Update: On May 16, 2024, the U.S. Department of Justice sent a proposed rule to the Federal Register to downgrade marijuana from a Schedule I to a Schedule III drug. This is the first step in a lengthy approval process that starts with a 60-day comment period.

Update: Originally published in April 2021, this piece was updated on Oct. 7, 2022, with information about President Biden’s announcement pardoning anyone convicted of federal marijuana possession, the 2022 mid-term election ballot initiatives and several new research studies. The map has also been updated.

Dr. Tauheed Zaman opens his presentation about marijuana with a photo of the Haight-Ashbury street sign, the historic part of San Francisco tied to the hippie and counterculture movements of the 1960s and 1970s, and where the clock is permanently set at 4:20. 

“It’s just to say that cannabis has really been in our communities and among my patients for a long time,” said Zaman, an addiction psychiatrist at the San Francisco VA Health Care System, during a 2021 virtual presentation hosted by the National Press Foundation for an audience of journalists participating in a fellowship on covering opioids and addiction. “And cannabis has historically also been quite controversial.” 

Marijuana use — and its potency — have only increased since the 1960s, research has shown. 

The percentage of people aged 12 years and older who reported using marijuana during the prior year increased from 11.0%  in 2002 to 17.5%, or 48.2 million people, in 2019, according to the report, “Key Substance Use and Mental Health Indicators in the United States,” published in September 2020 by the federal Substance Abuse and Mental Health Service Administration (SAMHSA). 

Marijuana is the most commonly used illegal drug among people aged 12 years and older, according to the SAMHSA’s  2019 national survey on drug use and health. It is the third most commonly used addictive drug, after tobacco and alcohol, according to the Centers for Disease Control and Prevention. “Illegal” in this case means the drug is not legal on the national level, although that is under consideration.

The House in December 2020 passed the MORE Act of 2020, a bill to decriminalize marijuana. Senate Majority Leader Chuck Shumer said the timeline for the bill is “soon” in an April 2021 interview with Politico.

On Oct. 6, 2022, President Joe Biden pardoned anyone convicted of a federal marijuana possession charge since it became a crime in the 1970s, and urged state governors to do the same for state offenses. He also asked the Secretary of Health and Human Services and the Attorney General to review how marijuana is scheduled under federal law.

As of February 2022, 37 states, District of Columbia, Guam, Puerto Rico and the U.S. Virgin Islands have approved medical marijuana or cannabis laws, according to the National Conference of State Legislatures, which keeps an up-to-date list of laws by state. Many state lawmakers continue to debate on marijuana legalization and decriminalization. NCSL provides an overview of this fast-evolving landscape in the U.S.

Marijuana is legal in 19 U.S. states and the District of Columbia. In the 2022 mid-term election, five more states — Arkansas, Missouri, North Dakota, South Dakota and Maryland — will decide on marijuana legalization, according to Ballotpedia, a nonprofit organization that serves as a digital encyclopedia of American politics.

In Oklahoma, a ballot measure that would have legalized marijuana and decriminalize marijuana possession won’t be on the 2022 ballot after the state’s Supreme Court ruling. State Question 820 will instead appear on a special state election in 2023 or in the 2024 election, according to Oklahoma Watch.

Research on medical benefits, or harm, lags behind the wider availability of cannabis products.

“So these are significant times for cannabis and cannabinoid research policy and health, and it is really important for us to delve into the research and also, as journalists, be able to disseminate what we know and what we don’t know and what the health risks are,” said Ziva Cooper, director of the UCLA Cannabis Research Initiative, during another webinar “Cannabis: Health Effects and Regulatory Issues,” hosted by SciLine in April. SciLine is a free service, connecting scientists with journalists, based at the American Association for the Advancement of Science.

To help journalists add scientific evidence to their stories about marijuana, The Journalist’s Resource has compiled research studies and information shared by experts in two recent virtual events: Zaman’s presentation, “Cannabis Use and Related Disorders,” and SciLine’s “Cannabis: Health Effects and Regulatory Issues” webinar, which included Cooper, Madeline Meier, an associate professor in the department of psychology at Arizona State University and Rosalie Liccardo Pacula, a professor and the Elizabeth Garrett Chair in Health Policy, Economics and Law in the Sol Price School of Public Policy at the University of Southern California.

Quick facts about marijuana — or is it cannabis? 

The cannabis plant has more than 100 known compounds, called cannabinoids. Cannabis plants have small, translucent, hair-like structures called trichomes that store all the cannabinoids. The effect of most of the cannabinoids on human brain and body is still not known. So far, only two cannabinoids have been well studied: tetrahydrocannabinol, or THC, and cannabidiol, or CBD. 

Although “cannabis” and “marijuana” are used interchangeably in everyday dialogue, they’re not quite the same. 

Cannabis is the broader term for all the substances derived from the cannabis plant, some of which could be without THC, including CBD products and terpenes. Meanwhile, marijuana, which is made of the dried leaves, flowers, stems, and seeds and can be smoked or prepared to a concentrated honey-like resin, has THC.  

Cannabis is the more accurate term to use if you’re talking about the industry and products derived from the plant, said Zaman.

Other cannabinoids such as cannabinol, cannabigerol, cannabidivarin are sold at some dispensaries, but have been studied in animals only. There is another set of chemicals in cannabis plants called terpenes, including Myrcene, Pinene, Linalool. They too have only been studied in animals and not humans. 

“There’s much more research to be done,” Zaman said. “Are there many other cannabinoids in there that can have a physiologic effect? Absolutely. I think we’re very early in understanding that.”

Why aren’t the other compounds studied in humans? There are two main barriers. 

First, marijuana is a Schedule I drug under the Federal Comprehensive Drug Abuse Prevention and Control Act of 1970, more commonly known as the Controlled Substances Act. Controlled substances are drugs that have the potential to be misused. They are categorized into five schedules, with Schedule I drugs having the highest potential for abuse.

“So researchers have to deal with a lot more regulation and a lot more barriers to study something that’s scheduled,” said Zaman.

The second barrier is the large number of chemicals in cannabis. 

“It takes a lot of scientific equipment and funding to really isolate each chemical and try to study them individually,” said Zaman. 

Cannabis is prepared in different ways. In addition to smoking it, it can be made into hashish, tinctures, hashish oil and infusions. Table 2 in this 2015 paper in JAMA, “Medical Marijuana for Treatment of Chronic Pain and Other Medical and Psychiatric Problems,” lists the different preparations. 

Cannabis-derived products aren’t to be confused with synthetic cannabinoids, which are sprayed on dried, shredded plant material to make fake marijuana, commonly known as K2 and spice. While synthetic cannabinoids are similar to the chemicals found in the marijuana plant and bind to the same brain receptors, they have a much more powerful effect. 

“Synthetic cannabinoids can lead to cardiac issues, renal issues, psychiatric issues, including psychosis, seizures and death,” said Zaman.

THC content in cannabis plants is increasing

THC is the main known psychoactive compound in the cannabis plants. The THC content of marijuana has increased in recent decades with new growing techniques. The rise has been well-documented and concerns health experts. 

In a November 2020 study, “Changes in Delta‐9‐tetrahydrocannabinol (THC) and Cannabidiol (CBD) Concentrations in Cannabis Over Time: Systematic Review and Meta‐analysis,” published in the journal Addiction, researcher Tom P. Freeman and his colleagues found that the quantity of THC in a typical gram of cannabis rose by 2.9 milligrams each year between 1975 and 2017 for all herbal cannabis, and by 5.7 milligrams each year for cannabis resin, which is a substance produced in the trichomes and can be used to make products like hashish. 

“Changes in THC concentrations over time could also influence the efficacy and safety of cannabis used for medicinal purposes, in the absence of standardized dosing information for illicit cannabis products,” the authors write. 

Meanwhile, the concentration of CBD in cannabis plants has remained the same, the study finds.

So what’s driving this increase? The answer isn’t simple. Pacula explained it this way: The vast majority of the people who consume of most intoxicating goods — whether it’s alcohol, cannabis or even some of the harder substances, is by the near-daily heavy users. They purchase the largest quantity of goods, but represent only about 20% of the total using population. This is known as the 80-20 rule. 

“Because heavy users are the largest purchasers, the industry is inclined to try to sell enticing products to that very small but frequently buying group of users,” said Pacula. “So are they responding to demand? If you’re talking about demand for this very small group of heavy, frequently using cannabis users, the answer is yes. They’re responding to that very small group. But usually when we think about cannabis use, most frequently, what we’re measuring in cannabis use is not those heavy daily users who are using large quantities frequently throughout the day.”

What about medical marijuana? 

“Medical marijuana” is a misnomer, said Zaman. In many instances, there’s little difference between medical marijuana and recreational marijuana.

“States that have legalized cannabis have said, ‘Well, we are calling it medical marijuana or medical cannabis because, under state law, we want to make it legal to get and, therefore, we’re calling it medical,’ but the content, in terms of cannabinoids might be quite similar to recreational marijuana,” said Zaman. 

But even though it’s called medical marijuana and consumers can buy it legally from a dispensary, customers may not be getting exactly what’s listed on the product label. 

In a 2015 study, researchers tested 75 edible marijuana products such as baked goods, beverages, candy or chocolate, purchased from dispensaries in San Francisco, Los Angeles and Seattle and found that only 17% had accurately labeled their THC content. 

“Greater than 50% of products evaluated had significantly less cannabinoid content than labeled, with some products containing negligible amounts of THC. Such products may not produce the desired medical benefit,” wrote lead author Ryan Vandrey in “Cannabinoid Dose and Label Accuracy in Edible Medical Cannabis Products,” published in JAMA. 

Even though labeling has improved over the years, “There’s still tremendous variability in terms of just THC or CBD content,” said Zaman. “But even if the CBD and THC were accurately labeled, there are so many other compounds in cannabis that are yet to be studied, measured.” 

Cannabis is not federally approved for treatment of any medical conditions 

To date, the federal Food and Drug Administration has not approved cannabis for treatment of any disease or condition. It has, however, approved three products related to or derived from cannabis:

• Cannabidiol, derived from cannabis and used to treat a rare form of childhood epilepsy. It’s marketed under the name Epidiolex, made by Greenwich Biosciences.
• Dronabinol, a synthetic cannabinoid marketed under the names Marinol, which was acquired in 2019 by India-based company Alkem Laboratories, although the company’s website doesn’t seem to be available, and Syndros, distributed by Benuvia Therapeutics, and used to treat anorexia and wasting in AIDS patients.
• Nabilone, a synthetic cannabinoid used for nausea and vomiting in patients undergoing chemotherapy. It’s marketed under the name Cesamet, made by Bausch Health.

These three medications are only available with a prescription. 

Even though cannabis products are touted to help with anxiety and stress, they are not approved by the FDA for any psychiatric conditions. 

In 2013, Zaman did six months of research to help the American Psychiatric Association write a position paper on cannabis use for psychiatric conditions and “all of that work basically boils down to one line, which is there are no current psychiatric indications for which any cannabis product has been proven to be helpful via rigorous scientific studies,” he said.  

That’s not because there have been a lot of negative studies showing that cannabis does absolutely nothing for many psychiatric disorders. But it’s because of the lack of studies, Zaman said.  

The association reviewed its position again in 2018 and still opposes the use of cannabis as a medicine for any psychiatric condition, “because there are so many associations with poorer mental health outcomes in some populations, and not enough studies really showing that there’s a long-term benefit in terms of mental health,” said Zaman. 

The American Society of Addiction Medicine, a professional medical society representing over 6,600 physicians, clinicians and associated professionals in the field of addiction medicine, has a wider ranging set of recommendations for medical professionals who treat addiction. 

Studies of note about health effects of cannabis

A widely cited and comprehensive report by the National Academies of Sciences, Engineering, and Medicine, a private, nonprofit organization, provides a rigorous review of research published between 1999 and 2017 on the health impacts of cannabis and cannabis-derived products, ranging from their therapeutic effects to their risks for causing certain cancers, diseases, mental health disorders and injuries. 

