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Opioid-Related Deaths Might Be Underestimated: CDC


Death certificates from drug-linked infections may not label painkillers as possible cause

By Dennis Thompson

HealthDay Reporter

TUESDAY, April 25, 2017 (HealthDay News) — America’s prescription drug abuse epidemic may be even more deadly than expected, a new report from the U.S. Centers for Disease Control and Prevention suggests.

Some opioid-related deaths may be missed when people die from pneumonia and other infectious diseases spurred on by drug abuse. Their death certificates may only list the infection as the cause of their demise, explained CDC field officer Victoria Hall.

That means a number of drug-related deaths are not being counted, since surveillance systems mainly track overdose deaths.

“It does seem like it is almost an iceberg of an epidemic,” Hall said. “We already know that it’s bad, and while my research can’t speak to what percent we are underestimating, we know we are missing some cases.”

More than half of a series of drug-related unexplained deaths in Minnesota between 2006 and 2015 listed pneumonia as the cause of death, Hall and her colleagues found.

Twenty-two of these 59 unexplained drug-related deaths involved toxic levels of opioids. But the death certificates didn’t include coding that would be picked up by statewide opioid surveillance systems.

“We found if you have really profound infectious disease, like really bad pneumonia, that may be the only thing written on the death certificate. And thus it’s not going to get picked up in opioid surveillance,” Hall said.

Opioids killed more than 33,000 people in the United States 2015. That’s close to as many deaths caused by traffic crashes that same year, according to federal statistics. Nearly half of all opioid overdose deaths involved a prescription drug.

This spring, the Minnesota Department of Health learned of a middle-aged man who died suddenly at home, Hall said. Two days earlier, he’d seemed ill and was slurring his words, but refused his family’s pleas to go to the hospital.

“He was on long-term opioid therapy for some back pain, and his family was a little bit concerned he was abusing his medications,” Hall said.

Testing revealed that he died of pneumonia brought on by the flu, “but also detected a very toxic level of opioids in his system,” Hall said.

“However, on the death certificate it only listed the pneumonia, and it listed no mention of opioids, so this death wasn’t counted in the state opioid death surveillance system,” she said.

Opioid medications — codeine, hydrocodone (including Vicoprofen), oxycodone (Oxycontin, Percocet), morphine and others — can help bring on dangerous respiratory infections or make them even worse, Hall said.

“Opioids at therapeutic or higher than therapeutic levels can impact our immune system, actually make your immune system less effective at fighting off illness,” Hall explained.

The sedative effect of opioids also affects a person’s respiratory system, causing breathing to become slow and shallow, and making the person less prone to cough, Hall said — “making it easier for something like a pneumonia to really set in.”

A review of Minnesota’s unexplained death database revealed 59 cases with evidence of opioid use. Of those, 22 cases had not been reported to statewide opioid surveillance because the involvement of drugs hadn’t been listed on the death certificate.

Pneumonia was listed as a cause of death in 54 percent of the unexplained drug-related cases, the researchers found.

The Minnesota cases raise the question of whether similar drug-related deaths are being missed in other states, particularly those hardest hit by the prescription drug abuse epidemic, Hall said.

Dr. Robert Glatter, an emergency physician with Lenox Hill Hospital in New York City, said that emergency rooms “see a fair number of patients who use opiates. And in those patients we see, in general, a higher risk profile for developing pneumonia and other respiratory illness.”

The risk is even greater among drug users who smoke or have a respiratory ailment, such as asthma or COPD (chronic obstructive pulmonary disease), Glatter said.

“This is another in a sequence of reasons to not use opiates,” Glatter said.

“Physicians and all health care providers should be attuned to this risk of developing pneumonia, especially if they’re going to prescribe opiates. It’s another reason to proceed with extreme caution,” he noted.

The study results were presented April 24 at a CDC meeting in Atlanta.

Which Prescription Drugs Are Commonly Abused?

According to the National Institute on Drug Abuse, the three classes of prescription drugs that are often abused include:

How Do Opioids Work on the Brain and Body?

Since the early 1990s, doctors’ prescriptions for opioid medications — such as codeine and morphine (Astramorph, Avinza, Kadian, MS-Contin, Ora-Morph SR) — have greatly increased. That increase can be attributed to an aging population and a greater prevalence of chronic pain. Other drugs in this class include:

Cherokee Nation Sues Wal-Mart, CVS, Walgreens Over Tribal Opioid Crisis

Tops to prescription bottles are pictured inside the Wal-Mart pharmacy.

Robert Sullivan/AFP/Getty Images

The Cherokee Nation is suing top drug distributors and pharmacies — including Wal-Mart — alleging they profited greatly by “flooding” communities in Oklahoma with prescription painkillers, leading to the deaths of hundreds of tribal members.

Todd Hembree, attorney general for the Cherokee Nation, says drug companies didn’t do enough to keep painkillers off the black market or to stop the over-prescription of these powerful narcotics, which include OxyContin and Vicodin. “They flooded this market,” Hembree says. “And they knew — or should’ve known — that they were doing so.”

Walgreens, CVS Health, and Wal-Mart are all named in the suit, along with the nation’s three largest pharmaceutical distributors: AmerisourceBergen, McKesson, and Cardinal Health. They act as middlemen between pharmacies and drugmakers, distributing 85 to 90 percent of the prescription painkillers that some see as fueling a growing opioid epidemic in the U.S.

When reached for comment, one of the defendants, Cardinal Health, sent a statement to NPR saying the suit was a mischaracterization of facts and a misunderstanding of the law. “We believe these lawsuits do not advance the hard work needed to solve the opioid abuse crisis — an epidemic driven by addiction, demand and the diversion of medications for illegitimate use.”

