Posts Tagged overdose

Drug Overdoses in Young People on the Rise

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Drug Overdoses in Young People on the Rise

PISCATAWAY, NJ – In American adolescents and young adults, death rates from drug poisoning, particularly from opioids, have sharply increased over the last 10 years, according to new research in the Journal of Studies on Alcohol and Drugs.

In 2006, the death rate from drug poisoning from any type of legal or illicit drug was 8.1 deaths for every 100,000 people in the population ages 15 to 24. This rose to 9.7 per 100,000 by 2015, mainly fueled by deaths from opioid use. In this age group, death rates from opioids — both prescription opioids and illicit opioids such as heroin — rose 4.8 percent on average annually from 2006 to 2015, with an even steeper incline of 15.4 percent a year between 2013 and 2015.

“The surge in drug poisoning deaths . . . among adolescents and young adults reflects the ease of access to pharmaceutical drugs, especially prescription opioids . . . and later transition to more potent opioids,” the authors write. Many young people are introduced to opioids through prescription drugs, such as Vicodin or OxyContin. They often misuse these drugs with motivations to relieve pain, relax, feel good, or get high.

“[W]hen people addicted to prescription opioids face difficulty accessing these drugs because of tighter controls, they often turn to increasingly available and cheaper heroin,” the authors continue. Those who switch from prescription drugs to heroin are at high risk for drug overdose because these individuals are “accustomed to titrated prescription drugs and do not realize that heroin varies in potency and can be cut or mixed with dangerous and potentially deadly substances,” such as fentanyl.

To conduct their study, researchers led by Bina Ali, Ph.D., of the Pacific Institute for Research and Evaluation in Maryland, analyzed mortality data from the National Center for Health Statistics from 2006 through 2015. In addition to examining average annual rate changes in drug poisoning death rates for adolescents (ages 15-19) and young adults (ages 20-24), Ali and her colleagues estimated the costs to society associated with these deaths. This included the costs of medical interventions (emergency transport; treatment in hospitals, nursing homes, and hospices; and autopsies), work loss (loss of earnings and household work that young people would have made over the remainder of an average life), and quality-of-life loss (the monetary value of intangible losses such as pain and suffering).

The investigators found that drug poisoning death rates in adolescents and young adults were higher for Whites (11.9 for every 100,000 people) and American Indian/Alaskan Natives (10.0) compared with Blacks (2.6), Asian/Pacific Islanders (2.3), and Hispanics (4.0). Over time, the rates significantly increased for Whites (1.7 percent per year from 2006 to 2015), Asian/Pacific Islanders (4.3 percent per year from 2006 to 2015), and Blacks (11.8 percent per year from 2009 to 2015).

Drug poisoning death rates in adolescents and young adults vary by state. For example, the rate in West Virginia was approximately 5 times higher than the rate in Nebraska (15.1 vs. 3.1 per 100,000). When looking at changes between 2006 and 2015, New York had the highest increase in drug poisoning death rate, with a 9.4 percent increase each year. This was followed by Ohio, Massachusetts and New Jersey (with 9.1 percent, 9.0 percent and 8.7 percent increases annually, respectively).

The estimated costs of drug poisoning deaths among young people in the United States were $27.1 million in medical costs, $8.5 billion in work loss costs, and $26.5 billion for quality-of-life loss in 2015.

“The burden of drug poisoning deaths among adolescents and young adults is substantial,” Ali and her colleagues conclude. “With the burden of drug poisoning deaths among adolescents and young adults estimated at $35.1 billion nationally, targeted state-specific efforts are warranted.”

Evidence-based and promising strategies exist, such as knowledge and skills development for physicians, young people, and their parents; expansion of prescription drug monitoring programs, prescription drug disposal methods, and naloxone distribution programs; and medication-assisted treatment that combines medications with counseling and behavioral therapies. Interventions that are tailored for high-risk populations and directed at multiple levels (individuals, communities, and public health systems) are needed to reduce premature deaths from drug overdoses, according to Ali.