For instance, the report found evidence that patients who were treated with cannabis or cannabinoids were more likely to experience a notable reduction in pain symptoms. But it also found evidence that smoking cannabis on a regular basis is associated with more frequent episodes of chronic bronchitis episodes and worse respiratory symptoms. 

Most studies involving cannabis show an association between the substance and certain changes in the body, but are not able to show cannabis actually causes those changes.   Researchers, however, have established that cannabis does affect psychosis — auditory and visual hallucinations, paranoia and, for some people, disorganized thinking.

More than a decade ago, in a 2007 systemic review of 35 studies, researchers concluded that there was enough evidence “to warn young people that using cannabis could increase their risk of developing a psychotic illness later in life.”

In people who have a family history of schizophrenia or another psychotic illness. Several days of heavy dose use can be enough to develop psychosis in this population, Zaman said.

“So in patients who have a history of psychosis, either personally, or who have it in their families, I absolutely feel I have an obligation to share this information with them,” he said.  

In the May 2021 study, “Relationship Between Cannabis Use and Psychotic Experiences in College Students,” published in the journal Schizophrenia Research, researcher Abigail C. Wright examines the association between cannabis use and hallucinations and delusions in more than 1,034 students at Boston-area colleges between 2010 and 2017. 

They learned that “College students who reported more frequent cannabis use in the past week reported higher levels of hallucinations and delusional ideation. Moreover, those who reported using cannabis more frequently had more distressing delusional ideas, which were held with more conviction.” 

Cannabis use also is associated with preterm birth and low birth weight. 

A study of 5 million live births in California between 2001 and 2012 shows that babies whose mothers had been diagnosed with cannabis use disorder were more likely to be born prematurely and have low birth weights, compared with babies whose mothers didn’t use cannabis. 

“The most notable observation is that exposed infants were 35% more likely to die within 1 year of birth than unexposed infants,” write researchers Yuyan Shi, Bin Zhu and Di Liang in “The Associations Between Prenatal Cannabis Use Disorder and Neonatal Outcomes,” published in April 2021 in the journal Addiction. 

Researchers say their findings call for prenatal cannabis use disorder prevention, treatment and policies. 

“The American College of Obstetricians and Gynecologists committee has recommended that physicians encourage pregnant women to discontinue cannabis use including medical use,” the authors write. 

What about the association between long-term cannabis use and other physical conditions? 

A 2016 study looks at the number of physical health problems as a function of the duration of cannabis use. It finds that cannabis use over a long period — up to 20 years — was associated with periodontal disease but no other physical health problems by age 38. 

Marijuana use at an early age could have negative long-term effects

Research indicates that when people start using marijuana in adolescence, they are more likely to become addicted to it. 

The brain matures from back to front. People’s frontal lobes, which are associated with thinking, executive function, cognition and impulse control, aren’t fully developed until age 26, which means they remain vulnerable during adolescence. 

“We want to protect the brain as long as we possibly can from the influence of substances, including cannabis, alcohol, opioids, because we want these frontal lobes to have a chance to myelinate and develop properly,” said Zaman. 

In “Young Adult Sequelae of Adolescent Cannabis Use: An Integrative Analysis,” published in Lancet Psychiatry in 2014, Dr. Edmund Silins and his colleagues looked at the association between frequency of cannabis use before age 17 and outcomes such as high school completion, cannabis use disorder and depression among more than 2,500 participants in Australia and New Zealand. 

They learned that people who began using higher doses of cannabis at a younger age were less likely to graduate high school, go to college, attempt suicide and develop an addiction to cannabis and other illicit drugs.

“Prevention or delay of cannabis use in adolescence is likely to have broad health and social benefits,” the authors write. “Efforts to reform cannabis legislation should be carefully assessed to ensure they reduce adolescent cannabis use and prevent potentially adverse developmental effects.”

In a 2012 study, Meier and colleagues look at how IQ is affected by persistent cannabis use. They assessed people’s IQ in childhood, before any of the study participants began using cannabis, and then again in adulthood, after some used cannabis for many years.

“As these adolescent users continued to use for more and more years, they showed more and more IQ decline,” said Meier. “The long-term, persistent, adolescent-onset users lost about eight IQ points from childhood to adulthood.”

Can people get addicted to marijuana?

The simple answer is yes. About one in 10 marijuana users become addicted, according to the CDC. 

“When you look at people who start in adolescence — again, early on, before that brain development has finished — the rate [of addiction] goes up to 17% at some point in their lives,” said Zaman. “Amongst daily users, 25% to 50% develop a use disorder at some point in their lives, depending on the study that you look at.”

People can also experience marijuana withdrawal. 

“I’ve had many patients go through marijuana withdrawal, particularly when they get admitted to the hospital or travel and suddenly don’t have access to their usual cannabis products,” said Zaman. 

Symptoms of withdrawal include irritability, anger, aggression, anxiety, sleep issues, appetite issues, restlessness, depressed mood and at least one physical symptom such as abdominal pain, shakiness, tremors, sweating, fevers, chills or headaches.

Legalization

Pacula pointed out that U.S. states have treated cannabis as more of a commercial enterprise because there’s still a lack of clear science that shows it’s a dangerous substance. As a result, many of the regulations tend to focus on licensing, dispensary locations, hours of operation at the local level or laws that allow on-site consumption.

“Testing [of the products] is done, but it’s largely for mold and pesticides,” Pacula said. “And taxation has largely been based on the sale of volume of the good instead of on the major ingredients within the cannabis plant.”

She said five key public health regulations are missing: restrictions on ingredients and extractions allowed from the cannabis plant; restrictions on the amount that can be sold; collecting taxes based on the potency of cannabis instead of the amount sold; compliance checks; and regulation of advertising and the promotion of cannabis products. 

“These are all things that we pay careful attention to when we’re talking about tobacco and alcohol in our state regulations and are things that are often not as carefully addressed in cannabis regulations, thus far,” said Pacula.

Pacula and her colleagues showed in a May 2021 study published in the American Journal of Preventive Medicine that all U.S. states that have legalized marijuana allow a large number of THC doses per transaction — larger than what daily consumers typically use in a month.

“States concerned about public health and diversion should consider reducing sales limits and basing them on total tetrahydrocannabinol content across all purchased products,” the authors write in “Current U.S. State Cannabis Sales Limits Allow Large Doses for Use or Diversion.” 

7 tips for journalists 

1. Take caution when reporting on animal studies. Findings from animal studies usually don’t bear out in humans. “I think it’s really important to keep the community and the U.S. population informed of the fact that what’s happening in a petri dish is very different than what we expect to happen in a human,” said Cooper. 

2. When citing academic studies in online news articles, include a hyperlink. “I really appreciate it when the reporters directly link … to the actual paper,” said Cooper. “So frequently, this does not happen. And it’s really upsetting, especially if somebody is a researcher who wants to go look at the original paper.”

3. When comparing studies, pay attention to differences in study design and the products used. “It’s really important that, as a reporter, you take a look at the [academic] article and see how the paper has defined ‘frequent’ or ‘regular’ or ‘heavy’ cannabis use,” said Meier. “Because lots of times, we’ll see that in one study, we’re talking about 30 or more lifetime uses, and in another study, we’re talking about daily use for 20 years. You can’t compare those two studies.”

Look at whether and how well the authors address alternate explanations for their findings, she added.

Journalists also should take note of which cannabis products are studied “so that we have a sense of how much potency was involved in those products,” said Pacula. “Daily use of a low-potency product is not likely to have any negative, harmful consequences in terms of psychoactive effects and may be very therapeutic and beneficial. Daily use of a concentrate that has an average potency of 70% THC is a different thing.” 

4. Look at how your state regulates alcohol and look for parallels in cannabis regulations. “We have a large number of regulations in place for alcohol that target the at-risk and heavy drinkers. We do not have the same cautions developed in our states or current discussions for national legalization [of marijuana] to protect the typical consumer from becoming a heavy user,” said Pacula. 

5. Don’t use the terms “abuse” or “dependence” when reporting on addiction. Instead, use the phrase “use disorder.” Addiction medicine specialists stopped using the terms “abuse” and “dependence” for two reasons, said Zaman. First, they realized that there was a lot of overlap between patients who were diagnosed with abuse versus dependence. Second, there was stigma attached to those labels. So the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition, or DSM-5 — a manual of all psychiatric diagnoses — uses the term “use disorder.” The severity of the diagnoses is then qualified as mild, moderate or severe. 

What about “addiction”? Zaman said it’s acceptable to use in news reports, even though it’s a colloquial term and not a medical diagnosis. And it’s a broader term, because people can be addicted to more than just substances, including gambling, internet gaming, etc.

The AP stylebook says that “addiction” is a preferred term and “substance use disorder” can be used in quotations or scientific context. It advises against using the terms “abuse” or “problem” and favors the term “use.” Avoid the terms “addict,” “user,” and “abuser.”

6. Be aware of your own biases and leave them out of your marijuana coverage. “Some people may know someone who is using [cannabis] to good effects. Others may have known someone who used it to bad effect or had other personal experiences,” said Zaman. “But I think we need to step back and look at the data, like really dispassionately look at the data. And I think that is kind of what’s missing during some heated discussions around cannabis.”

7. Stress the scientific evidence. “Regardless of whether we’re progressive or liberal or conservative, or whatever part of the spectrum, people should go by the scientific evidence,” said Zaman. “I think the issue is getting politicized and sometimes distracting  from the evidence. What about kids getting ahold of these products? What about adults who have addictions or have psychosis or mental health issues? All of that is being completely glossed over by a belief that A. — this is progressive politics and you better get on this side if you’re progressive — and B. — dollars, dollars, dollars, by which I mean the tax revenue and other financial aspects of the cannabis industry.”

More research studies

“Association of Racial Disparity of Cannabis Possession Arrests Among Adults and Youths With Statewide Cannabis Decriminalization and Legalization,” by Brynn E. Sheehan, Richard A. Grucza, Andrew D. Plunk, published in JAMA Health Forum in October 2021, uses arrest data from 43 states to compare “preimplementation and postimplementation differences in arrest rates for states with decriminalization, legalization, and no policy changes.” The study finds that overall, states that legalized or decriminalized cannabis saw large decreases in arrests compared with states that had no policy reform. “Because arrest rate reductions were occurring before policy changes in those states, there is no reason to expect cannabis legalization to have as large of an immediate effect in other states. While these results do not unambiguously favor decriminalization nor legalization, increases in arrest rate disparities in states without either policy highlight the need for targeted interventions to address racial injustice,” the authors write.

“The effect of medical cannabis on cognitive functions: a systematic review,” by Anders Wieghorst, Kirsten Kaya Roessler, Oliver Hendricks, and Tonny Elmose Andersen, published in Systematic Reviews in October 2022, is based on the review of 23 studies and finds “the majority of high-quality evidence points in the direction that the negative impact of cannabis-based medicines on cognitive functioning is minor, provided that the doses of THC are low to moderate.” However, longterm use of cannabis-based medicines may see have a negative effect on cognitive functioning, the authors write.

“Cannabis Use Patterns and Related Health Outcomes Among Spanish Speakers in the United States and Internationally,” by Renée Martin-Willett, Elizabeth Zambrano Garza, and L. Cinnamon Bidwella, published in the Yale Journal of Biology and Medicine in September 2022, is based on the survey of 549 Spanish-speaking people. Among them, 294 lived in the U.S., 174 lived abroad and others didn’t report the country of residence. Overall, the majority used marijuana for recreational reasons. But the U.S. group was significantly more likely to use marijuana for recreational and/or medical reasons. This group also smoked or vaporized marijuana significantly more often than those living outside of the U.S. or with an undisclosed location, and was more likely to use it daily. About 14% of all survey respondents said they used medical marijuana for anxiety and depression. The study “reveals that Spanish-speaking communities in the U.S. and internationally have both shared and divergent cannabis use patterns, particularly for smoking or vaporizing, medical use, and perceptions of safety or risks of using cannabis,” the authors write.

Watch the presentations and get the handouts

• “Marijuana and the Developing Brain,” Zaman’s virtual presentation at the National Press Foundation.
• “Cannabis: Health Effects and Regulatory Issues,” a webinar by SciLine.

