With Dr. Dennis Watson, Fairbanks School of Public Health
Opioid overdoses continue to make local and national headlines. We recently worked with a group of researchers to publish a study showing dramatic increases in fatal opioid-related overdoses in Marion County; however, the data we used were only through 2015. We feel it is important to update the residents of our community on more recent trends, and so we have been working with Philip Huynh (Fairbanks School of Public Health) to update the toxicology data and Peter Phalen (University of Indianapolis) to estimate and map trends in overdose. We have used the same methodology from our earlier study, which looks at the detection of substances rather than the cause-of-death. It is important to note that with this methodology cases are not mutually exclusive so a single drug overdose can contain several substances and would be counted in each of those categories.
The updated data Phil collected shows drug overdose deaths have continued to rise in Marion County, reaching an all-time high of 345 in 2016. This is more than four times the average number of yearly traffic fatalities (85) in Marion County. This rise in drug overdose deaths has continued into the current year. As of May 1, 2017 (our most up-to date data), there have been 130 drug overdose deaths. This is in contrast to the 98 deaths that were recorded at the same time last year.
In looking at the presence of substances among overdose fatalities, toxicology reports clearly show that recent increases are the result of fentanyl and heroin. While heroin-related overdoses slightly decreased from 2015 to 2016 (117 to 104), deaths containing fentanyl more than doubled during the same time period. Because of fentanyl’s much higher potency, heroin has been increasingly “laced” with it over the years, and this is reflected in our data.
In 2014, 14 percent of all heroin-related deaths also detected fentanyl; this increased to 17 percent in 2015 and to 30 percent in 2016. As of May 1, there have been 55 heroin-related deaths and fentanyl has been present in 36 percent of these.
Another deadly cocktail is heroin and benzodiazepines (such as Xanax or Klonopin). As shown in the figure above, the number of benzodiazepine-related deaths increased every year from 2010 through 2015*. Benzodiazepine has been present in more than 40 percent of all heroin-related deaths from 2014 through May 1 of this year.
Finally, given past year trends, Peter Phalen has used Bayesian modeling techniques to not only estimate future trends in overdose but also where these deaths are likely to occur. Peter’s analysis illustrates the massive increase of fentanyl in Marion County and estimates that in 2017 more than 50 percent of all drug overdose deaths will contain fentanyl. The model predicts that, given recent trends, there will be more than 59 heroin-related deaths and more than 151 fentanyl-related deaths in Marion County by year end. Moreover, using these same techniques he has also estimated where these deaths are likely to occur.
These trends are reflective of the broader opioid epidemic that is taking a significant toll on the rest of our state and nation. While there is no magic bullet to fix this problem, policies and programs aimed at tackling this issue can result in meaningful change if they are informed by both scientific and historical evidence.
Responses to issues like these are more often than not developed without complete understanding of the issue or outright disregard for scientific evidence, which may conflict with the personal opinions or experiences of policy makers and the public. This is highly unfortunate, because failing to translate science into action wastes public funding. An even more startling result in the case of the opioid epidemic is that poorly designed responses can result in hundreds or thousands of preventable deaths.
In the case of our current opioid epidemic, we need to learn from the misguided and failed war on drugs. We must give credit to the great strides law enforcement has made in keeping the public safe; however, there is a point where legal response is no longer as effective as a public health response. We have decades of evidence that locking people up does not solve the problem, and even creates worse ones.
For those who say jail is a motivator for recovery, research has demonstrated that people who are addicted to opioids are generally not in denial of their problems, are often highly motivated to engage in treatment, and, thus, don’t need to be locked up as a motivator. What these individuals do need is available treatment they can access without fear of legal repercussion.
Another study we are currently conducting highlights the need for nonjudgmental, non-punitive routes to treatment. We have collected survey data from individuals who have accessed the opioid overdose-reversing drug naloxone, which suggests that many individuals chose to not call 911 at the scene of an overdose because they fear the police. There is a possibility this fear may translate to death if the naloxone dose provided is not strong enough to completely counteract the opioids in the person’s system.
So, what does an effective public health response look like? It aims to reduce the number of people who die from opioid overdose and opioid-related harms that occur to users, their families, and the community. While police are not the solution, they can be an incredible ally to such a strategy. For example, IMPD has gained national recognition in its efforts to reduce overdose by providing naloxone to officers and should be applauded for such a progressive effort. But, as many law enforcement personnel have come to realize, society cannot arrest its way out of this problem.
Marion County can take several other steps to develop a comprehensive and effective public health response that is grounded in harm reduction:
- We need to combat the stigma associated with medication assisted treatments (MAT) like methadone and buprenorphine—the current gold standard in opioid treatment. This needs to be coupled with an expansion of providers willing to offer MAT. We also need to expand the distribution and education around naloxone, which is already saving hundreds of lives in Marion County every day. (In later posts we will illustrate how the majority of those who are revived by naloxone do not require additional doses and go on to live following this event.)
- We need to learn from the HIV outbreak in Scott County and implement and fund a mobile needle-exchange program before a similar public health emergency occurs here.
- We need to continue efforts to divert individuals out of the criminal justice system and into needed treatment and services and ultimately to decriminalization of substance use disorder and nonaddictive substances that treat chronic pain.
There is also more immediate action you can take. If you know someone who uses opioids tell them about the patterns we’ve described here in Marion County. Tell them that using benzodiazepines with opioids is deadly. Show them where fentanyl deaths are occurring. If possible, suggest they test for fentanyl, not use alone, and have naloxone on hand. Finally, inform yourself regarding current Good Samaritan laws and call 911 if you administer naloxone.
