American overdose crisis worsens. New hydrocodone product approved against
advice. Also overdose editorial by Prof
Shane Darke (see below*).
Reference: ‘New
Painkiller Rekindles Addiction Concerns’ pD1 Science Times, New York Times, Tues April
22.
This is a featured article by reporter RC Rabin about the marketing of a
new long-acting hydrocodone preparation in the context of ever-increasing
overdose deaths in the US. Such is the
crisis in Massachusetts that the Governor has taken the unprecedented step of
declaring a state of emergency over the overdoses. Gov. Deval Fitzpatrick banned this drug
outright, despite its approval by the FDA.
A court over-ruled the Governor and so Zohydro joins dozens of other
over-priced and dangerous opioid analgesics on American pharmacy shelves.
“Nearly half of the nation’s 38,329 overdose deaths in 2010 involved
painkillers according to the CDC. These
narcotics now kill more adults than heroin and cocaine combined, sending
420,000 Americans to emergency rooms each year.”
“The FDA approved Zohydro ER, a long-acting version
of the opioid hydrocodone, against the advice of it advisory committee”.
It was also Governor Deval Fitzpatrick who used his emergency powers for the
approval of naloxone for distribution to emergency workers, police and
ambulance who are now all supplied with these in Massachusetts. Since 2006 the drug has been made available
in that state as a nasal spray from existing approved syringe product, as an
off-label use for friends or relatives of known or suspected drug users in an
attempt to reverse overdoses. The
traditional ampoule of naloxone is cheap (around $30 per dose) and there are
claims that thousands of overdoses have been successfully resuscitated using
the drug nasally. A newly FDA approved
auto-load syringe has recently been publicised but will cost over $200 and two
may be required for a single overdose (it also has ‘talking instructions’ which I hope will be in two languages, like
America itself). It will not be
available for several months at least.
My view is that this intervention should be examined carefully by public
health experts to determine pros and cons.
On my recent trip to New York the overdose crisis was mentioned many
times and is the subject of great concern amongst the public and policy makers
alike.
And the elephant in the room?
Despite the life saving potential, nobody seems to be talking about
methadone and similar treatments which are simply not available to most
Americans who need them. Such treatments
were not even mentioned in this long NYT article. Methadone maintenance is limited to clinics
in the United States and buprenorphine is beyond the budget of many opioid
dependent citizens (and is usually given as a simple prescription without
supervision, psychosocial supports or urine toxicology - making it a
non-evidence based, expensive, experimental intervention - although probably
better than no treatment at all). On any
rational economic grounds such treatments should be subsidised by the
government which currently wastes millions of tax-payer dollars on law
enforcement.
There is a mistaken belief, even amongst educated Americans, that
methadone clinics are available for addiction treatments yet the workers on the
ground have reported that only about 1 in 7 opioid dependent Americans get
access to the opiate maintenance treatment they need and which is life saving
(and these figures were from long before the current crisis). For those who want or need abstinence based
treatments the line for treatment positions is even longer.
I have a personal theory to explain the present excessive death rates
from opioids in America. Popular drug
use, combined with the Puritan sentiment for abstemiousness may have led many
dependent citizens to go through cycles of short term sobriety, just as happens
with many smokers. The important
difference however is that a recently withdrawn opioid dependent person is at
enormous risk of death from overdose, having no tolerance. This is combined with other disadvantages in
America. For instance, whenever an
ambulance is called to an overdose the police are usually called as well; clean
needles are often hard to access; penalties are high for drug possession so
people may inject in haste; etc.
*The above should be seen in context with an enlightened article by Prof
Shane Darke, a world expert in overdose from Sydney. He has enumerated four oft-repeated myths
about overdose, knowing the facts prove quite the contrary: (1) most overdoses
are in young, inexperienced users; (2) it is a variation in the purity of the
drug which frequently leads to overdose; (3) the opioid is usually the culprit
rather than other drugs; (4) impurities lead to overdose symptoms.
After a lifetime of working the dependency field, Darke has a number of
lessons for public health policy in his lead editorial in D&A Review. He belabours that the greatest protection
against overdose is being in a treatment program, giving many references for
the fact that most overdose deaths occur in those not currently in
treatment. He also gives reasons why
this frequently observed fact might be so, including the lessened use of
opioids and non-opioid depressants in this population.
According to Darke, response to overdose is another area needing urgent
attention, especially the delays which occur in calling the ambulance. Also Darke supports the provision of naloxone
based on experience in numerous countries over a long period showing few
problems and anecdotal reports of many resuscitation cases. Darke also calls for emphasis on high risk
periods such as the 2 weeks after release from prison (or detox ward) when
tolerance is low and other factors raise the risk greatly (by a factor of 10 to
20 in some reports). Polydrug use
(including alcohol) is the last factor dealt with and he calls for public
education campaigns. It would be hard to
find more widespread publicity than the numerous recent overdose
deaths of high profile figures in the entertainment industry. Yet the problem continues with little or no
change in public policy in either American or Australia.
It is clear to me that opiate programs should be available to all who
need them in community based facilities at no cost to the consumer. Yet they remain few in number and poor in quality
with some demanding up to $100 per week for a drug which should cost about 50
cents per day. The universities and GP’s
colleges are still remiss in not treating this area as a priority in my view. Some states do not even have an active
sub-group dealing with this important field.
Written by Andrew Byrne .. Redfern addiction doctor.
Clinic web page: http://methadone-research.blogspot.com/
Opera blog: http://andrewsopera.blogspot.com/
