According to the latest data from the Centers for Disease Control and Prevention (CDC), many more people are dying from heroin overdoses than in past years. What is particularly disturbing is the rapid jump from 2012, when 5,927 people died from a heroin overdose, to 2013, when the numbers rose to 8,260 deaths, an increase of 39 percent.
After more than 50 years leading the fight to legitimize attention deficit hyperactivity disorder, Keith Conners could be celebrating.
Severely hyperactive and impulsive children, once shunned as bad seeds, are now recognized as having a real neurological problem. Doctors and parents have largely accepted drugs like Adderall and Concerta to temper the traits of classic A.D.H.D., helping youngsters succeed in school and beyond.
But Dr. Conners did not feel triumphant this fall as he addressed a group of fellow A.D.H.D. specialists in Washington. He noted that recent data from the Centers for Disease Control and Prevention show that the diagnosis had been made in 15 percent of high school-age children, and that the number of children on medication for the disorder had soared to 3.5 million from 600,000 in 1990. He questioned the rising rates of diagnosis and called them “a national disaster of dangerous proportions.”
“The numbers make it look like an epidemic. Well, it’s not. It’s preposterous,” Dr. Conners, a psychologist and professor emeritus at Duke University, said in a subsequent interview. “This is a concoction to justify the giving out of medication at unprecedented and unjustifiable levels.”
The Atlantic has a post about the role of needle exchanges in preventing HIV. It makes a pretty compelling case that needle exchanges reduce HIV infection rates among injection drug users. I don’t doubt this. And, provided it serves as an engagement point for recovery, I have no objection to needle exchanges.
However, there are a few things that bug me about these stories.
First, there’s not a single mention of addiction treatment or recovery. Not one word.
Second, one would walk away from this article assuming that injection drug users make up a huge portion of HIV infections. Not true. CDC numbers suggest that, nationally, injection drug users make up around 8% of all new infections.
Third, there’s not a single mention of overdose. The article focuses on LA as a success story, and they have been successful in reducing infections. In 2005, they had 83 new infections among injection drug users. How many overdose deaths? 508. Not a single mention of overdose. We’re busy bragging about the success of the surgery while the patient has died.
Fourth, while I don’t doubt that needle exchanges reduce infection rates, what else also reduces infection rates? We don’t really know. The only research that’s done on the matter focuses on methadone.
Finally, the story was prompted by a new report about infections in Washington DC. The writer says:
According to the department’s research, the repeal of a decade-long ban that prevented D.C. from using local funding for clean needle exchanges led to a major reduction of needle-caused HIV infections. The city is now reporting an astonishing 80 percent decrease in the number of newly diagnosed HIV cases where the reported mode of transmission was injection drug use. In 2007, the year Congress lifted the 1998 ban on D.C.’s needle exchanges, there were 149 cases of needle-caused HIV. In 2011, there were just 30.
That’s pretty great, right? Fewer infections is a great thing. However there’s one very big problem with the way this story frames the data. In 2007, injection drug users made up 29% of new infections. In 2011, they made up 27% of new infections. The big story is that new HIV infections dropped dramatically. Injection drug users are a slightly smaller portion of new infections.
It took me two minutes of googling and reading his own source documents to find this data. Why do so many of these stories fail to provide this context? Why didn’t a reporter spend a couple minutes with a search engine before submitting this? There are lots of stories like this every year. I don’t understand it.
“Giving Drug Addicts Free Clean Needles Is Worth Every Penny” is a good headline, but what’s the rest of the story? There’s more to HIV and addiction than an accounting exercise.
Motherlode notes a trend in e-cigarettes and is concerned:
I was standing outside our neighborhood ice cream shop one recent evening when I noticed a plume of smoke rise above a gaggle of teenagers waiting in line ahead of me.
“Wow,” I thought, “that takes some serious chutzpah.” These kids were smoking in public without the fear of getting caught.
A few minutes later, I realized that it wasn’t actually smoke coming out of their mouths; it was vapor, being inhaled and exhaled from battery-operated electronic cigarettes.
E-cigs are devices that vaporize an addictive nicotine-laced liquid solution into an aerosol mist that simulates the act of tobacco smoking. Also known as “personal vaporizers” and “electronic nicotine delivery systems,” e-cigs are sold in trendy shops and are increasingly turning up in bars, clubs, workplaces and other spots where traditional tobacco cigarettes have long been outlawed.
As a mother, I find this terribly distressing.
I’ve spent years telling my children that smoking can kill you. And thanks to decades of sensible public health policies — including laws banning cigarette advertising and smoking in public places — as well as brutally graphic antismoking marketing campaigns, my 15- and 21-year-old kids have grown up in a culture in which puffing on cigarettes is stigmatized. Last year, cigarette smoking among teens fell to a record low.
Now, it seems, all that progress is about to vaporize. “Smoking,” at least in the form of vaping, is becoming cool again. This week, the Centers for Disease Control reported that 1.8 million middle- and high-school students said they had tried e-cigarettes in 2012 — double the number from the previous year.
