Ravages of opioid drug abuse epidemic worsen, grow ever more complex

syphillis-150x150The myriad problems tied to the nation’s opioid drug abuse epidemic seem only to worsen and grow more complex by the day. They are, recent news reports say:

Drug overdoses, especially of prescription and synthetic painkillers like fentanyl and illicit narcotics like heroin, may have killed as many as 65,000 Americans in 2016, the New York Times has reported, based on its analysis of public health data. That toll may have made its largest annual leap ever, and means that such deaths exceed the highest peak, annual deaths for vehicle wrecks, HIV-AIDs, and guns.

The New York Times scrutinized drug overdoses on its own because it said public health officials, with their painstaking studies, often may not report crucial data for years.

And the drug carnage is only likely worsening in 2017, the paper reported earlier this summer.

Drugs and a fearsome sexually transmitted disease

In a recent story out of Oklahoma City, the New York Times says the socially conservative metropolis, as with other cities across the country, has been staggered by surge of syphilis infections linked to abusers of heroin and methamphetamines swapping drugs for sex.

This is occurring  among poor groups scorned and shunned by many: homeless people,  gang members, prisoners, prostitutes, pimps, and johns. Although syphilis most often has been detected among gays and bisexuals, most of them black or Latino, infection rates nationally are rising among young white women and their babies.

Doctors and public health officials may be missing new cases and outbreaks but syphilis infections had declined since the late 1990s. The disease, which can have relatively mild signs early than go dormant for long and dangerous periods, is difficult to diagnose. It requires a “cumbersome” two-step test to do so. Stocks are low of an antibiotic that has been effective in treating it. Federal funding to fight it has been slashed.

Although public health campaigns to stamp it out succeeded in cutting its toll to 6,000 or so cases nationwide by 2000, in Oklahoma City authorities have recorded 200 cases this year already. (Nationally, in 2015, federal officials reported there were almost 75,000 early- and late-stage syphilis cases). They’re struggling to contain the outbreak with a grim, tedious, and draining door-to-door effort to find and counsel the infected and their sex partners. Their labors take health workers all too often into their city’s bleakest, most run down, and crime-ridden areas to talk to furtive subjects about some of the most personal of matters.

Case workers say they confront a risky, distressing, and depressing situation in trying to curb syphilis in Oklahoma City.

Their rare ray of hope: They’re finding more success in tracking carriers via social media, notably Facebook. They have learned much more about their outbreak online than trekking around their region, including that women have been easier to identify (mostly because men are more willing to give them up) and that the infections appear to have spread from a drug-dealing gang to more stable, white abusers, first of prescription drugs, then heroin and more illicit narcotics.

A widening crackdown with disparate partners

Meantime, the campaign to cut the abuse of powerful painkilling drugs has spread to some disparate and disquieting quarters.

Hospices, for example, have found themselves in the awkward position of reconsidering their handling of potent meds. Their patients—at home, often in great pain, and dying—traditionally have been dispensed opioids in significant and justifiable quantity.

But incidents nationwide have forced hospice caregivers to rethink the security and post-mortem destruction of painkillers. That’s because of a growing number of cases in which patients’ family members and friends have turned out to be drug abusers all too willing to steal meds from the dying or dead. Their addiction has proven so bad that they are willing to see friends and loved ones suffer great pain so they can feed their habit.

Hard data is unavailable, though anecdotal information is becoming tragically abundant. Hospice caregivers say they have been unprepared to screen households to determine if drug abuse is occurring there or might happen. They haven’t traditionally tracked painkiller use by their patients—Medicare officials estimate that as much as a third of the medications it pays for, for hospice patients, are such powerful drugs. Families typically designate one person to be legally responsible for patients’ prescribed drugs and their administration.

By the way, though some state laws are changing, many states also actually forbid hospice staff from collecting or destroying patients’ medications on their death. The drugs belong to the families, and tampering with them, even by hospice workers, is a crime in many areas.

Meantime, dentists, and, yes, veterinarians now are joining hospice caregivers in new, perhaps surprising roles in trying to reduce opioid drug abuse.

