Polysubstance use in the U.S. Opioid Crisis

A new article co-authored by IBH President Robert L. DuPont, MD and Wilson M. Compton, MD, MPE and Rita J. Valentino of the National Institute on Drug Abuse (NIDA) urges new research on the prevalence and reasons for polysubstance use to inform and improve both the prevention and treatment of opioid use disorders. The current approach to substance use disorders (i.e., addiction) is substance-specific which neglects to address the common issue of polysubstance use.

Published in Molecular Psychiatry, authors highlight the overlap of substances used by American adults across the lifetime, noting, “as a general principal, the more widely a drug is used, the higher the percentage of users who do not use other drugs; and, the less widely used, the more likely a drug is to be used with other drugs.”

Fig. 1: Overlap of substances used across the lifetime. Weighted lifetime prevalence of substance use and mean number of other substances ever used by adults age 18 and older in the United States (n = 51,000; Source: 2018 U.S. National Survey on Drug Use and Health [adapted from Eric Wish, University of Maryland, Center for Substance Abuse Research]).

Abstract: Interventions to address the U.S. opioid crisis primarily target opioid use, misuse, and addiction, but because the opioid crisis includes multiple substances, the opioid specificity of interventions may limit their ability to address the broader problem of polysubstance use. Overlap of opioids with other substances ranges from shifts among the substances used across the lifespan to simultaneous co-use of substances that span similar and disparate pharmacological categories. Evidence suggests that nonmedical opioid users quite commonly use other drugs, and this polysubstance use contributes to increasing morbidity and mortality. Reasons for adding other substances to opioids include enhancement of the high (additive or synergistic reward), compensation for undesired effects of one drug by taking another, compensation for negative internal states, or a common predisposition that is related to all substance consumption. But consumption of multiple substances may itself have unique effects. To achieve the maximum benefit, addressing the overlap of opioids with multiple other substances is needed across the spectrum of prevention and treatment interventions, overdose reversal, public health surveillance, and research. By addressing the multiple patterns of consumption and the reasons that people mix opioids with other substances, interventions and research may be enhanced.

Compton, W.M., Valentino, R.J. & DuPont, R.L. (2021). Polysubstance use in the U.S. opioid crisis. Molecular Psychiatry, 26, 41–50. https://doi.org/10.1038/s41380-020-00949-3

Linked National Crises: Overdose in the Time of COVID-19

***Click here to view or print a PDF copy of this commentary.***

Linked National Crises: Overdose in the Time of COVID-19

The global pandemic of COVID-19 threatens every nation, demanding urgent efforts to meet the changing health care needs of their populations. At the same time, the United States faces a concurrent epidemic of drug-related overdose deaths. The effects of COVID-19 are particularly severe for individuals and families facing substance use disorders. Considering substance use disorders and overdose deaths must be a part of the national response to COVID-19.

Prior to the COVID-19 pandemic, the number of overdose deaths in the US rose steadily from 1990 peaking in 2017 with over 70,000 overdose deaths. Largely because of an increase in overdose deaths and suicides, US life expectancy declined for three straight years, from 2015 to 2017– the first decline since 1918 when the nation faced the previously disastrous flu pandemic.¹ Overdoses were not a factor in the deaths recorded at that time. What is happening now is a new, and worrisome trend that threatens several years of focused national and local efforts to reduce overdose deaths. In 2018 the US experienced a modest decline in drug overdose deaths, with a drop to 68,557. New preliminary data from the Centers on Disease Control and Prevention shows that progress was lost. A new record in overdose deaths was set at 71,999 in 2019.^2,3 Data from the Overdose Detection Mapping Application Program (ODMAP) indicates that yet another new record will be set during the era of COVID-19.

ODMAP, which collects data on overdoses from communities across the country, reports that in 2020 all overdoses – both fatal and non-fatal – increased compared to the same months in 2019: an 18% increase in March, a 29% increase in April, and a 42% increase in May.^4,5,3 Other national indicators suggest that illicit drug use is increasing. Following the March 13, 2020 declaration of COVID-19 as a national emergency, urine drug testing positivity rates showed statistically significant increases for fentanyl, methamphetamine, and cocaine.⁶ The positivity rate for heroin also increased but did not reach statistical significance.

