Mapping Fentanyl and the Data Gaps in the Opioids Crisis
By Rashida Kamal
President Trump has long promised that he will take action on the opioid crisis. This afternoon, he held a meeting with Tom Price, the Secretary of Health and Human Services, and other advisors at his golf club in Bedminster, NJ, to discuss the ongoing problem.
The meeting follows an interim report released last week by the President’s Commission on Combating Drug Addiction and the Opioid Crisis. The commission, led by none other than New Jersey Governor Chris Christie, recommended the declaration of a national emergency to mark the country’s ongoing struggle with the highly addictive class of painkillers.
The report made several additional recommendations to the Trump administration, including shoring up data sharing programs across states, particularly for drug prescriptions. The suggestion, in the broadest sense, echoes ESPN’s blog FiveThirtyEight: data would make a difference in fight against the opioid crisis. President Trump himself tweeted out a Fox & Friends clip about a study by a University of Virginia professor that found that overdose deaths were being underreported. For researchers and law enforcement seeking to sensibly allocate resources, better data could inform better choices.
The President’s solutions to the opioid crisis, at least thus far, have been found somewhatlacking. The President has chosen to focus some of his talking points on the proposed wall between Mexico and the United States, which he hopes will stop the inflow of illegal drugs into the country, and the recent drop in federal prosecutions for drug-related offenses.
While the illegal drug trade is certainly part of the problem, the opioid crisis is the result of interactions of a complex system, involving many stakeholders.
Public concerns about prescription opioids
A 2016 Gallup Poll showed that more than 4 in 10 Americans believe that opioids present a crisis for the American public, with the majority of those surveyed placing most of the blame on doctors inappropriately prescribing painkillers to their patients and pharmaceutical companies encouraging them to do so.
This narrative is not entirely new — and in fact, neither is America’s trouble with pain pills. The public’s concern about the prescribing practices of doctors and the marketing efforts of pharmaceutical companies is driven, in part, by the marketing blitz of the late 2000s that resulted in a $600 million dollar fine paid by Purdue, the manufacturer of OxyContin, in 2007. Purdue pleaded guilty to misleading prescribers about the addictive nature of its drug.
Today, the relationship between current prescription practices of doctors and the opioid epidemic remains complex, and the patterns are not consistent across all opioids. Amongst Medicare beneficiaries, the number of opioid-specific claims per beneficiary has gone down among several opioids. Notably, the opioids that are more frequently prescribed in cases of ongoing pain have continued to rise (highlight in yellow below).
The takeaways from this data, however, illuminates only a small slice of opioid use in the U.S. Medicare generally only covers the elderly or the disabled. Additionally, this data does not capture the strength of drugs prescribed (in morphine milligram equivalents) in each of those claims. The data for Medicaid, which provides assistance to low-income beneficiaries, is only publicly available for 2015.
The rise of fentanyl
Understanding the opioids use is further complicated by the misuse of legitimately prescribed drugs and of course, the use of illegal, unregulated substances for which there is often little publicly available data until there are deadly consequences. The Centers for Disease Control publishes data related to narcotics-related overdoses, and recent spike in drug overdose death is dramatic (and is estimated to continue its upward trend, according to an analysis by the New York Times). Some officials have attributed this deadly turn, in part, to the increased appearance of heroin laced with fentanyl, though they note that the connection cannot be made conclusively without additional data.
Though fentanyl is usually prescribed to cancer patients to help manage pain, law enforcement officials believe that the fentanyl accompanies heroin is more often created in Chinese labs, shipped to Mexican drug cartels, and finally, distributed throughout the United States.
The one of the few instances of meaningful data for examining the rise of fentanyl is produced by the Drug Enforcement Agency (DEA), which does not make its data broken down by state publicly available outside of embedded charts and maps in its reports.
Even then, the data requires further scrutiny. The DEA data, captured in the National Forensic Laboratory Information System (NFLIS), represents the number of times a subset of labs throughout the country have encountered fentanyl in the chemical analyses of substances submitted by law enforcement officials. The tests are run over a sample of what the police have seized (for example, not all bricks of heroin from one case are tested), and not all police seizures lead to a lab analysis of this sort. The pattern of increased appearances of fentanyl is troubling, but does necessarily give a full picture of the true prevalence of fentanyl (or its probable sources).
Meaningful action in face of an ongoing crisis
Meaningful action without meaningful information is difficult. Even the recommendation presented by the commission is unclear on whether prescription monitoring data (on a de-anonymized basis) would be made to the public so that researchers and journalists can independently analyze patterns without relying on the produced reports of government agencies.
For drug companies, monitoring these patterns has become essential. Purdue is facing yet another lawsuit alleging that they failed to notify the DEA that they suspected their drugs were being misused.
How the Trump administration reacts to the crisis will impact all stakeholders, from suppliers to providers to users.
For the president’s part, he told the press at Bedminster today, “We're going to have a tremendous team of experts and people that want to beat this horrible situation that has happened in our country -- and we will. We will win. We have no alternative.”
1 U.S. Drug Enforcement Administration, Diversion Control Division. (2017). Figure 3 & 4, Fentanyl reports in NFLIS, by State, 2001 & 2015. In NFLIS Brief: Fentanyl, 2001–2015 (p. 2). Springfield, VA: U.S. Drug Enforcement Administration.