Sunday, July 9, 2017

Does Farr's Law bring us Good News?

Narcotics are back in the news. I have not been effective at hiding my feelings about opioids. I have applauded Opioid Guidelines from the CDC. I have lamented the sheer volume of Americans that are dying of drug overdose. In Like a Broken Record, I recently updated the fatality rates,and frankly the numbers are staggering. It appears that despite a variety of efforts, national and local, the situation is not improving. Death by overdose 

I have noted Ohio's challenges with opioids, and the prescription drug monitoring program efforts. Ohio was noted in prior posts as having the fifth highest drug overdose death rate in the nation. Perhaps that is not so unexpected, it is the seventh most populous state. But Ohio has nonetheless made the news regarding overdose. In 2017, NBC News reported that one Ohio coroner lacked storage capacity for the bodies, and had resorted to a special trailer. 

NBC recently reported that in Florida there is a Death Race in which first responders rush from one overdose to the next. This report noted that in one small Florida town first responders recently attended to three overdose calls in two hours, all before the sun set one Friday evening. A firefighter was quoted concluding "The overdoses are everywhere." It is not a problem in specific populations or neighborhoods, it is now ubiquitous. Now, first "responders find people who have overdosed in restaurant bathrooms and on park benches, in private homes and while driving through busy intersections." 

Death Race concludes that the overdose death rate in 2015 was 52,000 Americans. That could be the entire population of Lompoc, California, or Cape Girardeau, Missouri. That is about the seating capacity of Sun Bowl Stadium (below, courtesy of Wikipedia.org) at the University of Texas, El Paso.  


That is a great many people, every year. 

The first responder battle against overdose has been aided by a product called Naloxone. It is an antidote that counteracts the effects of opioids. It is now being carried by first responders in most counties and towns. It has had immediate results in some cases, actually reviving patients that have lost consciousness following overdose. 

There are complaints, however, that first responders struggle to keep Naxalone in stock. According to the New England Journal of Medicine, Naxalone has been around for decades, and is produced in generic forms. The approval of "autoinjectors" to facilitate use by those without training was fast-tracked in recent years. States have worked to put Naxalone in the hands of people who could use it to prevent overdose in family members and others. Despite the availability of this drug solution to drug culture, fatalities continue to rise. 

Prescription Drug Monitoring Programs (PDMP) have been instigated in almost every state. Missouri remains the last hold-out, failing to see the benefits of monitoring prescriptions. The PDMP tool is showing progress. There is a great deal of effort being invested in slowing overdose and abuse. But overdose continues to plague us. Every few minutes, another American dies of overdose, leading me to ask What Worthwhile can you do in 11.2 Minutes

The Partnership for Drug Free Kids, says that drug overdose is expected to be about 52,000 again in 2017, about 16.1 deaths per 100,000 people. But it is not likely to be proportional around the country (some localities will be hit harder than others). In 2015, according to the Centers for Disease Control (CDC), the leading states were "West Virginia (41.5 per 100,000), New Hampshire (34.3 per 100,000), Kentucky (29.9 per 100,000), Ohio (29.9 per 100,000), and Rhode Island (28.2 per 100,000)." 

It is a relief to not see Florida in that group. However, the CDC says that Florida is among states with "statistically significant increases in drug overdose death rates from 2014 to 2015." That group of increasing states "included Connecticut, Florida, Illinois, Kentucky, Louisiana, Maine, Maryland, Massachusetts, Michigan, New Hampshire, New Jersey, New York, North Carolina, Ohio, Pennsylvania, Rhode Island, Tennessee, Washington, and West Virginia." 

It is probably significant that West Virginia, Ohio, Rhode Island, and New Hampshire made both the list of highest rates of death and the list of states experiencing "significant increases." 

But, there is perhaps light at the end of the tunnel. The Partnership for Drug Free Kids claims that "drug overdose deaths may peak in 2017." It cites "experts at Columbia University" and concludes that death rates will begin declining in 2018. Then by "2034 the overdose rate could fall back to rates last seen in the early 1980s." This, according to a study published in Injury Epidemiology, discussing Farr's Law. 

Farr's Law "states that an epidemic usually follows a symmetrical curve that rises before subsiding." This paradigm has been used to "map" and study outbreaks such as "the AIDS epidemic, smallpox outbreaks and cattle disease." The authors concede that application of Farr's Law has met with "mixed results." Perhaps this "law " is "more what you'd call "guidelines?" (Pirates of the Caribbean, Curse of the Black Pearl, 2003). 

