Transcript for CDC Telebriefing: New Vital Signs Report – Today’s Heroin Epidemic

Please Note: This transcript is not edited and may contain errors.

OPERATOR: Welcome, and thank you for standing by.  At this time, off participants rain in a listen only mode. To ask a question, press star-one and record your name at the prompt.  This call is being recorded. If you have any objections, please disconnect at this time.  I’d like to turn the call over to your host, Mr. Tom Skinner. You may begin. 

TOM SKINNER:  Thank you, Victor, and thank you all for joining us today for the release of a new CDC “Vital Signs,” this one on how states can help address the heroin epidemic. We’re joined today by the director of CDC, Dr. Tom Frieden. We also have Dr. Chris Jones with the Food & Drug Administration, one of the authors of the study to help us with your questions, if necessary. I’d like to turn the call over now to Dr. Frieden.

TOM FRIEDEN:  Thank you very much, Tom, and thank you for joining us to discuss this month’s vital signs report. The topic is the heroin crisis.  And we worked closely with the Food and Drug Administration or FDA on this report.  Heroin use has increased rapidly across the U.S. and throughout society. The bottom line is this — heroin use is increasing rapidly across nearly all demographic groups, and with that increase we’re seeing a dramatic rise in deaths.  Information available suggest that two factors are leading to this big increase.  It’s really a one-two punch. First is an increasing number of people primed for heroin addiction because they’re addicted to or exposed to prescription opioid painkillers; and second is an increase in the supply and accessibility and decrease in the cost of heroin. Those two factors we believe are driving this increase and drive the strategy that we need to use to turn it around. I’d like to put this into perspective to start.  In just a decade from 2002 to 2013, the landscape changed.  Although we saw an increase in heroin use among nearly all groups, the largest increases were among women, non-Hispanic whites, and others.  Groups that have historically had lower rates of heroin use.  Heroin use doubled among women and more than doubled among non-Hispanic whites. Alarmingly, nearly all people who used heroin also used at least one other drug in the past year; and most used at least three other drugs. The use of multiple substances increases a person’s risk of overdose.  Most were using alcohol, cocaine, and marijuana in addition to heroin. The relationship between heroin and opioid painkillers was particularly strong. In fact, abuse or dependence on opioid painkillers was the strongest risk factor for heroin abuse or dependence.  People who abuse or who are dependent on prescription opioid painkillers were 40 times more likely to have heroin abuse or dependence. Previous research has found that the rate of heroin addiction among people with a history of nonmedical use of prescription opioids was 19 times higher than those without a history of nonmedical use. As heroin use, abuse, and dependence have increased, so have heroin-related overdose deaths. In fact, we found that the rate of heroin-related overdose deaths nearly quadrupled.  In 2013 alone, more than 8,200 people died from heroin overdoses. Most heroin-related overdose deaths that year, 60 percent, involved at least one other drug.  I want to put this in perspective. There are by the best estimate a little over 500,000 people who are addicted to heroin in the U.S.  the fact that more than 8,000 of them died in a single year suggests that around 1 in 50 people who are addicted to heroin may die from it in each year of their addiction.  That’s a remarkably high proportion and reflection of how dangerous it is to have a heroin addiction, to have heroin supply from sources where the purity may change rapidly, and to use it by an intravenous route. I’d like to comment that there is sometimes a perception that as measures to improve prescribing of prescription opiates have been ruled out, there’s been a move to heroin among people who had previously been on prescription opiates.  I think that’s actually not what’s happening. That’s not what the data shows.  While it’s certainly the case that may be what happens for some individuals, in general what we’re finding is that the higher the rate of the prescription opiate use, the higher the rate of heroin use. What we really think is happening, it’s the one-two punch of more people primed for heroin addiction because they’re addicted to opiates, essentially the same chemical with the same impact on the brain as heroin.  Then second, that increase in supply and access and decrease in cost of heroin.  Heroin costs roughly five times less than prescription opiates on the street, although obviously the data on that is hard to come by.  The latest analysis of heroin trends adds to the real devastation that the opioid epidemic is causing in communities across the country.  Most people coming in to treatment for heroin addiction report injecting the drug; and I’ll tell you that as a doctor who started my career taking care of patients with HIV and other complications from injection drugs, it’s heartbreaking to see injection drug use making a comeback in the U.S.  we’re seeing clusters of Hepatitis C and of HIV coming from opioid injection. The opioid epidemic cuts across the life span.  In addition to abuse, overdose and death, we’re seeing rising rates of neonatal abstinence syndrome. That’s a series of issues for newborns exposed to drugs in the womb with tragic consequences. We’re also seeing drunk driving and opioid-related falls among senior citizens.  