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OPIOID CRISIS: MORE EVIDENCE THAT BUPRENORPHINE AND METHADONE OPIOID SUBSTITUTION TREATMENT (OST) IS WORSENING LETHAL EPIDEMICS – NEW YORK

By Clark Miller

Published January 9, 2020

Updated April 16, 2021

Reports last summer 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. and were hailed as evidence of progress in addressing the opioid crisis.

That result, as explained here, in fact affirmed consistent, accumulating evidence of the crisis worsening.

Data on naloxone reversals of potential deaths by overdose point to incidence of those reversals accounting 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).

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

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

Newly released data from New York reported in the USA TODAY Network reflect the same patterns and fabrication of false claims.

Governor Andrew Cuomo of New York generously offered his clinical understanding of the evidence:

NY opioid trends USAToday2

The figures are for areas outside of New York City and for the years compared – 2017 to 2018 – represent a decrease of 346 deaths in 2018. That same year in New York, outside of New York City, there were an estimated 9,831 uses of the opioid overdose death-reversing opioid antagonist naloxone (Narcan) administered, considered to be an underestimate. That availability and application of Narcan appears to have expanded rapidly and recently in New York as nationally with prescriptions doubling over the same years.

NY opioid trends USAToday3

That is, as for national trends, rapidly expanding use of Naloxone more than accounts for any deceases in opioid-related overdose deaths,

leaving no reduced deaths to be attributed to medical “treatment”. Deaths reduced – 346; opioid overdoses prevented from resulting in death by use of Narcan – 10,000 or so.

Every death prevented (reduced) by use of Narcan is a death that was not prevented by “treatment” of any type, in fact represents the failure of treatments to prevent high-risk use. Every use of Narcan represents the high-risk use of opioids resulting in overdose, that high risk use claimed to be prevented by publicly funded medical provision of substitute opioids.

The trend tells the story: opioid deaths increasing sharply over years during which and preceded by, beginning 2012 or earlier, significant expansion of provision of the medical “treatment” for opioid use disorder and the opioid crisis – MAT, or use of substitute opioids like methadone and buprenorphine – promoted falsely as effective in reducing high-risk use. Deaths did not decrease until last year, consistent with effects of the more recent, dramatic campaign to expand use of Naloxone.

NY opioid trends USAToday5

That is, the data from New York – far from pointing to any gains in addressing compulsive and high-risk opioid use driving worsening epidemics – like results consistently from locales across the U.S., nationally, and elsewhere, affirms a worsening epidemic fueled by the provision of an invalidated medical fix for the non-medical problem of compulsive opioid use.

And as in other locales consistently, data for New York for opioid injection-related infectious diseases points directly to worsening high-risk use over the same years of increasing provision of the medical fix for high-risk use was dispensed.

protestors in New York

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.

Every death prevented (reduced) by use of Narcan is a death that was not prevented by “treatment” of any type, in fact represents the failure of treatments to prevent high-risk use. Every use of Narcan represents the high-risk use of opioids resulting in overdose, that high risk use claimed to be prevented by publicly funded medical provision of substitute opioids.

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

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.

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.”

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.

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.

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).

Wisconsin OD deaths trend graph NIDAPNG
graph of opioid overdose trends in Michigan

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.

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.

Victoria OC comp

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.

And it’s a pattern –

as established here and here that, despite efforts of popularizers of the failed medical OST “treatment” – is not explained away by intentional abuse with known risks of fentanyl as the new distraction from the real causes of a continually worsening lethal epidemic.

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 new CDC data – affirming that 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) – 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.

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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