IBH President's Letter on Fentanyl Published in The Washington Post

In response to The Washington Post’s series on fentanyl, IBH President Robert L. DuPont, MD authored a letter to the editor, published on December 16, 2022:

The Cartel Rx series is an important contribution, recognizing the immensity of the U.S. fentanyl overdose problem and the inadequacy of efforts to turn back the devastating tide over the past two decades; however, three essential realities were overlooked.

First, there are virtually no drug overdose deaths where fentanyl is the only drug present. The “fentanyl” problem is 100 percent a polydrug problem. The United States has a five-decades-long history of demonizing one drug at a time (i.e., heroin, cocaine, methamphetamine, prescription opioids), yet these were, and still are, polydrug problems.

Second, the only way to meaningfully reduce the supply of fentanyl and other nonmedical drugs is to take away the $150 billion spent by Americans who use them. Leave that on the table, and there is no end to the supply by drug-trafficking organizations eager to collect money. There is nothing unique to either Mexico or China regarding fentanyl. It is easily synthesized anywhere in the world.

Third, though each overdose death is a tragedy for the individuals, their families and friends, most who use illicit drugs are well aware of the deadly risk of fentanyl and other drugs. The series noted more than 9 million opioid users in the country and more than 107,000 deaths; that is about 1 in 100 illegal opioid users dying of an overdose each year.

Robert L. DuPont, Chevy Chase

The writer, the first director of the U.S. National Institute on Drug Abuse and the second White House drug czar, is president of the Institute for Behavior and Health.

See the coverage on The Washington Post.

Dealing with the Addiction Crisis During the Nightmare of COVID-19

How do we deal with an addiction crisis during the nightmare of COVID? Individuals that suffer from substance use disorder (SUD) are facing even more challenges during COVID-19 as a vulnerable population that is experiencing isolation, loss of support, employment, food security, housing, transportation and safety issues. This stress and isolation have contributed to rising overdose deaths, up by as much as 42% compared to last year. Our addiction crisis is worsening during these unprecedented times and the impact to mental health is taking a toll on this population.

On November 17, 2020, the National Association of Drug Court Professionals (NADCP) and Averhealth sponsored a webinar to discuss the SUD epidemic prior to the pandemic, the current landscape, and offer solutions for how we can address these issues of social isolation, economic hardships and loss of support for those suffering with SUD.

IBH President Robert L. DuPont, MD presented alongside General Barry R. McCaffrey, U.S. Army (Retired) and Bertha Madras, PhD.

The recorded webinar can be watched online via Averhealth.

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