MEDIA: IN MARYLAND GOOD NEWS OF OPIOID OVERDOSE DROP, CRISIS “DOWNSWING” – MUST BE TRUE, RIGHT?
In Maryland as consistently elsewhere, data affirm the longstanding obvious meaning of recent drops in opioid overdose deaths and reported nonfatal overdoses – desperate intensive Narcan campaigns to moderate deaths due to continuously mounting high risk use and treatment failure represent a worsening crisis
by Clark Miller
Published December 13, 2024
The CDC data pointing to generalized and local decreases, including for Maryland, in opioid overdose deaths for a period spanning April to April, 2023 to 2024 had to provide some relief and encouragement for Maryland officials and public health experts after intense media attention for severity of the opioid crisis in Baltimore, with headlines like this –
That recent news from the CDC has to be good news.
Or not.
Could possibly could have been good news, if not that in Maryland the trends, data and reports are consistent with those from every other state, city or region, pointing on examination to reduced deaths being entirely attributable to emergency use of naloxone (most commonly as Narcan) to reverse otherwise fatal opioid overdoses.
Those reversals are happening in desperate, highly targeted, and successful campaigns precisely because opioid high-risk use continues to persistently increase, making the campaigns necessary as a new form of harm reduction, reducing established harm of expert, gold standard treatments driving substance use epidemics. The same surging naloxone reversals that are thankfully saving lives and reducing deaths are hiding mounting nonfatal overdoses (= high-risk opioid use) as the reversals increasingly occur in community settings where they are not reported, are hidden.
That pattern and outcomes, fueled by desperate medical/media collusion attempts to celebrate the “downswings” as triumphs of the approaches that have been failing for decades, are seen in analyses of the trends, patterns and data from –
Chicago – upcoming post
Let’s consider Maryland.
Consider, from that MARYLAND MATTERS news piece –
The number of Marylanders dying from overdoses fell over the past year, mirroring a national trend but lagging behind the nation on the pace of the decline, according to recent federal data.
The Centers for Disease Control and Prevention data estimates that 2,348 Marylanders died of an overdose from April 2023 to April 2024, down from 2,506 deaths the year before, a 6.16% drop. Overdose deaths in the U.S. during the same period fell 10%, according to current estimates.
“There’s a lot to be hopeful for right now,” said Special Secretary of Overdose Response Emily Keller, who leads the Maryland Office of Overdose Response.
Becky Genberg, an associate professor at Johns Hopkins Bloomberg School of Public Health who focuses on epidemiology, said that understanding why overdoses are decreasing will take time, and could be due to many factors — such as people having access to opioid reversal agents and avoiding more lethal drugs on the market. . . .
Keller believes that part of the reason overdoses have gone down in Maryland is recent state efforts to prevent overdoses by providing free fentanyl test strips and naloxone, an opioid overdose reversal medication. Genberg agrees that increased access to naloxone has likely contributed to overdoses decreasing overall.
“We have done a really good job of getting naloxone – most people know it as Narcan, the brand name – but naloxone is our best tool for reversing opioid overdoses and saving lives,” Keller said. “So we want to make sure people have universal access to it and that they know how to respond to an overdose so that they can save a life.”
She believes using local data to tailor state resources and programs to specific regions will continue to bring overdoses down.
“It’s definitely not for a lack of effort, and I think with all the very targeted outreach that we are doing and the measures we’re putting in place,” she said, “like tailoring to ZIP-code level data, like partnering with all of the jurisdictions and creating a collaboration plan … we’re going to see Maryland just continue to get better.
Huh! So it could be the Narcan?
But let’s not jump to conclusions, because lives depend on conclusions being supported by evidence.
Let’s see how the numbers add up.
Opioid OD deaths decreased per the CDC in Maryland for the April to April 2023 – 20204 period, and then by a modest amount compared to nationally and other locales, in Maryland by 2,506 – 2,348 = 158 fewer deaths, about 6 percent.
For an overlapping period in Maryland, 86 percent of those drug overdoses were tied to an opioid, so we can estimate that for the April to April period there were about 136 fewer opioid overdose deaths compared to the prior 12 months.
136 fewer fatal opioid overdoses
OD deaths attributed to any opioid actually began dropping in 2022 compared to 2021, per the state dashboard.
That decrease was 2507 to 2227 = 280 fewer deaths.
That makes sense.
Makes sense because it corresponds with the timeline of intensive efforts in Maryland for training and distribution of naloxone to targeted areas of need, including legislative action mandating and funding such efforts with implementation beginning mid-2022, the #1 Goal to “Get more naloxone in people’s hands using a public policy lever”.
But intensive, targeted efforts to get naloxone into the hands of those who could respond immediately to potentially fatal opioid ODs had begun well before then, and peak efforts immediately antecedent to the OD death reductions that began in 2022.
