A new report warns of soaring overdose deaths from the opioid crisis. Authors from the Lancet’s, “Responding to the Opioid Crisis in North America and Beyond: Recommendations of the Stanford-Lancet Commission,” published in February, said that in the USA and Canada, 2020 was the worst year on record for fatal opioid overdoses. The US overdoses rose 37%.
The Centers for Disease Control and Prevention (CDC) said that provisional data analysis estimates for the 12 months ending in May 2021, there were 75,387 deaths from opioid toxicity.
Opioids—mainly synthetic opioids (other than methadone)—are currently the main driver of drug overdose deaths, said the CDC, with 72.9% of opioid-involved overdose deaths involving synthetic opioids. And, overdose deaths involving psychostimulants such as methamphetamine are increasing with and without synthetic opioid involvement.
Also in February, Medscape reported a surge in the rate of Black Americans dying from a combination of opioids and cocaine, an increase of 575%. The rate for White Americans increased by 184%.
A recent analysis in the American Journal of Epidemiology, found that in the South, deaths from cocaine and opioids increased 26% per year among Black people, 27% per year among Latinx people, and 12% per year among non-Hispanic Whites.
Dr. Marc Zimmermann is a neuropsychologist and medical psychologist in Baton Rouge, with over 30 years experience. He is noted for his work in forensic psychology having testified in multiple states and jurisdictions, and he has been a consultant to many chemical dependency programs such as the Serenity Center and Lane Recovery Solutions. He is also a staff member at PTI in Baton Rouge.
Dr. Zimmermann said that according to the Louisiana Department of Health, the bulk of all recorded opioid overdose deaths occurred in the parishes of Southeast Louisiana. St. Tammany Parish experienced an average of over 47 opioid overdoses a year and Jefferson Parish averaged over 71 opioid overdoses a year.
While their age-adjusted rates are not as high as St. Tammany and Jefferson Parishes, Orleans and East Baton Rouge Parish experienced high average numbers of deaths from opioid overdoses during the same time period.
Dr. Tiffany Jennings is a Louisiana native who is the Rural Health Coordinator for the Louisiana Psychological Association and in full time private practice. Dr. Jennings has worked in a variety of settings, including outpatient, inpatient, state and Federal agencies. She was previously an Assistant Professor, Department of Neurology, at Ochsner LSU Health Shreveport and a Neuropsychologist at Overton Brooks VAMC in Shreveport, and for the US Army’s Traumatic Brain Injury Clinic at Fort Polk in Leesville.
How serious does she feel the opioid crisis is in rural settings for Louisiana? “The opioid crisis continues to be a serious crisis that has not shown any signs of abating,” Dr. Jennings said.
“The COIVD-19 may have exacerbated the crisis. The Louisiana Dept of Health’s website notes an increase in fatal and nonfatal opioid overdoses as people are ‘cut off from services and disconnected from support systems, have made it difficult for individuals to seek help.’
“The Louisiana Opioid Surveillance Program has noted an increase in deaths from overdose,” she said. “This was noted to be in part due to availability of synthetic opioid drugs, which are much more powerful than morphine. This results in a higher chance of death from use –– such as fentanyl.”
Has she seen any changes over the last couple of years? “There’s been several high-profile lawsuits against drug manufacturers for their alleged role in the opioid crisis,” Dr. Jennings said. “I believe there currently four US companies in the process of settling, to the tune of approximately $26 billion. This has certainly brought attention to the extent of the current opioid epidemic.
“Many insurance agencies, including Medicaid, expanded telehealth access due to the ongoing COVID-19 pandemic. Unfortunately, I have not seen much change with regard to access to service for rural health settings in Louisiana. There continues to be a wait list to see Medicaid providers. Reimbursement remains an issue. Also, those in rural areas may not have the technology to fully utilize telehealth services,” Dr. Jennings said.
The Lancet Commission Report pointed to the lack of accessible, high-quality, non-stigmatising, integrated health and social care services for people with opioid use disorder in the USA. The authors recommended reforming public and private health insurance systems to address this issue, including cutting off funding for care that is likely to be harmful.
Dr. Geralyn Datz is a licensed Clinical Health and Medical Psychologist and a national educator of healthcare providers, attorneys and the public. Dr. Datz is licensed in Louisiana, Alabama, and Mississippi, and specializes in pain psychology, forensic assessments, and public speaking. She is President and Clinical Director of Southern Behavioral Medicine Associates PLLC, in Hattiesburg, Mississippi, a group specialty practice devoted to treating patients with chronic pain, She is a past president of the Southern Pain Society, and previously with New Orleans Veteran Affairs Medical Center and Pennington Biomedical Research Center
We asked Dr. Datz if there is adequate treatment available? “No there is not,” she said. “The treatment of opioid use disorder is a very large, systems based issue that right now is in dire straits and vastly underfunded. The short answer is that we need more insurance reimbursed programs, and the treatment needs to extend well beyond ‘rehab’ as it is traditionally defined. Private treatment centers are one component of treatment, but cannot meet the needs of this diverse population, which often has serious mental health issues and/or comorbid pain conditions. There are effective treatment models like Pain Rehabiliation Programs, that help
people with medical conditions come off of opioids, but sadly these are no longer reimbursed by insurance.
