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Drug Epidemic

How Many Americans Really Misuse Opioids? Why Scientists Still Aren’t Sure

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With rates of prescription opioid use disorder and opioid-involved overdose deaths on the rise, the U.S. opioid crisis appears to be continuing unabated.

Data on overdose and death are pretty reliable. But there’s still much that’s unknown about opioid misuse that doesn’t lead to an adverse outcome such as overdose.

Drug surveys are reseachers’ main method of collecting data on opioid misuse. I’ve been in drug survey research for almost two decades, but in recent years I’ve learned that collecting accurate data on opioid misuse in particular is difficult. Why? Because many people underreport misuse, while others unintentionally overreport misuse.

Colleagues have been asking me how to ask about opioid misuse on surveys. I’m finding that there’s no easy answer. But one thing I’ve learned in my research is that many people may misunderstand the basics about opioids, preventing researchers like myself from understanding the full scope of the epidemic.

Medical use and misuse

Drug surveys are already difficult to conduct, as many people lie about use. For example, some people deny use to appear more socially desirable, and others simply try to finish the survey quickly without really reading it. But opioid surveys are especially challenging.

A friend of mine recently took my drug survey. She texted me the next day, saying she believed she incorrectly answered my opioid questions. Even though my survey asked only about using to get high or using without a prescription, she admittedly didn’t read the directions and reported misuse of dilaudid, a pain medication.

Situations like this lead some researchers to distrust reportedly high rates of opioid misuse. For example, a few years ago, my colleagues and I estimated that 12 percent of high school seniors have ever misused prescription opioids. However, some of my reports focusing on such national data have (perhaps rightfully) been questioned, but we are limited by what people report.

On surveys, opioid misuse is sometimes defined as using without one’s doctor telling you to do so. Other times, it’s defined as using without a prescription. The most accurate definition is use not directed by a doctor, including using opioids without a prescription or using greater amounts, or more often or longer than directed.

It’s important to include definitions of opioids and misuse on surveys. However, such definitions are meaningless if those taking the survey refuse to read them.

Misuse is also a confusing concept, as it is possible to use as prescribed and still enjoy the feeling resulting from use.

Lack of knowledge

Even though the public is now largely familiar with the term “opioids,” many people still don’t appear to know which drugs are opioids and which are not. For example, my colleagues and I discovered that a over a third of high school seniors who reported nonmedical Vicodin or OxyContin use denied using opioids nonmedically overall. This suggests many users may be unaware that these drugs are opioids.

Opioids are commonly referred to opiates, painkillers, pain relievers, narcotics and analgesics. While “opioid” now appears to be the most common term, an individual familiar with the term may become confused when asked about different terms such as prescription painkillers or narcotics. The term “narcotics,” for example, can lead to confusion, as the Controlled Substances Act also includes cocaine as a narcotic.

Confusion may also arise regarding drug names. For example, OxyContin misuse may be overreported by individuals who used weaker oxycodone formulations. Codeine misuse may also be overreported by those claiming misuse of Tylenol III, which contains codeine, when they only used regular Tylenol.

I’ve also noticed that many people also don’t know the difference between methamphetamine, a potent stimulant, and methadone, an opioid. I learned about such confusion firsthand, after receiving multiple questions about methadone from social workers during a presentation I was giving about about methamphetamine.

Concoctions that contain opioids, such as “Sizzurp” (also known as “Lean” or “Purple Drank”), typically contain codeine cough syrup in a soft drink such as Sprite. Many users of this concoction likely deny codeine misuse.

It’s difficult to determine whether estimates of U.S. opioid misuse are too high or too low. Accuracy of these statistics is important, as they guide research, prevention, harm reduction and policy.

Researchers can use surveys to help educate people about opioids while collecting data. But first we need to figure out how to get people to read the questions.The Conversation

This article is republished from The Conversation under a Creative Commons license. Read the original article.

Drug Epidemic

Even as Opioids Ravaged Western N.C., Folks Say Meth Never Went Away

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The Haywood County Health Department serves as a needle distribution site, but volunteers also travel to participants across the county. Photo: Liora Engel-Smith/Daily Yonder

While the current conversation surrounding drug use is dominated by opioids, residents in North Carolina’s Appalachians say meth has always been there.