So fundamentally the question is what can be done. There are things that can make a difference. With heroin impacting community and families across the nation, everyone can help fight this and become part of the solution.  Change at the state level is particularly critical to address the heroin epidemic. The approach has to include both prevention and treatment and recovery for those who abuse or are dependent on heroin.  States can make prescription drug monitoring programs timely and easy to use, can look at the data and practices of state Medicaid and workers’ compensation programs, and increase access to substance abuse treatment services including medication-assisted treatment or M.A.T. They can ensure that Medicaid and other insurer provide coverage for all forms of M.A.T.; and supported adoption of M.A.T.  in community settings and support and training for the administration of naloxone or narcan; and people have integrated prevention service including sterile equipment from a reliable source as allowed by local policy and law. They can help {local} jurisdiction put these effective practices to work where drug abuse or dependence is common. Health care providers can also play an important role by following best practices for responsible prescribing to reduce abuse or dependence, understanding that there’s a risk and a benefit to every medication; and for prescription opiates, the risks very palpable. A few doses and someone can have a life of addiction. A few pills too many, and someone can die from overdose. Prescribers can also use drug monitoring programs and ask patients about current or past drug and alcohol use prior to considering opioid treatment, they, prescribers can also use non-opiate means of addressing non-cancer pain or chronic pain syndromes and can link patients who do have problems with effective substance abuse treatment service and ensure if they are using prescription opiates, they use the lowest effective dose, and the minimum quantity needed.  In the federal government, we’re undertaking a series of measures to address the problem. One is developing prescribing guidelines for chronic pain. These guidelines will help advise health care providers and are due out early next year.  In the meantime, we’re asking providers to be judicious when prescribing these drugs because they are so powerfully addictive. We are also supporting the use of prescription drug monitoring programs which are electronic data bases that track the dispensing of certain drugs as a routine part of clinical practice, increasing access to substance abuse treatment services, expanding the use of medication assisted treatment, supporting the development and distribution of naloxone which can reverse overdoses, supporting the research, development, and approval of pain medication that’s may be less prone to being abused, although would still be addictive.  Improving surveillance to track trends, identifying communities at risk, and target prevention strategies. It’s so important that Secretary Burwell has introduced an opioid initiative that emphasizes prescribing but use of naloxone as keepers to reversing this epidemic. We’re working with closely with law enforcement, the drug enforcement administration, and local and state law enforcement entities to work together to focus on communities where heroin may be increasing. This is an important partnership so that we can support the efforts of law enforcement to make heroin less accessible and to increase effectively the cost of it as occurs with other addictive substances if the cost increases, the use decreases. Our goal is to prevent people from starting to use heroin by reducing prescription opioid misuse, reduce heroin addiction by ensuring access to medication-assisted treatment, and reverse heroin overdose by exposing the use of naloxone.  The bottom line is that heroin use increase s increasing among nearly all sectors of society largely driven by an increase in prescription of and addiction to opioid painkillers, claiming people for heroin use and for cheaper, more available supplies of heroin. We need an urgent, all-of-society response to improve prescribing, help those who are addicted for treatment, and work with law enforcement at all levels to reduce heroin supply. Everyone has a role to play.  States, public health, health care providers, families, communities, law enforcement, and to those who may be addicted or become addicted, seek help because treatment works. So I’ll stop here, and we’ll turn it over for questions. 

TOM SKINNER: Hey, Victor, I believe we’re ready for questions, please. 

OPERATOR:  Okay, sir. We will begin a question-and-answer session. To ask any questions over the phone, please press star-one on your touch-tone phone. Unmute your phone, and record your name at the prompt. To withdraw your questions, press star-two. One moment, please, for incoming questions. Our first question comes from Mike Stobbe with the Associated Press. Your line is open. 

MIKE STOBBE:  Hi, thank you for taking my question.  I have two questions actually. I think I heard Dr. Frieden use the name 500,000 to talk about the number of abusers of heroin. I was wondering, the survey talks about people that used heroin in the past year.  I was wondering in the 2011-2013 segment, how many people roughly that translate to? How many hundred thousand people said they used heroin in the past year? What had that number been back in the 2002 to 2004 range?  I have a second question.  I can tell you now or after that. 

