient programs and providing treatment and residential rehabilitation facilities, Drexler said.   

As a result, she said, the program saw a 33% reduction in patients receiving opioid medications, a 39% reduction in veterans on long-term opioid therapy and a 50% increase in the number of those on long-term therapy undergoing urine drug screening to monitor their intake from fiscal 2012 through fiscal 2016.

Still, the epidemic is wreaking havoc on generations, beginning with infants born with opioid drugs in their systems, who sometimes then undergo more trauma when separated from their parents, according to Jane Bisbee, deputy director of field operations at the Indiana Department of Child Services. Indiana, like other Midwestern states, has been hard hit by the opioid epidemic with tragic consequences.

“A one-month-old baby died of opioid overdose. Her mother was breast feeding. A drug screening of the mother was positive for heroin, morphine, Xanax and methadone. Dad was positive also. The child’s toxicology screen was positive for a high level of opioids,” said Bisbee during the congressional briefing. “I have one of 20 pages that I could read to you today about kids who have died in the state of Indiana.”

David Matia, a drug court judge in Cuyahoga County, Ohio, where deaths also have risen significantly, said incentives are needed to get hospitals to build more detox facilities, to encourage physicians to expand access to medication assisted treatments and to encourage medical students to pursue addiction and behavioral health specialties as their area of practice.

Among other initiatives needed are more rigorous analysis of the potency of illicit drugs being sold on the streets, information campaigns to inform the public of the analyses results and likely dangers, more treatment therapies to ease withdrawal symptoms, programs to get primary care doctors to treat and screen for addictions and wider distribution of Naltrexone, which can reverse an opioid overdose, said Ciccarone.

Naltrexone needs to be made readily available in the medicine kits of the families and friends of anyone with an opioid addiction disorder, Ciccarone said, adding, “It needs to be this generation’s EpiPen.”

[Associated image: Fotomaximum/AdobeStock]