The Opioid Epidemic and Monroe County: A Call for Public Health Collaboration
by Michael D. Mendoza, MD, MPH, MS
Attention to the opioid epidemic is at an all-time high, and it’s for good reason since by most measures the opioid epidemic shows no signs of slowing down. According to the Centers for Disease Control and Prevention (CDC), more people died from drug overdoses in 2014 than in any year on record,and heroin is responsible for a significant proportion of those cases. Deaths from heroin-related ingestions more than tripled between 2010 and 2014, with the largest increase in deaths occurring between 2013 and 2014 due to synthetic opioids, not including methadone.
In New York State, deaths from heroin use reached a record high in 2014, an increase of more than 23% from 2013 and a twenty-five-fold increase from the previous decade. Prescription opioids contributed to a large proportion of those deaths, at rates nearly four times the level seen in ten years prior. The increase in death rates for both heroin and prescription opioids increased more than almost any other state for which data are available. Here in Monroe County, we are also seeing a parallel spike in deaths from overdose. Through the first half of 2016, we have seen 74 overdose deaths from the county and our surrounding region, which is on track to surpass the previous highest number of 94 in 2014. Worse, we are seeing a sharp increase in the misuse of fentanyl and its derivatives. The Monroe County Crime laboratory is seeing fentanyl more commonly in ‘items’ seized in crime investigations. Fentanyl is being mixed with heroin, and more recently with methamphetamines and cocaine, as well as prescription medications like quetiapine and tramadol. And, as efforts mount to curb overprescription of controlled pain medications more and more who suffer from addiction are turning to heroin and other drugs.
Apart from the obvious impact that addiction has on health and public health, the imperative to address this epidemic stems also from its impact within the broader society. A 2011 study estimated the total annual societal cost of prescription opioid abuse alone at $55.7 billion with those costs divided almost equally between workplace costs and healthcare costs, along with a smaller proportion attributable to criminal justice costs.
In total, drug abuse is estimated to cost $120 billion in lost productivity. These figures paint only a numeric backdrop for the stories of the people who suffer from addiction and the pain that families endure as they witness the often ravaging effects of this illness. The U.S. Department of Health and Human Services estimates that one in ten children in the United States lives with at least one adult who suffers from a substance use disorder, and the majority of these children are younger than age 5.
A complex problem such as this warrants a comprehensive solution. As a medical community, we play an important role in education, appropriate prescribing, and providing access to evidence-based treatment. The Institute for Healthcare Improvement has proposed four ways in which health care delivery systems can address this problem:
Avoid starting opioids when appropriate, thus preventing opportunities for drug use and abuse.
Use adequate doses of opioids, and taper when appropriate while offering alternate strategies for pain management.
Address opioid-seeking behavior within healthcare settings through prescription monitoring and appropriate prescribing habits.
Approach addiction as a chronic disease and use proven patient-centered chronic disease approaches to managing addiction.
Yet, as a medical community, we cannot tackle this alone since so many of the factors contributing to this problem reside beyond the reach of even the most progressive office- based clinical settings. Integrated behavioral health and medical addiction treatment are a start, but unfortunately the availability of these services is not adequate to keep up with demand. While efforts to expand access to these services is important and ongoing, we will need to rely on efforts outside our clinical settings if we are going to succeed in shifting the tide of this mounting public health crisis.
The Monroe County Department of Public Health is committed to tackling this problem, working in partnership with our County Government, our health care systems, and a broad coalition of community partnerships. Our first goal is prevent unnecessary deaths from overdose. While efforts to reduce access to opioids are critical, we must also expand access within our community to naloxone (e.g., Narcan®) so we can maximize our chances of saving a life in the community settings where most overdoses will occur. Access to naloxone is only the first step – we need to pair access with the education and training on how to use these kits when necessary. Our health care settings can play a role in this, but they will not succeed alone. Second, we need to develop and promote access to on-demand treatment opportunities in our community. 24/7 hotlines that connect residents with information when they need it will increase the chance that a person in need will access the treatment they need, when they need it.
Finally, we need to reduce the stigma associated with addiction. Waging a “war on drugs” only aggravates the misconception that addiction is a criminal problem. When viewed as a chronic disease, we can re-conceptualize addiction as a disease that we can identify through screening, that we can treat using evidence-based practices, and that in time can lead to recovery.
Reference: Pain Medicine 2011; 12: 657–667
This article has been reprinted with permission from: The Bulletin (Aug/May 2016, Vol. 82, No. 3), published by Monroe County Medical Society, 132 Allens Creek Rd., Rochester, NY 14618, www.mcms.org.