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Drug Overdoses Rising, Many Users Have No Access to Clean Needle Programs

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Drug overdose deaths, primarily due to prescription pain relievers and heroin, have risen dramatically in the U.S. -- now exceeding deaths in motor vehicle accidents -- with opioids accounting for more than 28,000 deaths in 2014, according to a report from the Centers for Disease Control and Prevention (CDC). Another recent report found a lack of syringe exchange programs in rural and suburban areas, which account for much of the rise in HIV and hepatitis C among people who inject drugs.

As described in the January 1 Morbidity and Mortality Weekly Report, Rose Rudd from CDC's National Center for Injury Prevention and Control and colleagues analyzed recent multiple cause-of-death mortality data as recorded on death certificates from the National Vital Statistics System to track current trends and shifting characteristics of drug overdose deaths in the U.S.

Findings

  • A total of 47,055 drug overdose deaths were reported in 2014 -- a 6.5% increase from 2013 (from 13.8 to 14.7 per 100,000 persons).
  • Deaths due to overdoses of opioid drugs -- mainly prescription pain relievers and heroin -- rose 14% from 2013, reaching 28,647 in 2014 (from 7.9 to 9.0 per 100,000 persons).
  • 61% of all drug overdose deaths involved some type of opioid, including heroin.

o   Deaths due to natural and semi-synthetic opioid pain relievers (e.g., morphine, oxycodone, hydrocodone) rose by 9%, reaching 3.8 per 100,000 persons in 2014.

o   Mortality due to heroin rose by 26%, reaching 3.4 per 100,000 persons.

o   Deaths involving synthetic opioids other than methadone (e.g., fentanyl, tramadol) rose by 80%, reaching 1.8 per 100,000 persons.

o   Overdose deaths due to methadone, however, remained stable.

  • Drug overdose mortality rose across demographic groups, with significant increases among both sexes; people age 25-34, 35-44, 55-64, and over 65; and both whites and blacks.
  • Drug overdose deaths increased significantly in the Northeast, Midwest, and South census regions.
  • The 5 states with the highest overdose death rates in 2014 were West Virginia (35.5 deaths per 100,000), New Mexico (27.3), New Hampshire (26.2), Kentucky (24.7), and Ohio (24.6).
  • 14 states representing most regions of the country saw their overdose rates rise significantly from 2013 to 2014: Alabama, Georgia, Illinois, Indiana, Maine, Maryland, Massachusetts, Michigan, New Hampshire, New Mexico, North Dakota, Ohio, Pennsylvania, and Virginia.

"More persons died from drug overdoses in the United States in 2014 than during any previous year on record," the report authors wrote. "In 2014, there were approximately one and a half times more drug overdose deaths in the United States than deaths from motor vehicle crashes."

The 2014 increase follows a slight decrease in drug overdose deaths in 2012 and a stable number in 2013.

"The 2014 data demonstrate that the United States' opioid overdose epidemic includes 2 distinct but interrelated trends: a 15-year increase in overdose deaths involving prescription opioid pain relievers and a recent surge in illicit opioid overdose deaths, driven largely by heroin," the researchers continued.

They noted that the sharp increase in deaths involving synthetic opioids coincided with law enforcement reports of increased availability of illicitly manufactured fentanyl (although this cannot be distinguished from prescription fentanyl in death certificate data). The increased availability of heroin, combined with its lower price compared to diverted prescription opioids and its high purity, "appear to be major drivers of the upward trend in heroin use and overdose," they added.

"These findings indicate that the opioid overdose epidemic is worsening," the researchers concluded. "There is a need for continued action to prevent opioid abuse, dependence, and death, improve treatment capacity for opioid use disorders, and reduce the supply of illicit opioids, particularly heroin and illicit fentanyl."

"To reverse the epidemic of opioid drug overdose deaths and prevent opioid-related morbidity, efforts to improve safer prescribing of prescription opioids must be intensified," they recommended. "In addition, efforts are needed to protect persons already dependent on opioids from overdose and other harms. This includes expanding access to and use of naloxone (a safe and effective antidote for all opioid-related overdoses) and increasing access to medication-assisted treatment, in combination with behavioral therapies. Efforts to ensure access to integrated prevention services, including access to syringe service programs when available, is also an important consideration to prevent the spread of hepatitis C virus and [HIV] infections from injection drug use."

Syringe Exchange Availability

In a related report, published in the December 11, 2015, Morbidity and Mortality Weekly Report, Don Des Jarlais from Mount Sinai Beth Israel Medical Center and colleagues looked at availability of needle and syringe exchange programs, focusing on non-urban areas where at least half of people who inject drugs are estimated to live.