TOM FRIEDEN:  Why don’t we take the first question. I’ll turn that over to Dr. Chris Jones, he is the first author of the report. 

CHRIS JONES:  Sure. To answer that question, when you look at the first time cohorts we included in the study, 2002 to 2004, there were roughly 379,000 people who reported past year use of heroin.  That’s essentially any use of heroin in the 12 months prior to the survey being conducted. Contrast that with 2011-2013, and that number could annual average between the three years was 663,000. 

MIKE STOBBE: Okay.  Thank you. 

CHRIS JONES: Almost 300,000 more people reported past year use of heroin. 

MIKE STOBBE:  Okay. Thank you and the other question had to do with white people.  The table talks about the increase 114 percent increase in white people, and then a negative 15 percent in other groups. I was wondering why we think this is so concentrated among Caucasians; and when the statistic flip, I see going back through the years, it looked like 2008-2010 was really when we saw the biggest jump — what happened in those years if that was the time when white use eclipsed the use by other racial or ethnic groups? 

TOM FRIEDEN:  This is Dr. Frieden.  I’ll start the response, then turn it over to Dr. Jones to continue.  In general what we’re seeing is more of a leveling than a greater increase.  That though the rates higher in some groups than the other, what we’re seeing is an increase throughout money different sectors of society.  Dr. Jones? 

CHRIS JONES:  Right. So specific to your race/ethnicity question, I think, and this is consistent with other data sources that are in the peer reviewed literature, that we see a demographic shift in the last 10 to 15 years compared to 40 or 50 years ago where the profile of people who are reporting heroin use, again, as Dr. Frieden said, not finding declines anywhere, but where we’re seeing greater increases are among the population who seem to mirror the populations who reported high rates of prescription opioid abuse in the last 15 years or is on.  That’s the white, increases among males — sorry, females compared to male could privately insured higher incomes.  So I think you’re starting to see the population of heroin users more closely resemble what we’ve seen in the past decade or so with prescription opioids.  And i think it is as pointed out from the strong risk factor from this research around prescription opioid abuse independence and having specifically higher odds of heroin use independence and prior research shows that prior nonmedical use is a significant risk factor for heroin initiation. 

TOM SKINNER:  Next question, Victor. 

OPERATOR:  Our next question comes from Lenny Bernstein with the Washington Post. Your line is open. 

LENNY BERNSTEIN: Hi, thanks for taking my question.  Among the 8,200 people who overdosed in 2013, I think Dr.  Frieden said 60 percent involved one other drug.  Does that mean you found it in their blood streams, or they were known to be taking that drug?  What does “involved” mean? 

CHRIS JONES: This is Chris Jones.  So among the — way the particular drugs involved in  death are listed on the death certificate is the determination by the official who fills out the death certificate for the medical examiner or coroner that the other were a contributing cause, than they were simply present. 60 percent of deaths where other drugs were involved, what that means is they were determined to be a contributing cause to the death; and the death was an overdose or a drug poisoning and heroin was also a contributing cause. 

LENNY BERNSTEIN: Thank you.  And do you know, are prescription opioids the most common among those other drugs? 

CHRIS JONES:  They’re not actually.  Cocaine is the most common co-involved substance among the heroin deaths. 

LENNY BERNSTEIN: Thank you. 

TOM SKINNER:  Next question, Victor. 

OPERATOR: Our next question comes from Claire Hews with Times Union.  Your line is open. 

CLAIRE HEWS: Thanks for taking my question.  Dr. Frieden, I was hoping to clarify something that you talked about in terms of speaking about the move to heroin among people who had previously been on prescription opioids.  Is what you’re saying that the — they continue to take both the heroin and the opioids together and that it’s not a move from one drug to the other? 

TOM FRIEDEN:  I was addressing what is sometimes a perception. It is the case that there has been some progress in the last few years reducing overdose deaths from prescription opiates; and there’s a perception and for some individuals there may be the reality that because it got harder to get prescription opiates they switched to heroin. The broader trend that we’re seeing is that so many people, but 12 million, have used a prescription opiate in the U.S.  and those people, many of them, I shouldn’t say those people, many of those individuals, perhaps as many as half, may be frequent users of prescription opiates; and therefore, primed or highly susceptible to addiction. The chemical is essentially the same between the prescription medication and heroin. When heroin is five time cheaper and much more widely available, it becomes something that’s driving this trend of rapid increase in heroin use. I don’t know if that was clear. 