Source list for this piece

Dr. Tauheed Zaman: assistant professor of psychiatry at UCSF’s Weill Institute for Neurosciences and an addiction psychiatrist at the San Francisco VA Health Care System.

Ziva Cooper, Ph.D.: pharmacologist, director of the UCLA Cannabis Research Initiative and an associate professor in UCLA’s departments of psychiatry and anesthesiology.

Madeline Meier, Ph.D.: associate professor in the department of psychology at Arizona State University and the director of and principal investigator at the Substance Use, Health and Behavior Lab at the university.

Rosalie Liccardo Pacula, Ph.D.: professor and the Elizabeth Garrett Chair in Health Policy, Economics & Law at the University of Southern California’s Sol Price School of Public Policy.

The post Covering marijuana: Research roundup and 7 tips for journalists appeared first on The Journalist's Resource.

This piece was updated on June 12, 2023, with additional research.

In February 2021, the nation’s leading association for addiction medicine professional issued a statement addressing the systemic racism that pervades the United States’ drug policy and access to treatment. 

The six-page document, issued by the American Society of Addiction Medicine and titled “Advancing Racial Justice in Addiction Medicine,” is the first in a series. It recommends a more diverse addiction treatment workforce; advocates for policies that result in more equitable access to prevention, early intervention and treatment of substance use disorder; and it calls on addiction medicine professionals to examine their one biases. 

“We wanted to define [systemic racism] and we wanted to point out that systemic racism is a social determinant of health,” said Dr. Stephen Taylor, an Alabama-based addiction medicine specialist who helped ASAM craft its statement. “And that social determinant of health has had profound deleterious effects on the lives and health of Black, Indigenous and other people of color.”

Taylor spoke during a recent virtual presentation hosted by the National Press Foundation, for an audience of journalists participating in a fellowship on covering opioids and addiction. He said systemic racism is “defined as a system in which public policies, institutional practices, cultural representations and other norms work in various, often reinforcing, ways to perpetuate racial group inequity.”

 A large body of research reveals a long pattern of systemic racism in U.S. drug policy dating back to the late 1800s. To help journalists add historical context to their stories, this piece delves into:

• How racism took root in U.S. drug policy.
• How medication maintenance treatments for opioid addiction became racialized.
• And how research continues to show persisting disparities in the prescription of methadone and buprenorphine.

A brief history of systemic racism in U.S. drug policy

The story of how the war on drugs started in the United States and how it led to racial disparities in drug policies and addiction treatment dates back 1875, when San Francisco passed the nation’s first anti-drug law, the Opium Den Ordinance, banning opium dens. Specifically, the ordinance was directed at Chinese immigrants. 

“So what they created was this story that the use of opium by Chinese persons in opium dens was causing problems for society, including the people most valued in society, which are white people, specifically white women,” said Dr. Jessica Isom, a clinical instructor of psychiatry at Yale School of Medicine, a community psychiatrist and consultant for diversity, equity, inclusion and antiracism projects, during the National Press Foundation’s virtual event.

In other words, “to harass and denigrate a population, it requires that you assign characteristics to that population that are unfavorable,” said Isom. “What that means is that language such as “smugglers”, “gamblers”, “prostitutes”, and things of that nature, were ascribed to Chinese people, and they were also considered to be morally bankrupting white people.”

A few decades later, the story repeated itself, but this time for Mexican immigrants. 

The Mexican Revolution of 1910 led to immigration of Mexicans to the U.S. Southwest. Some of the immigrants brought with them their traditional means of intoxication: marijuana, according to a 1994 article in The Atlantic. Texas police officers claimed that marijuana aroused a “lust for blood” and led to violent crimes. El Paso, Texas, was the first city banning the sale or possession of marijuana in 1914 and other states followed, basing their decision on unfounded narratives of crimes and violence resulting from smoking marijuana. 

“One term that describes all of this, this overreaction to what really are unfounded relationships between a racial group and use of a substance — or some kind of social group, could be those who are considered lower socioeconomic status and a substance — is “moral panic”, and it’s a very effective strategy,” said Isom. 

Around the same time, in 1914, the Harrison Narcotics Tax Act was passed by the U.S. Congress, imposing “a special tax upon all persons who produce, import, manufacture, compound, deal in, dispense, sell, distribute, or give away opium or coca leaves, their salts, derivatives, or preparations, and for other purposes.” One clause in the bill also banned doctors from prescribing drugs that were opioid based. This led to the arrest and imprisonment of many doctors, formation of underground markets to buy and sell opioids and cocaine and increased police enforcement, according to an explainer by the nonprofit Drug Policy Alliance.

The enforcement of the law was dominated by “explicit racism directed against immigrant Asian and Hispanic/Latinx labor, Black men and concern about women stolen into “white slavery” – and it ushered in a period that prioritized policing over public health,” according to ASAM’s new policy statement, “Advancing Racial Justice in Addiction Medicine”. 

ASAM’s policy statement points out that systemic racism in drug policy is also recognizable in the Anti-Drug Abuse Act of 1986, “which enacted a 100-fold greater sentencing disparity for water-soluble cocaine base (“crack”) versus powder cocaine.”

For instance, distribution of five grams of crack carried a minimum of five-year sentence in federal prison, while distributing 500 grams of powder cocaine has the same sentencing, according to a 2006 article by American Civil Liberties Union.

Crack is cheaper than powder cocaine and over time the law resulted in the arrest of disproportionate number of Black individuals compared with whites.

“That’s one example of a policy where race is never mentioned, but there’s a clear racial intent,” said Dr. Helena Hansen, professor and associate director of Center for Social Medicine and Humanities at David Geffen School of Medicine at UCLA, during the National Press Foundation’s virtual event.

In 2010, the Congress passed the Fair Sentencing Act, reducing the sentencing disparity between crack and powder cocaine to 18 to 1. The amount of powder cocaine triggering minimum sentencing of five and 10 years remained the same, as explained in this Department of Justice memo.

In 2018, the First Step Act was signed into law, making sentencing reforms of Fair Sentencing Act retroactive, but its language left out those who were previously arrested for low-level offenses that involved 0 to 5 grams of crack cocaine.

The missing language led to Supreme Court case Terry v. United States, brought on by Tarahrick Terry who’s scheduled to be released from prison this year after 13 years for possession of 4 grams of crack cocaine. In May 2021, the Supreme Court heard the case but justices were skeptical that low-level crack cocaine offenders can benefit from the First Step Act, Reuters reported.

Another reminder of pervasive racism in portrayal of individuals with opioid addiction was George Floyd’s murder by a white Minneapolis police officer, who knelt on Floyd’s neck for 9 minutes and 29 seconds. 

“George Floyd’s drug use has been used by the [police officer’s] defense team to basically try to weaponize it against him, to make him seem like a dangerous, imposing criminal, who basically deserved what happened to him and whose death was caused more by the fact that he was a drug user than because of someone putting his knee on his neck for almost 9 and 1/2 minutes,” said Taylor, chief medical officer of behavioral health division at Pathway Healthcare, an addiction and mental health treatment center in Birmingham, Alabama, and medical director of the Player Assistance and Anti-Drug Program at the National Basketball Association. 

Even though Black and white people use illicit drugs at a similar rate, Black people made up more than a quarter of nearly 1.6 million people arrested for violation of drug laws in 2019, according to the Department of Justice data. In comparison, the Black population makes up 13.4% of the U.S. population. This is due to “targeted policing, surveillance, and punishment tactics,” according to the Drug Policy Alliance, which Isom cited in her presentation. 

Methadone, buprenorphine and disparities

Hansen first encountered opioid addiction medication treatment that could be dispensed in doctors’ offices in the late 1990s when she was a medical student. She was involved with the clinical trials of buprenorphine.

Her physician supervisors were excited about buprenorphine, which “they said was about to change the culture of medicine,” said Hansen, during the National Press Foundation presentation.

While methadone, another medication for treatment of opioid dependence, was, and is still, dispensed at clinics and requires daily trips to those clinics, buprenorphine came with the promise of becoming available at doctors’ offices. 

But as promising as that was, it didn’t take long for Hansen to begin noticing stark differences between buprenorphine and methadone patients by race and class. 

Methadone and buprenorphine are synthetic opioids and they act similarly by blocking the brain receptors that are activated by opioids such as heroin and morphine.

Methadone is a Schedule II controlled substance and can only be dispensed at federally-regulated treatment programs, a restriction that resulted from its potential to be diverted to the streets for illegal use and the possibility of overdose. 

The use of methadone as a treatment for heroin addiction was first introduced in a pilot study of 22 patients by Dr. Vincent Dole and Dr. Marie Nyswander, published in JAMA in 1965. 

“With the maintenance treatment, the patients have lost their craving for heroin,” the authors write in a subsequent 1966 study published in JAMA Internal Medicine. “No patient has become readdicted to heroin. A majority of the patients are now steadily employed.” 

“Systemic racism has been defined as a system in which public policies, institutional practices, cultural representations and other norms work in various, often reinforcing, ways to perpetuate racial group inequity.”

Dr. Stephen Taylor

By 1969, several thousand patients across the United States were enrolled in methadone maintenance treatment programs, according to a 2003 review, “From Morphine Clinics to Buprenorphine: Regulating Opioid Agonist Treatment of Addiction in the United States,” co-authored by Dr. Jerome Jaffe, the first director of the Special Action Office for Drug Abuse Prevention created by President Richard Nixon, and Dr. Charles O’Keefe. 

Over time, because of the growing stigma associated with addiction and methadone clinics, communities began resisting the establishment of clinics, pushing the clinics to marginalized neighborhoods in the cities, remote from other medical services. 

“So methadone, [which has] had this only quasi-medical status, also [gets] a quasi-criminalized status in that sense,” Hansen said. 

Fast forward to the early 2000s and the prescription opioid addiction epidemic. Most of the newly dependent people on the prescription pain pills were white, many middle- to upper-income, Hansen said. 

Around the same time, the Drug Addiction Treatment Act of 2000 (DATA 2000) had passed, allowing physicians to treat opioid addiction with narcotic medications such as buprenorphine, lifting a more than 80-year ban on opioid prescription since the 1914 Narcotics Tax Act banned it.

The law, however, kept the methadone system restricted to DEA-regulated clinics with direct observation of patients who have to go to the clinics daily.

“This remarkable legislative change marked a clear shift away from the ‘war on drugs’ policy and rhetoric that had dominated US drug policy for decades,” write Hansen and Julie Netherland in the 2017 study “White Opioids: Pharmaceutical Race and the War on Drugs That Wasn’t,” published in the journal BioSocieties.  

They continue: “The policy responses seen as appropriate for Black and Brown addicts – methadone and prison – were not seen as a viable option for White addicts. New alternatives were needed, and DATA 2000 provided them.”

Hansen said the makers of buprenorphine successfully lobbied lawmakers to classify buprenorphine as a Schedule III drug, indicating a moderate to low potential for dependence. Methadone, meanwhile, remains a Schedule II drug, with a high potential for abuse.

To prevent the illicit use of buprenorphine, the drug’s manufacturer along with the federal Substance Abuse and Mental Health Services Administration developed an eight-hour certification course that doctors are required to complete in order to prescribe the medication. 

The certification became yet another barrier for free clinics or clinics that serve low-income patients, because those clinics don’t provide time or incentives to pursue this kind of certification, Hansen said. 

“The shortage of public sector prescribers, along with the cost of buprenorphine itself have long kept buprenorphine in the private sector,” she said. 

In April 2021, the Biden administration released federal guidelines that will eliminate the required eight-hour training course, also called the X-waiver, for prescribers.

Several national organizations, including the American Medical Association and the American Society of Addiction Medicine applauded the guidelines and said that its a step in the right direction. 

Years of research show disparities

More than 400,000 people in the U.S. receive methadone. To receive the treatment, individuals have to show up every day for 90 days to receive their dose. Only after that, they’re able to take home a weekly bottle. To get a full month’s worth of take-home methadone, individuals need to have been going to the clinic for two years. 

“So if you could imagine driving to a clinic, standing in line for an hour, an hour and a half, and then going to work every single day, seven days a week? It disrupts everything. It disrupts your ability to have a job, to take care of your kids,” said Dr. Ruth Potee, director of addiction services at Behavioral Health Network in Massachusetts during the virtual presentation hosted by the National Press Foundation. 

