A number of stories centered around instances of high-profile crime or otherwise sensational anecdotes, which can be seen as an example of moral panic. There were several stories that relied on dramatic, shocking, and provocative information during coverage of Utah’s opioidepidemic. There were three local news stories that made up the majority of high-profile crime coverage. The first of these concerns the “St. George ‘pill pusher’ previously mentioned, who was sentenced to 8 years in prison,” as noted by a Deseret News headline about Simmon Lee Wilcox. The story described Wilcox as the “kingpin” of a massive oxycodone distribution conspiracy. The magnitude of the drug scheme was further elaborated by assistant U.S. attorney Vernon Stejskal, who was quoted, “Dr. Wilcox specifically used his position as a licensed and trained person to get those pills into the community. ... The word on the street was Dr. Wilcox was the place to go for pain medications in St. George or Las Vegas. ... He chose to become a pill pusher, essentially,” (Romero, 2016). The next high-profile story that received focus was a drug bust in Cottonwood Heights, described by Fox 13 as “the case of the biggest criminal pill press operation in Utah history” (Roth, 2016). The bust was further detailed in a later Fox 13 that described a criminal forfeiture of Aaron Shamo’s property and assets, including $1.2 million in cash. Additionally, Drug Enforcement Agency agent Brian Besser was quoted as saying that millions of tablets were allegedly distributing by Shamo throughout the continental United States and that hundreds of thousands of opioids were seized from Shamo’s property (Wells, 2016). A story by Good4Utah referenced Shamo’s arrest when warning that “illegal pill making operations are popping up in Utah and around the country” (Beeby, 2016). The story noted that law enforcement agencies seized around 95,000 counterfeit pills meant to resemble opioid painkillers like OxyContin and Xanax. The third story that received significant attention was that of two 13-year- old boys from Park City, who died from overdosing on “pink,” a synthetic opioid. Davis County Sheriff’s Sgt. DeeAnn Servey told the Deseret News that pink’s potency makes it so dangerous;
Abstract: The abuse potential of gabapentin is well documented; with gabapentin having been noted as an agent highly sought after for use in potentiating opioids. When combined with opioids, the risk of respiratory depression and opioid-related mortality increases significantly. In the US, gabapentin was approved by the Food and Drug Administration as a non-controlled substance. To date, and in spite of empirical evidence suggestive of diversion and abuse with opioids, gabapentin remains a non-controlled substance at the federal level. This has forced individual US states and jurisdictions – often significantly impacted by the opioidepidemic – to forge ahead with legislative initiatives designed to reclassify and/or monitor the use of gaba- pentin. Since August 1, 2016, 14 of 51 US states and jurisdictions have either implemented legislative mandates requiring pharmacovigilance programs, amended rules and regulations, are in the throes of crafting policy, or are in the midst of gathering additional data for decision making. This fragmented geographic approach yields only a modest benefit in combating the abuse of gabapentin and/or the national opioidepidemic. Herein, we report state-by-state efforts to enhance pharmacovigilance and call for a re-evaluation of the schedule status of gabapentin at the federal level, and design and implementation of a national pharmacovigilance program. Keywords: gabapentin, prescription drug abuse, opioids, pharmacovigilance, health policy
Not only has this crisis decimated almost every community in West Virginia and across the nation, the opioidepidemic has become a pivotal driver of declining labor force participation rates. New research from the White House Council of Economic Advisers finds that the cost of the crisis in 2015 was more than $500 billion, almost 3 percent of U.S. annual economic production. In fact, Princeton economist Alan Krueger suggests that the increase in opioid prescriptions from 1999 to 2015 may account for about 20 percent of the observed decline in the male labor force participation during that same period, and 25 percent of the observed decline in the female labor force participation. Consequently, over the past 15 years, the labor force
Several studies suggest that a switch from prescription opioids to heroin is fueling the opioidepidemic. Heroin use has increased in the United States over the last dec- ade . This is likely due to the increase in popularity of opioid pain pills. A review of surveys interviewing her- oin users who used opioid pain pills before the first time the individual used heroin range from 40 to 86% but was enough to suggest a relationship . From 2010 to 2013, individuals who had used an opioid in the past month began to use only prescription opioids less and used a combination of opioids and heroin more, according to a self-administered survey of diagnosed opioid abus- ers . The availability of heroin in the United States is increasing . This report also states heroin is less expensive than prescription opioids on the streets. The estimated cost of a 10 mg dose of oxycodone is approxi- mately $10 while it is estimated 50 mg of 50% pure her- oin is around the same price. Heroin use may also be favorable because of the increased potency of the drug compared to morphine; a larger amount of heroin is able to cross the BBB compared to morphine . Address- ing this epidemic requires: (1) the development of bet- ter options for treating pain that takes into account the necessity of crossing the BBB to elicit an effect; (2) the societal and political will to develop strategies to com- bat the problem; (3) increased capacity to treat opioid dependence; and (4) a change in attitude such that opioid addiction is viewed as a medical problem rather than a criminal offense.