We are losing the limited but important progress previously made in the battle to curb the overdose epidemic for several reasons. First, the drug supply is lucrative, widespread, and adaptable to COVID-19 related changes in the marketplace. Second, the COVID-19 pandemic has hindered significantly and even closed many inpatient and outpatient substance use disorder treatment programs. Third, the pandemic has incapacitated many community-based recovery support networks including, but not limited to, Twelve Step fellowships of Alcoholics Anonymous and Narcotics Anonymous. Fourth, substance use is often social, but it is also solitary; the broad isolation the population faces during COVID-19 may increase substance use and subsequent risk of overdose. As warned by Nora Volkow, MD, Director of the National Institute on Drug Abuse (NIDA), “Social distancing will increase the likelihood of opioid overdoses happening when there are no observers who can administer naloxone to reverse them and thus when they are more likely to result in fatalities.”⁷ Perhaps not surprisingly, a comparison of overdoses reported to ODMAP during pre-stay-at-home orders and post-stay-at-home orders in 2020 showed a 17.5% increase in all fatal and non-fatal overdoses.⁵

What can be done about the national rise in overdose rates?

• Use discussions of COVID-19 to highlight the problem of addiction, which is often solitary and hidden. Encourage families and others to intervene strongly when their loved ones are actively engaged in substance use. Get them into treatment and engaged in recovery support.
• Recognize the added threats of relapse even among those in recovery from substance use disorders in the time of COVID-19.
• Use media outlets aggressively to educate the public about the health threat posed by substance use, the warning signs of overdoses, and how to access and use naloxone to reverse an opioid overdose.
• Fund substance use disorder treatment and support programs as they innovate care during the COVID-19 pandemic. The American Medical Association recently outlined several action steps⁸ for states to take, including adopting rules and guidance from the Substance Abuse and Mental Health Services Administration (SAMHSA)⁹ and Drug Enforcement Administration (DEA)¹⁰ for programs that treat individuals with opioid use disorders.

As the nation faces the linked crises of the COVID-19 pandemic and a resurgence in overdoses, we must identify, protect, and assist those who are the most vulnerable. This includes individuals with substance use problems.¹¹

Robert L. DuPont, MD, IBH President

Caroline DuPont, MD, IBH Vice President

Corinne Shea, MA, IBH Director of Programs and Communications

References

[1] Woolf, S. H., & Shoomaker, H. (2019, November 26). Life expectancy and mortality rates in the United States, 1959-2017. JAMA, 322(20), 1996-2016. doi:10.1001/jama.2019.16932

[2] Ahmad, F. B., Rossen, L. M. & Sutton, P. (2020). Provisional drug overdose death counts. National Center for Health Statistics, US Center for Disease Control and Prevention. Available: https://www.cdc.gov/nchs/nvss/vsrr/drug-overdose-data.htm

[3] Katz, J., Goodnough, A., & Sanger-Katz, M. (2020, July 15). In shadow of epidemic, U.S. drug overdose deaths resurge to record. The New York Times. Available: https://www.nytimes.com/interactive/2020/07/15/upshot/drug-overdose-deaths.html

[4] Wan, W., & Long, H. (2020, July 1). ‘Cries for help’: drug overdoses are soaring during the coronavirus pandemic. The Washington Post. Available: https://www.washingtonpost.com/health/2020/07/01/coronavirus-drug-overdose/

[5] Alter, A., & Yeager, C. (2020, June). COVID-19 impacts on US national overdoses. Overdose Detection Mapping Application Program. Available: http://www.odmap.org/Content/docs/news/2020/ODMAP-Report-June-2020.pdf

[6] Millennium Health. (2020, July). COVID-19 Special Edition: Significant Changes in Drug Use During the Pandemic. Millennium Health Signals Report volume 2.1. Available: https://resource.millenniumhealth.com/signalsreportCOVID

[7] Volkow, N.D. (2020, April 2). Collision of the COVID-19 and addiction epidemics. Annals of Internal Medicine, 173(1), 61-62. Available: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7138334/

[8] American Medical Association. (2020, July 8). Issue brief: reports of increases in opioid-related overdose and other concerns during COVID pandemic. AMA Advocacy Resource Center. Available: https://www.ama-assn.org/system/files/2020-07/issue-brief-increases-in-opioid-related-overdose.pdf

[9] Substance Abuse and Mental Health Services Administration. (2020, March 19). Opioid treatment program (OTP) guidance. Available: https://www.samhsa.gov/sites/default/files/otp-guidance-20200316.pdf

[10] Drug Enforcement Administration. (2020, March 31). Prevoznik, Thomas W. Letter to DEA Qualifying Practitioners and DEA Qualifying Other Practitioners. Available: https://www.deadiversion.usdoj.gov/GDP/(DEA-DC-022)(DEA068)%20DEA%20SAMHSA%20buprenorphine%20telemedicine%20%20(Final)%20+Esign.pdf

[11] Pfefferbaum, B., & North, C. S. (2020, April 13). Mental health and the Covid-19 pandemic. New England Journal of Medicine. Available: https://www.nejm.org/doi/full/10.1056/NEJMp2008017

World Drug Day 2020

IBH President Robert L. DuPont, MD represents North America as a Member of the Board of Directors of the World Federation Against Drugs (WFAD). At the request of WFAD he wrote the following statement to celebrate International Day Against Drug Abuse and Illicit Drug Trafficking, better known as World Drug Day on June 25, 2020.