“I’ll be honest, I really think a lot of it is based on racism,” said Potee. “And if there’s a racial justice component to substance use disorder for me, it’s methadone.”

The first national study to show the racial identity associated with each medication was a 2006 report by the federal Substance Abuse and Mental Health Services Administration, showing that 91% of buprenorphine patients were white, compared with 53% using methadone as maintenance therapy. The report also showed that 56% of buprenorphine patients were college educated, compared with 19% of methadone patients. 

Less than a decade later, Hansen and her colleagues showed that the disparities persisted in their 2013 study, “Variation in use of Buprenorphine and Methadone Treatment by Racial, Ethnic and Income Characteristics of Residential Social Areas in New York City,” published in the Journal of Behavioral Health Services and Research. 

They found that across all ZIP codes in New York City, buprenorphine treatment was concentrated in areas with the highest incomes and highest percentage of white residents. In contrast, methadone treatment rate had an inverse geographic distribution in low-income, ethnic minority neighborhoods. 

In 2016, Hansen and colleagues once again showed the disparity in the study “Buprenorphine and Methadone Treatment for Opioid Dependence by Income, Ethnicity and Race of Neighborhoods in New York City,” published in the journal Drug and Alcohol Dependence. 

The team examined the uptake of buprenorphine compared with methadone treatment between 2004 and 2013 by income, race and ethnicity in neighborhoods in New York City.

They found that although buprenorphine treatment rates had increased across areas, it had a slower uptake in moderate income and mixed ethnicity areas. Methadone rates, meanwhile, had remained stable over time. 

“If there’s a racial justice component to substance use disorder for me, it’s methadone.”

Dr. Ruth Potee

In 2019, nearly 15 years after the 2006 report by SAMHSA, yet another study showed the racial disparities in buprenorphine treatment compared with methadone. 

In “Buprenorphine Treatment Divide by Race/Ethnicity and Payment,” published in JAMA Psychiatry in 2019, researchers showed that between 2004 and 2015 buprenorphine treatment was concentrated among white people and those with private insurance or the ability to self-pay. They found that between 2012 and 2015, 95% of doctor visits for buprenorphine were by white patients and only in 19% of the cases Medicare or Medicaid paid for the visit. 

Although Medicaid covers buprenorphine, its reimbursements are low, discouraging many to participate in the program or accept patients who have Medicaid. 

The disparities were confirmed in “Treatment for Opioid Use Disorder in the Florida Medicaid Population: Using a Cascade of Care Model to Evaluate Quality,” a study published in 2020 in The American Journal of Drug and Alcohol Abuse. 

“Older individuals and those who are black are less likely to receive a primary diagnosis and consequently are less likely to receive treatment for [opioid use disorder],” researchers write. “People who are dually eligible for Medicaid and Medicare are also less likely than people who are Medicaid eligible only to receive a primary diagnosis of OUD.” 

And yet another study, “Association of Racial/Ethnic Segregation With Treatment Capacity for Opioid Use Disorder in Counties in the United States,” published in April 2020 in JAMA Network Open, researchers showed that between 2018 and 2019 methadone clinics were significantly more likely to be located in highly segregated Black and Hispanic/Latino counties, while facilities providing buprenorphine were significantly more likely to be located in highly segregated white counties. 

“The differential availability of medications for [opioid use disorder] across U.S. counties represents an additional iteration of racism in the design and provision of health care services,” the authors write. 

In the Hispanic and Latino community, language barrier compounds the issue, explained Dr. Pierluigi Mancini, during the virtual presentation hosted by the National Press Foundation.

“When you’re in crisis, when you are addicted, when you have a mental health issue, when you are suicidal, we revert back to our original language,” said Mancini, project director at the National Latino Behavioral Health Association. “Half of the foreign-born individuals in this country cannot access these services because the providers don’t have the linguistic capacity.”

There are also cultural literacy barriers. 

“I had a client who told me his addiction was because his ex-girlfriend put a curse on him,” Mancini said. “And he truly believed that and he struggled with every step of treatment for the first few weeks, but that was his belief. So, we had to make sure that we address them in a way that he would not stop treatment, but in a way that he would be able to understand what we were trying to teach him.”

The federal Office of Minority Health has National Standards for Culturally and Linguistically Appropriate Services in Health and Health Care to help with health equity in various settings. 

“Having a bilingual bicultural clinician is the best solution,” Mancini said. 

In addition, there are not enough Hispanic doctors that have gone through the training to prescribe buprenorphine.

“So, if most Hispanics try and go to Hispanic doctors, especially if language is an issue, and if we don’t have Hispanic doctors in the buprenorphine registry even though they just expanded it, then we’re not going to be able to use buprenorphine to help people with opioid use disorder,” Mancini said. 

Looking ahead

Potee expected the issue of how methadone treatment is provided to be a hot topic this year, after the pandemic arrived in the U.S., causing interruptions in the daily access to the clinics.

“The rules and regulations regarding methadone were written 48 years ago and they have not changed in 48 years,” said Potee. “And it’s one of the most effective tools we have in our toolbox.” 

An April 2021 report by the George Washington University’s Regulatory Studies Center calls for the federal Substance Abuse and Mental Health Services Administration (SAMHSA) to extend the flexibility that it granted during the height of the pandemic by allowing patients to take their methadone doses home or consume it in an unsupervised setting. 

“We have patients in my methadone world who have said the following words: ‘I don’t want the pandemic to end. I don’t want everybody to get the vaccine because if that happens, my life will get worse because my life has been better under COVID,’” said Potee.

Hansen added that the media portrayal of people with substance use disorder has also contributed to the disparities. 

She and Netherland published “The War on Drugs That Wasn’t: Wasted Whiteness, “Dirty Doctors,” and Race in Media Coverage of Prescription Opioid Misuse,” in 2016 in the journal Culture, Medicine and Psychiatry, showing that Black and Latino individuals were more likely to be characterized as criminals and drug users by the media, while suburbanites addicted to OxyContin were consistently portrayed as victims of over-prescription or people struggling with real or existential pain.

“Journalists must do better at noticing the racism inherent in their coverage of the opioid epidemic and becoming more conscious of implicit bias in their reporting,” the authors write. “They can start by making sure that their portrayals of people who use drugs are fair and equitable across race and class.” 

Additional studies to consider

Drug Overdose Deaths in the United States, 2001–2021: The CDC report, published in December 2022, finds the rate of deaths from drug overdoses increased for each race and ethnicity except for Asian people between 2020 and 2021. Also, American Indian or Alaska Native people had the highest drug overdose death rates in 2020 and 2021.

“Racial‒Ethnic Disparities of Buprenorphine and Vivitrol Receipt in Medicaid,” by Christopher Dunphy, et al., published in the American Journal of Preventive Medicine in November 2022, finds Black people, American Indian or Alaska Native/Asian/Hawaiian/Pacific Islander people and Hispanic people were less likely to receive buprenorphine and Vivitrol (naltrexone) compared with white people.

“Racial/ethnic disparities in the availability of hospital based opioid use disorder treatment,” by Ji Eun Chang, et al., published in the Journal of Substance Abuse Treatment in July 2022, finds hospitals in communities with high percentage of Black or Hispanic residents had significantly lower odds of offer the most common opioid-use disorder hospital-based programs, including services that increase access to formal treatment services, education and community coalitions.

“Racial/Ethnic Disparities in Opioid-Related Mortality in the USA, 1999–2019: the Extreme Case of Washington D.C.,” by Mathew Kiang, et al., published in the Journal of Urban Health in October 2021, finds in 2019, the opioid-related mortality rate among Black D.C. residents was 11.3 times higher than white D.C. residents, resulting in 56 more deaths per 100,000 among Black people. “Localized, equitable, culturally-appropriate, targeted interventions are necessary to reduce the uniquely disproportionate burden of opioid-related mortality among Black D.C. residents,” the authors write.

Medications for Opioid Use Disorder Save Lives: The fifth chapter of this book, published in 2019 by the National Academies of Science, Engineering, and Medicine, provides an in-depth review of barriers to broader use of medications to treat opioid use disorder. 

“Drug Dependence, a Chronic Medical Illness”: This widely-cited study, published in JAMA in 2000, argued that addiction was comparable to other chronic diseases like diabetes and hypertension and needed to be treated as such. 

“Buprenorphine Treatment for Opioid Use Disorder: An Overview”: The study, published in 2020 in the journal CNS Drugs provides a review of the drug and discusses Naltrexone, another FDA-approved drug for treatment of opioid addiction. Naltrexone is different from buprenorphine and methadone in that it requires the patients’ full withdrawal from opioid. Methadone and buprenorphine remain gold-standard treatments for opioid addiction. 

“Opioid Treatment Deserts: Concept development and application in a US Midwestern urban county”: The study, published in May 2021 in PLoS One, used opioid overdose data from the Columbus Fire Department in Franklin County, Ohio, between 2013 and 2017, showing geographic areas with little or no access to treatment and recovery services. (Visit Pew Charitable Trust’s 2018 map of methadone clinics in the U.S. to see disparities in accessibility of the clinics in the Midwest.) 

Statutes, Regulations and Guidelines for medication assisted treatment (MAT) opioid treatment programs: This website by the federal Substance Abuse and Mental Health Services Administration offers a list of rules and regulations around opioid treatment.

“Methadone in Primary Care — One Small Step for Congress, One Giant Leap for Addiction Treatment”: This perspective, published in 2018 in the New England Journal of Medicine, argues that methadone treatment should be available in primary care practices in the U.S., just like Great Britain, Canada and Australia. 

Source list for this piece

Dr. Stephen Taylor: chief medical officer of behavioral health division at Pathway Healthcare, an addiction and mental health treatment center in Birmingham, Alabama, and Medical Director of Player Assistance and Anti-Drug Program at the National Basketball Association. Here’s Taylor’s National Press Foundation presentation.

Dr. Jessica Isom: clinical instructor of psychiatry at Yale School of Medicine, a community psychiatrist and consultant for diversity, equity, inclusion and antiracism projects. Here’s Isom’s National Press Foundation presentation.

Dr. Helena Hansen: professor and associate director of Center for Social Medicine and Humanities at David Geffen School of Medicine at UCLA. Here’s Hansen’s National Press Foundation presentation.

Dr. Pierluigi Mancini: project director at the National Latino Behavioral Health Association. Here’s Mancini’s National Press Foundation presentation.

Dr. Ruth Potee, director of addiction services at Behavioral Health Network in Massachusetts. Here’s Potee’s National Press Foundation presentation.

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A federal government database of doctors who provide medication-assisted treatment for opioid use disorder is rife with inaccurate information, making it difficult for people seeking help to schedule appointments, shows new research in the Journal of Psychiatric Practice.

Researchers combed the Substance Abuse and Mental Health Services Administration’s database of buprenorphine providers to verify the accuracy of phone numbers and confirm whether the provider was in fact prescribing buprenorphine and accepting new patients. SAMHSA is an agency of the U.S. Department of Health and Human Services.

Buprenorphine, sold under the brand name Subutex, and a component of the drug sold under the brand name Suboxone, is a drug commonly prescribed to treat opioid use disorder.

Researchers called SAMHSA-listed buprenorphine providers in the 10 states with the highest drug overdose death rates according to 2015 Centers for Disease Control and Prevention (CDC) drug overdose death data — West Virginia, New Hampshire, Kentucky, Ohio, Rhode Island, Pennsylvania, Massachusetts, New Mexico, Utah and Tennessee. They then focused on providers listed as practicing within a 25-mile radius of the county with the highest drug-related death rates in 2017, narrowing down the list to 505 providers.

The researchers secured appointments with just 28% — 140 — of providers contacted. In most cases, nobody answered the phone or returned the call, or the phone number listed was incorrect.

Over one quarter — 27.1% — of the numbers listed were incorrect, the researchers report. A similar percentage — 25.9% — of phone numbers corresponded to providers who did not offer buprenorphine.