It is also interesting that there is no distinction being drawn between the nature of events discussed. Certainly, addiction is a medical condition in many instances, but see Legislative Words. Some will nonetheless question whether Farr's Law can be effectively used to predict epidemiology of drug death, which has a very significant human action component. They will posit that overdose is not consistent with disease processes like smallpox, and that therefore spread and effect cannot be mapped or predicted using such a model. 

The Injury Epidemiology authors endorse the role of prescription medications espoused by others. They "note that when access to prescription medication becomes more difficult with enforcement of prescription drug monitoring programs, there is a danger that people will shift to alternative substances such as heroin." They encourage "multifaceted interventions such as the expansion of prescription limits, increased drug screening, requiring pain contracts, and the distribution of Naloxone to first responders,” 

The authors contend that if death rates begin to recede in 2018, it will be attributable to these and other efforts that have been deployed in response to our overdose pandemic. They contend that these educational and treatment efforts are similar to, and will effect similar results as, other epidemiological approaches to various medical condition challenges like smallpox. 

But, an Ohio city councilman has proposed another solution, FoxNews reported. This plan would require that people perform community service to compensate this city for the cost of medical care received from first responders. Those who have not completed that service requirement would not be eligible for first responder services after "two overdose rescues by first responders." So, limited resources (first responder's time, Naxalone, etc.) would be rationed based upon a patient's past performance. 

Overdose once, receive care, and begin to pay back with community service. Overdose again, receive care, and begin to pay back with community service. Overdose a third time before that community service is complete, under this proposal, and you are seemingly on your own. Dan Picard, the Ohio city councilman, apparently envisions emergency dispatchers evaluating incoming 911 calls for help, and "If the dispatcher determines that the person who's overdosed is someone who's been part of the program for two previous overdoses and has not completed the community service and has not cooperated in the program, then we wouldn't dispatch.” 

In a Washington Post story, it is reported that there are police agencies whose officers carry Naxalone. However, there are sheriffs and police chiefs who view that first responder role as one for firefighters or emergency medical technicians (EMT), not police officers. There is a debate regarding this distinction. One Ohio sheriff says “I'm not the one that decides if people live or die. They decide that when they stick that needle in their arm.” The Sheriff is in the same community as the councilman proposing the third strike rule. 

As I read that story, I was reminded of the movie Airplane, and its parody of various 1970s "point - counter point" news segments. In this parody, Jack Kirkpatrick (a fictional character in the movie) is addressing the fact that a plane full or passengers is aloft with many ill and a plane piloted by one of the passengers, their situation is serious. Jack makes his point to his co-host, saying "Shanna, they bought their tickets, they knew what they were getting into. I say, let 'em crash." 

It was a funny bit of Hollywood sarcasm. But is Councilman Picard's proposal different? Are we at a point where some will die because responders will not be dispatched? Some will undoubtedly note that dispatchers are daily engaged in high-stress, difficult decisions, and that they cannot be asked to take on such additional "financial" distinction decisions. It may therefore be unrealistic. Even without that, however, will we reach a point where people will die because of the sheer volume of overdose and the simple fact that there are only so many first responders, or so much Naxalone available? 

In the midst of America's response to opioids, perhaps it bears remembering that this county was led into the panacea of opioids in the 1990s. It was led in by the manufacturers of various pills and a medical community all to willing to distribute them. There were those who prescribed them freely, and there were assurances that Opioids were the solution to pain. We were assured that there was no down side, no danger, no problem. And we were mislead. More study should have been done, better understanding should have been demanded. We failed to be skeptical and failed to demand valid proof before stepping into this abyss and now people are dying at epic rates despite our best collective efforts to address both the new prescriptions, and the growing illicit supplies. 

I know I sound like A Broken Record, but people taking these drugs are not alone in their suffering. Their families, their children, are increasingly affected by the decisions to use drugs. When overdose takes them, they leave behind people who loved them, whose lives were supported or enhanced by their presence. And as we look forward to (hopefully) the Farr's Law predicted downtrend in overdose nationally there are those who predict that we may be rushing headlong into similar acceptance of other chemicals. Some lament that rush to acceptance of marijuana, questioning whether there is currently enough data and study to make valid conclusions about its side effects and potential complications. 

There is hope that the Farr's Law predictions will be valid. That we could see a marked decline in overdose death in coming years is indeed an encouraging thought. That we could otherwise witness difficult decisions about allocating the limited resources of first responders is troubling, and it illustrates that all resources are limited and allocation decisions are always difficult. But, allocation is more troubling when death is the probable outcome. Will the Farr's Law prediction bring relief, or will people continue to die. Could we have avoided this situation entirely? Tough issues that require thought as people continue to struggle with addiction, death, and familial/social devastation.




#opioids
#workers compensation
#farrs law
#overdose
#naxalone

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