CLAIRE HEWS: No, I actually did understand that.  I guess I didn’t understand what perception it was — this seems consistent with what we’ve been writing.  I don’t exactly understand what perception it was you were trying to overcome, was it that people think that one drug is leading to another and then it’s not an issue of availability, supply, et cetera? 

CHRIS JONES: This is Chris Jones. I think it was the idea from the policy perspective that policies that had been put in place to curb inappropriate prescribing are what’s driving the problem; however, you see in many states that there were shifts toward heroin long before states were robustly addressing the prescription opioid issue; and I think as this study points out and other studies have found similar things, it’s very much a gray area. People will initiate heroin use but will go back to prescription opioids or use in combination, depending on what’s available there. In 2013, 45 percent of people who used heroin in the past year, met criteria for abuse or dependence on prescription opioids. 

TOM FRIEDEN:  This is Tom Frieden again. Let me put it more clearly; approving practices for prescription opiates is part of the solution, not part of the cause of the heroin problem. 

CLAIRE HEWS: Okay, I understand the point you’re trying to make now. Thank you very much. 

TOM SKINNER:  Next question, Victor. 

OPERATOR: Our next question comes from Robert King with the Washington Examiner.  Your line is open. 

ROBERT KING: Thanks for taking my question.  I was wondering if you could touch on the role of abuse deterrent opioids, painkillers. Have they been helping to stem any of this transition or anything, or how have they aided the issue? 

CHRIS JONES:  I think the science on abuse deterrence is still very new and it’s important to point out that — sorry, this is Chris Jones. So it’s important to point out that the products that have received labeling from FDA, four products that talk about abuse deterrent properties, have been designed to deter primarily intranasal or injection drug use, but can still be abused by those routes; and certainly can be abused orally and retain their addictive properties and I would say that there are some studies that find some declines in abuse of particular products that have reformulated to an abuse deterrent product or have labeling for abuse deterrence. But I think it’s unclear of the longer term public health impact. More study needs to be done to really understand the role that abuse deterrent plays in the broader policy scheme of addressing opioid use. The goal would be to have pain medications effective at improving pain and function that are much less prone to abuse through all routes. I mean, the ultimate goal would be to have newer classes of pain relievers that are not prone to addiction or to have opioid products that are reformulated in a way that deters abuse by all routes. 

TOM FRIEDEN: I guess I would want to make clear that abuse deterrent doesn’t mean not addictive.  Means it may be harder to melt it down and shoot it up or abused in other ways, but they remain highly adaptive medications which if you take too many too doses will result in death. 

CHRIS JONES: I’ll add there have been no studies that show any product that has been reformulated has shown any reductions on addiction or any reductions in overdose death as far as any robust study. 

TOM SKINNER: Next question, Victor. 

OPERATOR: Once again for any questions over the phone lines, please press star-one on your touch-tone phone and report your name. Our next question is from Stacy Singer with the Palm Beach Post. Your line is open. 

STACY SINGER: Hi. Thank you. I’d like you to flush out a little this idea of alternatives to using these opioid pain medications, and I’m specifically wondering what — whether you and the FDA, whether the CDC and the FDA have been communicating with each other on this issue. I mean, I’m old enough to remember a time when pain of not treated with this class of drugs at all and seems like thing went better back then. Why are they still on the market?  That’s one of my questions. 

