Transcript for VitalSigns Teleconference: Opioid Overdoses Treated in Emergency Departments

OPERATOR: Welcome and thank you for standing by. All participants will be on a listen only mode until the question and answer session of today’s conference. At that time, you may press star, then one, to ask a question from the phone lines. Also, this conference is being recorded. If you have any objections, you may disconnect at this time. I would now like to turn the call over to your host, Ms. Kathy Harben. Ma’am, you may begin.

KATHY HARBEN: Thank you Katie, and and thank you all for joining us today for the release of a new CDC “Vital Signs,” which describes recent trends in opioid overdoses using emergency department data. We’re joined today by CDC Acting Director, Dr. Anne Schuchat and we’re also pleased to have the U.S. Surgeon General Dr. Jerome Adams. Dr. Adams will have to leave after his remarks. We also have Dr. Alana Vivolo-Kantor. She’s one of the authors of the study and she will also be part of the Q&A. I’ll turn the call over now to Dr. Schuchat.

ANNE SCHUCHAT: Thank you Kathy and thank you all for joining us today to discuss CDC’s Vital Signs report. Each month, we focus on the latest data about one of the critical health issues facing our nation, and what can be done about it. This month, we are reporting on recent emergency department visits for opioid overdoses, which unfortunately have increased in all parts of the United States. Data on the opioid overdose epidemic have featured death rates for the most part. We’re currently seeing the highest drug overdose death rates ever recorded in the United States, driven by prescription opioids and by illicit opioids such as heroin and illicitly-manufactured fentanyl. In 2016, there were more than 63,000 drug overdose deaths and more than 42,000 of those deaths involved an opioid. This means that, on average, 115 Americans died each day from an opioid overdose involving prescription or illicit opioids in 2016. We have been challenged to keep up with this fast-moving epidemic. This new release includes the most timely data available to CDC from large numbers of emergency departments, helping us track developing trends on opioid overdoses. Our results through September of 2017 show that opioid overdoses are increasing across all regions, most states, for both men and women, and most age groups. Our report is based on data from emergency department visits in 52 jurisdictions, within 45 states from July 2016 through September 2017. Out of 91 million emergency department visits, there were 142,557 suspected overdoses involving opioids. Opioid overdose emergency department visits increased about 30 percent overall in this national system. All five regions of the U.S. saw significant increases during this time period. The Midwestern states increased the most dramatically, about 70 percent. We saw substantial increases in both men and women and in all age groups 25 and over. Specifically, there was a 31 percent increase among those aged 25-34, a 36 percent increase in the 35-54 year old age group and a 32 percent increase for people 55 and older. We also had state-specific information for 16 states hit hard by the opioid overdose epidemic, and saw increases averaged 35 percent. 10 out of these 16 states saw significant increases during this time period. The largest increases were in Wisconsin, at 109 percent, which means the rate more than doubled there. A similar rise of 105 percent was seen for Delaware. There was variation among states in the Northeast and Southeast. In the Northeast, for example, while Delaware’s opioid overdose emergency department visits more than doubled, other states like Massachusetts, New Hampshire, and Rhode Island showed modest decreases that were not statistically significant. These decreases may possibly be related to implementation of interventions, including expansion of access to medication-assisted treatment. The largest decrease was in In Kentucky, which saw a decrease of 15 percent. The decrease in Kentucky during this period of time may reveal some fluctuations in drug supply, and we will need to investigate this further for confirmation. We saw increases in cities and towns of all types from the third quarter 2016 to the third quarter 2017. Opioid overdoses in large central metropolitan areas, which have a population of one million or greater, including a principal city, increased steadily each quarter, for a total increase of 54 percent. Up until now, we have been reporting on the tragic loss of life from overdoses, but for every fatal case, there are many more nonfatal cases, each one with its own emotional and economic toll. Research shows that people who have had at least one overdose are more likely to have another. However, if the person is seen in the emergency department, we are presented with an opportunity to take steps toward preventing a repeat overdose, ideally linking an individual to care and potentially preventing an overdose death. And ideally, alerting community partners to opportunities to improve prevention in the surrounding areas. We can all learn more about overdose prevention and what to do if an overdose occurs in order to save a life. For example, naloxone is a drug that can reverse the effects of opioid overdose and can be life-saving if administered in time. Everyone can learn about naloxone, its availability, and how to use it. Each time naloxone is used to “wake” a person from an opioid overdose, we can think of amplifying the wake-up call. The episode is not just a potential turning point for the individual who may be struggling with opioid use, but also a critical alert for the surrounding community to any underlying problematic opioid use. These episodes can mobilize response efforts that can help the community and the state. Now, I’m so pleased to turn the call over to Surgeon General Dr. Jerome Adams.

