UPDATE Opioid Crisis:

More Evidence that Buprenorphine and Methadone Opioid Substitution Treatment (OST) is Worsening Lethal Epidemics –

Tennessee

by Clark Miller

May 29, 2019

As public health resources are increasingly diverted to a medical “fix” for a worsening, lethal opioid crisis, evidence continues to mount pointing away from beneficial effects attributable to substitute opioid (buprenorphine, methadone) programs  (opioid substitution treatment, OST) instead to concurrently expanding use of naloxone – (Narcan) the opioid antagonist administered acutely to reverse respiratory depression in life-threatening opioid overdoses – as the factor accounting, directly, for any apparent moderation of national or local decreases in overdose deaths.

naloxone

That is, the evidence, critically examined, says that the medical “fix” is not helping with high-risk opioid use or overdose rates, more likely worsening it, and the “evidence” for reduced OD deaths attributable to OST (MAT) used to market the medical/pharmaceutical/harm-reduction industry “treatment” doesn’t hold up, never has, instead points to Naloxone as the effective factor in slowing deaths. Meanwhile diversion and abuse fueled by a runaway national “dose” of substitute addictive opioids – as in generation of the crisis – is integral to national high-risk opioid use economies – diversion and abuse of addictive opioids driving a street and prison economy; diversion and abuse of public healthcare funds driving a supplier economy constructed as “medical treatment”.

Below: New Evidence Fits the Invalidating Pattern

New (2019) data from the Tennessee Department of Health  paints the same predictable picture as from other areas in Canada and the U.S. –  high-risk opioid use and overdose continue to worsen  in response to increasing provision of the medical model fix for the opioid crisis, inconsistent with and invalidating of opioid (methadone and buprenorphine) substitution treatment.

The new evidence from Tennessee is part of a consistent, invalidating, predictable pattern that disconfirms benefit attributable to OST. That pattern, described in detail in this and multiple posts at A Critical Discourse includes accumulating results from –

Plumas County, California

In Dayton Ohio and Plumas County, California opioid-related overdose deaths climbed . . . and climbed . . . with no observable response to traditional treatment or opioid substitute programs, no response to increasing dose accorss the U.S. of the medical fix for high risk opioid use – addictive substitute opioids.

Then dropped dramatically with the implementation of intensive campaigns to distribute and effectively use the OD death-reversing opioid antagonist naloxone, with no decreases in deaths left to attribute to OST.

Cincinnati, Ohio

Cincinnati, Ohio now joins those anomalous locales –

years of worsening opioid-related OD deaths, associated with increasing dose of the medical cure, until  abruptly with initiation of an intensive naloxone campaign, OD deaths decline.

That’s a pattern that belies claims that OST is effective and warrants massive investment of public healthcare funds, based on unsupported claims that OST reduces overdose deaths.

Arizona

In Arizona, U.S. new mounting evidence: disconfirming prediction of benefit from increasing substitute buprenorphine and methadone medical “fix” for the opioid crisis – indicators of high-risk opioid use (non-fatal opioid overdose) rise significantly in response to medical “treatment” while OD deaths decrease in response to a naloxone campaign.

Rowan County, North Carolina

In Rowan County, North Carolina – as in Plumas County CA, Dayton, OH, and Cincinnati, OH – data and reports of healthcare workers and authorities attribute decreases in opioid OD deaths to directly observed and tracked use of naloxone.

And in Rowan County high-risk opioid use is observed to continue or increase – contrary to expectations if OST was providing benefit.

Bethlehem, Pennsylvania

In Bethlehem, Pennsylvania it’s the same predictable pattern: despite (that is, based on relevant lines of evidence, because of ) increases in provision of MAT with focus on OST, opioid overdoses have steadily and significantly increased over past years, but not overdose deaths, the reduction in deaths directly accountable for by increased provision and use of naloxone. These results consistent with and contributing to mounting, evidence: overdose deaths are not a meaningful measure of presumed effectiveness of opioid substitution, because naloxone campaigns account directly for any apparent decreases.

Increases in non-lethal or total opioid-related overdose incidents in contrast are meaningful, strong evidence of what has become clear, established: expanding provision of the medical “treatment” using the ”anti-addiction” drugs buprenorphine and methadone – addictive and abused substances that are diverted and fuel economies of opioid abuse – are worsening America’s opioid crisis.

Ontario, Canada

In Ontario, Canada new evidence: indicators of high-risk opioid abuse, independently of opioid-related overdose deaths, increase over years of heavily increased funding and provision of substitute opioid medical fixes (OST) for the medically-generated opioid crisis, results inconsistent with presumed yet unsupported benefit from OST.

Below: New Evidence Fits the Invalidating Pattern

New (2019) data from the Tennessee Department of Health  paints the same predictable picture as from other areas in Canada and the U.S. –  high-risk opioid use and overdose continue to worsen  in response to increasing provision of the medical model fix for the opioid crisis, inconsistent with and invalidating of opioid (methadone and buprenorphine) substitution treatment.

Nationally in the U.S.

Nationally the same picture emerges. The National Institute for Drug Abuse (NIDA) has released data attributing in the U.S a gain in number of potentially lethal opioid overdoses reversed by use of Naloxone as increasing, over 2010 to 2014, from 10,171 to 26,463. The NIDA data, through 2014, is almost certainly an underestimate unless we assume that most reversals, including private, are reported and recorded, and incidence of reversals almost certainly has increased in the interval since 2014 as Naloxone programs have expanded, as in Dayton. At a rate of net gain in potentially lethal OD deaths stopped by use of Naloxone of 4,000 per year, almost certainly conservative, Naloxone appears to directly account for any apparent moderation of opioid related overdose deaths in national trend.