“Someone who has opioid use disorder, if they try to use the federal database to locate someone to get medication-assisted treatment from, they’re going to find out that the database is full of wrong numbers and practices that aren’t even prescribing buprenorphine,” says author J. Wesley Boyd, an associate professor of psychiatry at Harvard Medical School.

Researchers made two attempts at contact during normal weekday business hours and left voice messages with a callback phone number when given the option. Calls were made over the span of two months. If the researchers made contact with the provider or office staff, they asked whether the provider currently prescribed buprenorphine. If yes, the researchers followed up by asking which insurance they accepted, including Medicaid, whether they were accepting new patients, and when their first available appointment was.

“One of the clinics that I called said to me, ‘Oh, Dr. Wartenberg hasn’t been in this clinic for over 12 years,’” Boyd recalls.

An evidence-based approach

Medication-assisted treatment is an evidence-based treatment for opioid use disorder. It has been shown to reduce the risk of overdose death for people who use opioids. These medications reduce symptoms of craving and withdrawal.

A study of 151,983 adults in England treated for opioid dependence between 2005 and 2009, published in Addiction, found the risk of fatal drug overdose more than doubled for individuals who received only psychotherapy compared with those who received medication-assisted treatment.

An April 2017 systematic review and meta-analysis published in The BMJ found that people receiving medication-assisted treatment were less likely to die of an overdose or other causes than peers with opioid use disorder who did not receive such treatment.

And a March 2015 review of randomized controlled trials in the Harvard Review of Psychiatry compared medication-assisted treatment of opioid use disorder with placebo or no medication and found that medication-assisted treatment “at least doubles rates of opioid-abstinence outcomes.”

Long waits and potential solutions

The researchers of the new paper verified that 310 of the 505 phone listings in their sample — 61.4% — listed correct numbers. Of all the providers who supposedly offered buprenorphine according to the database, only 195, or 38.6% actually did.

The researchers were able to ask 173 of these providers whether they accepted private insurance, and most — 75.7% — did. And more than half of the buprenorphine providers who were asked about whether they accepted Medicaid did — 62.9%.

“To me it was the one pleasant surprise of our findings, namely, that a decent chunk of the practices or individuals that we called did accept Medicaid,” Boyd notes.

But appointments typically required a wait — the average wait was 16.8 days, and the range spanned from 1 to 120 days. “Sixteen days is obviously a dangerous amount of time. Because as far as I’m concerned, every single time you use [opioids], you’re putting your life in jeopardy,” Boyd says.

Boyd notes that an underlying contributor to issues of access to buprenorphine is the relative scarcity of buprenorphine providers due to prescribing restrictions. Under the Drug Addiction Treatment Act of 2000, physicians must complete a training program if they want to prescribe medication-assisted therapy outside of an opioid treatment program.

“In order for people to be able to prescribe buprenorphine, the requirement for them to do additional training is, I think, obsolete and not necessary,” Boyd says. “So one thing is just to eliminate the requirement for specialized training over and above the training that one gets in order to be able to prescribe medications generally.”

Boyd suggests that SAMHSA might shore up the database through mass mailings to listed providers. He acknowledges that people can find medication-assisted treatment other than through the SAMHSA database, but as a provider listed in the database himself, he says he gets calls “infrequently, but regularly” about buprenorphine that likely stem from the listing.

“We were trying to replicate the experience of an opioid user looking for help,” Boyd says. “And this was the best way we thought that we could explore that issue.”

Boyd has conducted similar research on the issue of availability of mental health care. For more on the opioid epidemic, check out our long read.

The image on this page, obtained from Wikimedia Commons, is being used under a Creative Commons license. No changes were made.

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In the lead-up to the 2020 elections, the Journalist’s Resource team is combing through the Democratic presidential candidates’ platforms and reporting what the research says about their policy proposals. We want to encourage deep coverage of these proposals — and to do our part to help deter horse race journalism, which research suggests can lead to inaccurate reporting and an uninformed electorate. Our criteria for the proposals we’re covering is simple: We’re focusing on proposals that have a reasonable chance of becoming policy, and for us that means at least 3 of the 5 top-polling candidates say they intend to tackle the issue. Here we look at candidates’ proposals to address the opioid epidemic. Candidates are divided in their approaches; while nearly all favor increasing funding for and access to treatment for opioid use disorder, fewer candidates support harm reduction policy interventions, such as safe injection sites and needle exchanges. A few candidates incorporate broader criminal justice-level changes or physician-level interventions into their policy proposals.

Candidates favoring increased funding for and access to treatment

Michael Bennet*, Joe Biden, Cory Booker*, Pete Buttigieg*, John Delaney*, Amy Klobuchar*, Bernie Sanders*, Tom Steyer*, Elizabeth Warren*, Marianne Williamson*, Andrew Yang*

Candidates favoring harm reduction interventions

Michael Bennet, Cory Booker, Pete Buttigieg, Amy Klobuchar, Bernie Sanders, Elizabeth Warren

Candidates favoring action against pharmaceutical companies

Michael Bennet, Cory Booker, Pete Buttigieg, John Delaney, Tulsi Gabbard, Amy Klobuchar, Bernie Sanders, Elizabeth Warren, Andrew Yang

Candidates favoring interventions that target physician prescribing behavior

John Delaney, Amy Klobuchar, Andrew Yang

Candidates favoring decriminalization of possession of opioids

Pete Buttigieg, Andrew Yang

What the research says

Access to treatment: Medication-assisted treatment is an evidence-based treatment for opioid use disorder; it has been shown to reduce the risk of overdose death for people who use opioids. Methadone, buprenorphine and naltrexone are types of medication-assisted therapy for opioid use disorder. These medications reduce symptoms of craving and withdrawal. A systematic review and meta-analysis of medication-assisted treatment find that people receiving such treatment were less likely to die of an overdose or other causes than their peers with opioid use disorder who did not receive medication-assisted treatment.

Harm reduction: Harm reduction initiatives attempt to reduce the risks associated with using drugs. Such initiatives include needle exchange programs, widespread distribution of the opioid overdose antidote naloxone and supervised injection facilities. Supervised injection facilities, also known as safe injection sites or supervised consumption facilities, are not legal in the U.S. They exist legally in other countries, such as Canada and Australia, however.

Several studies have demonstrated a positive link between safe injection site use and entry into treatment. Safe injection sites also provide benefits to people who use drugs in the form of sterilized equipment and supervision to mitigate the dangers of overdose.

Over a dozen studies have linked needle exchanges with lower rates of hepatitis C and HIV infection among people who inject drugs.

A systematic review of research on take-home naloxone programs, which provide people at risk of opioid overdose with kits including the antidote, concludes that “there is overwhelming support of take-home naloxone programs being effective in preventing fatal opioid overdoses.”

The pharmaceutical industry: Big Pharma’s role in marketing opioids spurred physicians to prescribe more opioids, research shows. This, in turn, fueled the opioid epidemic the country faces today. Policies targeted toward Big Pharma include proposals to hold industry players liable for their role in the opioid epidemic with criminal penalties and fines.

Decriminalization: The rationale behind decriminalization of the personal use of narcotics is that criminal penalties essentially criminalize substance use disorder. Proponents of decriminalization argue that such drug use should, instead, be met with evidence-based treatment. There is not much research on the effects of decriminalization because it’s rare. However, in 2001, Portugal decriminalized personal acquisition, possession and use of illicit drugs. Research indicates that drug-related deaths have fallen since the southwestern European country decriminalized illicit drugs.

Physician-level interventions: These interventions target prescriber behavior. Examples include physician education programs, guidelines or restrictions on the quantity of opioids physicians can prescribe, and prescription monitoring programs that allow physicians to view patients’ prescription history to avoid overprescribing or illegitimate prescribing. While education and prescribing policies have curtailed prescribing habits, prescription monitoring programs have been less successful, studies indicate.

Key context

In late 2017, the U.S. Department of Health and Human Services declared the nation’s opioid crisis a “public health emergency.” The problem has been building for over a decade, spurred by sharp increases in prescriptions for opioids, commonly used to treat both short-term and chronic pain.

About 233.7 million opioid prescriptions were filled each year, on average, from 2006 to 2017, according to a March 2019 study in JAMA Network Open that looks at opioid prescriptions filled in retail pharmacies across the U.S.

Prescription painkillers have a high risk of abuse — across the academic literature, rates of misuse among patients taking opioids for chronic non-cancer pain average between 21% and 29%. Research indicates that as of 2013, more than 2 million people in the U.S. had prescription opioid-related opioid use disorder.

Prescription opioids can also pave the way for illegal drugs like heroin. Eighty percent of people who have used heroin have previously misused prescription opioids, according to an August 2013 analysis of national survey data collected from 2002 to 2011.

As opioid use and misuse has increased, deaths linked to the drugs have increased. In 2017, opioids were involved in 47,600 drug overdose deaths, accounting for nearly 70% of all overdose deaths nationwide that year.

Recent research

Access to treatment:

A review of randomized controlled trials comparing medication-assisted treatment of opioid use disorder to placebo or no medication finds that medication-assisted treatment “at least doubles rates of opioid-abstinence outcomes.”

A study of 151,983 adults in England treated for opioid dependence between 2005 and 2009 finds that the risk of fatal drug overdose more than doubled for individuals who received only psychotherapy compared with those who received medication-assisted treatment.

Harm reduction:

Two reviews — one published in Drug and Alcohol Dependence in 2014, and one published in Current HIV/AIDS Reports in 2017 — indicate that supervised consumption facilities promote help people access treatment. The more recent review looks at 47 studies published between 2003 and 2017 on supervised drug consumption facilities. The authors find a handful of studies that demonstrate a positive link between safe injection site use and starting treatment.

One of these studies compared enrollment in detoxification programs among those who used Vancouver’s supervised injection facility the year before and after it opened in 2003. Researchers find the facility’s opening was linked to a 30% increase in detox program use, which, in turn, was linked to pursuing long-term treatment and injecting at the facility less often. A later study of the injection facility focused on use of detox services located at the facility. It finds that 11.2% (147 people) used these services at least once over the two years studied. The authors conclude that supervised injection facilities might serve as a “point of access to detoxification services.”

A 2006 study of 871 people who injected drugs finds no substantial increase in rates of relapse among former users before and after the Vancouver site opened. However, the researchers also find no substantial decrease in the rate of stopping drug use among current users before and after the site opened. Another study of 1,065 people at this facility published in 2007 finds that only one individual performed his or her first injection at the site.

Though supervised injection sites are illegal in the U.S., one opened underground in 2014. Researchers interviewed those who used the underground site during its first two years of operation and their findings were published in 2017 in the American Journal of Preventive Medicine. The site’s users were asked the same set of questions about their use patterns every time they injected drugs at the site. The authors conclude that the site offered several benefits, including safe disposal of equipment, unrushed injections and immediate medical response to overdoses. The authors add that if the site were sanctioned, it might be able to offer additional benefits, including health care and other services.

Big Pharma:

Research suggests that physicians targeted with marketing from pharmaceutical companies prescribe opioids at higher rates than doctors not exposed to their marketing.

Several studies use data from the Centers for Medicare and Medicaid Services’ Open Payments database, which tracks payments made by drug and medical device companies to physicians. That information is used to analyze how relationships between physicians and drug companies are linked to prescriptions written.

These studies define opioid-related payments as cash payments — for example, speaking fees associated with promoting a drug — and payments-in-kind — free meals pharmaceutical representatives provide to doctors’ offices, for instance. These studies find that physicians who receive opioid-related payments tend to prescribe more opioids.

A study in PLoS One from December 2018 looks at physicians who received opioid-related payments, some in 2014 and some in 2015, compared with doctors who never received such payments. The authors find that physicians who received opioid-related payments had a larger increase in the number of daily doses of opioids dispensed, as well as in total opioid expenditures, prescribing pricier opioids per dose.

Another study looking at the same data offers further detail. The study, published in Addiction in June 2019, focuses on 865,347 physicians across the country who filled prescriptions for Medicare patients from 2014 to 2016. “Prescribers who received opioid-specific payments prescribed 8,784 opioid daily doses per year more than their peers who did not receive any such payments,” the authors write.