But the Cherokee tribe says these companies regularly filled large, suspicious prescriptions within the Cherokee Nation’s 14 counties in northeastern Oklahoma. They also say the companies turned a blind eye to patients who doctor shopped and presented multiple prescriptions for the same medication. Oklahoma, where 177,000 tribal members live, leads the nation in opioid abuse. Almost a third of the prescription painkillers distributed in that state went to the Cherokee Nation.

“There are safeguards that are supposed to be followed — federal laws — that they turn a blind eye to because their profits are much more important to them,” Hembree says. “We were being overran by the amount of opioids being pushed into the Cherokee Nation.” A spokesperson for Walgreens told NPR the company declines to comment on pending litigation. CVS Health said in a statement, “We have stringent policies, procedures and tools to ensure that our pharmacists properly exercise their corresponding responsibility to determine whether a controlled substance prescription was issued for a legitimate medical purpose before filling it.” The other companies did not immediately respond to requests for comment.

Nowhere has the country’s opioid crisis hit harder than in Indian Country. Compared to other racial and ethnic groups in the U.S., American Indians have the highest rate of drug-induced deaths in the country. The use of OxyContin by American Indian high schoolers is double the national average.

The lawsuit estimates opioid abuse led to over 350 deaths within the Cherokee Nation between 2003 and 2014.

Cherokee babies are often born with an opioid addiction resulting from their mothers’ use of prescription painkillers throughout the pregnancy. Some spend their first moments on earth suffering through withdrawals. “They will have shakes, they will cry, and a lot of these children go on to have developmental and cognitive issues,” Nikki Baker-Limore, executive director of child welfare for the Cherokee Nation, says. “These children are born and they don’t even have a chance the second they come out of the womb.”

Several studies suggest high rates of addiction in Indian Country stem from the violence and cultural destruction brought down upon natives over the past 200 years. Because both trauma and resilience are remembered in our DNA, the genocide and forced removal of Cherokee and other tribes from their homelands by the U.S. government during the early 19th century has resulted in generational trauma.

Cherokee nation claims in the suit that drug companies are making money off of a vulnerable population and ignoring epidemiological and demographic facts. While this is the first time an Indian Nation has sued top drugs distributors and pharmacies, it’s not the first case of its kind in the country.

The city of Everett, Washington recently filed suit against Perdue Pharmaceuticals, the maker of OxyContin, for allowing its drug to saturate the black market. West Virginia, one of the hardest hit places in the nation’s opioid epidemic, settled with Cardinal Health for $20 million last year. Soonafter, the federal government slapped Cardinal Health and McKesson with multi-million dollar fines for failing to report suspicious orders of controlled substances to the Drug Enforcement Agency.

“Legal action is one of the only effective measures we have against pharmaceutical companies and distributors,” Adriane Fugh-Berman, an associate professor in the Department of Pharmacology and Physiology at Georgetown University, says. Fugh-Berman has served as an expert witness in several cases against pharmaceutical companies. “Companies don’t like lawsuits,” she says. “It’s a great way to get information into the public domain.”

But the Cherokee Nation’s lawsuit is different than other cases in a fundamental way: they filed it in tribal court. By doing so, lawyers for the Cherokee Nation say they hope to gain quicker access to internal corporate records. However, Hembree says they expect the defendants will file a motion to move the case into federal courts.

“We’re ready for that jurisdictional battle and we look forward to trying this case in Tahlequah, Oklahoma,” Hambree says, referring to the Cherokee Nation’s headquarters. The suit seeks billions of dollars in damages, and Hambree hopes it will help change the behavior of drug distributors and pharmacies.

“I can’t put Cardinal Health and McKesson and Amerisource in jail, but I can make them responsible for the damages they’ve incurred,” he says.

Even if the tribe is successful, Fugh-Berman says a change in behavior isn’t going to cure the opioid crisis in Indian Country and the U.S. in general. “It’s just one piece in this whole fabric of how to stop the opioid epidemic,” she says.

But curing that one piece could really make a big difference in the Cherokee Nation, according to Baker-Limore. She says the tribe has the infrastructure to provide recovery and rehab services. “Somebody needs to stop letting these opioids be so readily available,” she says. “We’re a small-town community. It’s hitting us hard.”

Nate Hegyi is a reporter for Montana Public Radio. Follow him at @natehegyi.

Sonoma County Heroin Overdoses Have Spiked Recently, Coroner’s Office Says

The Sonoma County Coroner’s Office says that suspected heroin overdose deaths in the county are up sharply over the past five to 10 days.

Sonoma County Heroin Overdoses Have Spiked Recently, Coroner's Office Says

SONOMA COUNTY, CA — The Sonoma County Coroner’s Office on April 25 said that there has recently been an upward spike in suspected heroin overdose deaths.

In the last five days, the Coroner’s Office has received nine deaths attributed to what we believe is heroin overdoses.

“While the final cause of death has yet to be determined and next of kins have not been notified, we want to share this information early to warn the public of this disturbing trend,” the coroner’s office said in a statement released to Patch.

All the deaths so far have occurred in the Santa Rosa area, the coroner’s office said, adding that there’s concern that the heroin being distributed in Santa Rosa right now is very volatile and potentially toxic.

Get free real-time news alerts from the Mountain View Patch.

“All health, rehabilitation and treatment centers need to know that this substance is out there and any signs of overdose should be taken seriously,” the coroner’s statement read in part.

Anyone exhibiting signs or symptoms of an overdose should seek medical attention immediately or call 9-1-1, according to the Sonoma County Sheriff’s Office.

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