Jesse-Lee Dunlap goes where not even the mail carrier does. The Haywood County resident, who works with the N.C. Harm Reduction Coalition, routinely navigates into dirt pathways so narrow they hardly count as roads.

On a recent afternoon, Dunlap maneuvered a white rental van up one such trail, squeezing up a steep hill past a row of faded mailboxes. The 38-year-old parked the vehicle near a mobile home surrounded by shaggy bushes — the first supply drop of the afternoon.

Dunlap hopped out of the van, greeting the people who clustered on the driveway, then popped the trunk to pull out care kits that volunteers put together earlier that day. The brown bags and boxes had band aids and other wound care items, vitamin C packets and tiny cotton balls through which to filter drugs. There were also dozens of 30-gauge syringes, the type a diabetic person might use.

Jesse-Lee Dunlap organizes supplies for needle drop-offs to participants across Haywood County. Dunlap, 38, delivers needles and other harm reduction supplies to participants once a week and also holds pickups at the Haywood County Health Department. Photo: Liora Engel-Smith/Daily Yonder

But the people in the quiet neighborhood in Clyde, a town of almost 1,300 roughly 25 miles west of Asheville, aren’t getting needles because they’re diabetic.

There’s been much talk about drugs in Appalachia, particularly as opioids — first prescription pills, then heroin and its much deadlier cousin, fentanyl — tore through already distressed mountain communities. But even as state and federal agencies set their sights and budgets on ways to combat the opioid epidemic, another drug is wreaking havoc in Western North Carolina: methamphetamine. A stimulant that rose to national infamy in the 1990s and early 2000s, meth has been part of life here for years.

Residents say that even as opioid misuse blossomed, meth never went away.

‘THE drug’

Out of the shaded porch came Carrie Brayson, who grew up in the nearby community of Waynesville. Her eyes light up as she spots Dunlap. Having been part of the needle exchange since 2017, Brayson has come to trust the program. Dunlap comes around roughly once a week to collect used syringes and replace them with fresh ones.

The two chat amicably as Dunlap gathers the packages.

Drug overdose deaths in Appalachian Counties from 2013-17. Source: Appalachian Regional Commission
To explore the map further, visit the Appalachian Regional Commission.

Brayson shifts her gaze from Dunlap to the mountains that tower over her neighborhood. It’s a view that draws countless tourists to Haywood County and the mountain region. In 2013, domestic tourists generated $155.38 million for the county’s economy, up almost 5 percent over the previous year.

But not everyone in Haywood benefits from those tourist dollars. Many employment options in the county are low-wage service or retail jobs. And while the county’s older population is generally wealthier, families with children experience significant poverty,  the county’s 2018 community health assessment shows. The 2017 Census figures quoted in the report show that Haywood’s overall poverty rate is roughly 17 percent, but close to half of children under five live in poverty here.

The mountains may be pretty, Brayson said, but life here has significant disadvantages. Social services can be hard to come by. With limited transportation options, those who don’t have cars either have to walk or hitch rides from friends and family members.

Carrie Brayson’s home in Clyde is atop of a hill that overlooks the mountains. Photo: Liora Engel-Smith/Daily Yonder

Brayson, who says she used to be a nurse, came to drugs by a way of opioid pills at age 18. Later, she sought recovery and managed to stay clean for seven years. After her dad died, Brayson started using meth. The 37 year old said it was the lesser of two evils. Coming off of opioids was a horrible experience, she said, and she vowed to never take an opioid pill again.

“A lot of people think it is definitely heroin that is a problem, but meth, you can’t OD on it,” Brayson said. “It’s cheaper and lasts longer and gives you energy to where you can still maintain. You can still go to work.”

Dunlap, who knows many other people who use drugs in the county, said that a significant proportion prefer meth. Out of roughly a hundred clients who participate in the exchange, roughly three-quarters use meth, according to Dunlap.

And though some meth is now tainted with fentanyl, a synthetic painkiller 50 times more potent than morphine, the stimulant remains popular. So does the belief that it is safer.