Other research geographically links opioid marketing and opioid-related overdose mortality. The paper, published in JAMA Network Open in January 2019, analyzes county-level prescription opioid overdose deaths and county-level opioid marketing payments.

The authors find that deaths from prescription opioid overdoses increased with each standard deviation increase in opioid marketing as measured by dollars spent per capita, number of payments to physicians per capita and number of physicians receiving payments per capita. Standard deviation indicates the variation of a given value from the average. “Opioid prescribing rates also increased with marketing,” the authors write. They note that the higher prescription rate might be why overdose deaths increased.

Physician-level interventions:

An August 2018 study published in Science highlights the role physician education might play in addressing the nation’s opioid crisis. The intervention was simple: When a patient died of an opioid overdose, the county medical examiner sent the prescribing physicians a letter notifying them. The authors conducted a randomized trial of 861 physicians whose patients overdosed. The intervention group received the letter, which included a safe prescribing warning consisting of these recommendations:

• Avoid co-prescribing an opioid and a benzodiazepine.
• Minimize opioid prescribing for acute pain.
• Taper long-term users off opioids.
• Avoid prescriptions lasting for three consecutive months or longer and prescribe naloxone, an opioid overdose antidote.

The control group received no communication.

Physicians in the intervention group cut their opioid prescribing by 9.7% — as measured by milligram morphine equivalents in prescriptions filled — in the three months after the letter was sent. These physicians also started fewer patients on opioids and wrote fewer high-dose prescriptions than the control group.

Prescribing policies and guidelines also have successfully curbed physicians’ distribution of opioids.

In October 2017, the Michigan Opioid Prescribing Engagement Network released opioid prescribing guidelines for nine surgical procedures to clinicians participating in the Michigan Surgical Quality Collaborative, a statewide initiative to improve surgical care.

Researchers compared opioid prescribing before and after these guidelines were released, analyzing data from 11,716 patients across 43 hospitals collected from February 2017 to May 2018. They find that prescriptions declined, on average, from 26 pills to 18 pills per month after the guidelines were released.

Patients also took fewer of the pills they were prescribed. As measured by patient-reported survey data, opioid consumption following surgery dropped from 12 pills to nine, “possibly as a result of patients anchoring and adjusting their expectations for opioid use to smaller prescriptions,” explain the authors of the August 2019 New England Journal of Medicine study. Although patients received smaller prescriptions and used fewer pills after the guidelines were published, there were no substantial changes in the patients’ satisfaction and pain scores.

Similar to the study of Michigan’s opioid prescribing guidelines is a February 2018 study in the American Journal of Emergency Medicine that tracks the effects of an emergency department opioid prescribing policy. The policy resulted in declines in opioid prescriptions. Compared with the control emergency department, the two intervention hospitals had a more pronounced decline in opioid prescribing. The authors conclude that emergency department-based policies might help reduce opioid prescribing.

Prescription drug monitoring programs, which allow physicians to view patients’ prescription history to avoid overprescribing or prescribing opioids to people who don’t actually need them, have been shown to be less effective. A January 2018 study of national data published in Addictive Behaviors finds that there were not statistically significant differences in the likelihood that physicians would prescribe opioids for chronic pain when comparing states with prescription drug monitoring programs with those without.

Further reading

General overview

Modeling Health Benefits and Harms of Public Policy Responses to the US Opioid Epidemic

Allison L. Pitt, Keith Humphreys and Margaret L. Brandeau. American Journal of Public Health, October 2019.

The gist: “Policies focused on services for addicted people improve population health without harming any groups. Policies that reduce the prescription opioid supply may increase heroin use and reduce quality of life in the short term, but in the long term could generate positive health benefits. A portfolio of interventions will be needed for eventual mitigation.”

Safe injection sites

Attendance at Supervised Injecting Facilities and Use of Detoxification Services

Evan Wood, Mark W. Tyndall, Ruth Zhang, Jo-Anne Stoltz, Calvin Lai, Julio S.G. Montaner and Thomas Kerr. New England Journal of Medicine, June 2006.

The gist: A study of Vancouver’s supervised injection facility finds “an average of at least weekly use of the supervised injecting facility and any contact with the facility’s addictions counselor were both independently associated with more rapid entry into a detoxification program.”

Injection Drug Use Cessation and Use of North America’s First Medically Supervised Safer Injecting Facility

Kora DeBeck, Thomas Kerr, Lorna Bird, Ruth Zhang, David Marsh, Mark Tyndall, Julio Montaner and Evan Wood. Drug and Alcohol Dependence, January 2011.

The gist: “These data indicate a potential role of SIF [supervised injecting facilities] in promoting increased uptake of addiction treatment and subsequent injection cessation.”

“A Little Heaven in Hell”: The Role of a Supervised Injection Facility in Transforming Place

Ehsan Jozaghi. Urban Geography, May 2013.

The gist: “Participants’ narratives indicate that attending InSite [Vancouver’s supervised injection facility] has had numerous positive effects in their lives, including changes in sharing behavior, improving health, establishing social support and saving their lives.”

Process and Predictors of Drug Treatment Referral and Referral Uptake at the Sydney Medically Supervised Injecting Centre

Jo Kimber, Richard P. Mattick, John Kaldor, Ingrid Van Beek, Stuart Gilmour and Jake A. Rance. Drug and Alcohol Review, May 2009.

The gist: Researchers conducted 1.5-year study at a supervised injection site in Sydney. They find that 16% of clients at the site referred to treatment by health and social welfare professionals went on to receive it, leading the authors to conclude that the center “engaged injecting drug users successfully in drug treatment referral and this was associated with presentation for drug treatment assessment and other health and psychosocial services.”

Inability to Access Addiction Treatment and Risk of HIV Infection Among Injection Drug Users Recruited from a Supervised Injection Facility

M.-J.S. Milloy, Thomas Kerr, Ruth Zhang, Mark Tyndall, Julio Montaner and Evan Wood. Journal of Public Health, September 2012.

The gist: Many who use supervised injection facilities have the desire to access treatment. This study surveyed 889 people who were randomly selected to be surveyed at Vancouver’s supervised injection facility. “At each interview, ∼20 percent of respondents reported trying but being unable to access any type of drug or alcohol treatment in the previous 6 months,” the authors write. The main barrier to access, respondents said, was waiting lists for treatment.

Big Pharma

The Promotion and Marketing of OxyContin: Commercial Triumph, Public Health Tragedy

Art Van Zee. American Journal of Public Health, February 2009.

The gist: In the first six years it was on the market, Purdue Pharma spent about six to 12 times more to promote OxyContin than it had to promote another long-lasting opioid. The paper describes various marketing strategies including promotional giveaways and Pharma-funded medical education programs.

Industry Payments to Physicians for Opioid Products, 2013-2015

Scott E. Hadland, Maxwell S. Krieger and Brandon D. L. Marshall. American Journal of Public Health, September 2017.

The gist: This study examines payments pharmaceutical companies make to physicians to market opioid products. The authors find that 375,266 opioid-related payments that weren’t related to research work were made to 68,177 physicians over the study period. The authors estimate that about 1 in 12 physicians in the U.S. received a payment from a pharmaceutical company to promote their opioid medications during the 29-month study period. The bulk of the money went toward speaking fees or honoraria, but the most common expense was food and beverages – 352,298 payments totaling $7,872,581.

Association of Pharmaceutical Industry Marketing of Opioid Products to Physicians with Subsequent Opioid Prescribing

Scott E. Hadland, Magdalena Cerdá, Yu Li, Maxwell S. Krieger and Brandon D. L. Marshall. JAMA Internal Medicine, June 2018.

The gist: “Whereas physicians receiving no opioid-related payments had fewer opioid claims in 2015 than in 2014, physicians receiving such payments had more opioid claims,” the authors write.

Physician-level interventions

Differences in Opioid Prescribing Practices among Plastic Surgery Trainees in the United States and Canada

David W. Grant, Hollie A. Power, Linh N. Vuong, Colin W. McInnes, Katherine B. Santosa, Jennifer F. Waljee and Susan E. Mackinnon. Plastic and Reconstructive Surgery, July 2019.

The gist: Plastic surgery trainees were asked about their opioid prescribing education, factors contributing to their prescribing practices and what they would prescribe for eight different procedures. The authors find that, of the 162 respondents, 25% of U.S. plastic surgery trainees received opioid-prescriber education, compared with 53% of Canadian trainees. For all but one of the eight procedures, U.S. physicians prescribed significantly more morphine milligram equivalents than their Canadian counterparts.

Subject experts

Caleb Alexander, professor and co-director of the Center for Drug Safety and Effectiveness, Johns Hopkins University.

Michael L. Barnett, assistant professor, Harvard T.H. Chan School of Public Health.

Chinazo Cunningham, professor, Albert Einstein College of Medicine.

Scott Hadland, assistant professor, Boston University School of Medicine

David N. Juurlink, scientist, Sunnybrook Research Institute.

Thomas Kerr, associate professor, The University of British Columbia.

For more, check out JR’s long read on the opioid prescribing problem, our summary of research on where opioids are prescribed the most and our tip sheet for reporting on fentanyl and synthetic opioids.

This piece adheres to suggestions offered by the National Institute on Drug Abuse’s media guide, which recommends language that avoids the potentially stigmatizing term “addict” in the context of substance use. It states: “In the past, people who used drugs were called ‘addicts.’ Current appropriate terms are people who use drugs and drug users.”

*Dropped out of race since publication date.

The post Addressing the opioid epidemic: What the research says appeared first on The Journalist's Resource.

Blame for the opioid crisis in the U.S. often falls squarely on pharmaceutical companies, pharmacies or rogue prescribers — like the Virginia doctor who prescribed more than half a million opioid doses in two years.

But the whole story is more complicated, and it implicates a large portion of health care providers. Research shows that many doctors, nurse practitioners and physician assistants across the nation have oversupplied patients with opioids, spurring a national crisis that each year claims tens of thousands of lives.

“This isn’t just a story about rogue prescribers and pill mills,” says Caleb Alexander, co-Director of the Center for Drug Safety and Effectiveness at the Johns Hopkins School of Public Health. “A much broader swath of the medical profession is responsible for the oversupply of opioids in clinical practice.”

“Physicians are people, too”

Prescription painkillers have a high risk of abuse — across the literature, rates of misuse average between 21% and 29%. Research indicates that as of 2013, more than 2 million people in the U.S. had prescription opioid-related opioid use disorder.

Prescription opioids can also pave the way for illegal drugs like heroin. Eighty percent of people who have used heroin have previously misused prescription opioids, according to an August 2013 Center for Behavioral Health Statistics and Quality Data Review analyzing survey data collected from 2002 to 2011.

About 233.7 million opioid prescriptions were filled each year on average from 2006 to 2017, according to a March 2019 study in JAMA Network Open that looked at opioid prescriptions filled in retail pharmacies across the U.S.

Although the average amount of opioids prescribed per person declined over this period, the average prescription duration increased, this study found. So did the number of prescriptions written for a month or longer.

Research shows that a substantial share of the supply is not coming from high-volume prescribers or “pill mills.” One paper, published in Addiction in November 2017, analyzes 44.2 million prescription opioid pharmacy claims and finds low-volume prescribers were a major driver of the opioid supply.

Prescribers at the top-fifth percentile of total opioids distributed were more likely to give patients higher doses, longer supplies, more prescriptions, and greater overall amounts of opioids. But prescribers who make up the lower 95^th percentile still account for a large share of the prescriptions given to high-risk patients. Low-volume prescribers account for 15% to 29% of overall amounts of opioids prescribed and 18% to 56% of opioid prescriptions received by high-risk patients.

“We found that a small number of prescribers account for a majority of opioids prescribed,” says Alexander, lead author of the paper. He adds, “A substantial proportion of patients who were using high volumes of opioids intersect with low-volume prescribers.”

The finding that some physicians consistently prescribe more opioids than others indicates that “when it comes to the receipt of opioids, it’s not just about who you are, it’s about who you see,” Alexander says. “The same person going to two different doctors may end up with wildly different supplies of opioids. And this speaks to the lack of standardization of care.”

