UPDATE Opioid Crisis:

More Evidence Pointing to Overdose-Reversing Naloxone, Not Substitute Opioids, Reducing OD Deaths – Bethlehem, PA

by Clark Miller

May 1, 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”.

shutterstock Suboxone

Below: New Evidence Fits the Invalidating Pattern

In Bethlehem, PA, in Lehigh County hard-hit by opioid abuse and overdose, in Pennsylvania, third in the nation for opioid overdose deaths –

First, to Review

Dayton header NYT

Dayton, Ohio

Across the U.S., buprenorphine population “dose” has been substantially increasing over past years and would have been increasingly available in any U.S. city to persons needing it as “treatment”, to stop or reduce high-risk opioid use – if not as prescribed in a medically-managed MAT program, then within the bupe diversion economy. We know that because it is so extensively and widely diverted, available illicitly to anyone wanting it. Diverted so widely and extensively that in France – model for the U.S. publicly-funded opioid crisis fix – “sub” diversion fuels illicit opioid economies in other countries.

While availability of the presumed medical fix was widely available either directly or black market, for years, overdose deaths continued to climb . . . and climb in Dayton, until abruptly and concurrently, as in Plumas County, there was an intensive coordinated Naloxone campaign that included distribution, education, and training, was initiated. Then OD deaths dropped.

Plumas County, California

Preliminary results from Plumas County, California:

A Naloxone campaign that included widespread distribution and education began in September of 2016 and was immediately followed by a drop in opioid-related OD deaths to zero over 2016, from 3 or 4 in 2014 and 5 or 6 in 2015.

Since the start of that campaign, there has been just one confirmed OD death.

Suboxone use in a MAT program began two months later, with enrollment of a single patient in November of 2016, a factor unable to account for the decline in OD deaths to zero in 2016.

Naloxone, by contrast, prevents OD deaths directly and immediately as soon as it is available to trained individuals, and the campaign begun on a large scale in September of 2016 would reasonably account for the drop in OD deaths to zero.

Since the start of that campaign in September 2016, Plumas County recorded reports by patients of 14 potential OD death reversals, almost certainly an under-report according to Wilson, because these were voluntary reports, not based on surveys.

With an average of around 4 – 5 OD deaths in the preceding years of 2014 and 2015, the use of Naloxone would directly account for the entire drop in OD deaths.

Despite the dramatic rise in Suboxone prescribing in a MAT program beginning November of 2016, opioid-related Emergency Department visits remained high, with relatively slight decline over a period of a 200% increase in Suboxone use.

From these preliminary results, it appears that the Naloxone campaign, including intensive distribution and education efforts, almost certainly accounted for the drop in OD deaths, with any significant role for Suboxone in a MAT program open to question.

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.

(from the Toledo Blade – December 26, 2018)

Rowan County, North Carolina

The evidence – that any apparent moderation of worsening lethal opioid OD incidence is caused by increased use of naloxone – continues to mount and to disconfirm presumed OD death reduction benefit to substitute opioids.

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.

SALISBURY — While the number of people reporting to the local ER for opioid overdoses may be on the decline, local public health officials say the number of people still abusing opioids hasn’t faltered.
. . .

The overdose rates for people reporting to the ER in Rowan County and the state have gone down over the past last three years, said Neetu Verma, a grant manager for the Center for Prevention Services.
She attributes the downturn to the availability of Narcan and the introduction of the Good Samaritan Law, which says that anyone who helps a person who has overdosed will not face arrest.
. . .

In December, Dr. John Bream, medical director of Novant Health Rowan Medical Center’s emergency department, said the number of people being admitted to the ER for heroin overdose had decreased going from 162 people during January 2017 to December 2017 to just 68 people during January 2018 to December 2018.
The ER doctor said he believed public awareness was one of the contributing factors for the decline.

Rowan Public Health Director Nina Oliver agrees but says individuals are still abusing opioids at a rapid rate.
“I see this issue getting worse in the nation instead of better,” Oliver said.
. . .

“The amount of babies born with substances in their system has also increased sharply in North Carolina and in Rowan County. These children are now at-risk for multiple problems including medical, mental, and behavioral health issues throughout their life,” Oliver said

Bethlehem, Pennsylvania

Bethlehem PA opioid OD

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.

Despite increases in “treatment” including MAT

In Bethlehem in 2017, a state grant funded a MAT program at the Neighborhood Health Centers with more than 300 referrals in the first year.

Statewide, provision of buprenorphine (Suboxone) OST climbed significantly over the years that opioid overdoses continued to climb based on SAMHSA data on newly waivered MAT physicians.

First year waivered providers are allowed to dispense bupe to 30 patients, in following years 100. Crunching the numbers, a gain of 70 was used to figure net gain in OST MAT capacity per year. Statewide increases in capacity for LMP-provided OST, in number of patients:

2014 10,570
2015 12,620
2016 17,580
2017 24,500
Total = 66,270

Over the period of 2014 to 2017, concurrent with a tripling (187 percent increase) in opioid overdoses, statewide capacity for OST treatment of opioid users increased by 66,270. Figures by county were not available for this post, and it would be unsupportable to suggest that that increase does not represent a significant increase in OST capacity for problem opioid users over those years in the Bethlehem area.

That is, opioid-related overdose increased significantly in response to increases in provision of the medical “treatment” for high-risk opioid use in the Bethlehem area.

And Nationally

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.

Nationally, as in Plumas County and Dayton, Naloxone can directly account for any and all changes in overdose deaths, and there is no effect remaining to attribute to claimed benefit from provision of substitute opioids.

That substitute opioid effect would not be predicted.

Because as discussed in detail in posts here at A Critical Discourse, with links to primary research and other material, while the direct, observable, recordable incidences of naloxone used to prevent a potentially lethal opioid-related overdose death allow clear conclusions to be drawn for the role of naloxone in any moderation of lethal overdose rates, attributing moderated OD deaths, or other gains, to OST/MAT requires evidence of some psychosocial benefits from use of OST/MAT that act to reduce high-risk opioid use and thereby rate of lethal overdose.

There are no such bodies of evidence, instead consistent evidence pointing to no benefit or harms, as established with links to primary sources: here, here, here, here, and here.

To Summarize

There has never existed evidence to credibly attribute decreases in opioid-related overdose deaths or other gains for individuals trapped in the opioid crisis to buprenorphine MAT interventions, versus other plausible explanations. Available evidence that is varied and congruent overwhelmingly points to lack of effects constituting the psychosocial, functional, behavioral, or recovery benefits required as mechanisms to support conclusions that buprenorphine provision provides benefit in reduced OD deaths or other measures.

Instead, evidence consistently points to prescribed buprenorphine as generating and involved in harms including: continued opioid dependence; diversion; abuse; child exposure; involvement in overdose and overdose deaths; involvement in emergency medical visits; involvement in criminal drug trafficking.

Cincinnati naloxone