IN THE UNITED STATES last year 109,680 people died from drug overdoses.1 This is up from 106,699 in 2021. Monthly counts are released under the Vital Statistics Rapid Release program as an interactive data visualization and are available at https://www.cdc.gov/nchs/products/vsrr/drug-overdose-data.htm.
The drug crisis in America has not abated.
Of the total drug overdose deaths last year, 82,998 were opioid-involved. Opioids are a class of drugs that include the illegal drug heroin, synthetic opioids such as fentanyl, and pain relievers available legally by prescription, such as oxycodone (OxyContin®), hydrocodone (Vicodin®), codeine, morphine, and several others. Deaths involving synthetic opioids (including fentanyl) and psychostimulants (such as methamphetamine) continued to increase compared to the previous year.2
Xylazine is increasingly becoming identified in drug overdoses. It is a sedative and analgesic FDA-approved for veterinary use only, and is known as “Tranq” on the streets. One center of the growing public health crisis is the so-called “open air” drug market in the Kensington neighborhood of Philadelphia. Tranq is detected in over 90% of dope samples in Philadelphia.3 Xylazine overdose causes nearly immediate sedation and can lead to respiratory depression, especially when used with opioids. The CDC reported that in 2019, Tranq was involved in overdose deaths in 25 out of 38 states. DEA Administrator Anne Milgram said, “Xylazine is making the deadliest drug threat our country has ever faced even deadlier.”4 According to Milgram, the DEA Laboratory System reported that in 2022 approximately 23% of fentanyl powder and 7% of fentanyl pills seized by the DEA nationwide contained Tranq.5
Drug abuse is typically believed to be an urban problem. However, adults living in rural and farming communities use tobacco and methamphetamines at a higher rate than their counterparts living in the cities, and opiate addiction has been found in communities of every size. Rural adolescents and young adults drink alcohol at higher rates and are more likely to engage in high-risk behaviors, like binge drinking or driving under the influence. Between 2016 and 2020, 85,002 people have died in crashes on rural roads. That’s more than the entire population of Scranton, PA or twice the seating capacity of Citizens Bank Park, home of the Philadelphia Phillies. Adam Snider reports that the high rate of crashes on rural roads is caused by several factors, including lack of safety resources, simpler roadway infrastructure, poor emergency medical services, and, to a significant extent, risky driver behaviors. The most frequent causes of these accidents are impaired driving, speeding, not wearing a seat belt, and distraction.6
Prevention and Early Intervention
I grew up in the 1970s in a 3rd class city in Pennsylvania. My struggle with mental illness and active addiction went untreated. It seems no one really understood the medical component of addiction at that time; rather, it was seen as a form of delinquency, or a “moral” issue. There was a definite stigma attached to “doing drugs.” Rejection and shaming led to isolation. My only friends after high school were fellow addicts and binge drinkers. Compounding the problem was the the fact that adolescent psychological evaluation and counseling was nearly unheard of in rural and suburban regions of my home state. Instead, I heard things like, “Just stop!” and “If you loved us, you wouldn’t do this!” Saul Harrison, MD, wrote about “…the tragic lack of any unified commitment to children and youth” in the Journal of the American Medical Association (or JAMA) in 1971.7 Although much has changed regarding the treatment of mental illness and active addiction today, monitoring and prevention have yet to find strong footing.
According to the National Center for Drug Abuse Statistics (NCDAS), almost 32 million people (11.7% of the population) were actively using drugs in 2021.8 Jan Rader, firefighter and RN Paramedic in Huntington, West Virginia, has seen over 1,900 overdoses in her small rural town in a single year, with 169 deaths. Huntington is part of the Appalachia region of the eastern United States. Rader said in a recent TED Talk, “For this disaster, we need to redefine our job as a first responder.”9 Rader is also the subject of the documentary Heroin(e), which is streaming on Netflix, a film that centers on the opioid epidemic, specifically its effect on Huntington, West Virginia, where the overdose rate is 10 times the U.S. average. The Police Assisted Addiction & Recovery Initiative (PAARI), now a national network of nearly 600 police departments in 34 states, provides training, strategic guidance, support, and resources to help law enforcement agencies nationwide create non-arrest pathways to treatment and recovery.
In the Commonwealth of Pennsylvania, my home state, the CRS (Certified Recovery Specialist) peer-to-peer support program has been instrumental in providing early and ongoing peer support from former addicts and alcoholics to their addicted peers. The CRS program is also involved in “soft hand offs” at local emergency departments, focusing on finding a bed in a detox unit or rehab for individuals treated for drug overdose, rather than sending them back out to the streets to overdose again.
The National Institute on Drug Abuse (NIDA) says overdose deaths in the U.S. since 2000 are nearing 1 million! Deaths due to opioid overdose have increased 519.38% from 1999 to 2019, and are a factor in at least 7 out of every 10 overdose deaths. According to 2021 statistics, people aged 12 or older, approximately 1.1 million people reported using heroin in the previous 12 months.10 There has been an unprecedented increase in studies and treatment modalities, but treatment alone cannot not stop America’s pervasive drug problem. It is unfortunate that the stigma of addiction remains an issue. It seems a drastic increase in overdose deaths, especially among teens and young adults, had to occur before drug addiction could be seen not as a moral issue but a serious medical and mental health issue. Heroin, opiates (including Fentanyl), and Tranq have inundated cities and towns across the country.
