Mind and Body

Digging deeper into data on the opioid epidemic, the diseases of despair

The uncovering of a hidden national DEA database fans the flames for greater corporate accountability, while new data about alcohol abuse in Rhode Island raises questions about co-occurring disorders

Image courtesy of the R.I. Department of Health

A slide from Dr. Dr. Brian Daly, chief medical officer at the R.I. Department of Behavioral Healthcare, Developmental Disabilities and Hospitals, from his presentation, “Rhode Island’s Opioid Overdose Crisis and Co-Occurring Disorders,” showing the gaps in the way that mental health visits and opioid use disorders are dealt with.

By Richard Asinof
Posted 7/22/19
The revelations from the hidden DEA database about the extent of knowledge known about the distribution of addictive pain pills has shattered efforts by drug manufacturers and distributors and pharmacies to hide their apparent complicity. In Rhode Island, there is significant new data points related to the prevalence of alcohol as a co-morbidity in the epidemic of the diseases of despair.
When will there be a local Rhode Island dataset that captures the diseases of despair – deaths from alcohol, suicide and drugs? How can the collaboration built into the Governor’s Task Force on Overdose Prevention and Intervention be extended to growing the harm reduction toolbox in Rhode Island? What are the legislative priorities for the next session of the R.I. General Assembly? How can domestic violence and sexual abuse become more prevalent as part of the conversation around substance use disorders? Is it time for a screening tool for toxic stress to be implemented by pediatricians in Rhode Island?
It has been more than eight years since ConvergenceRI, then working at the Providence Business News, first reported in July of 2011 about the prevalence of deaths related to prescription pain killers in Rhode Island, based on data research by Traci Green.
Since that time, there have been hundreds of stories about the opioid epidemic in Rhode Island, a new COBRE research center established, innovative approaches developed around peer counseling and safe stations in collaboration with firehouses, efforts to improve the way that hospitals treat patients presenting with opioid use disorders, and tremendous volunteer efforts as part of the recovery community advocacy.
Still, the hidden database revealed by The Washington Post is shocking, detailing the callous way that corporate interests continued to feed dangerous, addictive painkillers to people across America – allegedly including businesses such as CVS and Walmart. Rather than monetary damages, wouldn’t the slam of the jail door behind corporate executives responsible for the decision-making prove to be a stronger deterrent?

PROVIDENCE – The data on hospital admissions related to alcohol intoxication and EMS runs in Rhode Island pales beside the revelations last week by The Washington Post as it delved into the heretofore secret database maintained by the Drug Enforcement Agency that tracked the path of every single pain pill sold in the U.S. – from manufacturers and distributors to pharmacies in every town and city.

The data came from previously undisclosed company data was released on Monday, July 15, as part of the largest civil action in U.S. history now underway before U.S. District Court Judge Dan Polster.

The secret database revealed what each company knew about the number of pills it was shipping and dispensing and precisely when they were aware of those volumes – year by year, town by town, according to the reporting by The Washington Post.

“In case after case, the companies allowed the drugs to reach the streets of communities large and small, despite persistent red flags that those pills were being sold in apparent violation of federal law, and diverted to the black market, according to lawsuits,” Washington Post reporters Scott Higham, Sari Horwitz and Steven Rich wrote in their story published on July 16.

What the database revealed was that between 2006 and 2012, 76 billion oxycodone and hydrocodone pain pills manufactured by the nation’s largest drug companies were distributed across the country, fueling “the prescription opioid epidemic which resulted in nearly 100,000 deaths from 2006 through 2012,” according to The Washington Post story.

For instance, between 2006-2012, in Hamblen County, Tenn., there were 59,853,440 pain pills supplied to residents, amounting to 138 pills per person per year, according to the database analysis.

Just six companies distributed 75 percent of the pills during this period, according to an analysis of the database by The Washington Post. They included: McKesson Corp., Walgreens, Cardinal Health, AmerisourceBergen, CVS and Walmart.

Each day, for the past week, Washington Post reporters have delved into the story, providing new revelations about how enormous numbers of prescription pain pills flooded communities.

“It appears that failures mark every point along the supply chain,” according to a story published by The Washington Post on July 21, “from manufacturers to distributors to pharmacies to the doctor all too willing to write a script.” The epidemic, the story continued, was not “something out of sight, behind closed doors, under a bridge. In full view, it intensified and the companies, health care professionals, law enforcement officials and government regulators were unable or unwilling to stop it.”

Data analysis in Rhode Island
Still, peeling back the onion on Rhode Island data around alcohol intoxication, hospital admissions, EMS runs and co-occurring disorders can provide important insights into how best to address what appears to be a much larger epidemic related to mental health, behavioral health, substance use disorders and suicide – the diseases of despair.

Here in Rhode Island, thanks in large part to the collaborative work by the Governor’s Task Force on Overdose Prevention and Intervention, there has been a concerted effort to drill down on the data related to overdose deaths, hospital admissions for substance use disorders, the prevalence of the distribution of naloxone, whether or not behavioral health and mental health conditions are treated holistically with substance use disorders, or not, among other data analyses.

Much of the data is transparent to the public and can be found on the PreventOverdoseRI website.

Some of the continuing, persistent questions that ConvergenceRI has raised have been related to databases were about the capability to connect the local data streams around alcohol, suicide and drugs, referred to by Syracuse University sociologist Shannon Monnat as the diseases of despair.