JEROME ADAMS: Good Afternoon and thank you, Rear Admiral Anne Schuchat. As the nation’s doctor, I am grateful for CDC’s work on getting ahead of the opioid overdose epidemic that is having such a devastating impact on individuals, families, and communities. I have encountered the complexities of treating and responding to opioid overdoses, not only professionally as a physician, but also personally, as this topic hits close to home for me. As many of you may have heard, my younger brother has struggled with addiction for decades, and I often contemplate on the fact that it could have been me. My brother and I, we’re not that different. My whole family, like many other families in America, have experienced a similar story, and over the years, have witnessed, first-hand, the pain that comes from opioid use disorder, which is commonly referred to as addiction. The science is clear: addiction is a chronic disease and not a moral failing. As you may have heard at the White House last week, the administration has three priorities. Number one, saving lives. Number two, decreasing supply. Number three, decreasing demand. As the United States Surgeon General, I am focused on several aspects of the opioid crisis. First, I am focused on putting naloxone in the hands of first responders and community members. Naloxone is a medication that can reverse the effects of an opioid overdose in an emergency, as Dr. Schuchat mentioned earlier. I want people to know that everyone can help save a life. Second, I am working to educate the public about the severity of the epidemic, and working with our communities to destigmatize addiction. It is a chronic illness that must be treated with skill, compassion and urgency. In the Office of the Surgeon General, we are working on a series of initiatives that will help Americans understand the severity of this epidemic. Third, we must prevent addiction before it starts. We are working with health care professionals to improve safe prescribing practices. We are trying to help patients understand the benefits of alternatives to opioids, as well as, how to safely use, safely store and safely dispose of prescription opioids. To successfully combat this epidemic, everyone must play a role. There are many ways that different responders can come together to prevent opioid overdoses and deaths. Health departments are central to a coordinated outreach among many players. They can use this emergency department and other health surveillance data to alert the community and help inform action plans for a timely response. For example, health departments can make sure there is enough naloxone in the hands of emergency responders or friends and family of those patients with opioid use disorder in accordance with state and local policies. Local emergency departments are key players for surveillance because they have direct access to patients who have recently had an overdose. They can provide naloxone to take home to prevent future overdoses, and give training to the overdose victim and their family on how to use it. They can also serve as important links for follow up for opioid use disorder. Emergency departments can link these patients to mental health and substance abuse treatment centers, which can assist them in gaining access to Medication-assisted treatment or MAT. MAT combines behavioral therapy and medications to treat substance use disorders. Innovative emergency rooms are even prescribing MAT directly in emergency rooms after an overdose. Public safety and law enforcement have a critical key role in this response, as they are a frequent touch point and can quickly identify changes in the illicit drug supply of an area. As trusted conveners, they can and should coordinate with local partners, particularly public health departments. Community-based organizations can assist in mobilizing a community-wide response to those most at risk. For example, they can provide resources to reduce harms associated with injecting drugs, such as facilitating screening for HIV and Hepatitis B and C. They can also help with referrals to treatment and naloxone provision. And finally, perhaps most importantly, community members and friends and family of those who use opioids can help bridge the gaps by connecting with organizations that provide public health and medical services. They can support people in treatment and recovery and work to increase naloxone distribution and use. As I mentioned earlier, this issue is personal for me. Only by committing to partnerships will we be able to turn this tragedy around, this tragedy that is the opioid epidemic. Thank you for this chance to join you today, I will now turn the call back over to CDC’s Acting Director, Dr. Schuchat.