The FDA’s desire to have enough authority to require e-cigarette sellers to manufacture them properly and label them accurately, to limit marketing aimed at minors, and to be able to force the removal of unsafe product from the market, seems quite reasonable. What’s not reasonable, and what is likely to be bad, on balance, for health, is the idea that anything that delivers nicotine vapor should have the same rules applied to it as an actual cigarette.
At the same time, he acknowledges the unknowable:
None of this is simple or straightforward. I can imagine myself, five years from now, bitterly regretting not having spotted the e-cigarette menace before it got out of control. But regulations can do harm as well as good, and what I’m not hearing right now is much willingness to think carefully and proceed with caution. The principle of aggregate harm minimization, net of benefits (and nicotine does have benefits, including at least a temporary cognitive boost) still seems to me the right approach, for nicotine no less than for cannabis or cocaine. Unless and until someone can point to demonstrated and serious risks, rather than speculative ones, e-cigarettes ought to be thought of mostly as a part of the solution rather than as a part of the problem.
What does Kleiman mean by part of the solution? A recent study found that e-cigarettes outperformed traditional nicotine replacement for smokers trying to quit:
the New Zealand government funded a head-to-head comparison study. Chris Bullen and his colleagues at the National Institute for Health Innovation in Auckland gave e-cigarettes to 289 smokers who were trying to quit. A separate group of 295 people were given nicotine patches, while 73 received dummy nicotine-free e-cigarettes.
Six months later, the team asked participants if their attempts to quit had been a success. Those who had used the nicotine e-cigarettes had the highest success rate: 7.3 per cent had managed to stay away from tobacco. Of the nicotine patch users, 5.8 per cent had quit. And of those taking the placebo around 4 per cent were successful.
“The quitting rates were about 25 per cent better than patches for the e-cigarettes, but statistically we’re more confident with saying that they were comparable, rather than superior,” says Bullen.
I’ve posted several times recently on the problem of opioid over-prescription and overdose.
Some might assume that I want some regulatory or statutory intervention to address the issue. Truth is, I’ve got more questions than answers and I would not support a response that forces us to choose between treating pain and preventing addiction and overdose.
It appears that opioids are a great solution to acute pain but a lousy treatment option for chronic pain. (Though, they may be the least bad option.)
I’m not an expert on policy in this area, just an observer. But, my first thought is that The Joint Commission played a huge role in shifting pain treatment and that they may be a good way to change the behavior of prescribers and health systems.
The current state of pain management is especially bad for addicts. It leads to bad care, neglect and stigma. Even addicts who really want non-opioid, but effective, pain management get brushed off as drug-seeking.
This feels like I’m stating the obvious, but it would seem that we need more education research on non-opioid treatment options, better access to the ones that already exist and better engagement strategies for the existing behavioral strategies.
Popular Science has a chart with US overdose deaths by drug:
…the rate of reported overdoses the U.S. more than doubled between 1999 and 2010. About half of those additional deaths are in the pharmaceuticals category, which the CDC has written about before. Nearly three-quarters of the pharmaceuticals deaths are opioid analgesics—prescription painkillers like OxyContin and Vicodin. And while cocaine, heroin and alcohol are all responsible for enough deaths to warrant their own stripes on the chart, many popular illegal drugs—including marijuana and LSD—are such a tiny blip as to be invisible.
…the number of clients receiving methadone on the survey reference date increased from about 227,000 in 2003 to over 306,000 in 2011
The percentage of OTPs offering buprenorphine increased from 11 percent in 2003 to 51 percent in 2011; the percentage of facilities without OTPs offering buprenorphine increased from 5 percent in 2003 to 17 percent in 2011
The numbers of clients receiving buprenorphine on the survey reference date increased between 2004 and 2011: at OTPs, from 727 clients in 2004 to 7,020 clients in 2011, and at facilities without OTPs, from 1,670 clients in 2004 to 25,656 clients in 2011
Read our position on buprenorphine maintenance here.
The AP has a story on the explosion of prescription opiate sales:
Nationwide, pharmacies received and ultimately dispensed the equivalent of 69 tons of pure oxycodone and 42 tons of pure hydrocodone in 2010, the last year for which statistics are available. That’s enough to give 40 5-mg Percocets and 24 5-mg Vicodins to every person in the United States.
The increases have coincided with a wave of overdose deaths, pharmacy robberies and other problems in New Mexico, Nevada, Utah, Florida and other states. Opioid pain relievers, the category that includes oxycodone and hydrocodone, caused 14,800 overdose deaths in 2008 alone, and the death toll is rising, the Centers for Disease Control and Prevention says.
It’s a good thing that pain patients have access to pain medication and I’m glad to hear that they appear to be focused on monitoring distribution and working on strategies to address diversion without restricting access to people without hurting pain patients.