Figure 1: Doctor Shopping Activity in New York ………………………………………4 Figure 2: Model #1. Implementation of the Everingham & Rydell and Caulkins model.30 Figure 3: Model #2 Light and Heavy Users; Deaths from Heavy User Population…….33 Figure 4: Model #2 output vs CDC data………………………………………………...34 Figure 5: Infographic from Dr. Tom Frieden of the CDC………………………………35 Figure 6: Drugs collected at a Tennessee “take back” event……………………………37 Figure 7: Model #3: Supply of pills is abundant, friends and family are supplied……...38 Figure 8: Input to and output from a typical run of model #3…………………………..39 Figure 9: Model #4 of the epidemic system based on my six underlying assumptions...40 Figure 10: Tennessee Health Department Regions……………………………………...43 Figure 11: Tennessee Prescription Rate by Health Department Regions 2007- 2011…..44 Figure 12: Regions with higher prescription rates have higher death rates……………..44 Figure 13: Sources of prescription opioids for non-medical use………………………..47 Figure 14: National average of opioid overdose death rates by age group……………...49 Figure 15: Patients receiving 120 mg or more opioid more than 50% of the time……...50 Figure 16: Model determination of the value of parameter proliferation of pills ……....52 Figure 17: Death rates data compared with model ……………………………………..54 Figure 18: A Stock-flow diagram for a simple epidemic model………………………..55 Figure 19: An unsuccessful System Dynamic model of the opioidepidemic…………..56 Figure 20: The effect of varying model parameter proliferation of pills………………..58
Socio-economic factors such as poverty rate [r(50)=.12, p=.39] and median income per family [r(50)=.02, p=.90], typically associated with most health issues in US, do not appear to be significantly related to the current drug/opioidepidemic affecting our nation. Educational level continues to be a factor related to drug misuse and abuse. There was identified a significant but inverse relationship between heroin use during the past year (2016) and the proportion of the adult population who had completed high school or a higher educational level, r(50)=-.35, p<.05.
There is a need for creative, public health-oriented solutions to the increasingly intractable problems associated with the North American opioidepidemic. This epidemic is a fundamentally continental problem, as routes of migration, drug demand, and drug exchange link the USA with Mexico and Canada. The challenges faced throughout North America include entrenched prescribing practices of opioid medications, high costs and low availability of medication-assisted treatment (MAT), and policy approaches that present substantial barriers to care. We advocate for the scale up of a low-threshold treatment model for MAT that incorporates the best practices in addiction treatment. Such a model would remove barriers to care through widespread treatment availability and affordability and also a policy of decriminalization. Given that MAT reduces the frequency of drug injecting among opioid injectors, this treatment model should also be guided by an understanding of the socially communicable nature of injection drug use, such that increasing MAT availability may also prevent the spread of injecting practices to individuals at risk of transitions from non-injection to injection drug use. To that end, the “ Treatment as Prevention ” model employed to respond to the individual- and population-level risks for HIV/AIDS prevention could be adapted to efforts to halt the North American opioidepidemic.