A March 2017 research letter published in JAMA Internal Medicine looks at trends among Medicare Part D prescribers — a group of over 800,000 physicians prescribing opioids to people who use Medicare to buy prescription drugs. Opioid prescriptions are more common in certain specialties, but general practitioners dominate prescribing, according to the letter.

“Medicare opioid prescribing is distributed across many prescribers and is, if anything, less skewed than all drug prescribing,” the authors conclude. “High-volume prescribers are not alone responsible for the high national volume of opioid prescriptions.”

Another study published in October 2018 in Health Services Research corroborates this evidence and points to another prescribing trend in Medicare data — nurse practitioners and physician assistants account for the largest increases in quantity of opioid prescriptions written between 2006 and 2012.

“There’s a lot more prescribing of opioids by nurses and physician assistants, where they are state-by-state allowed to prescribe them,” says Sarah Axeen, the study’s author and assistant professor of research in the department of emergency medicine at the Keck School of Medicine of USC. “That hasn’t been highlighted in the same way [as physicians’ prescribing practices].”

Another paper, published in August 2019 in JAMA Network Open, analyzes the relationship between the time of day at which primary care appointments occur and opioid prescribing patterns.

Hannah T. Neprash and Michael L. Barnett analyzed electronic medical records from 678,319 appointments in 2017 for 642,262 patients with a painful condition and the 5,603 doctors who treated them. The researchers found that the likelihood that a physician’s patient would receive an opioid prescription rather than non-opioid pain medication or physical therapy increased by 33% as the day went on, and by 17% as appointments ran late.

“Physicians are people, too,” says Jason Doctor, professor and chair of the department of health policy and management at the University of Southern California’s Sol Price School of Public Policy, who was not an author on the paper. “They’re not always making rational decisions in the best interest of the patient, and sometimes they’re affected by the environment, their work situation. Dealing with risky drugs like opioids — that could be a problem.”

State of emergency

The medical community and media sometimes portray emergency departments as a key source of prescription opioids. Research complicates that narrative, too. A paper in Annals of Emergency Medicine from June 2018 finds that the majority of growth in opioid prescriptions nationally from 1996 to 2012 can be traced to office visits and refills of previously prescribed opioids, rather than prescriptions given in the emergency department.

A paper forthcoming in the American Journal of Emergency Medicine finds that in recent years, emergency departments have started prescribing fewer opioids and more non-opioid painkillers, such as non-steroidal anti-inflammatory drugs. Over the six years studied, the rate of opioid prescriptions given to patients in pain who went to two urban emergency departments and received some form of painkiller decreased from 37.76% to 13.29% between 2012 and 2018.

Within emergency departments, opioid prescribing can vary drastically from doctor to doctor. In a February 2017 New England Journal of Medicine paper, researchers looked at Medicare data from 2008 to 2011 for a random sample of 377,629 people who had visited an emergency department and received a range of diagnoses, including chest pain, vertigo, fatigue and high blood pressure. Whether patients with similar diagnoses at the same hospital received opioids depended on which physician they saw.

“Within individual hospitals, rates of opioid prescribing varied widely between low-intensity and high-intensity prescribers (7.3% vs. 24.1%),” the authors find. These differences in turn are linked to varying risk of long-term opioid use. Patients who were treated by high-intensity prescribers had significantly higher odds of developing long-term opioid use than those treated by low-intensity prescribers.

The opioid epidemic in hindsight

In 1980, Hershel Jick and Jane Porter, a physician and graduate student at Boston University Medical Center’s Boston Collaborative Drug Surveillance Program, published a letter to the editor in the New England Journal of Medicine titled “Addiction Rare in Patients Treated with Narcotics.”

Jick and Porter looked at a sample of 11,882 patients who received at least one opioid while hospitalized at the eight medical institutions affiliated with the Drug Surveillance Program. They found that only four of these patients developed opioid addictions.

They conclude: “Despite widespread use of narcotic drugs in hospitals, the development of addiction is rare in medical patients with no history of addiction.”

The letter comes in at just 101 words. It became a heavily-cited piece of evidence in support of the safety of opioids. In June 2017, NEJM published another letter to the editor describing the influence of Jick and Porter’s letter over the next 37 years of opioid research.

The four authors of the 2017 letter identified and analyzed 608 citations of the letter in the academic literature. Their review finds that citations of the letter increased noticeably after the introduction of the brand-name opioid OxyContin in 1995. Additionally, 72.2% of all the citations used the letter as evidence supporting the rarity of addiction to opioids. And 80.8% of all papers citing the letter failed to mention that the patients were hospitalized when they were receiving opioids.

In other words, none of the patients were individuals receiving opioids on an outpatient basis, where it would have been harder to monitor potential misuse of the drugs.

“We believe that this citation pattern contributed to the North American opioid crisis by helping to shape a narrative that allayed prescribers’ concerns about the risk of addiction associated with long-term opioid therapy,” the authors of the 2017 paper conclude.

Jick maintains that he is not responsible for the way his letter was used to allay concerns about the safety of opioids.

“I didn’t even know about it,” Jick says, referring to widespread citation of the letter as evidence that opioids are safe. “No one called and asked me about it. But the only reference in the medical references was a letter to the editor that I wrote in 1980 that was restricted to hospitalized patients. And the eventual outcome was that dozens and dozens of doctors picked this up and misused it. And I didn’t even know about it. I really wrote something that was accurate, but was irrelevant to the disaster that’s going on now.”

Pain: the fifth vital sign

The 1980s also marked the start of the pain movement, which centers on the idea that patients have a right not to be in pain. An April 2017 paper published in Drug and Alcohol Dependence charts the historical course of this movement.

In the mid-to-late 1980s, palliative care specialists began to advocate for the use of opioids in cancer patients. At the same time, the World Health Organization created cancer-pain treatment guidelines, which, for the first time, recommended the use of opioids. The 1986 guidelines reassure patients that they need not worry about dependence: “Psychological dependence is not an issue when strong opioids are taken to relieve cancer pain.”

Next came the American Pain Society’s “Pain, the Fifth Vital Sign,” campaign in 1996. The Society aimed to elevate the importance of pain assessment and measurement to the status of the other four vital signs — pulse, temperature, respiration rate, and blood pressure.

“If pain were assessed with the same zeal as other vital signs are, it would have a much better chance of being treated properly,” said APS president James Campbell in his presidential address to the Society on November 11, 1996. “We need to train doctors and nurses to treat pain as a vital sign.”

The campaign’s first major success came in 1999, when the Veteran’s Health Administration adopted pain as the fifth vital sign.

By 2001, the Joint Commission on the Accreditation of Healthcare Organizations said that to maintain accreditation hospitals had to incorporate pain assessment and treatment into patients’ care.

“When the Joint Commission and the Veterans Health Administration declared pain as the fifth vital sign, I think that pain control became a really important metric that a lot of U.S. hospitals started tracking, in terms of trying to improve their patient satisfaction scores and national ranking,” explains Hollie Power, a plastic surgeon at the University of Alberta.

But the practice of medicine didn’t always have this emphasis.

Jason Doctor points to a landmark 1946 study published in Annals of Surgery, “Pain in Men Wounded in Battle,” which analyzes the treatment of 225 soldiers on the European front in World War II.

“That paper, prior to OxyContin, was a popular paper that people would read to understand that pain has a huge psychological component to it, and that the drugs really play a much smaller role,” Doctor says.

“Three-quarters of badly wounded men, although they have received no morphine for a matter of hours, have so little pain that they do not want pain relief medication, even though the questions raised remind them that such is available for the asking,” writes the author of that study, the late anesthesiologist Henry K. Beecher.

Beecher continues: “The man in shock complains far less frequently of wound pain than he does of the great distress produced by thirst.”

Marketing OxyContin: plush toys and free meals

In 1995, Purdue Pharma introduced OxyContin, an extended-release form of the opioid oxycodone.

Then the sales push began.

Over just one year — 2001 — Purdue spent $200 million to promote OxyContin.

In the first six years it was on the market, Purdue spent around six to 12 times more to promote OxyContin than it had promoting one of its predecessors, MS Contin, another long-lasting opioid, writes Art Van Zee in a paper in the American Journal of Public Health from February 2009.

The paper describes how health care providers received branded promotional items including OxyContin plush toys, music CDs and apparel.

Part of the marketing strategy involved influencing medical education programs. Purdue funded over 20,000 pain-related educational programs, such as clinical teaching presentations at hospitals, seminars at conferences and continuing medical education opportunities for doctors, from 1996 to July 2002, according to Van Zee’s paper.

Purdue sought to liberalize the prescribing of opioids for non-cancer related pain, and succeeded. “You won’t believe how committed I am to make OxyContin a huge success,” Richard Sackler, former chair and president of Purdue Pharma wrote in a May 29, 1999, email released in an unsealed court deposition. “It is almost that I dedicated my life to it.”

In just five years OxyContin prescriptions for non-cancer pain increased by nearly tenfold. There were 670,000 such prescriptions in 1997. By 2002, there were 6.2 million.

The relationship between marketing and prescribing

Research suggests that physicians targeted with marketing from pharmaceutical companies prescribe opioids at higher rates than doctors not exposed to marketing.

Several studies use Centers for Medicare and Medicaid Services’ Open Payments data, which tracks payments made by drug and medical device companies to physicians, to analyze how relationships between physicians and drug companies are linked to prescriptions written.

These studies define opioid-related payments as including cash payments, such as speaking fees associated with promoting a drug, and payments-in-kind, such as free meals provided by pharmaceutical representatives to doctors’ offices. These studies find that physicians who receive opioid-related payments tend to prescribe more opioids.

A study in PLoS One from December 2018 looks at physicians who received opioid-related payments, some in 2014 and some in 2015 compared with peers who never received such payments. The authors find that physicians who received opioid-related payments had a larger increase in the number of daily doses of opioids dispensed, as well as in total opioid expenditures, prescribing pricier opioids per dose.

The findings suggest that direct marketing to physicians provides a healthy return on investment, says Mark Zezza, director of policy and research at the New York State Health Foundation and the paper’s lead author. For every dollar spent marketing opioids to physicians, there was a nearly $25 increase in opioid purchases.

“We also found the more payments they receive, the higher those increases were in opioid prescribing. Another key finding is that not only were they prescribing more opioids, but they were generally prescribing more expensive drugs. So, perhaps they were moving towards more brand name drugs,” Zezza says.

“It does kind of sound the alarm that these relationships between drug manufacturers and physicians should be more carefully monitored,” he adds. “Especially for drugs that are highly addictive, and have the potential to cause real harm to patients.”

Another study looking at the same data offers further detail. The study, published in Addiction in June 2019, focuses on 865,347 physicians across the country who filled prescriptions for Medicare patients from 2014 to 2016. “Prescribers who received opioid-specific payments prescribed 8,784 opioid daily doses per year more than their peers who did not receive any such payments,” the authors write.

Payments had the effect of increasing prescriptions for the specific opioid with which they were associated. Hydrocodone-related payments were linked to 5,161 additional daily doses of hydrocodone, oxycodone-related payments were linked to 3,624 additional daily doses of oxycodone, and fentanyl-specific payments were linked to 1,124 additional daily doses of fentanyl compared with peers who did not receive such payments. Additionally, among those who received opioid-related payments, a 1% increase in the amount received was linked to an additional 50 daily doses of opioids.

A series of recent studies further investigate the relationship between pharmaceutical marketing and physicians’ prescribing habits. These studies also use the Open Payments database to look at trends from 2013 to 2016. They were led by Scott Hadland, a pediatrician and addiction specialist at Boston Medical Center and Boston University School of Medicine.

The first study, published in the American Journal of Public Health in September 2017, establishes the extent to which pharmaceutical companies pay physicians to market opioid products. The researchers found that 375,266 non-research opioid-related payments were made to 68,177 physicians over the study period. The authors estimate that about one in 12 physicians in the U.S. received a payment from pharmaceutical companies promoting their opioid medications during the 29-month study period. The bulk of the money spent went to speaking fees or honoraria, but the most common expense was food and beverage payments – 352,298 payments totaling $7,872,581.

“I know that physicians have the opportunity to say no to marketing, but I think in many places, these marketing practices are normalized and felt to be just sort of a part of everyday clinical practice,” Hadland says.