From the academic research publication,
Maryland has a robust statewide program for community-based naloxone distribution led by the Center for Harm Reduction Services (CHRS), within the Maryland Department of Health (MDH). CHRS authorizes individuals and local entities to dispense naloxone in community settings, including local health departments, nonprofit organizations, law enforcement agencies, SUD treatment programs, and syringe service programs. Dispensing outside of the patient-provider relationship is permitted through a state standing order (Maryland Code Health, n.d.). CHRS provides training on naloxone administration and distributes naloxone to local entities free of charge to ensure broader access among people who are likely to witness or experience an overdose. CHRS took steps to maintain operations during the COVID-19 pandemic, although the extent to which training and distribution was sustained is not known. . . .
From April 2019 to March 2021, CHRS-affiliated ORPs held 6,325 naloxone training events. At those events, 101,332 people were trained and trainees were supplied with 295,067 doses of naloxone for use or community distribution. Among the trainees, 54.1% were lay responders, 21.5% were occupational responders, and 23.4% had unknown responder status.
[emphasis added]
That fits well with the comments we saw from Emily Keller, head of the Maryland Office of Overdose Response,
“We have done a really good job of getting naloxone – most people know it as Narcan, the brand name – but naloxone is our best tool for reversing opioid overdoses and saving lives,” Keller said. “So we want to make sure people have universal access to it and that they know how to respond to an overdose so that they can save a life.”
Clearly trainings and targeted distribution of naloxone were surging heading into the reversal of increasing opioid OD deaths beginning in 2022.
As concluded by authors of the study –
Trends in naloxone trainings among lay responders recovered quickly while trainings among occupational responders did not recover to pre-pandemic levels after 12 months. Lay responders trained through Maryland ORPs are reached primarily through harm reduction organizations such as syringe services programs and peer outreach organizations. Our findings underscore that harm reduction organizations may be more resilient and effective in reaching populations that are in need of naloxone especially in times of crisis. The rapid recovery of lay responder trainings within six months of the pandemic suggests that ORPs were able to adapt their operations. For example, some programs have added telephone-based, mail-based, and virtual naloxone trainings to their programming (Hughes et al., 2022; Krawczyk et al., 2021).
That level of Narcan targeted saturation and use literally leaves no prevented opioid overdose deaths in Maryland over the relevant periods to possibly be accounted for by other factors, factors like America’s gold standard MAT substitute opioid treatment, or rehab, or “addiction treatment”.
The prevented deaths are all accounted for by Narcan saves, accounted for many times over.
To dispute that requires supporting with evidence the argument that compared to prior years, thousands more each year of potentially fatal opioid ODs were not prevented in 2022 and 2023 and by targeted provision of the more than 250,000 naloxone units distributed over prior years to 2021, then in 2022, 2023 and into 2024.
Right.
There is no question or uncertainty
regarding how to understand the sudden, recent fatal opioid OD decrease, correlated with Narcan campaigns. The question is how to understand that the drop was only by at most a few hundred deaths in each of those years, when over the same period provision of expert, gold standard treatments in Maryland was also increasing.
Again, from the MARYLAND MATTERS news piece, Becky Genberg, the associate professor at Johns Hopkins Bloomberg School of Public Health, offering explanations for the recent fatal OD decreases, explains that,
“If you talk to people who use drugs, or people who work with people who use drugs, I think a lot of people have adapted their strategies for drug use to keep themselves and keep others safe, given how potent the drugs are in the marketplace right now,” Genberg said. “They might be using less or using slower. Using when someone’s around to help — that could be part of it.”
That makes sense, doesn’t it, to be sure to account for information being provided by direct reports and by direct observations of those closest to the behaviors and choices being made by high-risk drug users. And the information being provided is that:
– Users are not reporting that their peers are exiting the illicit opioid economy to get into treatment or get on substitute opioids, then no longer engaging in high-risk opioid use, the potential prevention of high-risk opioid use the only outcome by which medically prescribed opioids and other “gold standard” treatments can be effective
– Instead, they are adjusting their behaviors while they continue to engage in high-risk use, high risk use, as will become apparent, not decreasing, pointing to expert treatment failures as their provision has increased
– “using less or using slower” to manage risk of unintentional fatal OD tied to an unstable drug supply with new, increasingly potent opioids and opioid combinations would have been required over past years, fentanyl part of an increasingly dangerous supply over nearly a decade. That does not explain fatal OD reductions occurring suddenly and not until the past year, or two in cases like Maryland.
– “using when someone’s around to help”, is established (including in the states and locales listed and linked to above) as the driving factor for reduced fatal ODs, corresponding to dramatic increases in naloxone distribution and training in communities, and getting it where it is needed, targeting areas of high-risk use.
The numbers don’t lie, nor do the front line healthcare, community, and support workers who are witnessing first-hand the intensively expanding distribution, training, effective use, and outcomes of campaigns to make the potentially lethal opioid overdose reversal agent naloxone more accessible in communities, witnessing and hearing directly reports of surging reversals of otherwise fatal opioid overdoses.
But what about trends in provision of expert treatments over the same period,
the proven, evidence-based, medical and other gold standard approaches to addressing problem, compulsive opioid high-risk use?
As explained in detail in this post, Maryland was expanding access to medical cure substitute opioids over preceding years, becoming near the top of states for number of outpatient opoid treatment programs and for amounts of methadone dispensed.
