The Opioid Epidemic in the Eastern States Joyce Manchester ...

The Opioid Epidemic in the Eastern States

Joyce ManchesterSenior Economist

September 11, 2019

Overview

• How has the opioid epidemic affected the Eastern States?– How does the drug overdose death rate per

100,000 compare across the states?• Why look at the overall drug overdose death rate rather

than the more targeted opioid overdose death rate?

– Why does it differ?

• How can policy choices affect the severity of the opioid epidemic?

2Vermont Legislative Joint Fiscal Office9/11/2019

CDC: 70,237 drug overdose deaths occurred in the United States in 2017. About two-thirds involved opioids, with another 12% unspecified (but 20% in

earlier years). The age-adjusted rate of overdose deaths was 21.7 per 100,000. 3Vermont Legislative Joint Fiscal Office9/11/2019

“Exploring Causes of and Responses to the Opioid Epidemic in New England”

• May 2019 paper co-authored with Riley Sullivan • Using county-level data, we expected to find that rural areas with weak economies

were more affected by the opioid epidemic• In fact, we found that the supply of prescription pain pills was the most critical

factor behind the crisis– Areas with the lowest rates of legal opioid prescribing are associated with the lowest rates of

fatal overdoses– https://www.bostonfed.org/publications/new-england-public-policy-center-policy-

report/2019/exploring-causes-of-and-responses-to-the-opioid-epidemic-in-new-england.aspx


The paper also explored how the New England states have responded to the crisis

• Increasing education about alternative approaches to pain management

• Monitoring prescriptions • Increasing access to recovery treatment • Enhancing criminal justice efforts to crack down

on illicit opioid use

Ï Treating the epidemic as a public health problem appeared to hold the most promise


Opioid prescription rates varied across counties in 2011 and best explain opioid deaths 4 years later


Here, we used the number of prescriptions filled per 100 residents by county. Source: CDC.

Washington Post data on prescription pain pills sold in the U.S., 2006-2012

• Released July 2019 using data on oxycodone and hydrocodone pills from the Drug Enforcement Administration (DEA)– Those two types of pills account for ¾ of total pill shipments– Automation of Reports and Consolidated Orders System

(ARCOS)• Based on previously unreleased drug company data

supplied to the DEA to show number of pills shipped and dispensed by year– 8.4 billion pills in 2006 rose to 12.6 billion pills in 2012

• The drug companies distributed 76 billion pain pills between 2006 and 2012– Six companies distributed 75 percent of the pills (McKesson,

Walgreens, etc)– Pills per person per year: WV 65.8, TN 56.7, NH 30.5, VT 28.2


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WV KY TN SC AL IN DE ME FL OH MI MS NC U.S. PA RI GA WI NH MD VA VT MA CT NJ NY IL DC

The Washington Post: Rx pain pills distributed 2006-2012 per capita per year, Eastern States; note different strengths of pills, ideally want MME* (active ingredient)

*Note: MME is morphine milligram equivalent; 50 mg of hydrocodone has the same MME as 33 mg of oxycodone.Sources: Prescription pain pills: Washington Post, July 2019; Population: U.S. Census, 2010 Decennial Census


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Eastern States: Drug Overdose Death Rates per 100,000 Population (Age-Adjusted) ME Maine

NH New Hampshire

VT Vermont

NY New York

MA Massachusetts

RI Rhode Island

CT Connecticut

NJ New Jersey

PA Pennsylvania

DE Delaware

MD Maryland

DC District of Columbia

MI Michigan

OH Ohio

IN Indiana

IL Illinois

WI Wisconsin

WV West Virginia

VA Virginia

NC North Carolina

TN Tennessee

KY Kentucky

SC South Carolina

GA Georgia

AL Alabama

MS Mississippi

FL Florida

US United StatesSource: Kaiser Family Foundation analysis of data from the Centers for Disease Control and Prevention (CDC)

data on # pain pills distributed

KY


WV

NH

OH

Two reasons to focus on death rates in 2013-2014

• We have pain pill data for 2006 through 2012– The midpoint is 2009, so the death rate in 2013-2014 is

about four years later

• After 2013-2014, deaths from illicitly manufactured fentanyl began to rise– Fentanyl is a synthetic opioid, 50 times stronger than

heroin, often added to street drugs – Different states had very different experiences with deaths

associated with fentanyl


In 2017 across the United States, 47,600 deaths were attributed to opioid overdoses. Of those, 28,869 deaths or 61% were from synthetic opioids, the vast majority from fentanyl.

Source: The Washington Post, “The Fentanyl Failure,” March 13, 2019.


Source: Washington Post, March 13, 2019, “The Fentanyl Failure,” using CDC data on cause of death.


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WV KY RI OH NH PA DE TN MA IN MI CT MD WI ME DC VT US NJ AL SC NC FL IL GA NY MS VA

2013-2014 Drug Overdose Deaths per 100,000; Eastern States and U.S.

