By R Carter
As someone who has followed the opioid overdose problem since 2000, what stands out in this report from the CDC, dated February 6, 2020, is how far behind in policy we are in relationship to what is occurring in our communities. That’s not to imply the CDC has been unaware of a synthetic opioid problem, they have, as early as 2013, it’s just that current policy doesn’t reflect it. Instead, with regards to policy, we remain focused on hydrocodone and oxycodone, they are given preferential treatment in policy because they are the easiest to control. All you have to do is demonize them and their prescribers often enough and before you know it, you’ve got everyone one looking in the wrong place for a problem that’s somewhere else.
In 2016 headlines from the CDC and other agencies within the federal government who monitor drug policy and drug abuse were singularly focused on opioid prescribing, claiming prescribing was the cause of the opioid crisis.
Only those who are poorly read and informed would claim opioid prescribing played no role in opioid overdoses, those involved in healthcare would know better. Our healthcare system was built on a premise of trustworthiness, prescribers were viewed as professional, objective, responsible and dedicated men and women of science whose primary interest was the wellbeing of their patients. What any healthcare provider will tell you in private though, is that this is not true 100% of the time.
As managed care spread across America between the 1980s and 2000, driving down the cost of healthcare at the expense of profit, providers scrambled to maintain a lifestyle they had spent decades building up. One of the hidden facts not reported on by those who cover the healthcare profession is how it operates contrary to the conventional ideas of efficiency and profit. What is sold to the American public is that cutting out waste lowers cost and raises the quality of care and this is true for insurance companies and healthcare manufactures, it’s rarely the case for providers. And this fact should be screaming at us in 2020 with access to affordable healthcare as the top issue in an election year.
Say you have a community of 10,000 families served by a community hospital, 20 doctors and one or two surgeons. When I new doctor comes to town and sets up a practice, there are now fewer patients to go around and the response from providers traditionally has been an increase in rates to offset the loss of income each provider now faces.
This fact, mostly unreported by the media, is what drove up the cost of care for decades in America. Between 1960 and 1980 the number of practicing doctors in America more than doubled and with that came a corresponding increase in rates. Rates that insurance companies paid because there was no collective bargaining between providers and the hundreds of thousands independent providers and small clinics to regulate the rate increases.
That is until the late 1970’s and 80’s when facing a crisis, the insurance industry responded with managed care. The idea was simple, because most employers were now offering health insurance as an employee benefit, insurance carriers would do their collective bargaining with corporate America. Once they owned the contracts to provide coverage, providers were at their mercy. Either accept the rates insurance carriers were offering or get none of their patients.
Insurance carriers then drove down rates so low that small community hospitals like the one in my example, could no longer afford to keep their doors open. When the hospitals closed, the doctors moved to where the hospitals were but that only solved part of the problem. To cover things like school loans that would take two decades to pay off, doctors would have to earn a reasonable income and to do that, the only solution was to double the number of patients they saw each day.
Soon insurance carriers were offering doctors kickbacks and incentives to keep patients out of the hospital and away from more expensive diagnostic procedures and care. All that profit that used to be spread widely amoung our small communities was now concentrated in the hands of the insurers who used it to buy up other smaller insurers until they had all but a monopoly on controlling the cost of healthcare.
Large thousand-bed hospitals in large cities suffered as well, as insurance companies put pressure on them to provide services at a lower cost. With all the overhead of these large facilities, they could not continue the services they provided unless they bought out smaller hospitals and clinics, which they did, further consolidating control into the hands of just a few.
As pressures such as this were applied across the board, some who would not have otherwise crossed a line, seized on the opportunity to treat chronic pain, and a smaller number, using the natural dependency that opioids produced, ensured that their patients kept coming back.
And with a system designed primarily to operate on trust, the scene was set for both providers and patients to exploit the loops holes which existed in that system, which they did, until the opioid crisis brought about some needed changes. But as we’ve all seen, this did not stop the opioid crisis it only slowed it down for a while.
Many would disagree with this explanation on how we got here and they are right to do so, for all of us didn’t arrive in here in the same manner. This is my perpective because it is what I experieced. The actual problem is much larger incorporating many methods that were used, some appropriate but more which were not, to get a handle on the publics desire for a higher high.
The opioid crisis was and continues to be a complex problem and in desperation, our government has adopted an approach of primarily limiting supply as a solution. But as we can see from this CDC report, it’s not solving the problem and in limiting itself to this approach, the government has created a new class of disabled individuals, those who have a legitimate need for medication which returns them to functional and employed status but are denied the care over misplaced fears of misuse.
Carfentanil Outbreak — Florida, 2016-2017
Chris Delcher, PhD1; Yanning Wang, MS2; Russell S. Vega, MD3; John Halpin, MD4; R. Matthew Gladden, PhD4; Julie K. O’Donnell, PhD4; Jessica A. Hvozdovich, MS5; Bruce A. Goldberger, PhD5 (View author affiliations)
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What is already known about this topic?
Deaths involving fentanyl analogs, such as carfentanil, have increased the severity of the opioid overdose epidemic in Florida.
What is added by this report?
During January 2016–December 2017, 224 of Florida’s 1,181 carfentanil-involved fatal overdoses occurred in the Sarasota area, preceding a larger statewide outbreak in the rest of the state. The outbreak ended in the Sarasota area in August 2017, but carfentanil continued to be detected in overdose deaths in other areas of Florida through the end of 2017.
What are the implications for public health practice?
Accelerated reporting, better communication and data sharing across agencies, and increased surveillance for novel substances are needed to mitigate harm associated with introduction of illicitly manufactured fentanyl analogs into drug markets.
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Increased prevalence of illicitly manufactured fentanyl and fentanyl analogs has contributed substantially to overdose deaths in the United States (1–3). On October 26, 2015, CDC issued a Health Advisory regarding rapid increases in deaths involving fentanyl. This CDC Health Advisory has been updated twice to address increases in fentanyl and fentanyl analog overdoses and their co-occurrence with nonopioids (4). Deaths involving carfentanil, an analog reportedly 10,000 times more potent than morphine and 100 times more potent than fentanyl, were first reported in Florida, Michigan, and Ohio in 2016 and described in an August 2016 CDC Health Advisory (1,5). Carfentanil is used to rapidly immobilize large animals in veterinary medicine and has no U.S. approved therapeutic use in humans. Carfentanil’s street price per dose is likely lower than that of heroin. During 2016 and 2017, an outbreak of carfentanil-involved fatal overdoses in Florida emerged, and the Medical Examiner jurisdiction serving Sarasota, Manatee, and DeSoto counties (the Sarasota area) was the outbreak epicenter. This report describes toxicology profiles, sociodemographic information, and geographic distributions of carfentanil-involved fatal overdoses (carfentanil deaths) in the Sarasota area compared with those in the rest of Florida (i.e., all Florida counties excluding Sarasota area) from January 2016 to December 2017. The Sarasota area accounted for 19.0% of 1,181 statewide carfentanil deaths that occurred during this time and experienced a peak in carfentanil deaths preceding the larger Florida outbreak. The report of a single carfentanil death from August to December 2017 (compared with 73 reported deaths during the same period in 2016) appeared to mark the end of the outbreak in the area. The threat of such rapid, intense fatal overdose outbreaks highlights the need for accelerated reporting, reliable data sharing systems, and novel proactive surveillance to support targeted prevention and response efforts by public health and safety organizations (6).