ANN SCHUCHAT: Thank you so much for your remarks and for all that you are doing for the nation. Today’s Vital Signs includes critical new information on opioid overdoses, and how to respond to them in your area. This fast-moving epidemic does not distinguish age, sex, or state or county lines, and is still increasing in every region of the U.S. The sharp increases and variation across states and counties indicate the need for better coordination and readiness for regional or multiple state outbreaks. Closer coordination between public health and public safety can serve to address changes in the illicit opioid supply and use of illicit opioids, which affects overdose rates. Having the right data available at the right time can help direct the right resources to the most impacted areas. We don’t have to wait until it is too late. Just as important, we need to prevent overdoses by stopping opioid misuse and addressing opioid use disorder, which has been commonly referred to as addiction, so that overdoses don’t occur in the first place. CDC is educating healthcare providers and the public about opioid use disorder, and opioid overdose, and providing guidance on safe and effective pain management. Health departments and law enforcement personnel are coordinating actions to reduce production and impacts of the illicit opioid supply in America through the High Intensity Drug Trafficking Areas (HIDTA) Program. Health departments and medical personnel can support the use of the CDC Guideline for Prescribing Opioids for Chronic Pain to inform clinical practice and protect patients at risk. The bottom line is that no area of the United States is exempt from this epidemic. It will take an effective, coordinated effort by communities, the medical community, public health, law enforcement, and government and to combat it. We need to care for our family members, friends, and neighbors living with or impacted by opioid use disorder, and reduce the risks of opioid overdose and death.

KATHY HARBEN: Thank you, Dr. Schuchat and Dr. Adams. Katie, we are now ready for the Q& A session.

OPERATOR: Thank you. At this time, we would like to begin the question and answer portion of today’s conference. If you would like to ask a question from the phone lines, please press star then one, unmute your phone, and record your name when prompted. If you need to withdraw your question, please press star, then two. Once again, to ask a question from the phone lines, please press star then one and record your name when prompted. One moment please while questions que up. Our first question comes from Mike Stobbe with AP. Your line is open.

MIKE STOBBE: Hi, thank you for taking my call. Two questions, if I may. First, Dr. Schuchat, you mentioned NSST national data, that there was a group, there was a 30 percent increase from quarter three of 2016 to quarter three of 2017 and that there were 142, 000 something overdose visits during that period. Could you give us what the number – what was the number in quarter three of 2016 and the number in quarter three in 2017, so we can see what the 30 percent increase was from. And my second question, you both, Dr. Adams and Dr. Schuchat, talked about better partnerships. Could you give me [inaudible] that suggest we had a problem? That there haven’t been adequate partnerships in place. Clearly, the epidemic is worsening. Could you give us an example of where there have been breakdowns in partnerships or particular areas where partnerships need to be included…improved I mean. Thank you.

ANNE SCHUCHAT: Sure thanks for those two questions. I don’t have the numbers you asked for and we’ll follow up later to see if we can get you them after the call, if they are accessible. In terms of partnerships, they are absolutely central and I would say that it’s been very helpful that we’ve been able to fund 45 states and the District of Columbia through the state health departments in ways that they are working across sectors. Prescription drug monitoring programs in some states are run through the law enforcement programs and in other states are run through the health department. Strengthening the link between the two are vital because clinicians do need access to the information in treating individual patients and the law enforcement needs to oversee those through their purposes as well. We have seen coalitions form in many states and in a lot of communities pulling together public health, public safety, law enforcement, businesses to try to address the epidemic where it is in that individual area. But while I wouldn’t point to an area, where it’s broken down. I would just say this is such a complex epidemic touching really every aspect of life that improving partnerships is essential.

OPERATOR: Our next question comes from Aubrey Whalen with Philadelphia Inquirer. Your line is now open.

AUBREY WHALEN: Hi, thank you guys. I was wondering might be able to speak – I have two questions as well to the significance of looking at ER data and how that compares to just overdose death data in general. You mention this is a more timely way to look at how overdoses are working and I was wondering if you could just expand on it a little bit. I also wanted to ask about the significance in Delaware and Pennsylvania and if you have any idea what happened here and why this is so much higher than in some of the other states.