Victoria, B.C. Canada

As reported in the opioid crisis special series, provision of buprenorphine OST has been significantly increasing in Victoria, including relaxation of restrictions by the province in 2016 and concerted efforts to start provision of suboxone in ER visits.

Yet since then, there are no signs of high-risk opioid use decreasing, instead increasing or at best not improving, based on levels of emergency medical responses to overdoses and observations of law enforcement. No signs of the expanded provision of medical fix moderating “An epidemic that, despite government acknowledgement and increased resources, is showing no signs of slowing down.”

But overdose deaths, as opposed to high-risk use and overdose, have appeared to level off, and that change is directly attributable, based on recorded incidents of reversals, to a campaign to increase dispersal and use of naloxone: by law enforcement; by emergency medical responders; on the streets; at safe injection sites.

That is, as is consistently evidenced in other locales, emergency responders are saving lives, often repeatedly, by reversing opioid overdoses, accounting for all moderation in lethality trends, leaving none to attribute to OST, while the invalidated medical “treatment” continues to fuel street economies of high-risk opioid use.

The mounting, consistently invalidating pattern was predictable, all along, because there has never been credible evidence to support effectiveness for OST, instead all lines of evidence disconfirm effectiveness and point to increasing harm.

SAMSHA bupe client trends2

The more medical cure provided to the diseased brains, the more deaths mount.

Overdose deaths US trend The Guardian

And it’s a pattern  – despite efforts of popularizers of the failed medical OST “treatment” – that is not explained away by the known risks of fentanyl.

Apart from invalidation by relevant lines of evidence these arguments are disingenuous, partly because the risks of getting and using illicit heroin or other illicit opioids on the street has become well-known to any illicit opioid user, that use representing a choice to engage in high-risk use instead of accessing now widely and easily available opioid substitutes methadone or buprenorphine whether supplied on the street or by a medical provider. Consistently reported trends in increased use, and overdose by, heroin that may contain fentanyl is stronger and more definitive evidence for harm versus “treatment” provided by MAT with substitute opioids – representing high-risk use with risks known in response to increasing accessibility to and provision of the medical “fix”.

Tennessee is a state hit early and hard by the opioid crisis. The response described in the 2019 Tennessee Department of Health report has included significantly increased provision of the medical “treatment” for opioid use disorder – MAT (opioid substitution treatment OST) with buprenorphine or methadone –

CSMD data show an increase in the utilization of buprenorphine for medication-assisted treatment (MAT).

Prescriptions filled for buprenorphine for MAT increased from 164,800 prescriptions in the first quarter of 2014 to 232,300 in the last quarter of 2018.

This increase coincided with a 57.9% increase in the number of patients filling buprenorphine for MAT and a marked increase in the number of buprenorphine for MAT patients on long-term prescriptions (>270 days per year).

About 75% of TN counties experienced an increase in the rate of buprenorphine prescriptions filled.

If buprenorphine (Subutex, Suboxone) provision results in beneficial effects in reducing mortality and other costs related to opioid use, that occurs by the mechanism of bupe use reducing high-risk use of opioids, e.g. by injection, with illicit drugs, using street drugs like heroin that may have fentanyl added. Moderation of opioid-related overdose deaths is not a meaningful measure of effectiveness of MAT with bupe, because it’s established that naloxone, concurrently increasing in availability and use, is able to account directly for any apparent moderation.

It is also established that the recent (2014) emergence of highly-potent fentanyl in illicit economies of opioid abuse cannot explain away the consistent, invalidating increases in opioid overdoses and OD deaths as provision of the medical MAT “fix” has steadily and significantly increased over past decades.

The new data from Tennessee factors out confounding effects of fentanyl and OD death-reversing naloxone by providing comparison of medical MAT “treatment” provision trends with trends in non-lethal heroin overdose incidence, a measure of high-risk opioid use.

Non-fatal opioid excluding heroin overdoses are increasing, and heroin non-fatal overdoses are rapidly increasing based on hospital discharge data through 2017 (Morbidity data section, starting page: 46)

Prior to the ICD-9-CM to ICD-10-CM transition, outpatient visits for non-heroin opioid overdoses increased from 3.9 per 100,000 residents in Q1 2013 to 6.1 per 100,000 residents in Q3 2015. A shift was observed after Q3 2015, with an increase to 8.1 per 100,000 residents in Q4 2015, the increasing trend generally continued through end of 2017.

Prior to the ICD-9-CM to ICD-10-CM transition, non-heroin opioid inpatient stays showed small fluctuations both up and down, with 5.5 per 100,000 residents in both Q1 2013 and Q3 2015. After the transition, an upward shift was observed to 8.3 per 100,000 residents for non-heroin opioid overdoses stays in Q4 2015, similar to the rate of outpatient non-heroin opioid overdoses visits in the same quarter, but decreased to 6.7 per 100,000 residents in Q4 2017.

A large increase was observed for outpatient visits for heroin during 2013-2017 (0.8 per 100,000 residents in Q1 2013 to 11.8 per 100,000 residents in Q4 2017) with a gradual increase from Q4 2015 to Q4 2017 (3.4 to 11.8 per 100,000 residents).

These results from Tennessee, consistent with accumulating data from additional locales and nationally, appear to be unequivocally invalidating of presumed benefit for problem opioid use and the medically generated lethal opioid crisis from provision of substitute opioids without evidence-based treatment for compulsive opioid use. That was a predictable result, the presumed benefit – as in generation of the iatrogenic opioid crisis – driven by fabricated evidence in a collaboration of America’s top medical and research institutions, public health oversight, and media helpfully along for the ride.

As in generation of the lethal opioid crisis.