“Naloxone” and “buprenorphine” were the most popular words coming from the speakers at a Sept. 16 briefing on opioid overdoses in Washington, followed closely by references to U.S. Sen. Edward Markey’s “TREAT” Act, which would expand buprenorphine access. The Capitol Hill briefing, “The Opioid Epidemic: Reporting from the Front Lines of America's Big Cities," was hosted by the Big Cities Health Coalition and Markey, the Massachusetts Democrat who in July introduced The Recovery Enhancement for Addiction Treatment (TREAT) Act, which would remove limits on the number of patients a physician could treat with the medication to combat opioid dependence.
In addition to increasing access to buprenorphine and making naloxone, the medication that reverses opioid overdoses, more accessible, panelists, from New York City, Chicago and Boston recommended that Good Samaritan protections be expanded to the federal level. Good Samaritan bills allow witnesses to call 911 to report an overdose without fearing prosecution by law enforcement.
The Big Cities Health Coalition represents the public health officials of the largest metropolitan areas in the country, said director Shelly Hearne, DrPH, who moderated the panel. Citing a new report from the Centers for Disease Control and Prevention (CDC) showing that opioid overdose deaths have quadrupled since 1999, Hearne said more is needed than “piecemeal Band-Aids,” and that common strategies are required. “The hard-working city leaders” are the “boots on the ground” where innovations take place, and this is where key investments are needed, she said.
New York City
The opioid addiction and overdose problem is not just about prescription drugs, but about heroin as well, said Mary Travis Bassett, MD, commissioner of the New York City Department of Health and Mental Hygiene. She cited statistics showing a 350% increase in overdose deaths from prescription painkillers in New York City between 2010 and 2013, and a more than doubling of heroin overdoses during the same time period (following four years of declining heroin overdoses).
Using the city’s drug surveillance system, the health department pinpointed one borough—Staten Island—where prescription opioid overdose deaths were concentrated, and set out to make door-to-door visits to more than 1,000 physicians to educate them about proper prescribing, said Bassett. “Our 2013 data shows some good news” as a result, she said, including a 32% percent reduction in prescription opioid overdose deaths on Staten Island.
Since 2009, the city has worked to ensure that naloxone is available to family and friends of opioid users, and in 2011 the state passed a Good Samaritan law that makes this possible. More than 14 overdoses have been reversed in New York City this year, and more than 500 in total, she said, adding that these numbers represent only the reported reversals.
“The numbers of lives saved would be more if naloxone were available over the counter—we need legislation to allow this,” Bassett said.
Medication-assisted treatment with methadone or buprenorphine constitutes the most effective way to treat opioid addiction, noted Bassett, who went on to talk mainly about buprenorphine. “Buprenorphine is available in primary care, and has the added benefit of drawing people in to primary care,” she said. “But buprenorphine treatment has been hindered by federal policies,” she said. Federal regulations allow only physicians to prescribe it, and limit the number of patients to whom a physician can prescribe—30 in the first year, and up to 100 afterward. “These restrictions limit, completely unnecessarily, access to treatment,” she said.
The Big Cities Health Coalition has asked Congress to take action to allow nurse practitioners and physician assistants to prescribe buprenorphine, and it also supports the lifting of the cap in the TREAT Act, she said.
Some people have expressed concern that as initiatives to combat prescription opioid addiction and overdoses are successful and these medications become less available, users are switching to heroin. Hillary Kunins, MD, Assistant Commissioner for Alcohol and Drug Prevention & Treatment with the New York City health department, commented on this in response to an e-mailed question from Addiction Professional.
“The increase in heroin overdose deaths began before implementation of our efforts to promote safe and judicious opioid prescribing among health care providers,” Kunins says. “However, we are concerned about the increase in heroin deaths and are conducting real-time qualitative studies to better understand the situation. These studies suggest there are likely three groups of new heroin users: people who transition from opioid analgesics to heroin, people with prior heroin use who relapse, and people who start using heroin without prior use of opioid analgesics.”
Bechara Choucair, MD, Commissioner of the Chicago Department of Public Health, focused his comments on the lawsuit by Mayor Rahm Emanuel against pharmaceutical companies that have sold prescription opioids to physicians. “Big Pharma gave the wrong information, saying that these highly addicting drugs could be prescribed for conditions they were not intended to treat,” said Choucair. “As a result, patients developed tolerance, requiring more and more of the drugs, and started becoming addicted.” The city then bore the costs of treating the addiction, as well as the impact of overdoses, he said.