Click here to download or print a PDF copy of this statement.

Although the challenges posed by the COVID-19 pandemic are dominating our lives, let us not forget the equally deadly pandemic that continues to rage across the globe: drug abuse. This modern scourge, started in the late 1960s, continues to enslave and kill people of all nations in ever-changing ways. In Sweden, one of the first places the drug use pandemic hit, psychiatrist and professor, Nils Bejerot worked with the Stockholm police to fight the rising tide of methamphetamine and heroin use. Dr. Bejerot saw that the government’s initial response of providing users with physician-prescribed opioids and stimulants was futile. Not only did this policy fail to reduce drug use, but many of those drugs were diverted by users and ended up being sold on the street, leading to increased levels of drug use overall. Based on his first-hand experience with hundreds of patients, Dr. Bejerot concluded that providing addicts with drugs only prolonged their addiction and encouraged the spread of drug use throughout Swedish society. He saw that the only way to free users from the grip of addiction was to insist that they remain abstinent from all drugs. The world owes a debt of gratitude to Dr. Bejerot. Thanks to the instrumentality of his efforts over 50 years ago, Sweden’s commitment to abstinence-based drug use prevention and treatment was born.

With such a history it comes as no surprise that in 2009 the World Federation Against Drugs was established in Stockholm to create a better drug policy vision for the world by building on the Swedish experience. This was a vision in stark contrast to the increasingly dominant view that the most appropriate public health response to addiction was “harm reduction.” That strategy sought to reduce some of the harm produced by addictive drug use while permitting and even sometimes encouraging continued drug use.

WFAD is not opposed to harm reduction programs as a part of the response to the modern drug epidemic—as part of a continuum of care ending in treatment. However, WFAD insists that these programs be evaluated on the basis of their ability to help addicts become drug-free. That means seeing harm reduction as a step toward eventual abstinence. Although facilitating drug use among addicts is better than allowing them to die from overdose, such use is not in their own long-term interest as it carries many serious risks to physical and mental health. Harm reduction without eventual recovery “enables” continued drug use and addiction. That is not in the interest of addicted people or the societies in which they live. WFAD supports the use of medication-assisted treatment (MAT) for people suffering from opioid use disorders. When medications such as buprenorphine and methadone are used as prescribed and there is no other recreational or illicit use of substances, MAT patients are considered to be drug-free.

The UN Treaty on the Rights of the Child, the only UN treaty to focus on youth drug use, calls on all nations to help protect children from drugs. WFAD has the same clear goal for youth prevention as the ideal outlined in the treaty: that children be able grow up drug-free. For youth, there is no safe or healthy recreational use of drugs, including alcohol, nicotine, or marijuana. This drug-free, no-use, goal is based on the recognition of the unique vulnerability of the developing adolescent brain to drug addiction.

WFAD celebrates and supports the growing Recovery Movement worldwide. The recent emergence of millions of people who have overcome their own drug addiction not only inspires a world confronted by epidemic levels of deadly drug use, but it also reinforces the notion that true recovery is drug-free. People in recovery are the pathfinders for modern drug policy; this large and rapidly growing population offers hope to all addicted people.

WFAD is a world leader in promoting drug-free solutions for health and well-being. Composed of a diverse global array of organizations and individuals working together to combat drug addiction, WFAD is the antidote to the modern drug epidemic.

NEW REPORT: Fentanyl as Sentinel - The Emerging Threat of Synthetic and Counterfeit Drugs

Authored by John J. Coleman, PhD and Robert L. DuPont, MD, and published by The Heritage Foundation

This compelling report outlines the story of fentanyl and identifies key policy recommendations to address the national drug epidemic. 

Fentanyl is a sentinel calling our attention to the potential for a slew of laboratory-based drugs produced by an ever-expanding illegal global drug market to meet a growing demand. Included in this threat are the fentanyl-laced counterfeit drugs manufactured to look like well-known and trusted pharmaceutical products but containing deadly amounts of fentanyl instead of the expected active pharmaceutical ingredient. Unrestrained by regulatory controls and labeling requirements, today’s drug trafficker-entrepreneur poses a serious threat to patients and non-patients alike. If we hope to meet these challenges successfully, we will need radically new thinking, better data systems, and improved technology to keep counterfeit drugs and deadly fentanyl analogs out of our communities and medicinal drug supplies.

Read the Full Report and print a PDF copy here.