ANNE SCHUCHAT: Yes, thank you for those two questions. Looking at emergency room data can help us get information before people die and it can be more timely. But we can also learn from this more timely information. Things like where this person was coming from, what time of day, what day of the week, things that can be very helpful for the local community resources to respond. So most states now are using their emergency department data, what we call syndromic data, to identify where resources are needed and where there are gaps. We want there to be warm handoff in the emergency department between resuscitation or saving a life and addressing the longer-term needs for that individual or their support system. So we think the emergency departments are essential [inaudible] in this fast moving epidemic. The Delaware and Pennsylvania increases were concerning. The increase in Delaware, as I mentioned, over the third quarter of 2016 to the third quarter of 2017 was 104 percent and the increase in Pennsylvania was 81 percent. Both of those really reflecting nearly a doubling of the rate. That may be a reflection of recent changes in the local drug supply or the toxicity of the drugs that are available there. We can see very small area variations in which drugs around that are being used on the streets. We don’t have enough data over a long enough period yet to evaluate the different interventions that are occurring. And whether perhaps in Massachusetts, Rhode Island, New Hampshire, where we know they’ve been dealing with this problem for a long time and have put together a lot of programs and policies, whether the lack of a rise in those areas reflect some protection that they’ve been able to afford, even if some of these toxic drugs are finding their ways through their streets. Operator, next question.

OPERATOR: Our next question comes from Tom Howell with the Washington Times. Your line is now open.

TOM HOWELL: Hi, thanks for doing the call. I just want to know what you make of the uptick in kind of urban areas, urban centers, metropolitan centers. Sometimes this has been characterized as a problem mainly for rural areas or rural centers. What do you attribute the urban factor to?

ANNE SCHUCHAT: Yes, I think that was an interesting finding to us in terms of the 16 states where we had data. One note of caution is that that result came just from the 16 states surveillance system, so we will be looking at that in a larger set of states as the system has been expanded. It may reflect changes in the drug supply in the urban centers. We have talked in the past about the rural areas being hard hit with the opioid overdose epidemic. We know that prescribing patterns for prescriptions of opioids have been high in some rural areas, so there may be a difference between the prescribing levels versus the illicit supply. But I would say that we’re going to need to look over a longer time and in more cities and states to understand whether this is consistent or was just at this one snapshot in time in this 16 states. Next question.

OPERATOR: Our next question comes from Corky Siemasko with NBC News. Your line is now open.

CORKY SIEMASKO: Hi, thanks for doing this. I wanted to follow up on my colleagues question on the rise in urban areas. In places like Columbus and in Chicago, we’ve been writing stories about local drug dealers have been cutting their heroin with fentanyl raising the toxicity of it. Is that something that you’re seeing as well. Also, why the decrease in West Virginia? Is that another reporting thing?

ANNE SCHUCHAT: The issue of cutting the heroin with fentanyl or some of the fentanyl analogs like carfentanil is a very major problem right now. We have seen in a number of areas, the toxicity of the drugs, even being a risk for the responder community. So, I think what you were seeing in Columbus for instance is for sure occurring in other areas. The second question – West Virginia, yes, okay. West Virginia has been a very hard hit state and they have been putting in place some measures. I think we, my analysts tell us we have to be quite cautious in the places where we’re seeing declines or no rises. But we do know that West Virginia, the health department, the public law enforcement, the governor, people are really — have been focusing on this. So we hope that it’s a positive sign that will persist.

CORKY SIEMASKO: Very good.  Thank you.

ANNE SCHUCHAT: Next question, operator?

OPERATOR: Our next question comes from Abby Goodnough with the New York Times. Your line is now open.

ABBY GOODNOUGH: Hi there, thanks. I have two questions, actually. I’m wondering, one, if you see a role for emergency departments to actually initiate medication assisted treatment before an overdose victim leaves the emergency room, whether that’s something you would recommend. And also I’m wondering if it’s fair to say that most of these overdoses are attributable to heroin, and especially fentanyl, and whether you can parse out how many are due to prescription opioids and where at this point?