In addition, the treatment of opioid misuse is ideally multidisciplinary and requires medical and mental health follow up, which frequently does not occur. The Commissions comment on using the Chronic Disease Model for treatment, and in healthcare, is exactly on point.”
Is treatment covered by funding such as insurance for those who need help? “.Again…no. There are wide ranges in what insurance will and will not cover in treating opioid overuse and addiction. Often, comorbidities, such as pain or severe or even mild mental illness, are left untreated. In addition, there are variations between what private addiction centers will accept which insurances if any at all. As a result, care ends up being parsed out for opioid-dependent individuals and not as effective. Furthermore, many individuals do not have insurance coverage at all, further complicating the problem,” Dr. Datz said.
“The 2008 Mental Health Parity and Addiction Equity Act was designed to make treatment of mental health and substance abuse conditions as easily and fairly reimbursed as medical conditions. This Act was a step in the right direction but is still not fully realized. A recent report showed that many insurances are non compliant, and showed wide disparities between behavioral health care and medical/ surgical healthcare. Mental health parity needs increased attention, and enforcement, in order to address the public health needs that we are now facing.”
Dr. Jennings agrees. “Given the number of deaths from opioid overdose, I would say there is not nearly enough treatment, recovery and support systems in place for this population. This is especially true of those in rural settings,” she said.
“The state has enacted laws in an attempt to better regulate prescriptions and to reduce the chance of ‘doctor shopping’ for those addicted or who have developed a tolerance to their pain medication. Government agencies on federal and state levels are holding providers accountable for illegal prescriptions for opioids,” said Dr. Jennings.
“Louisiana is expecting to receive approximately $325 million from a national settlement of opioid lawsuits. The intention is to divide monies into addiction treatment, response and recovery services. The goal is to send the monies–divided up over a 20-year period–to local agencies that directly work with those suffering from opioid addiction,” she said.
“For some patients, education into the nature of chronic pain and their ability to manage pain can be helpful. There are evidence based psychotherapy treatments (such as Cognitive Behavioral Therapy for Chronic Pain) that can be used to help a patient manage pain. For patients in need of an increase in structure or level of care, there is certainly a need for agencies that provide this care. Again, insurance and location can often be a barrier to treatment.”
Pain costs society up to $635 billion annually, according to the CDC, and is the number one reason for disability. Pain is becoming better understood as a multifaceted phenomenon with psychological factors.
In 2016, CDC authors published Guidelines and said that there was no evidence for a long-term benefit of opioid pain medications. The authors found strong evidence for serious risks, including overdose, opioid use disorder, and motor vehicle injuries. The CDC said that other treatments, including psychological approaches, had long-term benefits, without the high risks of opioids.
“It is now widely accepted that pain is a biopsychosocial phenomenon,” Dr. Datz, told the Times in a previous interview. “The Guidelines are really exciting because they explicitly state that physicians should be using nonpharmacological strategies including cognitive behavioral therapy as well as exercise for patients with pain,” Datz said.
“This is a departure from the traditional belief that pain was primarily physical, and to be only treated by medical means, which was the biomedical model,” Datz said.
“The benefits of pain psychology are that the person experiencing chronic pain ultimately has more control over their pain process, their reaction to it, and their life,” Datz said. “This is accomplished by teaching patients about how their expectations, their attention, and their stress levels interact with chronic pain and can greatly exacerbated.”
“A large body of research,” said Datz, “has shown that use of structured cognitive behavioral therapy, and in particular cognitive behavioral therapy combined with physical therapy, as happens in functional restoration programs, are extremely effective ways of dramatically improving physical function, mental health, and overall well-being in patients with chronic pain,” she said.
“Unfortunately, these methods have been sorely underused, partly due to insurance coverage issues. With the advent of the ACA however, this is getting a lot better. Also, I think providers and patients are more open to these ideas now that the opioid epidemic has become such a hot topic nationally,” she said. Among the key messages of the Lancet Commission report, the authors noted that “The profit motives of actors inside and outside the health-care system will continue to generate harmful over-provision of addictive pharmaceuticals unless regulatory systems are fundamentally reformed.”
Dr. Datz will be presenting “Forced Opioid Tapers and the Culture of the Opioid Crisis: Time to revisit pain psychology” at the American Academy of Pain Medicine in Scottsdale Arizona on March 19. She will speak about how the approach of using pain psychology during opioid therapy is not new, but is enjoying a renewed urgency in the context of rising rates of opioid tapers and the safety issues surrounding preventable side effect from forced opioid tapers.
Lancet Commission authors warned that pharmaceutical companies based in the USA are actively expanding opioid prescribing worldwide, and are using fraudulent and corrupting tactics that have now been banned domestically.