“Meth is THE drug here,” Dunlap said.

‘You get some stuff done’

Overdosing on meth is not impossible, said Cynthia Kuhn, professor of pharmacology at Duke University School of Medicine. Methamphetamine gives its users energy, she said, keeping them awake for prolonged periods and sometimes causing hallucinations and paranoia.

“You can absolutely overdose and die with a methamphetamine,” she said.“I think what helps people titrate, to dose a little bit better, is the behavioral excitement that you feel can allow you to sort of track the dose that you’re getting.”

Over time, methamphetamine can damage the cardiovascular system and in large quantities, it can cause a heart attack or a stroke. Unlike the high that opioids create for a user — a sleepy, dreamlike state that can also depress breathing — meth supplies a frantic, hyper-focused high.

It’s those stimulating qualities that can allow meth use fly under the radar, Dunlap said.

“[People who use meth are] more productive,” Dunlap said. “You’re not seeing this person that’s injecting something and nodding out and going to sleep, you see someone that’s working two jobs because that’s what you do when you’re on meth — you get some stuff done.”

A numbers problem

It’s hard to quantify exactly how common meth use is in Haywood County. National studies have noted a rise in meth use, either alone or in combination with opioids, but state data on indicators of meth use such as overdoses and hospitalizations aren’t reported as frequently as opioid data. North Carolina updates its opioid dashboard monthly, but methamphetamine-related deaths are clustered with other psychostimulant drugs — methamphetamines, Ritalin, Adderall and ecstasy — and these are updated once a year. The most recent year for which data is available is 2018.

Haywood County had seven fatal overdoses from psychostimulants in 2018, and a total of seven such deaths from 2009-2017, the data show. In that same timeframe, psychostimulant use caused at least 69 hospitalizations in the county, 12 of which occurred in 2018.

A representative from the state Department of Health and Human Services said in an email that the data focuses on the harm of opioids because these drugs make up the bulk of the deaths in North Carolina. But the data show there has been a rise statewide in deaths from psychostimulants, from nine in 2009 to 267 in 2018. Because of that surge, the spokeswoman wrote, the department plans to release a monthly medication and drug emergency department visit report for psychostimulants and cocaine — another drug with increasing impact in the state — beginning next year.

Whether the data capture it or not, there are telltale signs that meth is available on demand in Western North Carolina. Though law enforcement agencies in Clyde and Haywood County did not respond to interview requests for this story, there are news reports of recent meth busts and arrests across the region. Last year, the Haywood County Sheriff’s Office also told local media that methamphetamine use is a persistent problem.

“You don’t have many people overdose on meth,” one law enforcement officer told the Mountaineer. “You don’t have that dramatic incident in their life like you do with an overdose of opioids.”

Those who use it have largely moved away from producing small quantities of meth in local labs, according to the article. Instead, most of the county’s meth supply comes from Atlanta.

Up until a few weeks ago, Brayson was among the group that’s driving local demand for meth. She had said she wasn’t ready to give up meth.

“If you’re not ready, you’re wasting their time, you’re wasting your time,” she said. “I will know when I’m ready.”

But that’s changed, according to Dunlap who said Brayson has been sober for weeks. Further, she’s been helping Dunlap distribute needle exchange supplies.

Nestled in every needle exchange kit are pamphlets with local recovery resources. Those who receive the kits may not be ready for recovery yet, but they may change their minds. And when they do, Dunlap wants to be sure the information they need is at their fingertips.

This article was originally published by the Daily Yonder.

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Drug Epidemic

HIV Infection “Clusters” Put Focus On Harm Reduction Programs

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Photo: Mary Meehan/Ohio Valley ReSource

This article was originally published by Ohio Valley ReSource.

Health officials in Huntington, West Virginia, say a cluster of HIV infections has grown to 71 confirmed cases. That’s in a city that usually sees about eight HIV infections in a year. As with an earlier such cluster in northern Kentucky, officials say the primary cause of infection is needle drug use.

Health officials say a harm reduction program is an effective tool against HIV infection. The programs usually offer a syringe exchange, access to addiction counseling and health screening services such as HIV testing.