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Ali, B., Fisher, D. A., Miller, T. R., Lawrence, B. A., Spicer, R. S., Swedler, D. I., & Allison, J. (2019). Trends in drug poisoning deaths among adolescents and young adults in the United States, 2006-2015. Journal of Studies on Alcohol and Drugs, 80, 201-210. doi:10.15288/jsad.2019.80.201

The Journal of Studies on Alcohol and Drugs is published by the Center of Alcohol Studies at Rutgers, The State University of New Jersey. It is the oldest substance-related journal published in the United States.

To learn about education and training opportunities for addiction counselors and others at the Rutgers Center of Alcohol Studies, please visit https://education.alcoholstudies.rutgers.edu.

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Study: Doctors Reduced Opioid Prescriptions after Learning a Patient Overdosed

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Study: Doctors Reduced Opioid Prescriptions after Learning a Patient Overdosed

Will clinicians become more careful in prescribing opioids if they are made of aware of the risks of these drugs first-hand? That was one of the core questions researchers set out to explore in a new study published in the August 2018 issue of Science. In doing so, they found that many clinicians do not learn of the deaths of those patients who overdose as they just disappear from their practice, outcomes unknown.

This disconnect from the personal experience of losing a patient due to fatal overdose, related to a prescription for opioids to relieve pain, makes the problem of the nation’s opioid crisis seem remote – statistics happening elsewhere. While the epidemic continues to exert its outsized impact, opioid prescription-writing levels have not responded with adequate risk-benefit analysis by prescribers tasked with caring for patients with complaints around pain.

“Clinicians may never know a patient they prescribed opioids to suffered a fatal overdose,” explained lead author Jason Doctor. “What we wanted to evaluate is whether closing that information gap will make them more judicious prescribers.” Doctor is the Director of Health Informatics at the USC Schaeffer Center for Health Policy & Economics and Associate Professor at the Price School of Public Policy.

The study leverages behavioral insights and psychology to give prescribers personal experience with the risk associated with opioids and finds that when a clinician learns one of their patients had suffered a fatal overdose they reduced the number of opioids prescribed by almost 10 percent in the following three months.

Doctor and his colleagues conducted a randomized trial between July 2015 and June 2016 of 861 clinicians who had prescribed to 170 patients who subsequently suffered a fatal overdose involving prescription opioids. Half the clinicians, who all practiced in San Diego County, were randomly selected to receive a letter from the county medical examiner notifying them that a patient they had prescribed opioids to in the past twelve months had a fatal overdose. The letter, which was supportive in tone, also provided information from the Centers for Disease Control and Prevention on safe prescribing guidelines, nudging clinicians toward better prescribing habits.

In the three months after receiving the letter, prescribing decreased by 9.7 percent compared to the control group who didn’t receive a letter. Furthermore, clinicians who received the letter were 7 percent less likely to start a new patient on opioids and less likely to prescribe higher doses.

The results are particularly exciting given that numerous, more traditional state regulations which often involve mandated limits on opioids have not been shown to have much impact. The authors point to numerous reasons why this study showed more promising results including its simplicity, that the letters still allows clinicians to decide when they will prescribe opioid analgesics and that it provides an important missing piece of clinical information to them.

This intervention is easily scalable nationwide as existing state and national resources already track the information necessary around overdose deaths associated with prescription and illicit drugs.

“Interventions that use behavioral insights to nudge clinicians to correct course are powerful, low-cost tools because they maintain the autonomy of the physician to ultimately decide the best course of care for their patient,” said Doctor. “In this case, we know opioids, though beneficial to some patients with certain conditions, come with high risks that the doctor may not fully grasp when observing patients in the clinic. Providing information about the harm that would otherwise go unseen by them gives physicians a clearer picture.”

