Being completely honest, it’s as difficult to write about the opioid crisis as it is to read about it. Why? Because the more you learn about it, the more you realize that it is the very definition of a national crisis. It’s not something that only affects those who aren’t immunized, or that only affects those who are a certain age. It’s not something that affects only those who are homeless or only those who are wealthy. The simple truth is, the opioid crisis is exactly that - a national crisis that doesn’t discriminate who its next victim will be.
Over the next few weeks, I want to share with you the reality of the world we now live in. A world where we are struggling to control the disease we ourselves have created through our own clever engineering and science. A world where in an attempt to, ironically enough, master the art of pain relief, we have caused so much, unbearable pain. No one ever could have imagined that so much desire for good would be the basis for so much devastation and horror. And yet – here we are.
So, now what?
We’ve created a problem that is solvable – but will take a level of focus, commitment, societal change and investment that we’ve rarely seen before. While brilliant minds like Jonas Salk could change the future of America with his polio vaccine, there is no single all-encompassing solution with opioids. Instead – it is going to take the understanding and compassion of a nation to recognize the very magnitude of the problem and rise up to meet the enemy.
Sometimes, it is only by looking to the past that we can understand the future. History can be a predictor of a world we haven’t yet seen.
Let’s begin with some positive news. We are getting better at managing the number of deaths from prescription opioid pain relievers. In fact, a Stanford Medicine study from 2017 found that hospital discharges for illicit opioids has surpassed those related to prescription opioids. Each year, the Centers for Disease Control and Prevention (CDC) painstakingly looks at the underlying cause of death based on the information on the death certificates throughout the U.S. (The graphs I’ve shared are a visualization of the CDC’s numbers by the National Institute of Drug Abuse.) Since 2011, we’ve made an impact managed to actually decrease the number of deaths from prescription opioids based on population normalized number. That’s great news. However, it is the rest of the news that’s not nearly as favorable.
As a Chief Technology Officer of Stanford Hospital, one of my responsibilities was to support a complex security environment that included many real-time monitors that would detect suspicious activity or the presence of malware. I had up to the minute information which was critical to detect and contain threats, as well as a standardized incident response protocol ensuring consistency. Retrieving causes of death from death certificates for showing a mortality rate takes months to get the information submitted from all states which is why the figures are only current through 2016 – approximately 15 months behind. It’s like trying to drive a vehicle looking in a rear-view mirror. Health IT needs to look for more real time options including working with the National Syndromic Surveillance Community of Practice Steering Committee and consider making the CDC’s National Syndromic Surveillance Program more tightly integrated into ED workflows and the EHRs and ultimately with EMS as well. This will begin to give us the real time telemetry we need to identify problem areas quickly and react immediately through coordinated deployments of resources and community programs through technologies such as ESSENCE.
Opioids exist as legally controlled substances (such as OxyContin, Dilaudid and Roxicontin – largely DEA Schedule II drugs) and illegal substances (Schedule I drugs) of which the most prevalent is heroin. On the East Coast, it’s packaged into small ‘bags’ made of glassine because of its lightness and air, moisture and grease resistant qualities (since heroin is destroyed by moisture). The bags often contain a stamp indicating a moniker for the dealer. This also helps identify the quality of the product. These stamps (the more famous being ‘TANGO & CASH’ which killed many in 1991) are unique to the NorthEast. The ‘bags’ are typically sold for about $10 each. On the West Coast, the heroin often comes into the country from Mexico and central America as a black tar like substance (an important difference that I’ll share more about in the next post). Our success at making it more difficult to misuse prescription medication has forced opioid addicts to move to heroin. For example, in 2010 Purdue changed their OxyContin pills (known as OC80s) to a version that prevents abuse and diversion (known as OP80s). As a result, the costs of OC80s soared on the streets to $80 or more and the availability quickly evaporated having the unfortunate side effect of accelerating the move to heroin for those who have fallen under its addictive spell.
The result of this and other factors has been an unbelievable increase in the number of deaths from overdoses of heroin. As you can see from the graph showing the number of deaths involving heroin – this impacts men and women of all ages. This alarming increase comes at a time where we’ve seen an outbreak of yet another opioid many times more potent – fentanyl. I’ll give you much more information about that in my next post. The rapid increase that is shown should alarm you. Whether you are a statistician or not – the rapid change is something not seen before. Unlike prescription medications, we have not been successful at controlling the rapid growth of street heroin.
Many people associate heroin as a ‘street drug’ generally used by homeless people. It’s been an easy problem to ignore or dismiss by thinking it’s a “class” issue. Let me introduce you to one of the individuals I’ve worked with to understand this challenge from the perspective of an addict. His name is Zach and he grew up in New York. Zach attended a public school on the Upper East Side with classmates raised in affluence. He started experimenting with drugs and soon found himself enjoying the euphoric feeling created by heroin. It started with ‘snorting’ the drug enveloping him in a feeling that was pleasant and relaxing. The problem is that as it ran out – he wanted more. Soon he was injecting the drug because it was more efficient and cost effective. With each dose, he needed more of the drug to achieve the same feeling. When he wasn’t high, he felt terrible and just wanted to find that euphoric space once again. This is how heroin – and all opioids – begin to ‘own’ their victim. Zach could no longer work and subsequently started to sell his belongings to afford his $120 / day habit. Soon, he was late on bills, in debt to friends, and was selling anything he could to avoid the miserable feeling of not being high. The nausea, anxiousness and sometimes anger was a motivation for him to keep focused on finding ways to get the next 6 or 7 bags he’d need for the day. Eventually, Zach found himself on the street – panhandling in midtown. Zach – like so many heroin addicts – wasn’t homeless when he found heroin but became homeless because of it.