Substantive defenses relate both legal and ethical respon- sibility. Despite similarities to cases brought against tobacco companies and firearm manufacturers, the prescription opioidepidemic is decidedly more ethically complicated. Unlike tobacco and firearms, prescription opioids have a potentially positive medical value. Physicians responsible for approv- ing use have advanced scientific training and an established code of ethics. In conjunction with Schedule II classification and approval for specific use by the FDA, physicians have a sound ethical and legal basis for issuing prescriptions. Like tobacco but unlike firearms, those most harmed are also those consuming the products. However, diversion of prescription opioids is illegal while tobacco consumption and, with proper licensing, firearm possession are both legal. The illegal action of those being most harmed by prescription opioid diversion is a key component of defense strategies for all types of defendants. “Intervening conduct” of prescribing physicians and patients breaks the legal link between manu- facturers and distributors of prescription opioids and the harm caused by the product. 20 The “ethical-is-legal” implication for
Previous work has shown the importance of public opin- ion polls on policy making (Cook & Brownstein, 2017). As the opioid problem evolves and even worsens, determin- ing public support (or opposition) for the expansion of treatment services in one’s own community is a critical component for policy makers given the devastating impact of the opioidepidemic. Not only did these measures examine support for the expansion of treatment services, it did so in the context of asking about specific support “in your community”, an important inclusion considering the NIMBY phenomenon. The current study found that Virginians overwhelmingly supported the expansion of treatment centers and recovery housing in their own com- munity although much lower levels of support were found for the provision of needle exchanges to IV drug users (further discussion provided later).
both the consequences of the opioidepidemic for children and how these consequences can be prevented or ameliorated. Currently, there are not even accurate estimates of the number of children growing up in a household with a parent who has an opioid use disorder. There are no estimates of the substance use treatment or parenting services that these families are already receiving nor of the gap between the need for these services and states’ capacities to provide them. There is also substantial opportunity for the refinement of existing interventions and the development of improved interventions for families affected by opioid-related problems. As states seek to meet the needs of children affected by the opioidepidemic, a better evidence base can help guide decision-making.
The problem of addiction spares no age and afflicts even the unborn. Neonatal Abstinence Syndrome (NAS) occurs when a fetus has been exposed to neuroactive substances in utero and then experiences withdrawal symptoms after birth. WV leads the nation in the incidence of NAS. In WV approximately 58/1000 (5.8%) live births are diagnosed with NAS and about 140/1000 (14%) live births are exposed to substances in utero. These numbers reflect that WV deals with NAS and maternal substance exposure at a rate eight to nine times higher than that of the rest of the country. NAS is just the tip of the iceberg. NAS is the end result and a small representation of the grand scope of substance use disorder ravaging our community. Identifying the various substances these infants are exposed to reflect the ever changing face of substance abuse. Women of childbearing age are a subset of the entire community grappling with substance use disorder. When they become pregnant their child will be at risk for developing withdrawal. When an infant is born exposed to drugs in utero a referral to Child Protective Services (CPS) must be made by the hospital to comply with federal regulations. CPS must then evaluate the safety of each individual’s circumstances to prepare for the best outcome upon discharge. Ideally there are supportive circumstances in the home: mother and/or father in recovery or stable in a supervised treatment program, family support in a substance free environment, social services and early intervention programs available to those at risk families, and motivation and assistance to remain compliant with treatment. Unfortunately those circumstances are not always able to be achieved; so infants must have alternative placement or worse outcomes if the system fails them and they are sent home into a dangerous environment. Our area is at the heart of the opioidepidemic but it has also seen the rise of public health emergencies as a result of substance abuse. The growing rates of hepatitis C are alarming. Harm reduction strategies are being
Given the magnitude of the opioidepidemic and its sustained impact on population health, our findings suggest that greater attention towards the provision of pharmacotherapies for the treatment of opioid-related use disorders is warranted, such as understanding the reasons why uptake of pharmacotherapies for the treatment of opioid-related use disorders has been mod- erate among civilian healthcare providers. This can complement ongoing and sustained efforts to alter prescribing practices  and to generate novel formulations of abuse-deterrent opioid analgesics . The relatively low numbers of civilian SAT facilities reporting the availability of buprenorphine therapy is concerning, given research which suggests that drug-free treat- ments may contribute towards greater patient mortality than medication-assisted therapy . Though buprenorphine prescription has, to date, been strictly limited by law, researchers have called on lawmakers to consider relaxing such restrictions as they may contribute to greater
prescriptions. Pain clinics and prescription “pill mills” proliferated. For drug companies, the ability to market addictive drugs by leveraging close relationships with doctors was facilitated by a variety of legal strategies that allowed for willful blindness on the part of physicians, which limited their risk of regulatory and criminal liability. The contrast relative to the enforcement strategies associated with use of traditional illicit drugs has been described as stemming in part from the presence of many white, middle-class users and the relatively minor amount of violence and crime compared to the cocaine and methamphetamine epidemics. We add to that the influence of a large industry with a prominent role in the legal economy—an industry that encountered diluted regulatory governance over a product that has numerous legal and beneficial uses as well as the potential to be extremely destructive. Tort law still casts a shadow over some aspects of the opioidepidemic, but its reach and consequences in this context depend at least as much on the constraints affecting tort litigation and access to courts (including limits on class actions and remedies) as on the content of tort law doctrine.
