Urban-rural divide exacerbates opioid crisis, despite prescription drop

Urban-rural divide exacerbates opioid crisis, despite prescription drop
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The number of opioid prescriptions written in the United States has declined in recent years, according to newly released federal data, but the number of people who have fallen victim to fatal overdoses from prescription painkillers or heroin continues to rise.

The problem is especially acute in small town and rural America, where the unemployment rate remains high and a disproportionate number of residents are on Medicare or Medicaid, according to the data released by the Centers for Disease Control and Prevention. 

The rapid growth in opioid prescriptions in the last two decades has coincided with and contributed to a spike in the number of drug overdoses in the United States. And even as prescriptions have slumped, more people are dying: More than 52,000 people died of drug overdoses in 2015, the last full year for which data is available. 

Early estimates suggest the number of overdose deaths was far higher in 2016, and growing still in the early months of 2017. 

Nearly two-thirds of overdose deaths in 2015 involved an opioid, the CDC reported. The agency said about two million Americans are addicted to opioids. 

“It’s important to understand what’s driving this, and there are two drivers, and they’re distinct. One of them is an increase in prescriptions, and that’s the main driver,” Tom Frieden, the former head of CDC, told The Hill in an interview. 

Second, he said: “We’re seeing a huge spike in the availability and a reduction in cost of heroin and fentanyl. With addictive substances, if you increase availability and reduce cost, more people use them. It’s kind of a law of nature.” 

“If law enforcement is able to make heroin and fentanyl more expensive and harder to get, fewer people will use it,” Frieden said.

Opioid prescriptions peaked in 2010, at about 81.2 prescriptions per 100 Americans. But while overall prescriptions have fallen, the numbers of prescriptions in about half of American counties remained steady or increased.

The number of prescriptions for thirty or more days jumped almost 59 percent between 2006 and 2012. The total amount prescribed, measured in morphine milligram equivalents, is three times as high today as the level in 1999.

The amount of opioids prescribed in America is nearly four times higher than that of Europe.

“The epidemic of opioid misuse, overdose, and death is a multifaceted crisis that requires partnership across sectors to respond with effective health care and public safety strategies,” the authors wrote in the Journal of the American Medical Association. “Reducing overprescribing practices prevents people from becoming addicted in the first place, potentially changing the demand for opioids.”

Today, the average opioid prescription covers 17.7 days, a third more than the rate in 2006. The length of a prescription matters, CDC experts say, because the risk of addiction rises the longer one takes the drugs.

The CDC data shows the counties where opioids are prescribed most often are those still suffering the effects of the great recession. The highest-prescribing counties are likely to be in rural areas or “micropolitan”  towns with fewer than 50,000 residents, where the unemployment rate stands nearly two percentage points higher than the national average.

Those counties hit hardest by the epidemic are more likely to be dominated by white Americans: The average county in the highest quartile of opioid prescriptions is 83.6 percent white, while the lowest quartile is just 76.9 percent white. 

And the chasm between those quartiles is immense: Doctors and dentists in the worst-hit counties wrote six times more prescriptions for opioids than did providers in the lowest-prescribing counties. 

Counties where people are most likely to be prescribed opioids are in places like rural Appalachia, in states like Tennessee, West Virginia and Alabama. Rural communities in northern California and southern and eastern Oregon also see high rates of prescriptions.  

A small handful of more urban cores, including the Las Vegas area, also have high rates of prescription. 

Frieden, who ran the CDC for eight years under President Obama, said addressing the burgeoning crisis will require better and more accessible treatment, as well as narcan, a drug that can reverse the effects of an overdose. But that only addresses those who are currently addicted to or at risk of addiction to opioids. 

“The bigger picture is the other 300 million-plus people who don’t have an opioid dependency but might be prescribed [an opioid] tomorrow,” Frieden said. “To reduce supply, you have to improve prescribing and improve law enforcement. To reduce demand, you have to improve the management of addiction and increase community awareness and support.” 

Many of the states hardest hit by the opioid crisis have taken steps to limit the number of prescriptions being written.  

States like Ohio and Kentucky have implemented new restrictions on prescriptions, as well as new statewide drug monitoring systems. In the vast majority of both states, opioid prescriptions have fallen between 2010 and 2015, according to the authors of the CDC study. 

But even with the successes in some states, the number of deaths has grown. Preliminary tallies in Ohio compiled by The Columbus Dispatch show a 36 percent increase in the number of overdose deaths between 2015 and 2016. Many counties told the paper their overdose deaths were mounting at a faster clip in 2017.

The CDC scientists said the increased death rates could be attributed to the growing use of illegal opioids and their substitutes, like heroin and fentanyl. The experts found a link between illicit opioids and those who had filled a prescription within the last few months.

State lawmakers have considered more than 1,000 measures in recent years to confront the opioid epidemic, according to the National Conference of State Legislatures. Thirteen states have passed new laws to limit the length of opioid prescriptions or the number of pills prescribed over the last two years.

Forty nine states have implemented a Prescription Drug Monitoring Program, statewide databases that allow doctors to see whether a patient has already been prescribed an opioid. A bill to create a similar program in Missouri stalled earlier this year.

In recent months, attorneys general from Ohio, Missouri and Oklahoma have filed lawsuits against pharmaceutical companies that manufacture opioids over marketing practices the states say contribute to the number of prescriptions. About half of state attorneys general are investigating the industry, as are two committees in Congress. 

Frieden said the report shows progress is happening, but that a solution will be a long time in the making.

“Turning off the tap of excess opiates from prescriptions and from the drug cartels are both going to be important, and providing services to those who are addicted and can survive is important too,” Frieden said. "It took a generation to get in this bad shape, and it’s not going to be quick for it to get turned around."

-Updated at 11:10 a.m.