Source: Centers for Disease Control and Prevention, National Center for Health Statistics; Kaiser Family Foundation.


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NH RI MA CT PA IL NJ MD OH VT WV WI NY DE MI U.S. KY VA IN ME NC GA TN FL AL MS SC

2013-2014 Drug Overdose Deaths per 100,000 Divided by 2006-2012 Pills Per Capita Per Year (not adjusted for MME)

Sources: JFO analysis; Drug Overdose Deaths per 100,000 from Kaiser Health Foundation using CDC data; Prescription pain pills 2006-2012from the Washington Post using Drug Enforcement Agency data, July 2019; Population from U.S. Census, 2010 Decennial Census.

Note: DC is omitted here.


Can we adjust for the “strength” of the pills?

• By using the underlying data available in the WaPodatabase, we can look at type and size of pills– Hydrocodone pills come in four different sizes

• 2.5, 5, 7.5, 10mg– Oxycodone pills come in many different sizes

• 2.5, 4.5, 4.84, 5.0, ..., 20, 30, 40, 60, 80mg– A 10 mg Oxycodone pill has 50% more MME (the “active

ingredient”) than a 10mg Hydrocodone pill• The CDC says MME per day affects likelihood of overdose

– >50 MME/day implies double the risk for overdose compared with <20 MME/day

• After adjusting for MME per capita, 2006-2012– The death rate per MME in VT is lower than that in WV– The death rate per MME in WV is lower than that in NH

Vermont Legislative Joint Fiscal Office 179/11/2019

9/11/2019 Vermont Legislative Joint Fiscal Office 18

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2013-14 Drug OverdoseDeath Rate

Pills per capita, 2006-2012

Average MME percapita, 2006-2012

Deaths per 1,000 perpill

Deaths per 1,000 perMME

Preliminary: Comparing Death Rates, Pills, and MME in VT, NH, and WV

VT

NH

WV

What have we learned?

• The Eastern States have been hit especially hard by the opioid epidemic

• States received distributions of prescription pain pills at different rates

• Fentanyl is playing a big role in more recent opioid deaths, especially among the Eastern States

• Going forward, treatment alone may not be sufficient to deal with the issue


Thank you!

My contact info:Joyce ManchesterSenior EconomistVermont Legislative Joint Fiscal [email protected] 828-3099


Extra Slides

The CDC Prevention for States program includes evaluation of awarded states’ program activities to monitor performance, demonstrate effectiveness, and capture success stories.


The CDC Prevention for States Program

• The purpose of Prevention for States is to provide state health departments with resources and support needed to advance interventions for preventing prescription drug overdoses.

• Through 2019, CDC plans to give selected states annual awards between $750,000 and $1 million to advance prevention in four key areas. Awarded states are collaborating with key partners to maximize efforts and address issues that impact prescribing and drug overdoses.– Maximizing PDMPs– Community or Insurer/Health Systems Interventions– Policy Evaluations– Rapid Response Project

• Funds awarded: $14 mil in 2015 + $10.8 mil + $11.4 mil + $24.1 mil • Total through 2019: $60.3 million


Eastern StatesAmount

AL $7,967,873CT $5,500,157DC $2,000,000DE $2,000,000FL $27,150,403GA $11,782,710IL $16,328,583IN $10,925,992KY $10,528,093MA $11,742,924MD $10,036,845ME $2,039,029MI $16,372,680MS $3,584,702NC $15,586,724NH $3,128,366NJ $12,995,621NY $25,260,676OH $26,060,502PA $26,507,559RI $2,167,007SC $6,575,623TN $13,815,132VA $9,762,332VT $2,000,000WI $7,636,938WV $5,881,983U.S. $478,429,992

The 21st Century Cures Act offers grants through grants under the program, State-Targeted Response to the Opioid Crisis.

The grants are administered by the Substance Abuse and Mental Health Services Administration (SAMHSA).

2017 was the first year of funding, and the column on the right shows the award amount for the Eastern States.

Funds were awarded based on rates of overdose deaths and unmet need for opioid addiction treatment.


Time Line• 1996 First wave of the opioid epidemic hit after Purdue

Pharma introduced OxyContin, a prescription pain pill• 2005 Law enforcement (DEA) began cracking down on

prescription opioids (OxyContin, Vicodin)• 2007 Purdue paid $600 million in fines, and its executives

pleaded guilty to federal charges for claiming the product was less addictive than other painkillers; marketing must conform to federal rules

• 2010 Heroin from Mexico became more prevalent on the streets, and overdose deaths rose

• 2013 Fentanyl arrived on the streets, often from Chinese labs; 50 times more powerful than heroin; deaths spiked first in RI, then in NH the following yearThe “Holder Memo” directed federal prosecutors to stop pursuing low-level, nonviolent drug charges to reduce incarceration

• 2014 Vermont Governor Shumlin’s State of the State speech on opioids

• 2017 Jan.17th Obama called fentanyl a national crisis; 28,869 people died from synthetic-opioid-related overdoses, a 46% increase from 2016Attorney General Sessions focused on law enforcement actionsFentanyl became the leading cause of overdose deaths in the U.S.


