By Pat Anson, Editor

A prominent Alabama physician says the U.S. opioid epidemic has changed so profoundly in the last 3 years that a serious reconsideration of government policy is needed.

Stefan Kertesz, MD, an associate professor at the University of Alabama at Birmingham School of Medicine, says heroin and illicit fentanyl are now the driving forces behind the opioid epidemic – not prescription pain medication.

“Reducing opioid prescribing is not going to save many lives at this point, even though it gives many officials a chance to look like they are doing something,” says Kertesz, who is also a primary care physician trained in internal medicine and addiction.

“If we have been reducing prescribing for several years, and the misuse of prescription pain relievers is near all-time lows… and overdoses are either staying very high or skyrocketing, then we need to change our assessment of the problem and refocus our response.”

Kertesz cites recent data from Jefferson County, Alabama showing that most overdoses in the county are now linked to either fentanyl, heroin or a combination of the two. Only 15 percent of the overdoses are associated with prescription opioids.

In Ohio’s Cuyahoga County, about 11 people die each week from fentanyl or heroin overdoses. By the end of the year, the county medical examiner estimates that a total of 770 deaths will be caused by fentanyl or heroin, nearly ten times the number that will die from prescription opioid overdoses.  

“Heroin and fentanyl have come to dominate an escalating epidemic of lethal opioid overdose, while opioids commonly obtained by prescription play a minor role,” Kertesz wrote in a commentary published in the journal Substance Abuse.

“The observed changes in the opioid epidemic are particularly remarkable because they have emerged despite sustained reductions in opioid prescribing and sustained reductions in prescription opioid misuse. Among U.S. adults, past-year prescription opioid misuse is at its lowest level since 2002. Among 12th graders it is at its lowest level in 20 years.”

Kertesz says the Centers for Disease Control and Prevention relied on faulty data and failed to address the changing nature of opioid abuse when it released its opioid prescribing guidelines in March. Since then, many pain patients have reported their opioid doses have been lowered or discontinued, while some have been discharged by their physicians and forced to seek treatment elsewhere.

He likened the situation to Pontius Pilate washing his hands.

“Discontinuation of prescribed opioids, coupled with encouragement to seek an inaccessible treatment, frees the physician from risk of prosecution or sanction. Inevitably, some patients so discharged will die from drugs they purchase on an increasingly lethal illicit market. At that point, an assertion of ‘clean hands’ by physicians, regulatory authorities or the federal government seems facile,” said Kertesz.

“The changing epidemiology of opioid overdose in 2016 offers no easy resolution to such difficult challenges. But it suggests that a relentless focus on physician prescribing for pain has become less relevant to correcting the forces behind a wave of deaths in 2016. Federal efforts to turn the tide risk becoming a riptide for patients, physicians and communities where access to evidence-based treatment remains a priority neglected for too long.”

By “evidence-based treatment,” Kertesz means access to addiction treatment medication such as buprenorphine and methadone, which is lacking in many parts of the country.

As Pain News Network has reported, the DEA says the U.S. is being “inundated” with illicit fentanyl produced in China and Mexico. Illicit fentanyl is often mixed with heroin to increase its potency or used in the manufacture of counterfeit pain medication.

Massachusetts recently reported that three out of four opioid overdoses in the state are now fentanyl-related.  Only about 20 percent of the overdose deaths in Massachusetts involve prescription opioids.

Massachusetts was the first state to begin using blood toxicology tests to look specifically for fentanyl. Toxicology tests are far more accurate than the death certificate codes used by the Centers for Disease Control and Prevention to classify opioid-related deaths.