The programs have expanded rapidly in the Ohio Valley, a region hit hard by the opioid crisis and at highest risk in the nation of infectious disease outbreaks due to needle drug use.

Credit: Alexandra Kanik/Ohio Valley ReSource

But many people remain wary of syringe exchanges, and health officials are concerned that a backlash means some programs will close just when they’re most needed. The Huntington cluster of HIV cases appears to be correlated with the controversial closure of a nearby harm reduction program.

“The boomerang effect, the recoil, is going to be if these programs start closing, you’re going to see explosions of blood-borne pathogens, specifically HIV,” said Dr. Michael Brumage, director of the Preventive Medicine Residency Program in the West Virginia University School of Public Health.

High-Risk Region

In 2016 the Centers for Disease Control and Prevention spotlighted the counties in the U.S. at the highest risk of an HIV outbreak. Of the 220 high-risk counties, about a quarter were in Kentucky, West Virginia and Ohio. The 10 counties CDC found at highest risk were all in Kentucky and West Virginia.

Public health officials in the region have been working to implement syringe exchange harm reduction programs, which are widely supported as the most effective tool in combating HIV and other infectious diseases associated with needle drug use.

Photo: Alexandra Kanik/Ohio Valley ReSource

Dr. Greg Corby-Lee is the strategist with the University of Kentucky’s Harm Reduction Initiative. He said community-based harm reduction programs can be a lifeline to those still using drugs.

“It takes a while for them to build that level of trust up to come in,” he said. “That’s their one bridge, where they can be respected, and be given nothing but help to stay healthy.”

Corby-Lee said HIV prevention is the primary focus.

“That’s what they were designed for. But there are a lot of other benefits that come with it,” he said, such as peer counseling and screening for other diseases, such as Hepatitis C.

HIV/AIDS educator Greg Corby-Lee talking about harm reduction. Photo: Mary Meehan/Ohio Valley ReSource

Corby-Lee said prevention and testing for HIV are becoming more widely available in the area, and stigma – which can thwart outreach, testing and treatment – is gradually diminishing.

But he and other health officials also worry about a backlash brewing in many communities, threatening the harm reduction programs. They fear that misconceptions about the programs may threaten the very communities at greatest risk of an outbreak.

Daniel Raymond is Deputy Director of Planning and Policy for the National Harm Reduction Coalition. He said that while harm reduction programs are generally expanding, some are closing in the communities where they are needed most. The programs can become the focal point for other problems associated with the addiction crisis, he said, such as litter from used needles, homelessness and petty crime.

“A lot of these programs have been starting in communities that don’t have a long history with harm reduction,” Raymond said. “So the programs that end up being at risk of closure are often the ones that are getting scapegoated for a community’s drug problem.”

Closure, Then A Cluster

Dr. Brumage says that’s part of the problem he encountered when leading a harm reduction program in Charleston, West Virginia. The program ended most of its services last year amid local political pressure and complaints about discarded needles.

“I think it’s a simplistic view to look at and blame one program for all of the city’s woes, with homelessness, with use, with all these other things,” Brumage said. “And I think that’s a trick that many politicians use very well, is to find a culprit scapegoat and to blame it rather than really looking at deeper issues.”

Dr. Michael Brumage directs the Preventive Medicine Residency Program at West Virginia University. Photo: Courtesy WVU

The deeper issue, he says, is that the HIV threat is real and not going away. Less prevention equals more sick people. In Huntington, one person in the HIV cluster has died. However, Brumage is concerned that some Huntington residents are now viewing the cluster of infections as evidence to close its harm reduction program as well.

“Currently, some people in that community are saying, ‘Well, look, we have the syringe program, and we still got HIV, maybe we just need to close the program,’” he said. “The fact that you have a fire doesn’t mean you should close the fire department. You know, you bring more trucks on the scene.”

Brumage worries that the closure of the Charleston program may have contributed to the rise in HIV infections Huntington is now experiencing. The two cities are less than an hour’s drive apart along Interstate 64. And Brumage argues that Huntington’s cluster of infections could be much worse without a syringe exchange in place.