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Co-authors include Andy Nguyen, Roneet Lev, Jonathan Lucas, Tara Knight, Henu Zhao, and Michael Menchine. Funding for the study was provided by the California Health Care Foundation and the National Institute on Aging at the National Institutes of Health (R21-AG057395-01).

The Leonard D. Schaeffer Center for Health Policy & Economics, one of the nation’s leading health policy centers, aims to measurably improve value in health through evidence-based policy solutions, research and educational excellence, and private and public sector engagement. The Center is a unique collaboration between the USC School of Pharmacy and the Sol Price School of Public Policy at the University of Southern California (USC).

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Alabama SB39: Another Shot in the Opioid Battle

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Alabama SB39: Another Shot in the Opioid Battle

On March 28, 2018, Alabama Senate Bill 39 was sent to Governor Ivey’s desk for signature. SB39 introduces stiffer penalties related to fentanyl possession and distribution. It amounts to a local effort forming part of a nationwide, multi-pronged response to the opioid epidemic that has plagued the country in recent years. While this bill is not yet law as of the date of this article, it came to the Governor’s desk with broad support from both the House and Senate, and an awareness of its contents (and its place in the larger opioid crisis) is valuable.

Fentanyl is a particularly strong opioid that has of recent been the target of much abuse. The National Institute on Drug Abuse notes that in 2016, fentanyl contributed to more than 20,000 overdose deaths; medical examiners reported that fentanyl or fentanyl mixtures were involved in the deaths of the musicians Prince and Tom Petty. SB39 includes several related features stiffening enforcement of abuses of fentanyl and related drugs: the bill would:

  1. add fentanyl and related analogues (e.g., butyrfentanyl and acetyl fentanyl) to Schedule I of the controlled substances list;
  2. make a person (unless otherwise authorized by law) who possesses, distributes, or traffics such drugs guilty of a felony, and conviction for distribution subject to enhanced penalties;
  3. include under the meaning of “trafficking” possession of fifty or more individual packages of the substance

A related proposal that was introduced but ultimately rejected by the legislature was a change to allow prosecution of physicians for over-prescribing opioids.

Of particular note are the low thresholds set for amounts of fentanyl and fentanyl analogues — an acknowledgment of both the potency of the drug and the severity of the current crisis. The bill would amend §13A-12-231 of the Alabama Code to make possession of one gram or more of fentanyl or a fentanyl analogue a felony of “trafficking in illegal drugs,” and includes substantial fines. As noted above, conviction can also occur if one is in possession of 50 or more individual packages of fentanyl or a fentanyl analogue, notwithstanding the fact the combined weight of the fentanyl or fentanyl analogues in the packages may be less than one gram.

At this point of the opioid epidemic, some physicians may well be experiencing opioid fatigue. News articles, legislative and regulatory initiatives, personal testimonies, seminar topics, and other avenues have been bringing this issue to the health care industry’s attention for years now. It is a complex problem, with a multiplicity of root causes and a variety of faces. The several penalties included in this recent bill are a reminder that staying abreast of all the many changes, initiatives and tools aimed at addressing opioid abuse is well worth the time and attention.

Whatever the eventual fate of SB39, this will not be the last shot fired in the response to opioid abuse. This bill is a reminder that the responses to this crisis are varied, and that although the opioid epidemic is a national problem, it also plays out on the state and local level. As “opioid” refers to a diverse range of drugs, the “opioid epidemic” refers to a complex quagmire. Being well aware of the problem, in general, is no substitute for familiarity with the many paths being carved through it. In addition to introducing potential changes to the criminal law code such as SB39, Alabama has also taken such steps as forming the Alabama Opioid Overdose and Addiction Council, formed in August 2017 by Governor Ivey, which has made such recommendations as improving and modernizing Alabama’s prescription drug monitoring program; the Alabama Department of Public Health is leveraging funding from the CDC’s Data-Driven Prevention Initiative (DDPI) on Opioid and Heroin Abuse to identify stakeholders of and solutions to the problem; Alabama Attorney General Steve Marshall filed a lawsuit in February 2018 against one of the largest drug manufacturers in the nation.