CDC Timeline on the Opioid Epidemic

• More than 399,000 people died from overdoses involving any opioid, including prescription and illicit opioids, from 1999-2017.

• The first wave began with increased prescribing of opioids in the 1990s, with overdose deaths involving prescription opioids (natural and semi-synthetic opioids and methadone) increasing since at least 1999.

• The second wave began in 2010, with rapid increases in overdose deaths involving heroin.

• The third wave began in 2013, with significant increases in overdose deaths involving synthetic opioids, particularly those involving illicitly-manufactured fentanyl (IMF). The IMF market continues to change, and IMF can be found in combination with heroin, counterfeit pills, and cocaine.


CDC 2018 Annual Surveillance Report of Drug-Related Risks and OutcomesPublished August 31, 2018

www.cdc.gov/drugoverdose/pdf/pubs/2018-cdc-drugsurveillance-report.pdf

aRate per 100 persons. According to the rules established by VT in July 2017, adults suffering from moderate pain are allowed an average of 24 MME per day; patients with severe pain are allowed an average of 32 MME per day. https://ballotpedia.org/Opioid_prescription_limits_and_policies_by_state#Vermont


Boston Fed Paper: Does economic despair cause people to abuse opioids?

• We looked at different measures of economic despair– types of jobs that remain in a county – the labor force participation rate of prime-age

residents – the rate of Disability Insurance receipt– the suicide rate– an index that combines seven metrics

• We found mostly weak associations of economic factors with opioid deaths– Inadequate access to health care does play a role


Boston Fed Paper: Different approaches in state policies can affect outcomes

• Educate medical professionals– Alternative pain management– Prescription drug monitoring programs

• The medical approach– Medication assisted treatment (MAT) uses drugs such as methadone

and buprenorphine to alleviate cravings and withdrawal symptoms– Vermont was a leader with its hub-and-spoke model, and about half of

its opioid users are in treatment (only 15-20% across the country)• Law enforcement approach

– Investigate illegal trafficking of controlled substances – NH;• Notes: inhospitable environment makes a difference (gift rule,

encourage generics); training at high-rating schools makes providers less susceptible; fewer Rx pills means more likely to get street pills; less health insurance associated with lower death rate; higher SES has higher death rates


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WV OH DC PA NH KY MD DE MA ME RI CT IN NJ MI TN FL VT NC U.S. IL SC NY VA AL WI GA MS

Drug Overdose Deaths per 100,000; Eastern States and U.S., 2016-2017 Average

Source: Centers for Disease Control and Prevention, National Center for Health Statistics; Kaiser Family Foundation.


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NH MD PA MA CT NJ OH IL RI WV VT DE NY ME MI WI VA U.S. FL NC IN KY TN GA SC AL MS

2016-2017 Drug Overdose Deaths per 100,000 divided by 2006-2012 Pills per Capita per Year (Time Lag is likely too long)

Sources: Drug Overdose Deaths per 100,000 from Kaiser Health Foundation using CDC data; Prescription pain pills 2006-2012 from the Washington Post using Drug Enforcement Agency data; Population from U.S. Census, 2010 Decennial Census.


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2011-12 2012-13 2013-14 2014-15

Drug Overdose Death Rate, 2-year Average, divided by Pills per Capita per Year, 2006-2012

AL

CT

DE

FL

GA

IL

IN

KY

MA

MD

ME

MI

MS

NC

NH

NJ

NY

OH

PA

RI

SC

TN

VA

VT

WI

WV

U.S.

NH

MA

RICTPAMDOHIL

VT

WVNJ

NYDE, WIMI

SC

ME, U.S., KYVA, INNCGA, TNFL

AL, MI

Source: CDC Drug Overdose Death Rate, Age Adjusted; The Washington Post, published Drug Enforcement Agency data.


y = 0.1823x + 9.8846R² = 0.2461

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Pills per Capita per Year vs. Drug Overdose Deaths per 100,000

DCIL

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MA

VT

VA

MD

NH

WI

GA

RI

PA

U.S.NC

MS

MI

OH

FL

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DE

IN

AL SC

TN

KY

WV


Scholl L, Seth P, Kariisa M, Wilson N, Baldwin G. Drug and Opioid-Involved Overdose Deaths — United States, 2013–2017. MMWR MorbMortal Wkly Rep 2019;67:1419–1427. DOI: http://dx.doi.org/10.15585/mmwr.mm675152e1

DO NOT USE THIS – RHS has only 20 states that meet reporting criteria


The Opioid Epidemic in the Eastern States Joyce Manchester ...

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