TOM FRIEDEN: CDC and FDA do work closely together. In fact, this is Dr. Frieden, sitting here with Dr. Jones, first author on the article and previously with CDC. The — if you go back in time far enough, you’ve seen a pendulum swing multiple time about use of opioid medications for pain and other conditions. Initially going back almost 100 years, they were widely used.  Then it was widely understood how devastating the addiction was.  For then about a generation, they were not used, and even there were — battle days when people with excruciating pain from cancer or other conditions were not treated, and then the pendulum swung again. I can see that when I went to medical school could we got one lecture on pain which we were told that someone with pain who got an opiate would not get addicted.  And that’s absolutely false.  We’re seeing now the need to really get it right in terms of risks and benefit. If someone has severe terminal pain from cancer, you absolutely want to provide all palliation. If someone has excruciating pain from a surgical procedure or a car crash, you absolutely want to provide pain relief.  For chronic non-cancer pain, you really have to look at the risks and the benefits and the risks are very, very clear. A few pills and you can get addicted. A few pills too many, and you can die. The benefits are far less clear because of acclimation to the drug and way the liver metabolizes these drugs, people need higher and higher doses which come closer and closer to lethal doses. Now, getting that risk/benefit ratio right is a challenge. I can say that for myself personally and for patients and friends I’ve cared for, even with severe pain we look for alternative ways to get treated because we recognize that these are dangerous drugs. Those can include nonsteroidal medications, anti-inflammatories of various types, physical therapy, the use of ice, heat, or local measure, movement and  modification of some of the ways that you can trigger or avoid pain, realistic sense of how long it will take for a pain syndrome resolve, encouragement if you see that resolving gradually.  There are a whole host of things that can be done to support patients in a way that’s both safe and effective. Dr. Jones? 

CHRIS JONES: I’ll add from an FDA perspective, I think we recognize the limitations of opioids in treating all types of pain, and certainly the revisions we made to our labeling a couple of years ago for the release long-acting opioids of an attempt to clarify the patient population who are likely to have benefit from receiving opioids and one particular point of that labeling change is in the limitations of use. We actually specify to providers to reserve these products for use in patients for alternative treatment options that includes non-opioid analgesics or immediate relief opioids, that would not be adequate to provide sufficient pain management.  At the same time, we recognize for many types of chronic pain or musculoskeletal and neuropathic pain, opioids are not the best treatment option. We have tried to work with the drug industry to incentivize development of non-opioid pain medication; and we’ve approved several in the last four or five years that have indications for chronic low back pain or other types of musculoskeletal pain that are — may be more beneficial in those patients than receiving opioids. 

STACY SINGER: I’m in South Florida. Just this morning on the radio, I was listening to radio ads over and over again from a dentist who keeps saying, come to me for dental pain, dental pain, pain, pain. I went, oh, man, dentists are using these, too. How would we tackle that? 

CHRIS JONES: I think partly, you know, from a regulatory perspective, it’s trying to provide the most up-to-date scientific information to help prescribers make the best decision when prescribing.  Fundamentally across the profession, there’s inadequate information.  From collectively an HHS perspective and agencies to work with schools to train new providers to adequately address pain comprehensively, not just writing a prescription for an opioid, but what are the best ways to treat pain for the patient you’re treating. I think that’s a fundamental area of interest for the department. 

TOM FRIEDEN: In addition, the use of prescription drug monitoring programs can identify providers who may have outlier patterns of prescribing opiates and may need either information and education or enforcement action if they’re serving essentially as pill mills. 

TOM SKINNER:  Victor, we’ll take one last question and then have Dr.  Frieden conclude our call. 

OPERATOR: Absolutely, sir.  Our next question comes from Kimberly Leonard with U.S. News & World Report. Your line is open. 

KIMBERLY LEONARD: Hi, thank you for taking my call.  I just want to make sure that I understand this clearly. Are — is the reason that these prescription drugs are given at such a high rate, does a lot of it have to do with misunderstanding by providers?  Dr. Frieden, you mentioned the lecture you received in medical school. Are providers just not aware of the danger they could be putting patients in with these medications? 

TOM FRIEDEN:  I think it can be challenging for providers; and often the path of least resistance is to write a prescription rather than spend the time to address some of the root causes of the patient’s pain and it may be that the individual doctor doesn’t see the long-term consequences for that individual of addiction, overdose, death, and the social and medical impacts that it can cause. I wouldn’t want to blame physicians. There are real challenges in addressing what patients expect and taking the time in what can be a very busy office encounter it ensure that what we’re providing as physicians is not the most treatment but the best treatment and the most appropriate treatment. 

KIMBERLY LEONARD: So is it clear whether most of these prescription comes directly from a doctor or whether there are teens who maybe going g into grandmother’s medicine cabinet or something?  Is it clear where they’re getting access?  Does it t seem to come mostly from physicians and people who shop around for doctors? 

CHRIS JONES:  This is Chris Jones. I would say the vast majority of prescription opioids used for nonmedical purposes originate from a prescription. 

KIMBERLY LEONARD: Okay. 

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U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES