As the availability of prescription opioids has increased across the US, illicit drug use has gone down in many areas. However, one unexpected consequence of this shift is that many individuals who would not be likely to use heroin otherwise are introduced to opioids through prescription opioids, and then later turn to heroin as their tolerance for the substance increases or they no longer have access to the medication. One result of this shift is that heroin use is actually starting to increase again, especially among affluent people living in the suburbs, a very different group from those generalized as having heroin use disorders in decades past.
Importantly, stricter policing practices, not atypically linked to the rise in drug-related overdoses, can themselves contribute to increasing drug-related deaths, principally as people with substance use disorders move underground and witnesses to overdoses are reluctant to call for help. Perhaps optimistically, the growing burden of drug-related overdose has made it abundantly clear that drug-related overdose is not simply a law enforcement or public safety issue, but a public health issue. One major aspect of public health relevance is that overdose is usually preventable, and individuals rarely overdose alone, providing a unique opportunity to avoid death, particularly for those witnessing an overdose. Provision of the opioid antagonist naloxone, a practice that is being implemented in many areas, is one example of a way to potentially stop the harm of an overdose before it leads to death. Hearteningly, some innovative efforts across the US, including several here in Massachusetts, are taking the initiative to move beyond thinking of substance use as a legal issue to thinking of it as a public health issue.
A study published in the Proceedings of the National Academy of Sciences brought home the consequences of drug use by simply and effectively showing that if the death rate among those aged 45 to 54 had continued to decline the way it had between 1979 and 1998, we would have avoided half a million deaths between 1999 and 2013, comparable to the number of lives lost to AIDS in the US; I referred to this paper in a prior Dean’s Note.
It is important to note that mortality is far from the only consequence of drug use. Other associated outcomes include hospitalization cost and lost work productivity. Additionally, consequences of nonfatal overdose among victims include cardiac and muscular problems, cognitive impairment, renal failure, and other injuries. Moreover, following the lifecourse paradigm, effects of substance use can spill over from generation to generation; maternal smoking during pregnancy is associated with low birth weight, among other effects in offspring, and using alcohol and other substances during pregnancy is associated with a myriad of outcomes, including pre-term birth, placental abruption, neonatal withdrawal, and cognitive deficits.
The growing focus on non-medical opioid overdose state-wide and nationwide is welcome, but this approach deals only with a small part of a much larger problem with the use of substances worldwide. The burden of substance use is very much a chronic challenge to population health that has long been underappreciated and on the fringes of mainstream public health. Unfortunately, this marginalization is accompanied by substantial shortage in opportunities for treatment for those with substance dependence, attendant unmet need, and an even deeper paucity of engagement around prevention of substance use and misuse. The recent attention to the issue is an important, if small, turn in the right direction.
I hope everyone has a terrific week. Until next week.