examine key policy considerations and options for this issue, including implementation of the recently enacted Family First Prevention Services Act, that offer alternative approaches to serving children and families affected by the opioidepidemic. The identification of parental substance use disorders offers the opportunity to address unmet parental needs that may threaten a parent’s ability to care for their child or children while maintaining family stability. By supporting the resilience of families and equipping parents with the skills to successfully parent children, public policy can ensure children who have experienced prenatal substance exposure or parental substance use disorders have the safe, stable, nurturing relationships they need to thrive while also supporting the foster care system as a therapeutic safety net for the children who require placement.
there needs to be consequences. These deceptive marketing practices not only led to the opioidepidemic but have also been the background for rapidly increasing the seriousness of the epidemic. This Note has discussed the ways that have already been proposed, from allowing Narcan to be carried and bringing awareness to the epidemic. Even after these proposals have been implemented though, they are still not successful in stopping or even decreasing the amount of deaths from overdoses we are seeing each and every year. With several states now realizing that the drug pharmaceutical companies are at the core of this problem, more and more states are bringing law suits against them in an attempt to hold them accountable.
program. Other study strengths include our focus on patients initiating an anti-depressant treatment in the baseline period with no prior opioid use, focus on patients with and without cancer, and two approaches to measuring PDC thresholds. There are several limitations to our findings. First, the proportional hazards assumption was violated for some of the models which implies that the baseline hazard rates observed in this study may vary with time. Second, measuring prescription fills using administrative data may not represent true adherence. Third, although we adjust for patient level comorbidities, demographic, and enrollment variables, there are several unmeasured confounders that may influence adherence (e.g. patient-prescriber relationship, patient’s experience of using antidepressants, healthy-user bias) that cannot be accounted for given the nature of observational data. 127,128 Fourth, limiting our analyses to only PA Medicaid claims reduces generalizability of our findings. Fifth, our data cannot identify events that occur outside of the health system. For example, patients who obtain their prescriptions from other sources such as safety-net programs cannot be captured. Our findings highlight the need for further research on this topic using prospective data that address the limitations listed above.
examined Medicaid records of >1 million children and adolescents in Tennessee between 2 and 17 years of age who had no complicating severe medical illness and who were prescribed opioids as outpatients. They then identified those who had an “opioid-related adverse event, ” defined as an emergency department visit, hospitalization, or death after an opioid prescription. To confirm the relationship of the opioid prescription to the adverse event, medical records were then obtained on a subset of ∼875 cases, which were reviewed by 2 study investigators for confirmation of opioid etiology. Their conclusion is alarming: “One of every 2611 study opioid prescriptions was followed
disease, disability, and premature death among those aged 15 to 24 and is arguably the most important modifiable health risk behavior impacting adolescents. Youth today face a vast landscape of more potent products, synthetic alternatives, and new delivery methods (such as electronic cigarettes, potent cannabinoids, and fentanyl) that are far more addictive than psychoactive substances that were available to teenagers in the past. Alcohol, marijuana, and tobacco products are the most common substances used by high school students and almost always precede opioid and other drug use; thus, secondary prevention (ie, initiating treatment of other substance use before opioid use ever begins) is a logical strategy. The American Academy of Pediatrics has called on pediatricians to screen all adolescents and young adults for substance use and manage the entire spectrum, from preinitiation to SUD. 41 Integrating SUD treatment
data suggest there was a wide variability in an infant’s risk of drug withdrawal based on opioid type, dose, SSRI use, and number of cigarettes smoked per day by the mother (Fig 2, Table 3). Future studies should evaluate new care models for opioid-exposed infants at different risk levels of developing NAS. For instance, some low-risk infants may be safely discharged from the hospital sooner, whereas high-risk infants may require longer hospital observation.