By Adam Zolotor, MD, DrPH
The headline in the New York Times on August 15 should alarm us all. A record was set of 72,000 overall drug overdose deaths in 2017, with a large jump in the number of deaths from opioid overdose. For years, policymakers, licensing boards, and insurers have been focusing on strategies to curtail prescribing of opioids (medicines such as oxycodone, morphine, and methadone). Prescribers have, in succession, been invited, encouraged, coerced, and now required by law in most states—including North Carolina—to check patient histories on the state prescription drug monitoring program and to limit the number of pills and total amount of opioids prescribed.
These efforts have been modestly effective at curtailing prescribing. The US has seen a drop of 13% in opioid prescribing from the peak in 2010 to 2015. However, Americans are still prescribed 60% more opioids than Canadians and about 400% more than most European countries. It is also clear that not all prescribers are following the STOP Act, a North Carolina law passed in 2017 to help restrict opioid prescribing practices (SL 2017-74). Analysis by the NC Department of Health and Human Services presented in May showed that in March over 16,000 physicians (of 27,000 licensed physicians) may have violated the STOP Act by prescribing opioids for a longer period than allowed. Despite curtailed prescribing, investments in naloxone distribution (to reverse opioid overdoses), and small investments in addiction treatment, opioid overdoses are at an all-time high in the US and NC. Overdose deaths increased 22% from 2016 to 2017, from 2,053 in 2016 to 2,515 in 2017, making the increase in NC the second highest in the country during that time. We also have some communities that suffer more than others, with Gaston, Vance, New Hanover, and Brunswick counties having the highest rates of heroin overdose deaths in the state.
One reason for the increase in opioid overdoses is that people have moved to heroin as a cheaper and more easily available alternative. Heroin is also more prone to use in lethal doses. More recently, fentanyl and other synthetic opioids have entered the illicit marketplace, either as a sole product or contaminating heroin and making it much more lethal.
Where do we go from here? Yes, continued efforts at opioid prescribing will eventually lead to fewer people addicted to these dangerous medicines. There are law enforcement strategies to keep illicit opioids off of our streets. But ultimately, the foundation for preventing opioid overdose deaths will be treatment and prevention of addiction. Treatment will require sustained attention to evidence-based strategies, including sufficient access to medication-assisted therapy, counselling, and peer support. We also must address the conditions that lead to addiction in our communities, conditions such as economic despair, violence, and trauma. A recent issue of the North Carolina Medical Journal presents some of the current efforts in NC and opportunities to do more at the state and community level. As the crisis grows, we must find the political will and financial resources in our communities, our state, and across the country to address opioid use, addiction, and overdose.