Primary care physicians who provide care for children, adolescents, and families are in an ideal position to deliver prevention messages and to intervene early in the development of substance use and abuse among their patients.
Treatment, while certainly necessary, has proven to be insufficient in addressing the ever-widening overdose crisis in our country. Increased focus on prevention of initial drug experimentation and escalation to full-blown Substance Use Disorder (SUD) are critical if we wish to avert tragic outcomes we have been experiencing. There is a movement afoot to locate prevention efforts in primary care facilities in order to prevent risky choices such as experimenting with illicit drugs, especially among teens and young adults. In order to make this a national effort, it will require changes in healthcare funding, screening, and referral to prevention services.
Perhaps we need to begin by identifying and quantifying the current heavy burden on healthcare for illness, injury, and long-term health risks associated with chronic substance use disorder and alcoholism. The U.S. already focuses on well-child screening and prevention of illness among adolescents. Yet, two persistent barriers have precluded implementation of prevention and early intervention of drug and alcohol abuse among younger patients: lack of reimbursement from insurance companies; and, physician concerns regarding burdens on their staff (time and costs, lack of training and referral networks, perception that screening tools have high false-positive rates, and fear that screening could alienate patients).11 Funding is not the only necessary condition; provider support also is required.
Regardless of any barriers or blow-back to pediatric screening and prevention, R. Shah and colleagues write, “Addiction is a disease that frequently begins in adolescence or even childhood. We need to consider drug misuse as a developmental, pediatric disease.”12 Pediatric primary care clinicians are in an ideal position to intervene in this growing, critically important health problem by providing prevention, early intervention, and/or referral to preventive and treatment services. Sadly, adolescent exposure to drug and alcohol use and abuse often begins in the home. It is critical that these risks are identified as soon as possible, as early childhood development can profoundly affect a child’s educational trajectory and subsequent life-course. The best approach to reducing substance use disorder in America is increased efforts at determining risk factors and intervening prior to first use or the progression from first use to addiction.
Steven Barto, BS Psy, ThM
FIND HELP NEAR YOU
The following can help you find substance abuse or other mental health services in your area: www.samhsa.gov/find-treatment. If you are in an emergency situation, people at this toll-free, 24-hour hotline can help you get through this difficult time: 1-800-273-TALK. Or click on: www.suicidepreventionlifeline.org.
References
1 NCHS: A Blog for the National Center for Health Statistics, “Provisional Data Shows U.S. Drug Overdose Deaths Top 100,000 in 2022,” CDC, May 18, 2023, retrieved Aug. 25, 2023,https://blogs.cdc.gov/nchs/2023/05/18/7365/
2 Ibid.
3 “Community Groups, Medical Experts Work to Combat Emerging ‘Tranq’ Drug Crisis, July 28, 2023, ABC News, retrieved Aug. 25, 2023, https://abcnews.go.com/US/community-groups-medical-experts-work-combat-emerging-tranq/story?id=101716074
4 Anne Milgram, “DEA Reports Widespread Threat of Fentanyl Mixed with Xylazine,” DEA: Public Safety Alert, retrieved Aug. 25, 2023, https://www.dea.gov/alert/dea-reports-widespread-threat-fentanyl-mixed-xylazine
5 Ibid.
6 Adam Snider, “Rural Roads Are Disproportionately Deadly, New GHSA Study Finds,” GHSA, Sept. 1, 2022,retrieved Aug. 24, 2023, https://www.ghsa.org/resources/news-releases/GHSA/Rural-Road-Safety22
7 Saul I. Harrison, MD, “Crisis in Child Mental Health: Challenge for the 1970’s,” JAMA, Feb. 22, 1971, retrieved Aug. 27, 2023, https://jamanetwork.com/journals/jama/article-abstract/360336
8 “Drug Abuse Statistics,” National Center for Drug Abuse Statistics, retrieved Aug. 25, 2023, https://drugabusestatistics.org
9 TED Talks, “In the Opioid Crisis, Here’s What it Takes to Save a Life,” Jan Rader, Nov. 2018, retrieved Aug. 24, 2023, https://www.ted.com/talks/jan_rader_in_the_opioid_crisis_here_s_what_it_takes_to_save_a_life
10 “What is the scope of heroin use in the United States?” National Institute on Drug Abuse, Feb. 13, 2023, retrieved Aug. 24, 2023, https://nida.nih.gov/publications/research-reports/heroin/scope-heroin-use-in-united-states
11 L. Ziemnik, R. Harris, S. Rabinow, et al., “Screening Adolescents for Alcohol Use: Tracking Practice Trends of Massachusetts Pediatricians, ” Journal of Addiction Medicine, Nov/Dec 2017, 427–434, retrieved Aug. 27, 2023, https://pubmed.ncbi.nlm.nih.gov/28731863/
12 R. Shah, S. Kennedy, M. Clark, et al., “Primary Care–Based Interventions to Promote Positive Parenting Behaviors: A Meta-Analysis,” Pediatrics, May 2916, retrieved Aug. 28, 2023, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4845871/
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