Jeremiad: Heroin Deaths Go Unnoticed

by Mark Publicker, MD, FASAM | January 29, 2014

Philip Seymour Hoffman's tragic death puts a face on what has been ignored. A few weeks ago, there were 22 heroin overdose deaths in Pittsburgh that went unreported. When a story was finally published several days late, finding it required quite a bit of scrolling through the online paper, and the content focused on impersonal facts rather than the underlying issues that are making heroin deaths commonplace.

Ironically, the "brand" name for this lethal heroin in Pittsburgh is "Theraflu" - though I am very sure that the public eye does not approximate flu deaths with those caused by heroin. Surely, had the 22 Theraflu deaths been caused by the flu we would have seen a major news story. While searching for reports of overdose, I confirmed this theory by easily finding a flu-related death reported in Allegheny County.

The Pittsburgh Theraflu deaths and their lack of coverage are not unique; there were also over 20 deaths in Rhode Island in the first two weeks of January. Deaths from overdoses have quadrupled in Maine between 2012 and 2014 and doubled in Vermont. None of the parents of my patients have slept soundly in years, kept awake by fear of that midnight phone call.

These deaths are preventable. ASAM supports the increased availability of naloxone to anyone in the position of being a first responder (see our Public Policy Statement).

The nation is late awakening to the heroin epidemic, just as it was late to discover the prescription drug epidemic. Other than some hand-wringing, nothing has been done or likely will be done. In Maine, where I live, the response has been to criminalize addiction. The state has already severely limited access to care, both to behavioral as well as medication therapies. Coverage and payment for both outpatient and residential therapies has been cut. A two-year retroactive limitation for buprenorphine treatment is into its second year. And on January 1 ‘non-categoricals’ lost their Medicaid coverage (single, no dependent children). Our patients on buprenorphine and methadone have been abruptly thrown into withdrawal, risking relapse, illness and death.

ASAM’s Patient Advocacy Task Force (PATF) has taken the lead in establishing the effectiveness and cost-effectiveness of all FDA-approved medications for the treatment of opiate addiction. And yet, the nation continues to only treat the symptoms of this metastatic cultural cancer, not the disease.

Opiate addiction is a chronic brain disease. We have the proven-effective opiate addiction chemotherapy that is a necessary part of the holistic treatment of this disease. The ultimate prevention for overdose deaths is treatment. And treatment is contingent on insurance coverage. Because of stigma and fear our patients and their families are often silent in demanding access to treatment. The PATF has created the advocacy tools. Use them and speak out loudly for our patients.


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  1. R Johnson Sep 26, 2015 - 02:30 PM
    Medication assisted treatment has proven to be an effective part of the entire heroin recovery process.  Those who are affecting governmental policy would be wise to support the use of these medications in order to prevent future overdose deaths.
  2. Mary G. McMasters, MD, FASAM Feb 24, 2014 - 12:17 PM

    Other reasons prescribers are prescribing so many controlled substances:
    •“Safe”,i.e., if something goes wrong, it is always the addict’s fault
    •Little to no education about the most risky iatrogenic effects of controlled substances: abuse and addiction



  3. Thomas Lindsay MD Feb 23, 2014 - 06:13 PM
    I agree with the comments and philosophies noted above. However, as a Suboxone prescriber, I prefer to have the external limit of 24mg of buprenorphine/day, and haven't seen the need to exceed this dose. This limit stops the perpetual struggle with patients for an increased dose. I just haven't seen a need to exceed this dose.
  4. Peter Rostenberg, MD FASAM, Feb 21, 2014 - 07:30 PM

    Bravo Mark Publicker for your letter!!

    Our 2010 Naloxone Public Policy recommendations are spot on. The background needs updating. 

    There may be movie goers who were unmoved by PSH's loss, but I have not found one.  So this is a time of deep cultural wound and is an historic moment: people will listen. 

    Now is the time for an ASAM OVERDOSE ACTION ALERT that would emphasize naloxone. Before methadone and buprenorphine, there must be life. 


  5. John McCarthy, M.D. Feb 20, 2014 - 05:33 PM

    The article by Dr. Publicker and comment by Dr. Swan are both right on. I'm in Sacramento where the overdose problem is acute and also under-reported. I had a young 28 year old man who reported that 20 of his friends were dead. Most of the many young patients we are admitting know someone who has overdosed and died. It is at times the proximate cause for coming into treatment.

    If this was any other disease, there would be a national outcry, not a day or two of reporting on another tragic film star death. I

  6. David S. Swan, MD Feb 20, 2014 - 03:50 PM
    Opiate dependence is a severe physical disease of the brain. MRI scans of the brain of addicts clearly so degenerative changes in the areas of critical cognitive thinking. Clinically this is very evident in treated individuals who note that following the induction of appropriately administered buprenorphine therapy,  their clarity of thought and ability to meet the demands of the modern society are greatly improved. Evaluation of neural plasticity has clearly shown that with active cognitive thinking an increase in the ability to reach and make rational decisions can be obtained. I have personally watched a large number of individuals go from bland unplanned lives depended only on finding the money, finding a drug, taking the drug, finding the money, finding the drug, taking the drug, to the exclusion of almost all other human activities, move on to rational and productive lives
    Experience has clearly shown us that with proper dosing, to avoid cravings and desires for narcotics, sustained remission of addictive behavior can be obtained. Understanding the neurologic pathology involved leads us to believe that by adequately controlling the cravings which drive the use of drugs, the psychological cycle noted in addicts can, over time, be markedly weakened. At the same time if their cognitive functions can be improved with education, counseling, and positive experiences it is postulated that significant recovery, cessation of drug support and permanent avoidance of the addictive state can be achieved.
    Addiction and Kentucky is a highly lethal condition. Our latest statistics from 2010 show it causing more deaths than automobile accidents in the state. It is a very major contributor to a number of other activities that are detrimental to our society. I wish to reemphasize that it is an actual physical disease. It is not some type of moral impairment or other psychological condition. It may have psychological roots but once the addictive state has been achieved it is a purely a physical disease that needs to be treated in an appropriate and sustained fashion as is done with any other chronic disease.
    The insurance companies have now arbitrarily set drug limits that go across all individuals regardless of the specific needs of the patient. This policy is not carried out in any other chronic disease situation. Certainly these companies do not set arbitrary limits for how much insulin a diabetic can take since it would be absolutely ridiculous for someone in an office with no contact with the patient make that type of arbitrary determination.  Nevertheless in the case of addiction under treatment by a qualified physician the insurance companies somehow feel that they are at liberty to do so.
    Each patient has a significantly different physiology, drug absorption and metabolism, and variable  drug dependence and opioid tolerance. All of these factors make setting arbitrary limits irrational and contrary to good medical practice. At the current levels in force of 24 mg, in my experience, would leave at least 30 to 40% of patients without adequate treatment.  This leaves this patients at a very high risk for returning to illegal drug abuse, the very disease that we are trying to treat.
    You may argue that the individual should go ahead and pay for the extra that they need if they have to, unfortunately, most of these individuals are coming out of an extremely damaged financial status. But with buprenorphine therapy they can begin to reestablish a proper lifecycle pattern, a proper psychological pattern and develop reasonable money management techniques. However the cost of drugs to these individuals who are significantly financially impaired is essentially a denial of service.
    The ancillary costs of addiction to our community far outweigh the cost of providing adequate medication for those addicts who made the decision to attempt to treat their chronic disease. I would hope that you as a physician and member of the pharmaceutical committee can realize the need to carefully individualize care for this serious and lethal disease.

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