ANNE SCHUCHAT: Thank you. We think that the idea of initiating medically assisted treatment in the emergency department is an innovative and exciting strategy. There are some who are concerned that it may be difficult to do that or that it may be better to give the person a little bit of time to wake up and recover and be aware that they are initiating, but I think that further study of it is very important and right now there’s enough diversity of what’s going on around the country that we do think trying innovative approaches makes sense, ideally coupled with evaluations. Many — another innovative approach is the idea of navigators. So a person in the emergency department whose job it is to follow up with the person after they’re awake, after they’re home to make sure that they do get connected and potentially help link them with medically assisted — medication assisted treatment a few days out. So I think both a navigator, a warm handoff and initiation in the emergency department are important strategies to address. You also asked about what was the drug or the combination of drugs, and I need to say that our analysis does not include that data. As you know, it can sometimes take a bit of time to determine which of many drugs was present in the setting of an emergency department overdose or a fatal overdose through the medical examiner’s offices. I have learned in the course of my travels that in some emergency departments drug testing is not routinely done because once the person has woken up, there’s not a clinical reason to know what the drug was and there’s not an insurance reimbursement for testing that drug. So right now that’s somewhat of a barrier for us in knowing exactly what products were on board. We also have limitations in some of the toxicity testing to test for all of the newer analogs and the turnaround time for that testing. So as you’ve heard us say before, the infrastructure to fully tackle this problem is fragile and we’re glad that there is so much attention and policy interest and potentially additional resources to help with that. We know that prescription drug use in the U.S. even with the declines that we’ve seen in the past few years is still three times higher in the United States than in Europe, but that on top of that the heroin and other illicit drug supply has gotten even more dangerous than it used to be. So for the overdoses in this emergency department I can’t answer your question. Sorry for the long non-answer. Next question, operator?

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

LEONARD BERNSTEIN: Hi. Thanks for taking my call. I’ve been in places where you have like a fentanyl cluster and then across the street or very near — very close by you have empty treatment beds or you have available treatment and no one is taking advantage of it. Are you suggesting that initiating the treatment in the emergency department is a way around that or — and if not, what would you do about that?

ANNE SCHUCHAT: You know, as you heard the surgeon general describe, opioid use disorder or addiction is a long-term disease. It is not unexpected for people to have relapses even after recovery and learning the best way to help people be ready for care and help them succeed with care is critical. So, you know, SAMHSA, the Substance Abuse and Mental Health Agency really leads the treatment work for the health and human services department and is exploring ways to increase access and assure the quality of care, but how we actually most successfully get people in care that will work for them is still a challenge. We know in some parts of the country access to care is a barrier and others, as you mentioned, there may be care that’s not being used. I think, operator, we have time for one more question?

OPERATOR: Our final question today comes from Felice Freyer with the Boston Globe. Your line is now open.

FELICE FREYER: Hi. Thank you. I have a question about states that saw a decline in — in these overdoses. Were these states — we only have the change, we don’t have the actual rate and I’m wondering if in places like Massachusetts and West Virginia the rate of overdoses is still higher than the average.

ANNE SCHUCHAT: Thank you for your very astute question. Sometimes places that have such high rates don’t really have much more room to increase and the decrease may actually reflect a little bit of instability. So you are right that, you know, Massachusetts, New Hampshire, they are — and Kentucky, they are states that have had among the highest rates of our drug overdose deaths, that there’s sort of two factors there. They’ve been doing more because of that very high rate and they’ve been doing more longer because the problems started earlier, but whether the — we’re seeing real, true, persistent decline or these are really statistical fluctuations, we just don’t know yet. So i think that’s — you know, we wish that it was going down everywhere and we wish that it would go down even further, but we did try to find a little good news in the report that is overall quite, quite concerning. So I want to just thank everybody for joining and conclude saying this is a very difficult and fast-moving epidemic and there are no easy solutions, but despite the challenges, there are opportunities to make real progress. This data sends a wake-up call about the need to improve what happens when patients leave the emergency department. All of us working together, government, public health, the medical community, law enforcement and community members themselves can help fight this epidemic and save lives.

KATHY HARBEN: Thank you very much, Dr. Schuchat and we also thank Dr. Adams for joining us today. Thank you, reporters, for also being here. In addition to today’s Vital Signs release, we have a companion editorial that will publish today in the Annals of Emergency Medicine.” There is also a webinar scheduled for March 13^th on coordinating clinical and public health responses to opioid overdoses. Both Dr. Schuchat and the surgeon general will join that webinar and you can find the details on the Vital Signs website. If you have follow-up questions, please call us at 404-639-3286 or you can e-mail us at media — I’m sorry, e-mail us at media@cdc.gov. Thank you very much for joining us. This concludes our call.

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U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES