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OPIOID CRISIS CALIFORNIA – INCREASING SAVES BY NALOXONE, NOT TREATMENT, DIRECTLY ACCOUNT FOR ANY DECREASES IN OPIOID OVERDOSE DEATHS

The increasing need for reversals due to high-risk opioid use is fueled by predictable failure of publicly funded medical MAT “treatment”

By Clark Miller

Published April 30, 2021

Reports back in 2019, pre-pandemic, on preliminary data for 2018 compared to 2017 from the Centers for Disease Control (CDC) pointed to a possible 5 percent decrease in opioid-related overdose deaths in the U.S., that result affirming consistent, accumulating evidence of the crisis worsening.

Yes. Affirming consistent, accumulating evidence of the crisis worsening. 

Why? 

Data on naloxone reversals of potential deaths by overdose point to trends of frequency of those reversals – as programs and communities have instituted campaigns to increase its availability and use – accounting in magnitude for estimates of reduced mortality, leaving no opioid-related mortality reduction that can be attributed to the invalidated medical fix for the non-medical condition of compulsive opioid use – variously termed medication assisted treatment (MAT), opioid agonist therapy (OAT), or opioid substitution treatment (OST).

New evidence from California – from New York in a previous post – affirms that the magnitude of directly observable and recorded potentially lethal opioid ODs reversed by use of naloxone would directly account for any apparent reductions in regional and national trend of lethal opioid overdose – with 17,500 instances recorded in New York alone last year. While some portion of those may represent multiple revivals of individual substance users, and some reports may represent use of naloxone by private citizens when a user in apparent overdose was not at risk of death, the projected magnitude of naloxone use nationally based on the New York figures is remarkable and significant. The result affirms that not only are there no reductions in OD deaths attributable to the invalidated medical substitute opioid “fix”, but further that high-risk, overdose-generating use must be continuing to increase at rates that are reflected by the remarkable magnitude of increasing need for naloxone use in emergency responses.

Moderation of high-risk use is the only mechanism by which MAT could provide benefit, so decrease or increase in high-risk use serves as a measure of success or failure of the medical “treatment”.

In California, as in other locales and nationally,

public health and related programs have initiated and implented an expanding Naloxone campaign to reduce incidence of opioid-related OD deaths.

Locales like Santa Barbara County report notable increases in reports of use of the kits to reverse potentially lethal overdoses.

Over the same time frame, support for, implementation, and provision of the medical “fix” – substitute opioid provision, OST or “MAT” – has expanded significantly as well.

From Kaiser Health News:

Buprenorphine, a relative newcomer in the treatment of opioid addiction, is growing in popularity among California doctors as regulatory changes, physician training and other initiatives make the medication more widely accessible.

The rate of Medi-Cal enrollees who received buprenorphine nearly quadrupled from the end of 2014 to the third quarter of 2018, according to data released by Medi-Cal, the state’s Medicaid program. The rate for methadone — an older and more commonly used drug — was almost unchanged from the end of 2014 through the last quarter of 2017, the most recent period for which data are available.

. . .

The MAT expansion initiative, launched with two federal grants totaling $264 million, is helping to cover the cost of treatment not only for Medi-Cal enrollees but also for people with no insurance and those with private insurance that won’t pay for the treatment.

Marlies Perez, chief of the Substance Use Disorder Compliance Division at California’s Department of Health Care Services, said an expansion of methadone programs is underway, and she expects to see the rate of Medi-Cal methadone claims rise.

Over that period – of expanding provision of the medical model opioid “treatment” for the medically-generated opioid crisis and of established moderation of OD deaths by emergency revival – vulnerable Californians experienced the outcomes predictable from provision of an evidence-free medical fix for an entirely non-medical condition.

California trends in problem opioid use
[from the California Opioid Overdose Snapshot linked to at the California Opioid Overdose Surveillance Dashboard ]

Note that not only have opioid related OD deaths continued to climb – climb against known reversals by the Naloxone campaign – but opioid-driven non-lethal ED visits, the direct measure lack of effectiveness of the medical fix (because substitute opioid provision can reduce deaths and problem opioid use only through the mechanism of reducing high-risk use) climbed as well.

At least one outlet has noted the obvious –

If emergency treatment, rather than reduced drug use, is behind the fall, this would mean an increasing number of US adults are living with substance abuse disorders. 

Almost but not quite. This would simply affirm, as established in multiple series of posts that an increasing number of vulnerable Americans are becoming trapped in the epidemic of compulsive high-risk opioid use that is fueled – due to lack of benefit from, diversion and abuse of, and central use as currency and commodity in illicit economies of opioid use – by medically-provided substitute opioids including methadone and Suboxone.

Indeed, given that any and all reductions in mortality due to overdose by emergency use of naloxone for reversal of lethal respiratory depression at the same time represents – measures – incidence of high-risk opioid use, the evidence simply reinforces the failure of MAT to moderate high-risk use, instead as established by consistent and accumulating evidence reinforces the medical fix as worsening the lethal epidemic.

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.

The more “gold standard” medical cure provided to diseased brains, the more deaths mount.

But that’s not the message about the new CDC figures that’s been provided by America’s top medical authorities, responsible for the public health response to vulnerable Americans trapped and dying in lethal substance use epidemics.

Let’s review and take a look.

As established and explained in a series of related posts, in contrast to the directly measurable OD death-preventing effects of naloxone use, attribution of any benefit of MAT requires evidence for MAT acting by affecting behaviors of opioid users, specifically by reducing high-risk use, the only mechanism by which MAT would provide benefit.
The confounding effects of naloxone campaigns and resultant reductions in death by overdose have never been adequately controlled for in studies used and spun by the coalition of pharma/medical industry, public health institutions, media and popularizing writers manufacturing “evidence” for the fabricated effectiveness of MAT – exactly as “evidence” was fabricated to support the never-validated runaway over-prescription of schedule II opioids that generated the lethal epidemic.

Legitimate, validated evidence for use of substitute opioids as a medical “treatment” has never existed, instead all lines of accumulating evidence point to OST driving and worsening the lethal opioid epidemic, fueling street and prison economies of illicit and high-risk opioid use. That evidence includes measures of high-risk opioid use including increasing incidence of opioid overdose (as distinct from overdose deaths) as well as of opioid injection-related infectious disease – as  provision of the medical “treatment” has increased. The constructed distraction of increased presence of fentanyl in illicit opioid economies, on analysis, cannot account for failure of MAT to moderate high-risk opioid use over decades of increased provision of the medical “treatment”, instead to worsen high risk use and the opioid crisis.

Predictably, increased provision of a medical “treatment” for problem opioid use in lethal epidemics, never supported by evidence, is consistently failing everywhere:  in Scotland as it is in the U.S., France, Canada, and other parts of the world. Predictable because the “evidence” for its effectiveness was never credible or held up to critical analysisjust as for the fabricated evidence used to rationalize medical misuse of opioids generating lethal opioid crises – and because consistently all lines of relevant accumulating evidence point to increasing harm as the prescribed substitute opioids fuel street economies of high-risk opioid use and divert resources and patient motivation away from longstanding evidence-based therapies for problem substance use.

Dayton, Ohio

As recently reported in the NY Times, Dayton, Ohio can be added as another outlier, like Plumas County in California, pointing directly away from influence of substitute opioid programs, away from traditional “addictions treatment”, instead to direct reduction of OD deaths due to reversals by use of Naloxone.

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  joins other 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.

How the treatment program has worked in Arizona, actually, is to have predictably – based on longstanding evidence bearing on OST – increased instead of decreased high-risk opioid use as clearly illustrated by a measure of high risk use: non-lethal opioid-related overdoses – non-lethal overdoses to factor out confounding effects of changes in use of naloxone to prevent OD deaths.

Let’s look at the timeline and epidemiology.

For both non-lethal and lethal opioid-related overdose prevalence, the numbers decrease after the naloxone campaign is implemented, and prior to OST expansion, through October 2017 – that’s when rapid increase in provision of substitute opioids buprenorphine and methadone was initiated.

Then things change. For non-fatal overdoses – a measure of high-risk opioid use – prevalence then shows a steady increase through January of this year, over a period of 13 months.

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.

Connecticut

For the epidemiological data for Connecticut, subtracting OD death counts for deaths with heroin and fentanyl present from those for “Heroin in any death” provides deaths attributable to heroin in overdose without fentanyl: 173 – 249 – 290 – 307 – 229 – 141 – 82 over the years 2012 to 2018.

That is, over the years 2012 to 2015 heroin overdose deaths – a measure of high-risk opioid use prior to the confounding effects of a naloxone campaign – were increasing significantly in opioid overdoses without fentanyl contributing – a period over which provision of substitute opioids – the gold standard medical treatment for high-risk opioid use – had been increasing since at least 2011.

 

The evidence from Connecticut is part of a consistent, invalidating, predictable pattern that disconfirms benefit attributable to medical provision of the substitute opioids  methadone and buprenorphine in Opioid Agonist Treatment (OAT) programs.

By 2013, buprenorphine prescriptions statewide were provided to more than 20 thousand individuals increasing in 2014 to 22,763, and individuals treated with methadone had been steadily increasing in OAT programs, also known as opioid substitution treatment (OST) or medication assisted treatment (MAT).

Those increases in provision of the gold standard  medical “fix” for problem opioid use and the opioid crisis – by reducing high-risk opioid use and associated problems including overdose mortality, overdose, and other problems – occurred prior to the dangerously more potent opioid fentanyl having a significant presence in street economies of illicit opioid use nationally and in Connecticut.

Tennessee

Data (2019) 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.

Colorado

“The number of new admissions at highly regulated opioid treatment programs in Colorado increased from 1,388 in 2013 to 3,566 in fiscal year 2017. According to federal numbers cited by The Denver Post, there were more than 5,000 methadone patients across the state as of last week.”

By additional measures, provision of the medical substitute opioid “treatment” increased over that time frame – number of waivered (approved) prescribers of substitute opioids buprenorphine or methadone had been increasing, to 702 in 2017.

And the average daily census of opioid dependent patients treated with substitute opioids in Opioid Treatment Programs (OTP) was expanding rapidly

Over that same period of expanded provision of the medical substitute opioid “fix” for the medically generated opioid crisis, opioid-involved overdose deaths were also increasing, including for heroin as distinct from OD deaths attributed to fentanyl.

Mississippi

“Opioid-related hospital stays and ER visits increased by 26.2% and 50.7%, respectively, from 2014 to 2017. Initiatives such as Stand Up, Mississippi seek to discourage those trends by focusing on education, prevention and treatment policies and partnerships around treating opioid addiction.”

A gain of 450 new waivered prescribers (= approved medical dispensers of substitute opioids including buprenorphine) over 2002 – 2019 almost certainly represents an expansion in access to and provision of OST (= opioid agonist treatment, OAT) in Mississippi.

That is, over that same period that the medical substitute opioid “fix” for the medically generated opioid crisis had been expanding, opioid-involved ED visits and hospital stays – measures of high-risk opioid use – continued to increase.

Park Rangers in Missouri being trained for opioid overdoses

Michigan

The latest data, from 2015, showed 142 out of 448 Michigan facilities offered what’s called medication assisted treatment, according to amfAR, a foundation that funds AIDS and HIV prevention research. That’s up considerably from a decade ago, when just 87 of 452 facilities offered such treatment.

That’s an increase by 63 percent over a decade ending in 2015, and would have to be assumed to represent a corresponding increase in numbers of problem opioid users provided opioid substitute MAT

 

 

 

Over that same period that the medical substitute opioid “fix” for the medically generated opioid crisis had been expanding, opioid-involved inpatient stays – a measure of high-risk opioid use – increasing by about a third.

That’s the opposite of predicted if OST (OAT) was providing benefit by reducing high-risk use.

And in a more recent and overlapping time frame, 2012 to 2017, opioid-related overdose deaths due to heroin increased significantly, a result also invalidating of presumed benefit from increased provision of the medical fix.

Due to heroin, not fentanyl.

In 2017, there were 2,033 overdose deaths involving opioids in Michigan—a rate of 21.2 deaths per 100,000 persons, which is higher than the national rate of 14.6 deaths per 100,000 persons. The greatest increase in opioid deaths was seen in cases involving synthetic opioids (mainly fentanyl), from 72 deaths in 2012 to 1,368 in 2017. Deaths involving heroin increased from 263 to 783 deaths in the same 5-year period. Prescription opioid involved deaths also rose from 378 deaths in 2012 to 678 deaths in 2016 but saw a recent decline to 633 deaths in 2017 (Figure 1).

trends in opioid overdose deaths in Michigan;
graph of opioid overdose trends in Michigan

Ontario, Canada

In Ontario, Canada: 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.