This is a constantly changing landscape, and the opportunity for missteps abound. Some of these missteps have consequences that reach beyond issues of reimbursement and licensure. The fate of SB39 is worth watching — its wide support in both chambers of the Alabama Legislature make it a prime candidate for signing into law by the governor. However, beyond offering a description of this one bill, this present article should serve as a reminder that opioid-related news deserves close attention because of, not despite, the frequency of the topic. New laws and initiatives are coming out regularly, and if you’ve seen one you have not seen them all.

Article written by Chris Thompson, an attorney with Burr & Forman LLP practicing in the firm’s healthcare group. Burr & Forman, LLP, is a partner with the Medical Association. Read other articles from Burr & Forman LLP.

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Office of Civil Rights Issues Guidance on HIPAA in Light of Opioid Crisis

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Office of Civil Rights Issues Guidance on HIPAA in Light of Opioid Crisis

With an increased focus on opioid use and addiction, the Department of Health and Human Services Office of Civil Rights has issued guidance related to the Health Insurance Portability and Accountability Act of 1996 due to misunderstandings over when a health care provider can share an individual’s protected health information in situations of overdose or need for emergency medical treatment related to opioid use. Generally speaking, HIPAA restricts a health care provider’s ability to share PHI, but there are instances when a health care provider may disclose PHI even if the patient has not authorized the disclosure.

Many health care providers mistakenly think they must have an authorization or the patient’s permission to release PHI. However, there are circumstances in which the patient’s permission is not required. HIPAA allows a health care provider to share information with a patient’s family or caregivers in certain emergency or dangerous situations. As outlined in the guidance, a provider may share information with family and close friends who are involved in the care of the patient if the provider determines that doing so in the best interest of an incapacitated or unconscious patient and the information shared is directly related to the family or friends involved in the patient’s health care or payment of care. OCR’s guidance states that a provider may use his/her professional judgment to talk to the parents of someone incapacitated by an opioid overdose about the overdose and related medical information, but the provider could not share general information not related to the overdose without the patient’s permission.

Another situation in which information may be shared without the patient’s permission is if the provider informs a person who is in a position to prevent or lessen a serious or imminent threat to the patient’s health or safety. OCR states “a doctor whose patient has overdosed on opioids is presumed to have complied with HIPAA if the doctor informs family, friends or caregivers of the opioid abuse after determining that the patient poses a serious and imminent threat to his or her health through continued abuse upon discharge.”

If a patient is not incapacitated and has decision-making capacity, a health care provider must give the patient an opportunity to agree or object to disclosure of health information with family, friends or others even if they are involved in that individual’s care or payment for care. The health care provider is not permitted to disclose health information about a patient who has the capacity to make his/her own health care decisions unless, as mentioned above, there is a serious or imminent threat of harm to the health of the individual.

The difference between capacity or incapacity can be a difficult determination for providers and may change during the course of treatment. OCR points out that decision-making incapacity may be temporary or situational and does not have to rise to the level where someone has been or must be appointed to act by law, i.e. power of attorney or guardianship. If during the course of treatment, the patient regains the ability to make decisions, the provider must give the patient the opportunity to object or agree to providing or sharing health information.

As has always been the case, HIPAA allows a health care provider to release or disclose information to a patient’s “Personal Representative.” HIPAA defines personal representative as a person who has health care decision-making authority under state law. In Alabama, a person holding general Durable Power of Attorney executed after 2012 is presumed to be the Personal Representative for purposes of HIPAA. Additionally, a parent of an unemancipated minor or someone holding a guardianship or conservatorship would also qualify.

To read OCR’s guidance, visit https://www.hhs.gov/sites/default/files/hipaa-opioid-crisis.pdf

Article contributed by Angie Cameron Smith, a partner at Burr & Forman LLP. Burr & Forman LLP is a partner with the Medical Association.

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