HIV incidence among people who inject drugs declined by approximately 80% during 1990-2006, coinciding with the expanded availability of syringe service programs (SSPs), they noted as background. Research regarding hepatitis C virus (HCV) infection has been less consistent, though a "marked decline" in the incidence occurred during 1992-2005 in selected locations when targeted risk reduction efforts for the prevention of HIV were implemented.

But injection drug use has increased over the past decade in the U.S., primarily injection of prescription opioids and heroin among people who started out using oral opioid painkillers and transitioned to injecting.

"Much of this drug injection has occurred in suburban and rural areas," the study authors wrote. "The recent HIV outbreak in Scott County, Indiana, and the emerging HCV epidemics in multiple areas throughout the United States have focused attention on the limited coverage of prevention services for both types of infections among [people who inject drugs] in rural and suburban areas."

The researchers analyzed data from a recent survey of SSPs by Beth Israel and the North American Syringe Exchange Network, looking at program characteristics (e.g., size, clients, and services) and comparing programs in urban, suburban, and rural location. As of March 2014, a total of 204 SSPs were known to be operating in the U.S. in 2013. Directors of 153 (75%) of these programs participated in the mail and telephone survey.

Substantially fewer SSPs were located in rural and suburban areas (30 and 14 programs, respectively) compared with urban areas (105 programs). Nationally, 20% of SSPs were in rural locations, 9% were in suburban locations, and 69% were in urban locations. The West and Northeast had the most SSPs, while the South had the fewest. The West and Midwest had a higher percentage of rural programs, while the South and Northeast had the highest percentage of urban programs.

Overall, nearly 60% of SSP participants were men. Urban SSPs reported considerably higher percentages of African-American and Hispanic clients than rural or suburban programs, though whites still accounted for the majority of all SSP clients. Two-thirds of urban and suburban SSP clients mainly injected heroin, falling to about half of rural clients, as rural SSPs saw higher proportions of amphetamine and opioid analgesic injectors. Suburban SSPs were most likely to report difficulties in reaching potential participants.

Looking at syringe numbers, urban programs distributed 31.5 million syringes, compared with 4.4 million for suburban programs and 2.7 million for rural programs. Most SSPs in all locations offered HIV and HCV testing, but rural programs were less likely to provide naloxone (37% vs 57% of suburban and 61% of urban SSPs).

Not surprisingly, rural programs had smaller budgets on average (mean $26,023), while suburban programs and urban programs had much larger budgets (mean $116,902 and $184,738, respectively). However, they were equally likely to receive local or state government funding (60%, 64%, and 60%, respectively). But "a majority of SSPs in all location types reported experiencing funding and resource shortages in 2013," the authors wrote. (Until recently the U.S. banned use of federal funds for syringe exchange programs; a recent change allowed the use of funds for program expenses other than syringes themselves.)

The authors noted that the existence of a SSP in an area will not necessarily prevent an outbreak of HIV or HCV infection, as drug injectors need access to an adequate number of sterile syringes -- UNAIDS recommends 200 syringes per injector per year for a high level of coverage.

"HIV prevention for [people who inject drugs] has been successful where it has been implemented in the United States," the researchers concluded. "During the last decade, however, injection drug use has increased in many new areas, particularly rural and suburban communities, where HIV and hepatitis C prevention programs and services are often lacking. Providing all populations of [people who inject drugs] in the United States with access to sterile injection equipment as well as comprehensive treatment and prevention services for drug use and HIV and HCV infection could help prevent worsening of these epidemics."

"Syringe service programs have been very effective in reducing HIV transmission in the U.S. and throughout the world," Des Jarlais said in a Mount Sinai press release. "Our data show that rural and suburban SSPs face some special challenges in recruiting clients, funding, and staffing, but that these programs can provide the needed services when they are implemented. The biggest problem is simply that we do not have enough of them in rural and suburban areas. State and local governments can save lives by extending these programs."

1/19/16

References

RA Rudd, N Aleshie, JE Zibbell, et al. Increases in Drug and Opioid Overdose Deaths -- United States, 2000-2014. Morbidity and Mortality Weekly Report 64(50):1378-1382. January 1, 2016.

DC Des Jarlais, A Nugent, A Solberg, et al. Syringe Service Programs for Persons Who Inject Drugs in Urban, Suburban, and Rural Areas -- United States, 2013. Morbidity and Mortality Weekly Report 64(48):1337-1341. December 11, 2015.

Other Source

Mount Sinai Beth Israel. Harm Reduction Services Less Available in Areas Plagued by Rising IV Drug Use and HIV Infections. Press release. December 10, 2015.