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 generally, as in Dayton, Ohio and other locales. 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

A new six-part special report by Victoria News paints the same predictable picture as from other areas in Canada and the U.S. – while high-risk opioid use and overdose continue to worsen or not improve in response to increasing provision of the medical model fix for the opioid crisis, any apparent moderation of opioid overdose deaths is directly attributable to campaigns to increase use of the OD death-reversing opioid antagonist naloxone.

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 and others 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.

And it’s a pattern – as we’ll see and despite efforts of popularizers of the failed medical OST “treatment” – that is not explained away by the known risks of fentanyl as established in recent posts here and here.

To summarize,

increased use of the emergency response opioid overdose death reversing opioid antagonist naloxone (Narcan) accounts for an apparent slowing and possible reduction of opioid overdose deaths driven by steadily worsening overdose and opioid-related disease incidence due to high-risk use of opioids, those increases associated with and driven by increased provision of addictive, diverted, abused substitute opioids constructed as a form of medical “treatment”, funded by public healthcare resources.

By way of strict analogy, campaigns to increase availability and use of Automated External Defibrillators (AED) to save lives in acute emergency response to atrial fibrillation are expected to be measured as moderating acute deaths due to heart disease in America’s cardiovascular disease epidemic. Increased demand for emergency revival by use of AEDs of course would reflect a worsening heart disease epidemic, not any moderating benefit from treatments to address incidence of cardiovascular disease. Portraying any such moderation of heart disease-related mortality, moderation directly attributable to emergency use of AEDs, as progress in treatment of the heart disease epidemic that is driven largely by modifiable health behaviors would represent profound, if not pathological, deficits in capacity for research literacy, for critical thought and intellectual integrity, and for response to public health need.

That is, the CDC data heralded by lapdog media as pointing to gains against a lethal epidemic – congruent with all evidence, including data evidencing mortality-moderating effects of increased use of emergency revival of potential OD deaths (increased response to increasing high-risk opioid use) – in fact affirms worsening lethal substance use epidemics with fabricated medical “treatments” for the non-medical condition fueling addiction and high-risk use while diverting public healthcare funding away from evidence-based psychosocial treatments and supports.

That is, evidence continues to mount establishing that the substance use epidemics trapping and killing vulnerable Americans are worsening, iatrogenic, and criminal.

Despite lethal assurances otherwise.

official statement on progress on the opioid crisis

Crisis is a necessary condition for a questioning of doxa, but is not in itself a sufficient condition for the production of a critical discourse.”

– Pierre Bourdieu  Outline of a Theory of Practice (1972)

In Bourdieu’s Theory of Practice, heterodoxy is dissent, challenge to what “goes without saying” – the accepted, constructed doxa, “knowledge”, reality, that goes without saying precisely because it “comes without saying”, without real scrutiny, untested, unquestioned. The function of doxa is not knowledge or truth or promotion of the collective good, but to protect and serve the interests of those with the power, the cultural capital, to create it.

Why A Critical Discourse?

Because an uncontrolled epidemic of desperate and deadly use of pain-numbing opioid drugs is just the most visible of America’s lethal crises of drug misuse, suicide, depression, of obesity and sickness, of social illness. Because the matrix of health experts and institutions constructed and identified by mass media as trusted authorities – publicly funded and entrusted to protect public health – instead collude to fabricate false assurances like those that created an opioid crisis, while promising medical cures that never come and can never come, while epidemics worsen. Because the “journalists” responsible for protecting public well-being have failed to fight for truth, traded that duty away for their careers, their abdication and cowardice rewarded daily in corporate news offices, attempts to expose that failure and their fabrications punished.

Open, critical examination, exposure, and deconstruction of their lethal matrix of fabrications is a matter of survival, is cure for mass illness and crisis, demands of us a critical discourse.

Crisis is a necessary condition for a questioning of doxa, but is not in itself a sufficient condition for the production of a critical discourse.

Pierre Bourdieu - Outline of a Theory of Practice 1972

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