Turning the tide or riptide? The changing opioid epidemic

ABSTRACT

The US opioid epidemic has changed profoundly in the last 3 years, in ways that require substantial recalibration of the US policy response. This report summarizes the changing nature of overdose deaths in Jefferson County (home to Birmingham, Alabama) using data updated through June 30, 2016. Heroin and fentanyl have come to dominate an escalating epidemic of lethal opioid overdose, whereas opioids commonly obtained by prescription play a minor role, accounting for no more than 15% of reported deaths in 2015. Such local data, along with similar reports from other localities, augment the insights available from the Centers for Disease Control and Prevention's current overdose summary, which lacks data from 2015–2016 and lacks information regarding fentanyl in particular. The observed changes in the opioid epidemic are particularly remarkable because they have emerged despite sustained reductions in opioid prescribing and sustained reductions in prescription opioid misuse. Among US adults, past-year prescription opioid misuse is at its lowest level since 2002. Among 12th graders it is at its lowest level in 20 years. A credible epidemiologic account of the opioid epidemic is as follows: although opioid prescribing by physicians appears to have unleashed the epidemic prior to 2012, physician prescribing no longer plays a major role in sustaining it. The accelerating pace of the opioid epidemic in 2015–2016 requires a serious reconsideration of governmental policy initiatives that continue to focus on reductions in opioid prescribing. The dominant priority should be the assurance of subsidized access to evidence-based medication-assisted treatment for opioid use disorder. Such treatment is lacking across much of the United States at this time. Further aggressive focus on prescription reduction is likely to obtain diminishing returns while creating significant risks for patients.

KEYWORDS:

• Opioids
• opioid use disorder
• overdose
• pain
• prescriptions
• primary care
• treatment access

Acknowledgments

The author gratefully acknowledges summaries provided by Bill Yates, Chief Deputy Coroner of the Jefferson County Coroner/Medical Examiners' Office. He also thanks Dr. Saul Weiner for critical review of the manuscript. The author declares that he has no conflicts of interest. Views presented in this article are solely those of the author and do not represent positions or views of the US Department of Veterans Affairs, the State of Alabama, or the Jefferson County Coroner/Medical Examiners' Office. Dr. Kertesz serves on the Treatment Access Subcommittee of the collaborative group mentioned in this article (www.knowdope.org).

Funding

No external funding was received in support of this article.

Author contributions

Dr. Kertesz conceived of this work and authored it. He obtained information from public agencies (Jefferson County Coroner/Medical Examiner and the Alabama Board of Medical Examiners) but did not collect or analyze data for this article.