By Brenda Goodman, MA
WebMD Health News
Reviewed by Brunilda Nazario, MD
Dec. 20, 2016 -- The front line in the epidemic of drug overdoses in the U.S. has shifted from the prescription pad to the street, a new study shows.
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The study, released Tuesday, shows that heroin is the leading cause of overdose deaths in the U.S. In 2010, the main culprit was the prescription pain medication oxycodone. The study also shows the startling rise in deaths from fentanyl overdoses. In a single year, from 2013 to 2014, the number of people who died by overdosing on the drug fentanyl more than doubled.
Fentanyl is a lab-created opioid prescribed by doctors to treat severe pain. But experts say fentanyl prescriptions aren't the major problem.
"Fentanyl is a particularly dramatic increase in overdose deaths, even though the prescribing of fentanyl has not increased," says Adam Bisaga, MD, a professor of psychiatry at Columbia University Medical Center in New York City. "So most likely, fentanyl is coming from outside the official market. We're talking about illicit fentanyl that's being brought to this country."
In the past few years, the U.S. has seen a flood of illegal Chinese supplies of the potent and fast-acting drug
The study used a new method to search the notes on thousands of death certificates to look for the names of specific drugs and words like "drug" and "overdose."
The results show a change. In 2010, oxycodone was responsible for about 5,000 deaths. By comparison, heroin killed about 3,000 people that year.
By 2014, heroin had become the deadliest drug, killing more than 10,000 people, while deaths from oxycodone remained steady.
The shift probably reflects a pattern of addiction that's become more common in recent years: Patients often first become addicted to prescription painkillers, but when those become too expensive or too difficult to get, they turn to street drugs to get high. Drugs like heroin and fentanyl have become cheaper and easier to get in recent years. Some drugs sold on the street are so potent now that police officers have been warned not to handle them because they can be deadly even if touched.
"These epidemics are intertwined," say Rose Rudd, a health scientist at the CDC in Atlanta.
In 2014, the 5 drugs most commonly cited as causes of death were:
Fentanyl made the largest jump, moving from eighth on the list of drugs involved in overdose deaths in 2010.
The study comes on the heels of updated numbers released by the CDC that show that deaths due to drug overdoses continue to increase in the U.S., a trend observed since 1999. Drugs now kill more people in the U.S. than car crashes.
Nearly 5,400 more people died of drug overdoses in 2015 than they did in 2014, an increase of 11%.
Deaths from synthetic opioids, like fentanyl, were a major driver. Those increased 72% from 2010 to 2015. Deaths from heroin were up 20% over the same time frame.
"It just confirms what we are seeing in the clinic. And we're seeing it on a national scale," says Bisaga, who treats patients who are suffering from substance abuse. "There's a significant increase since only a few years ago."
There were some bright spots in the new numbers. Overdose deaths from methadone, an opioid that's used to treat pain and also as a therapy for opioid addiction, are coming down.
Rudd says new policies to make methadone prescribing safer are having an impact. Those include new guidelines and new dosage limits.
The FDA and Substance Abuse and Mental Health Services Administration also teamed up to educate the public on safer use of the drug.
Also, President Obama recently signed the 21st Century Cures Act, which allocates $1 billion for substance abuse treatment over the next 2 years.
Bisaga thinks it may not be enough to turn the tide.
"Our treatment system is really outdated," he says.
Bisaga says most of the substance abuse treatment programs in the U.S. rely on a model that encourages short-term detoxification followed by abstinence. He says that approach actually increases the risk of overdose, since people lose their tolerance to the drugs but may go back to using their usual amount.
He says medical studies and real-world experience show that medication-assisted therapy, which uses opioid replacement drugs like methadone and buprenorphine, may be a safer way to help people who are struggling to break the cycle of addiction.
After a rash of heroin overdose deaths in the 1990s, for example, France expanded access to methadone treatment and slashed its rate of overdose deaths by 75% within 5 years.
In the U.S., by contrast, "We have three very effective medications that are hugely underutilized," Bisaga says. "Only 10% to 20% of people who have the disorder are being treated with those medications. We don't have enough providers interested in providing treatment. We have 1 million physicians in this country. Only about 2% to 3% are prescribing these medications."
In France, he says, 25% of physicians were prescribing medication-assisted treatment.
To make a dent in the opioid epidemic, Bisaga says we have to work on reducing the stigma associated with addiction and make medications easier to get.
"Unless you change the system, unless you change how the providers think about treating this disorder, it's going to have limited impact," he says.
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