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Should We Have Seen the Opioid Crisis Coming?

February 19, 2019

This article was co-authored with John Carnevale, Ph.D., of Carnevale Associates, Washington, D.C.

The President’s Commission on Combating Drug Addiction and the Opioid Crisis highlighted an important truth last year: if you know where to look, data can foreshadow an ominous trend. And such warnings can provide time to prevent or mitigate the human toll that addiction takes.

Too often drug policy is reactive, addressing a crisis that’s in full swing. We must anticipate problems and adopt preventive measures before epidemics become well-entrenched.

Well-entrenched understates the opioid epidemic. The Centers for Disease Control and Prevention (CDC) reported 49,000 opioid-related deaths in 2017, double the number four years earlier. Was it possible to predict this? Yes.

A look at four metrics can suggest a looming disaster and help us prepare for the inevitable next one.

1. Track use patterns among new populations, particularly young users.
For opioids, the rate in the 18-24 year old group has tripled since 2002. Data from the government’s Treatment Episode Data Set tracking system of those entering publicly funded treatment programs show admission to treatment for injection use of any opioid increased 93 percent from 2004 to 2014. This was particularly acute among persons 12-29.

2. Look for use in places not seen in the past.
The new users include suburban and rural young adults, unlike previous opioid epidemics that centered on cities.

3. Look at where there is disproportionate production and prescriptions for opioids.
Systems such as the state prescription drug monitoring programs and retail pharmacy audits contain the numbers and locations for dispensing opioids. In 1996, U.S. retail pharmacies dispensed 94 million opioid prescriptions. By 2016, the figure had hit 214 million. In 2016, it was reported that over a two-year period, nearly 9 million hydrocodone pills were shipped to a single pharmacy in Kermit, W. Va. (pop.  392).

4. Look at supply-side information.
Law enforcement data are often the canary in the coal mine. The rise in seizures of fentanyl went from one kilogram in 2013 to 675 kilograms in 2017, according to U.S. Customs and Border Protection (CBP).

We can apply this sort of trend detection to other drugs to anticipate problems. Take heroin. The National Survey on Drug Use and Health shows persons initiating heroin use more than doubled from 2004 to 2014. A decade ago typical heroin users were in their 40s and 50s–often holdovers from an earlier surge. No longer. Today users are younger, and there are more of them.

They are in new places, too. The rise of young users in the Arrestee Drug Abuse Monitoring (ADAM) system appeared not only in traditional heroin centers such as New York and Chicago, but also in Charlotte, Minneapolis, Denver and Indianapolis. In addition, more rural states such as West Virginia, Tennessee and New Hampshire are places where a gradual appearance of heroin use should have set off alarms early on. Another troubling sign: death rates from overdoses in rural areas outpace the rates in large metropolitan areas. The Drug Enforcement Administration reports that seizures of heroin in the United States increased 80 percent from 2010-2015 as dealers tried to meet and expand demand.

Today we see the same troubling story for cocaine, whose use is on the rise after declining for several decades. The National Survey on Drug Use and Health shows a 70 percent increase in the number of persons reporting first time cocaine use, numbers not seen since 2002-2007. In addition, according to the CDC, fatal cocaine overdoses skyrocketed 135 percent from 2012 to 2016. Colombian coca production more than tripled between 2012 and 2016. And the CBP recently reported that it seized twice as much cocaine in 2017 as in 2016.

Similar trends are appearing with methamphetamine. Data suggest the nationwide decline in use since the mid-2000s may be over. The number of fatal overdoses involving methamphetamines increased 188% from 2012 to 2016.

Data can be tedious until they highlight a crisis and splash it across the front page.  But well before that, data collection can help us see that a crisis is coming—and prepare for it. The opioid epidemic points to the need for continuous tracking and coordination of the four metrics mentioned above.

Unfortunately, we now face treating people who use opioids with a reduced substance use disorder treatment workforce, fewer evidence-based treatment programs and not enough physicians trained in medication assisted treatment.

We know what works. We must fund it. The proof: When Ohio expanded Medicaid in 2015, 700,000 low-income adults got access to free addiction and mental health treatment. That is a major factor in helping opioid-ravaged Montgomery County cut overdose deaths by more than 50 percent so far in 2018, according to county data.   

We likely could have predicted this crisis. We must do better in the future. The key is not clairvoyance. It’s paying attention to clear data—and using the tools at hand to prevent repetition of the ruinous consequences we now face.

Dana E. Hunt, PhD., ran the ADAM program and is a Cambridge, Mass.-based Principal Scientist at Abt Global, which supported the CDC in drafting opioid prescription guidelines. John Carnevale, PhD., is founder of Carnevale Associates in Gaithersburg, MD, and helped formulate drug policy in three administrations.

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