Also, due to reporting following the closure of the Emergency Department at Memorial Hospital and uncovering that the leading impression for EMS services in 2017 at Memorial was alcohol intoxication, ConvergenceRI wondered what was the relationship between substance use as defined by drug overdoses and alcohol abuse as a co-morbidity.

One of the recovery community advocates had told ConvergenceRI recently that alcohol was a co-morbidity in 84 percent of drug overdoses. The question is: how do you get at that data?

Two presentations at June 12 Task Force meeting, one by Dr. Brian Daly, chief medical officer at the R.I. Department of Behavioral Healthcare, Developmental Disabilities and Hospitals, “Rhode Island’s Opioid Overdose Crisis and Co-Occurring Disorders,” prompted ConvergenceRI to pursue the questions again.

In his footnotes, Daly had cited three data points around suicide: Suicide is the 10th leading cause of death in the U.S., and the second leading cause of death for people between the ages of 10-34; more than 90 percent of people who die by suicide show symptoms of a mental health condition; and each day an estimated 18-22 veterans die by suicide.

A second presentation by Samara Viner-Brown, chief of the Center for Health Data and Analysis at the R.I. Department of Health, looked at “Behavioral Health: Hospitalizations and Emergency Department Visits.”

Asking the questions
The questions asked by ConvergenceRI were:

What is the breakdown of EMS transports of acute alcohol intoxication in 2018?

When looking at the number of hospitalizations for substance use disorders, how many are for alcohol, versus, other drugs, according to the codes?

Is there an opportunity to develop a database around the diseases of despair, alcohol, suicide and drugs, for Rhode Islanders?

Thanks in large part to the diligence of Joseph Wendelken at the R.I. Department of Health, here are the answers, based on hospital discharge data.

In hospitalizations with primary diagnosis related to substance use among Rhode Island adults, 69.5 percent [3,721] were alcohol-related in 2016, 73.3 percent [4,341] were alcohol-related in 2017, and 75.5 percent [4,528] in 2018.

The top three “most common primary diagnoses among those with a substance abuse diagnosis” in 2018, according to codes, were: alcohol related disorders, 4,053 [code F10]; opioid related disorders, 918 [code F11]; and alcohol liver disease, 404 [code K70].

Further, in regard to the number of EMS-related runs, there is currently no case definition for alcohol intoxication-related EMS runs, according to the R.I. Department of Health, which said it uses a national EMS Information database utilized by Rhode Island Emergency Medical Services providers. As a result, the data recorded is for alcohol-related primary and secondary “impressions.”

Those impressions may include: alcohol intoxication; alcohol dependence with withdrawal; alcohol dependence with withdrawal; alcohol related disorders; and alcohol use, unspecified. Also, the data entered into the database for primary and secondary impressions is not “mutually exclusive,” making it more difficult to ascertain the total numbers.

Still, the data for 2018 reveals some disturbing trends related to alcohol intoxication:

The total number of EMS runs for alcohol intoxication in Rhode Island was 9,493; the total number of alcohol-related in the primary or secondary impression fields was 10,083. Together, the total amount for both is 19,576, which is roughly 11 percent of all EMS runs [172,729] in the state in 2018, a significant number.

[Editor's note: The figures were updated by the R.I. Department of Health to correct initial inaccurate figures given. And, as mentioned above, because the figures cited for primary and secondary impressions are not mutually exclusive, there could be some overlap.]

Translated, alcohol abuse plays a significant role in substance use disorders in Rhode Island, and the focus on opioid-related overdoses may need to be broadened to encompass that knowledge.

Measuring the impact of fentanyl test strips
One more missing data point, yet to be calculated, is what evidence exists around how the distribution of fentanyl test strips in Rhode Island may be impacting the number of overdose deaths in the state, because there is no existing database to collect that information.

Colleen Daley Ndoye, the director of Project Weber/RENEW, offered some insights into the difficulty into attributing outcome data points just to the distribution of fentanyl test strips.

“I don’t know how we would hear that the strips would prevent an OD because it is essentially preventing something from happening, and when it doesn't happen, how could we know that it was the strips, if that makes any sense?” Daley Ndoye told ConvergenceRI.

She said her agency has only recently started ramping up the distribution of fentanyl test strips. “I would also mention that we are targeting non-heroin users with these strips,” she explained, “since fentanyl has so completely saturated the heroin market, it is a much better use of the strips to target people using substances that they do not think would be laced with fentanyl.”

Daley Ndoye also questioned whether or not the distribution of fentanyl test strips could be quantified in having something to do with the reduction in overdose deaths. “I sincerely doubt it, since it was such a small pilot in 2018 and the OD numbers also went down in 2017,” she said. “I believe it is much more due to the comprehensive nature of our [and by our I mean all of the members of the Governor’s Task Force] working on multiple fronts – rescue, prevention, and recovery, getting thousands of Narcan kits into the hands of those who need them, the prison MAT program, and the Emergency Room peer recovery coach program.

Daley Ndoye called fentanyl test strips one tool in the harm reduction toolkit. “To say that it will reduce overdose deaths alone is totally unrealistic, but to say that it is a useful tool to educate people who might have no idea that there is fentanyl in their drugs [especially party drugs] is true. They might continue to use but might do so more cautiously.”

She continued: “It is also a good hook to introduce ourselves to people who might be using and not interested in getting help – it gives a useful tool to them and potentially connects us to them as a provider. If, in the future, the person decides they want recovery, they will trust us and know to come to us. So, it is a relationship-building tool as well as a harm reduction tool.”

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