Dentists turn out to be major prescribers of painkillers for young people, ages 10 to 19. That’s because so many youths undergo extractions, including the pulling of 3 million wisdom teeth each year.

Although research finds startling numbers of opioid drug abusers got started with legitimate, necessary prescriptions, youths who get short orders from dentists of potent painkillers rarely get addicted, studies find. Still, dentists and dental schools are ramping up their precautions, reminding patients and practitioners alike that many kinds of tooth pain can be more appropriately treated with aspirin and common, less powerful, and even over the counter nonsteroidal anti-inflammatory drugs (aka NSAIDs like brand name Tylenol or Advil).

Dentists, by the way, also are putting under new scrutiny their practices in sedating young patients for many common and uncomfortable procedures, including extractions. Kids are highly sensitive to powerful drugs, including anesthesia and sedatives. Their airways are smaller, and they can get in trouble faster. That can be a real problem in smaller, less intensively staffed dental offices.

As for veterinarians, who would have thought they would have a role to play in the campaign to curb opioid abuse? It turns out, as the government affairs site Governing points out, animal docs typically don’t prescribe commonly abused meds like “Vicodin, OxyContin or Percocet, but they do dispense Tramadol, a painkiller; ketamine, an anesthetic, and hydrocodone, an opiate used to treat coughing in dogs.”

And, to the dismay of those who treat four-footed patients, their two-legged masters apparently are desperate or addicted enough to swipe and down their pets’ meds.

DVMs are in a difficult position because they aren’t usually focused on human behaviors, and it’s unclear whether they must report their suspicions about pet owners. States, including Maine and Virginia, have stepped in with laws limiting the period a vet may prescribe and treat animals with opioids. Colorado allows DVMs, before dispensing opioids for animals, to tap into state prescription databases to see if owners are in them, while Maine requires them to do so before ordering powerful painkillers for pets. Veterinary associations also have spread the word to members to be wary of owners who bring in pets and seek specific meds by name for their care.

Halting policy responses

The public policy responses to the nation’s opioid drug crisis continue to be messy, at best.

Despite the president’s  public declarations that he would declare the epidemic a national emergency, the Trump Administration has been slow to make it officially so. The New York Times’ Upshot column has explained what this entails, and what it means that this has not occurred.

Policy makers, especially in the nation’s capital, also have feuded over a persistent, counter-factual claim that the nation’s drug abuse problems have been worsened by Medicaid and the expansion of this health coverage program for the poor, children, old, and chronically and mentally ill under the Affordable Care Act, aka Obamacare.

This is a convoluted argument lacking evidence. It is rooted in the notion that because Medicaid increases coverage, it ups the prescribing of drugs in general and opioids. Obamacare’s expansion of Medicaid only caused an explosion of prescription painkillers, this argument against the ACA contends.

It just isn’t so, according to experts who have carefully considered facts and evidence.

Disputes over issues like these, of course, occupy policy- and law-makers so that they may not be able to give full attention to growing worries, such as those surrounding the increasing clout of one high-tech company, which arguably is playing a pivotal role in combatting drug abuse. Kentucky-based Appriss has stepped into a vacuum and now provides much of the software that allows doctors and nurses in huge swaths of the nation to check and monitor patients’ drug prescriptions, especially for opioids and other medications easily and dangerously abused.

The firm says it works with states to protect patients’ privacy. But Appriss is sitting on a wealth of invaluable information on drugs and their use and abuse. It has talked already of combining its databases with other available and proprietary health records—moves that are starting to raise privacy advocates deep concerns.

This is a situation that requires careful oversight.

In my practice, I see the significant harms that patients suffer while seeking medical services and the major woes they can be subjected to by dangerous drugs. The pernicious effects of the opioid drug abuse epidemic are unacceptable, and, as we see its toll and its other damages spread throughout the health care system it becomes clearer by the day that doctors, hospitals, policy experts, and lawmakers need to step up even more their efforts to combat this scourge.

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