This week’s news was dominated by a grab bag of activity by the White House and Congress, at least some of which was positive. There were also some clarifications about CDC overdose statistics, horrifying accounts of specific overdose incidents, and illuminating or intriguing developments from Delaware, the United Kingdom, and Tasmania.
With the signing of Congress’s $1.3 trillion spending bill, many news outlets reported that at least $4 billion would be going to contain the opioid epidemic. The Hill helpfully explains that this does not represent new appropriation. Rather, it is about allocating sums previously agreed upon in the earlier budget deal, where it was decided that $6 billion would be allocated over two years for fighting the opioid crisis and for mental health. The winners in the spending bill, according to Susannah Luthi of Modern Healthcare, include NIH (a $3 billion boost in its budget), efforts to develop alternative, nonaddictive pain medications, community health centers, and telehealth measures. (We have an article on why telemedicine has become so important for distributing buprenorphine in rural areas here.)
Since the Trump Administration continues to beat its death-penalty drum, Politico looks into the proposal seriously and discovers that there is already a statute on the books that purports to authorize capital punishment for drug dealers. Prosecutors don’t use it, however, because Supreme Court precedents make it pretty clear that doing so would be unconstitutional unless homicide is involved.
Meanwhile, a group of Republican Senators is seeking to lower thresholds (currently 40 mg) for imposition of mandatory minimum sentences for dealers of fentanyl, per The Hill.
When it comes to reducing overdose deaths, however, throwing more people in jail is probably going to achieve less than offering medication-assisted treatment to those who are already there. Prisoners with substance abuse histories have a notoriously high rate of overdose death upon reentry into society. During the first two weeks of liberty they have 129 times greater risk of overdose death than the general population, according to a 4000-word story in Vox. That article discusses why this is so and what can be done about it. We do the same, in fact, in a shorter story here. Both stories focus on an extremely successful program recently implemented in Rhode Island, that has cut overdose deaths among recently released inmates 60%, and has lowered statewide overdose rates, also—all despite an escalating fentanyl crisis. The Vox story emphasizes the fact that the Rhode Island program offers all three forms of medication-assisted therapy (MAT)—methadone, buprenorphine, or naltrexone. Our story, on the other hand, stresses the fact that Rhode Island found a treatment provider that could not only serve inmates while in prison, but could also seamlessly continue to do so after their release at any of 12 community locations scattered around the state.
Speaking of naltrexone, STAT has an interesting story about how the White House is apparently favoring the use of one particular medication in federal prisons—naltrexone in its injectable form—which is made by only one manufacturer. The only current such product, Vivitrol, is marketed by Massachusetts-based Alkermes. Compared to methadone and buprenorphine, naltrexone has less empirical evidence backing its effectiveness, according to the STAT, and it’s also quite expensive—more than $1,000 a dose. In addition, California attorney general Kamala Harris has opened an investigation of Alkermes’ marketing of Vivitrol, according to the STAT story.
In news that exceedingly few will lament, opioid prescribing rates have now come down to the point that Tasmanian poppy farmers are feeling the pinch. Tasmania, the Australian island state, grows almost half the world’s lawful supply of morphine, codeine and thebaine (the opiate from which, for instance, oxycodone is derived). “Prices on contracts have fallen by about a quarter over five years,” one farmer complains to the Financial Times. Two of the main companies that grow the plants, Tasmanian Alkaloids and TPI, are considering “diversifying into medical marijuana in search of new income stream,” the newspaper reports.
Last week, Indivior, which makes about $1 billion in annual revenue from sales of Suboxone, the most popular form of buprenorphine, lost a patent suit in US District Court in Delaware against Alvogen, a manufacturer that wants to market a generic version. The development, which could lead to generic competition and lower buprenorphine prices, is reported by BiopharmaDive. Suboxone, which includes naloxone as an abuse deterrent and comes as a strip of film that is placed under the tongue, enjoys 57% share in the market for buprenorphine. Indivior has appealed, however, so no generic will appear soon.
Good news, bad news. The good news is that the CDC’s estimates of the number of overdose deaths from prescription opioids may have been overstated in recent years, according to a study published in American Journal of Public Health by four CDC researchers. Traditionally, the agency assumed that overdoses attributed to synthetic opioids were from prescription drugs like tramadol or fentanyl patches, like Duragesic. In recent years, however, the overwhelming majority of such deaths are from illicitly trafficked fentanyl. The authors recommend counting the synthetic category as non-prescription drugs now. In truth, few have been misled. The CDC publications I’ve been reading in recent months have already been assuming that the synthetics involved in fatal ODs were illicit fentanyl. In any case, even under the new, more conservative computations, ODs involving prescription opioids are still rising, though at a relatively modest 3% per year.
The bad news, according to NPR, is that the country is probably underestimating the total share of drug overdose deaths attributable to opioids by about 20%. Because certain states or counties either don’t test for specific drugs, or don’t report the results of those tests on death certificates of overdose victims, a new study in Addiction, by Christopher Ruhm, concludes that the number of opioid OD deaths in 2016 was probably closer to 50,000 than the official CDC count of 42,000.
Incidentally, even though opioid prescribing has been decreasing nationally, Kaiser Health News discovered that in 10 states the opioids Vicodin and/or Norco (hydrocodone plus acetaminophen) are still the most frequently prescribed drugs in the state. (Suboxone wins that distinction in Tennessee.)
Here’s some really awful stuff:
In more uplifting news, the British Medicines and Healthcare Products Regulatory Agency (MHRA) appears poised to fix a bizarre anomaly that the Evening Standard exposed last week. The MHRA had been requiring that drug makers post explicit addiction risk warnings on the weakest of opioids, like codeine cough syrup, but not on much more powerful ones, like fentanyl, morphine sulfate, oxycodone, tramadol, and buprenorphine (apparently used as a painkiller there).
And finally, ending on a light note, we share KHN’s health haiku of the week, from Ernest R. Smith. With reference to the fact that drug makers are preparing to work in partnership with NIH to find nonaddictive painkillers, as reported in, for instance, STAT, he writes:
Pharma wants to help
Fix opioid disaster.
Nah, you’ve done enough.