I’m sure some of you aren’t yet convinced that this really couldn’t affect ‘you’ or your circle of friends. Let’s look at the other end of the spectrum – cocaine. Cocaine has often been associated with upper class individuals. Images of well-off people buying a vial or two of cocaine (each one containing just a gram of white power) for $100 each before going to a party where it was carefully poured out onto a mirror – or more recently, a smartphone or tablet – and ‘cut’ into individual lines of powder that were snorted by the party goers through a straw or rolled up dollar bill. Many people who loved the nearly instantaneous high and energetic feeling that the cocaine gave them also loved the euphoria of opioids. Regrettably – we’re now seeing that the combination of opioids and cocaine are also causing a tremendous increase in the deaths. This combination may be intentional (some drug users inject both heroin and cocaine) or accidental (fentanyl laced cocaine is becoming a reality). Check out the red line on the graph to the left. That shows that cocaine and opioids are causing even more death from overdoses.
This is a crisis that knows no class boundary. It is a crisis that needs to consider the homeless and the professional or privileged. The young and the old. Male and female. It is a crisis that we’ve never seen before because it is not something we can completely control through legislation and law enforcement. Pandora’s box has been opened and now we must figure out a way forward.
I wish the news was better in our battle against opioids. But we’re losing.
Time reported recently that child hospitalizations due to opioid overdoses nearly doubled between 2004 and 2015 according to a new study in Pediatrics. It’s impacting our children.
In March, the CDC released a Vital Signs report that overdoses from opioids increased by roughly 30% across the U.S. in just the last 14 months. While not all of these resulted in death, the CDC recorded 142,000 overdoses in U.S. hospital emergency departments between July 2017 and September 2017 (and that wasn’t even all states reporting). Dr. Ann Schuchat, acting director of the CDC added “The infrastructure to fully tackle this problem is fragile”.
We at Medigram understand that this is a very complex problem, and we are working with multiple organizations to provide expertise and resources to provide ways to help respond to this crisis from both a technology and policy perspective. Our efforts include looking at the problem from both a scientific and societal perspective.
The next post will discuss fentanyl. A synthetic opioid, fentanyl has become rightfully the flashpoint of the opioid crisis. Many reports attribute the increase in death rates to fentanyl.
With each post, I’ll also be providing some suggested reading or media that will help all our readers understand the problem with greater clarity and resolve. In 1999, HBO created a documentary with Steven Okazaki called Black Tar Heroin: The Dark End of The Street. This is filmed largely in the Tenderloin district in San Francisco. It will give you an idea of the age and depth of this problem that we are now trying to fix. While difficult to find, it’s well worth the effort. In 2015, he embarked on his next project – Heroin Cape Cod, USA. By the time filming was done, 2 of the 8 addicts in the film were dead of overdoses.
We have a problem. The time to act is now. We all need to start by recognizing and getting to know the enemy we are fighting. I hope I have captured your interest and trust that you’ll find the next blogs exciting you with ways we can impact our future.
About Dean Shold VP, Technology at Medigram
Dean Shold is the VP of Technology for Medigram. Before his current role, Dean was the VP of Infrastructure and Chief Technology Officer for Stanford Health Care, and was previously the VP of Global Data Operations for Zephyr Health. With a degree in computing science and a passion for social good, real time data analysis and mobile computing, he brings a unique background and perspective to the healthcare industry. At Medigram, Dean drives enterprise customer complete solution development, implementation, support, and customer success. At Stanford Health Care, he led a global team of 180+ personnel at 24x7 support to 50+ locations including multiple hospitals. He managed the technology and support budgets and built and reorganized teams to drive performance and reliability. He built a command center based on FEMA's (Federal Emergency Management Agency Guidelines) and oversaw data center performance and builds.
Dean also has deep passion for practically addressing the opioid crisis. His interests are in the scientific and the social sides of the opioid crisis bridging the addict with the researcher and the lawmaker. He is fascinated by how the worlds of legal and illegal opioids intertwine and how our societal biases impact treatment and recovery. In his work, he brings a vision of how Health IT can be leveraged to better understand and address the crisis. This includes examining the following key dimensions in addition to Health IT such as fentanyl, naloxone, harm reduction, detox, treatment and recovery.
Outside of the office, Dean also co-founded a non-profit organization to create novel ways to donate to charities. Dean is an instrument rated pilot and avid music lover. He and his wife, Pauline recharge by exploring harm-reduction organizations, the arts, craft beer and music scenes.
Links to check out:
National Institute on Drug Abuse: Overdose Death Rates
Stanford Medicine: Hospital discharges for prescription opioids down, heroin discharges surge http://med.stanford.edu/news/all-news/2017/10/hospital-discharges-for-prescription-opioids-down-heroin-discharges-up.html
CDC: Opioid Overdoses Treated in Emergency Departments: https://www.cdc.gov/vitalsigns/opioid-overdoses/
CDC: Syndromic Surveillance Community of Practice Portal:
The Guardian: Opioid crisis: overdoses increased by a third across US in 14 months, says CDC
Time: Childhood Opioid Overdoses Nearly Doubled in Last 10 Years
HBO: Heroin Cape Cod, USA