Then in 2020, along with other states, Maryland complied with recommendations and permissions to more fluidly dispense higher levels of buprenorphine (Suboxone) and methadone by significantly relaxing safe prescribing and dispensing rules that had been in place for decades.
How has that worked out?
This is when we are obligated to think carefully about how to measure the severity of the ongoing opioid crisis in order to be accurate about claims of gains against it, of a “downswing” to be celebrated.
It is clear, incontrovertible, that changes and differences in incidence of fatal opioid overdoses generally cannot serve as a valid measure of severity of the epidemic, those figures intractably confounded by decreases due to reversals with naloxone, and those emergency reversals no more a measure of reduced incidence of high-risk opioid use or lower prevalence of problem, compulsive opioid use than, for example, urgent campaigns for increasing distribution and emergency use of AEDs to prevent cardiac event fatalities would constitute gains against heart disease. Instead, that would indicate the opposite.
What has been a more valid measure of high-risk use and severity of the crisis has been nonfatal overdoses, each instance representing an instance of high-risk opioid use.
But no longer. As Narcan saves by laypersons in community settings have dramatically surged, nonfatal overdoses have become increasingly underreported, necessarily so, to the extent that community reversals are not reported and recorded, as illustrated in these studies and in the consistent reports of professional and others working with and being informed by high-risk opioid users.
So, reports of decreases in nonfatal opioid ODs, as recorded for example by EMR staff or through hospital ED records and coming from medical data sets, tell us nothing. Worse than nothing, actually, providing additional opportunities for American’s Medical/Research/Media collusion to lie about the crisis.
Credible data demonstrating increases in incidence of nonfatal ODs, in contrast, point with high confidence to a worsening crisis, each incidence of overdose constituting an incidence of high-risk, potentially fatal opioid use, further affirming the lethal failure of expert gold standard treatments.
That’s what we see in Maryland,
including in this Fox News report from May, 2024 –
While there were 2,456 fatal overdoses in Maryland from February 2023 through January 2024, 4.1% fewer than the 2,560 reported from February 2022 through January 2023, the data shows in the 12 months ending in January 2024, there were 13.1% more non-fatal, opioid-related hospital emergency department visits compared to the previous 12 months, increasing from 8,589 to 9,714.
And in this data from the Maryland state dashboard showing trends in nonfatal opioid overdoses recorded as emergency department visits for opioid overdose –
That fits with decreased levels of instances of Narcan reversal administrations provided by emergency medical services (EMS) personnel over the same years, predictable based on surges in unreported community saves beginning in 2020 and increasing (figure above comparing “Lay responders” and “Occupational responders”).
Have nonfatal opioid overdoses been increasing?
That can be doubted only if over the period 2020 through currently, the described dramatic surges in targeted community distribution and training for Narcan reversals of opioid overdoses – provision of nearly 300, 000 units from one source alone and from 2019 to 2021 alone, increasing beginning early 2020 – did not result in year-to-year gains in thousands of unreported community reversals of opioid overdoses.
The Baltimore City Health Department estimates that,
“Since 2015, BCHD has trained 43,591 people. From 2015 to 2024, BCHD and its partners trained over 163,464 Baltimore residents, contributing to more than 18,000 overdose reversals.”
That’s about 2000 reversals per year, yearly increases unknown, just for Baltimore, and if we extrapolate to Maryland, recent yearly increases in reversed overdoses in communities are reasonably predicted to have been in the thousands.
Lacking evidence to dispute that, we are compelled, obligated to conclude that nonfatal opioid overdoses have at best not decreased, almost certainly increased over past years. That is, expert gold standard treatments have persistently failed over those years, requiring desperate naloxone campaigns as harm reduction.
The lethal degree to which careless thinking and gross negligence are distorting and generating fabricated representations of the evidence driving the epidemic is illustrated by this material in the county dashboard of Howard County, contiguous with Baltimore.
As noted by the county, data include “numbers reported by the Howard County Police Department only”, excluding those potentially gathered from EDs and EMS responders, most importantly those uncounted from surging, unreported numbers of opioid overdoses occurring and reversed in communities, appearing with near certainty to be thousands more each year. And from that, we have the conclusion that “Since 2020 there has been a consistent decrease in non-fatal and fatal opioid overdoses.”
That is a lethal distortion.
In Maryland as elsewhere,
in 2023 and earlier, opioid overdose deaths were reduced by a small amount as a result of desperate, effective, targeted, successful efforts to dramatically increase use of naloxone in community settings for emergency revivals of incidences of high-risk opioid use, the small reductions pointing to a worsening crisis of high-risk opioid use demanding such Narcan campaigns as a form of harm reduction.
A worsening crisis requiring dramatic harm reduction efforts while American experts’ gold standard treatments were increasingly dispensed.
The salient and pressing question is, How is it conceivable that over a period of yearly increases in use of naloxone to reduce numbers of opioid overdose deaths – almost certainly by thousands per year – opioid OD deaths could decrease only by a few hundred per year?
That’s no mystery. We know why that is.
Those answers have been established for years.