“My guess is had Huntington not had a syringe program, this problem would have exploded far worse.”

Other health officials say the growing HIV cluster in Huntington is a cautionary tale.

“It’s the looming disaster that we were all afraid of,” West Virginia University School of Medicine Professor Dr. Judith Feinberg told Mother Jones magazine.

Signs of Hope

Still, harm reduction proponents remain optimistic. The National Harm Reduction Coalition says that for every program closing, 20 more open. Kentucky has witnessed rapid growth in such programs.

Van Ingram, who leads Kentucky’s Office of Drug Control Policy, said that has only been possible with a fundamental shift in thinking about drug use as a health problem instead of a problem for law enforcement. He admits he was skeptical that the programs could take root in Kentucky. But it’s happening.

Van Ingram Executive Director

“I never dreamed we’d have 56 programs,” he said. “I did not think as many communities would have said, ‘Yes, we have a problem, and yes, we’re addressing big issues.’ Those communities are much, much quicker in recognizing the problem than I thought they would. I’m glad to say, I was wrong.”

Bourbon County, Kentucky, is an example of the phenomenon Ingram is describing. After several failed votes the county approved a syringe exchange program last year. Judge Executive Mike Williams said he braced for the complaints and backlash.

“I got gas yesterday afternoon and had three conversations at the gas pump about three different things,” he said, but the syringe program was not one of the things people had concerns about.

Since the syringe program opened, helping about 100 people, he said he’s only heard concerns from three people.

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Drug Epidemic

Unseen Impacts: Overdose Deaths Created a Shortage of Autopsy, Transportation Resources in W.Va.

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This van is used by the JCESA to transport deceased who are non-medical examiner cases and who have no prior death arrangements. JCESA purchased this van in 2017 to tackle an increase in calls and manage a loss in local resources. Photo: Liz McCormick/WVPB

Opioid-related overdose deaths have doubled in recent years in West Virginia, according to the West Virginia Department of Health and Human Resources.

The latest data from DHHR shows that in 2017, there were 875 opioid-related overdose deaths in West Virginia. While in 2012, there were 473.

Anytime someone dies of a suspected overdose in West Virginia, an autopsy is required, and these are performed in Charleston by a state medical examiner, also called a forensic pathologist.

“The impact of the substance use epidemic has really been on the caseload,” Dr. Catherine Slemp said. Slemp is the state health officer and Commissioner for the West Virginia DHHR’s Bureau for Public Health.

“It really has changed operations in terms of the number of cases that our forensic pathologists are handling and the staff that are part of that,” she said. “We are doing autopsies sometimes six to seven days a week.”

In 2012, there were more than 4,000 autopsies done in West Virginia, but compared to last year’s cases, that number has almost doubled. Slemp said 70 percent of all autopsies performed by a forensic pathologist are substance use related. That could be drugs or alcohol.

There are only three full-time forensic pathologists in West Virginia and five vacancies.

In an effort to fill those positions, the West Virginia Legislature recently approved an increase in the wages for forensic pathologists from $180,000 a year to $255,000 a year. That change went into effect on July 1, 2019.

But even with a higher salary, it’s not easy to recruit qualified candidates.

“This is an area that there’s only about 20, 25 individuals that come out of training every year,” Slemp explained. “And yet, there are probably 40 or 50 vacancies at any one time.”

Slemp said that’s because forensic pathologists have to go through medical school and do a residency in pathology. They must also take part in an ongoing fellowship in that field. It’s about 16 years of training.

“They’re very special and unique individuals,” Matthew Izzo, Director of the West Virginia Office of the Chief Medical Examiner said. “They have a passion for what they do. They believe in what they do.”

Izzo’s office is the same office that houses the state’s forensic pathologists.

In addition to an ever-increasing workload, both Izzo and Slemp claim about 30 to 40 percent of working forensic pathologists in the United States today are nearing retirement age.

Transporting the Dead in Jefferson County

When someone passes away unexpectedly, we don’t often realize the chain of events that happen behind the scenes to safely transport the bodies. Add the increase in premature deaths from the opioid epidemic to this, and it gets more complicated.

About five or six years ago, Jefferson County emergency officials noticed an uptick in call volume for deceased persons, and it was an adjustment period for officials as they learned to navigate the issue in a new way. 

Inside the garage of Eackles-Spencer & Norton Funeral Home in Harpers Ferry, Jefferson County, there’s a space where both Jefferson County emergency officials and the local, county medical examiner can temporarily store a body until certain decisions are made in Charleston.

“What we’ve tried to do is make a place, provide a place, for the staging area and the stopping point in between,” Alan Norton, co-owner at Eackles-Spencer & Norton Funeral Home said.

Jefferson County is so small that it doesn’t have a county morgue, and about five or six years ago, that became a problem as local officials began to see an increase in calls for deceased persons while, at the same time, they were struggling with staff shortages, and they lost the location the dead would normally be taken – the local hospital.

“So, we contacted the state medical examiner and said, we now no longer have a place to take these folks,” Bob Burner, Operations Commander for the Jefferson County Emergency Services Agency said. “And this really isn’t an [Emergency Medical Services] thing anyway. Once a person is deceased, there’s nothing in our skill set to help them. It’s a medical examiner, health department kind of an issue.”

For a long time, when someone died in Jefferson County unexpectedly, and had no prior death arrangements, people like Burner would come to the scene, attempt to save the person, and if the person was truly dead, a local medical examiner would be called, and the body would be transported via ambulance to the local hospital’s morgue until certain decisions were made.

But as more calls started coming in, the local hospital said they could no longer transport or provide space for the bodies, due to limited room and safety concerns.

For instance, it takes a long time to disinfect an ambulance after transporting a dead person – one to two hours, at least. And that can tie up calls where that ambulance is needed to serve the living.

“It’s not really appropriate to transport deceased folks who may have unknown pathologies in an ambulance where 20 minutes later, you’ll be transporting a newborn or an elderly person with a compromised immune system,” Burner said.

The hospital’s decision to pull back put Burner’s agency in a real bind, but he said he understood the reasoning.

So, Norton’s funeral home, the Jefferson County Emergency Services Agency and the local medical examiner formed a unique partnership to address the uptick in call volume and provide transport for the deceased.

“They can come on into our building, use our prep room, and we made a place for them to put their cooler,” Norton explained. “[This way] we can give them the space and the access and electricity, so that Jefferson County can have a staging area, and/or morgue in transit, while these bodies are getting to where they need to be.”

And the funeral home provides this service for free.

The Jefferson County Commission also joined this partnership and provided Burner and his agency $20,000 to purchase a van to transport a body to the funeral home. JCESA said, on average, they transport about 20 non-substance use related bodies in their van every year. These are folks who will not require an autopsy.

But if it’s a case that necessitates an autopsy, such as death by an overdose or foul play, Burner’s team worked with the state medical examiner’s office in Charleston, and the local ME, to contract a local fire department to transport the dead, first to Norton’s funeral home, and then to Charleston for a full autopsy.

It’s a lot of moving pieces.

And it’s usually a slow process that can take several hours from first arriving on scene, determining whether it’s a medical examiner case, and then transporting the body.

While Burner and other Jefferson County officials may have figured out a working system to transport the deceased, they hope the West Virginia Legislature looks at the issue and drafts legislation to clearly define what entity should be responsible for transporting the dead.

What’s the Cause?

Jefferson County officials agree, the opioid epidemic has played a role in the uptick in dead bodies, but they also say, population growth in the Eastern Panhandle region has likely contributed to it, too.

In fact, together, Berkeley, Jefferson, and Morgan Counties saw a nearly 20 percent population boom in the region between 2010 and 2018, according to the U.S. Census Bureau.

W.Va. DHHR’s data on opioid-related deaths in Jefferson County in recent years has fluctuated, but overall, has increased since 2012.

DHHR reported that in 2017, there were 27 opioid-related overdose deaths in Jefferson, 89 in Berkeley, and 10 in Morgan.

The counties with the most opioid-related overdose deaths in 2017 were Cabell County with 184 deaths and Kanawha County with 117.

This article was originally published by West Virginia Public Broadcasting.

 
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