Building on that finding, Hadland looked at how those payments were linked to subsequent prescription trends in a follow-up paper published in JAMA Internal Medicine in June 2018. Using Medicare prescribing data, the authors began with opioid prescriptions filled for Medicare beneficiaries in 2015, and then identified physicians who had written at least 10 opioid prescriptions that year. The authors then analyzed the payments those high-prescribing physicians had received through opioid-related marketing, and looked to see whether there were changes in prescriptions written compared with the previous year.

“Whereas physicians receiving no opioid-related payments had fewer opioid claims in 2015 than in 2014, physicians receiving such payments had more opioid claims,” the authors write. “In multivariable modeling, receipt of any opioid-related payments from industry in 2014 was associated with 9.3% more opioid claims in 2015 compared with physicians who received no such payments.”

Further, the authors found that each additional meal physicians received from a drug company was linked to a subsequent increase in opioid prescriptions.

“Physicians are human,” Hadland says. “Humans are subject to marketing — often in ways that they don’t perceive that marketing can change our behavior in very subtle ways — which, on the level of a single physician may not matter that much. But if you look at marketing widespread across the entire country, these changes in prescribing behaviors really add up.”

Hadland’s final paper in the series geographically links opioid marketing and opioid-related overdose mortality. The paper, published in JAMA Network Open in January 2019, analyzes county-level prescription opioid overdose deaths and county-level opioid marketing payments.

The authors found that mortality from prescription opioid overdoses increased with each standard deviation increase in opioid marketing as measured by dollars spent per capita, number of payments to physicians per capita and number of physicians receiving payments per capita. “Opioid prescribing rates also increased with marketing,” the authors write. They offer that the higher prescription rate might be why overdose deaths increased.

Potential solutions

Because physicians are gatekeepers to highly addictive prescription drugs, researchers have studied ways to moderate prescribing such that opioids are given in limited quantities and only when needed.

One area where researchers agree physicians in the U.S. could stand to benefit is in education around opioid prescribing.

A survey of 162 plastic surgery trainees in the U.S. and Canada published in Plastic and Reconstructive Surgery in July 2019 highlights the issue. Respondents were asked about their opioid prescribing education, factors contributing to their prescribing practices and what they would prescribe for eight different procedures. The authors found that, of the 162 respondents, only 25% of U.S. plastic surgery trainees received opioid-prescriber education, compared with 53% of Canadian trainees. For all but one of the eight procedures in question, U.S. physicians prescribed significantly more morphine milligram equivalents than their Canadian counterparts. Morphine milligram equivalents is a measure that standardizes the strength of opioids by the amount of morphine that would be needed to achieve the same pain-relieving effect.

Both U.S. and Canadian trainees were unlikely to routinely offer their patients preoperative counseling on the use of opioids.

“Health care delivery is very different between the U.S. and Canada,” explains Hollie Power, the lead author of the study. “Obviously, nobody wants our patients to suffer. But it [pain management] became an important metric in quality [in the U.S.] as well. That’s not so much of a consideration in Canada, where healthcare is government funded, and patients don’t tend to look at hospital rankings or things like that.”

Power notes that Canada has had tighter regulations in effect for decades around opioid prescribing.

“We need to be educating our providers to be able to know what they need to prescribe,” Power says. “Another gap that we identified was that there doesn’t exist guidelines in our literature for how much medication do patients actually require for procedures that we’re doing commonly.” She suggests a multi-faceted approach, combining both prescriber education initiatives and policies to limit quantities of opioids prescribed.

Here’s what that might look like in practice.

In October 2017, the Michigan Opioid Prescribing Engagement Network released opioid prescribing guidelines for nine surgical procedures to clinicians participating in the Michigan Surgical Quality Collaborative, a statewide initiative to improve surgical care.

Researchers compared opioid prescribing before and after these guidelines were released, analyzing data from 11,716 patients across 43 hospitals collected from February 2017 to May 2018. They found that prescriptions declined on average from 26 pills to 18 pills after the guidelines were released.

Patients also took fewer of the pills they were prescribed. As measured by patient-reported survey data, opioid consumption in the post-operative period dropped from 12 pills to nine pills, “possibly as a result of patients anchoring and adjusting their expectations for opioid use to smaller prescriptions,” the authors of the August 2019 New England Journal of Medicine publication explain. Although patients received smaller prescriptions and used fewer pills after the guidelines were published, the researchers found no clinically important changes in the patients’ satisfaction and pain scores.

Similar to the study of Michigan’s opioid prescribing guidelines is a February 2018 study in the American Journal of Emergency Medicine tracking the effects of an emergency department opioid prescribing policy. The policy resulted in declines in opioid prescriptions. Compared with the control emergency department, the two intervention hospitals had a more pronounced decline in opioid prescribing. The authors conclude that emergency department-based policies might help reduce opioid prescribing.

Prescription drug monitoring programs, which allow physicians to view patients’ prescription history in order to avoid overprescribing or illegitimate prescribing of opioids, and which have been implemented in many states, have proven less effective. A January 2018 study of national data published in Addictive Behaviors finds that there were not significant differences in the likelihood that physicians would prescribe opioids for non-cancer chronic pain between states with prescription drug monitoring programs and those without.

An August 2018 study published in Science attempts to make the relationship between opioid prescribing and overdose deaths more visible to physicians. The intervention was simple: a letter from the county’s medical examiner explaining to the prescribing physicians that their patient had subsequently died of an opioid overdose. The authors conducted a randomized trial of 861 physicians whose patients overdosed. The intervention group received the letter, which included a safe prescribing warning consisting of these recommendations:

• Avoid co-prescribing an opioid and a benzodiazepine.
• Minimize opioid prescribing for acute pain
• Taper long-term users off opioids
• Avoid prescriptions lasting for three consecutive months or longer and prescribe naloxone, an opioid overdose antidote.

The control group received no communication.

Physicians in the intervention group decreased their opioid prescribing by 9.7% — as measured by milligram morphine equivalents in prescriptions filled — in the three months after the letter was sent. These physicians also started fewer patients on opioids and wrote fewer high-dose prescriptions than the control group.

“I think physicians believe there is an opioid epidemic, but they think it’s not happening in their clinic, right? It’s happening elsewhere, there are these bad doctors,” says Jason Doctor, lead author of the study. “They can watch the news and see all the terrible things happening and believe that this is happening, but think they’re not part of the problem.”

He continues, “You can be a bad actor without knowing you’re a bad actor. You can be influenced to do these things through marketing campaigns and believing that pain can be knocked out with opioids.”

The aftermath

Overprescribing is a cause. Addiction is an effect.

As physicians attempt to address opioid use disorder, the focus has turned to evidence-based treatment, such as medication-assisted therapy. Methadone, buprenorphine and naltrexone are examples of medication-assisted therapy for opioid use disorder. These medications reduce symptoms of craving and withdrawal. Under the Drug Addiction Treatment Act of 2000, physicians must complete a training program if they want to prescribe medication-assisted therapy outside of an opioid treatment program.

Ironically, the very marketing tactics that contributed to America’s opioid crisis might also contribute to the solution. A September 2019 study in the Journal of Substance Abuse Treatment finds that physicians who received payments from pharmaceutical companies as part of marketing efforts for medications that treat opioid use disorder prescribed 1,080 daily doses more of these medications each year than their peers who received no such payments.

“We’ve got a problem in this country right now with the sort of weird policies where it’s harder to prescribe buprenorphine to treat an opioid addiction than it is to prescribe the opioid in the first place,” says David Bradford, senior author and chair in public policy at the University of Georgia. “You don’t need extra training to prescribe an opioid, but if you want to prescribe a medicine to help people get off opioid addiction, you do need it. And so, how do we overcome that barrier? Well, it may be that pharmaceutical marketing helps you in that.”

The image at the top of this article was obtained from the Flickr account of Cindy Shebley and is being used under a Creative Commons license. No changes were made.

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United States military service members who experience combat are more likely to misuse prescription painkillers than those who don’t engage in combat, according to a new working paper from the National Bureau of Economic Research.

Prescription painkiller misuse is 7 percentage points higher among service members whose units were deployed to combat zones and engaged with enemy fighters, compared with those deployed to combat zones whose units didn’t engage the enemy, the authors find.

“This study is the first to estimate the causal impact of combat deployments in the Global War on Terrorism on opioid abuse,” the authors write.

They also find that younger, enlisted personnel are at greater risk for misusing prescription painkillers after combat exposure. Service members in the authors’ sample come from similar socioeconomic backgrounds. This suggests the association is driven by what happens on the battlefield, not other factors like race, ethnicity and income levels that have been broadly linked to opioid misuse.

“Among military populations, combat is a very major reason for the opioid epidemic,” says Resul Cesur, an associate professor of healthcare economics at the University of Connecticut and one of the paper’s authors. “It’s not because of who these people are. It’s because of what they are being exposed to.”

The authors conservatively estimate that government health care costs top $1 billion per year to treat active-duty service members and veterans who misuse prescription painkillers.

While not all prescription painkillers are opioids, oxycodone, hydrocodone and other opioids are among those prescription painkillers generally most likely to be misused — compared with painkillers like nonsteroidal anti-inflammatory drugs, which typically aren’t thought to be addictive.

“For this reason, I think these [prescription painkiller data] are very good proxies for what we want to capture,” Cesur says.

Combat exposure is also associated with higher rates of heroin use, according to this paper. Looking at a different dataset, the authors find deployed service members who saw combat used heroin at a 1.4 percentage point higher rate than deployed service members who didn’t engage with enemy fighters. The authors identified the largest effects among service members in the Army, Marines and Navy, relative to service members in the Air Force. The government cost of treating active-duty service members and veterans who misuse heroin is nearly $500 million per year, the authors conservatively estimate.

Enlisted personnel bear the brunt

The U.S. military has two distinct career tracks: enlisted personnel and commissioned officers. One of those tracks bears the brunt of the opioid crisis in the military, this research finds.

Enlisted personnel perform tasks. They usually receive specialized training, and their specialties can vary widely. Enlisted personnel may scout a battlefield, or service biomedical equipment, or care for government-owned animals or perform any number of other specialties. A four-year degree is not required to enlist.

Commissioned officers serve primarily as management. They handle operations and strategy and give orders to lower-ranked officers and enlisted personnel. Each branch of the military has slightly different paths toward becoming an officer, but most include having or obtaining a four-year college degree.

In addition to having more formal education, officers also typically earn more money than enlisted personnel.

Enlisted personnel account for nearly all of the association between combat exposure and painkiller misuse, the authors find. Of the nearly 2.8 million service members who have served overseas since 9/11, 86% were enlisted, according to a 2018 analysis by the RAND Corporation.

“We find the effects among officers are almost zero,” Cesur says. Younger enlisted service members, age 18 to 24, who saw combat are also more likely to have misused painkillers, the authors find.

Data sources

The authors draw their findings from two surveys of military service members.

The first is the National Longitudinal Study of Adolescent and Adult Health, also called Add Health. This nationally representative survey originally interviewed about 20,000 adolescents in grades 7-12 during the 1994-1995 school year. Researchers asked about kids’ social and economic backgrounds, their performance in school and their psychological and physical well-being. They followed up with the original respondents during 2007-2008.

From Add Health, the authors analyzed a sample of 482 men aged 28 to 34 who reported actively serving in the military during the Iraq and Afghanistan wars in the early- and mid-2000s. Detailed socioeconomic information allowed the authors to study respondents who had similar upbringings. This sample led to the finding that prescription painkiller misuse was 7 percentage points higher among service members whose units were deployed to combat zones and engaged with enemy fighters.

The other, much larger sample was the 2008 Department of Defense Health and Related Behaviors Survey. This survey included nearly 30,000 active-duty service members aged 18 to 50. The authors’ sample included responses from 11,542 soldiers deployed overseas who provided information on recent prescription painkiller misuse. Respondents were also asked about other illicit drug use.

This sample led to the finding that heroin use is higher among service members who experience combat, and to the broader finding that enlisted personnel account for almost all of the link between combat exposure and painkiller misuse.

Men made up more than three-fourths of enlisted personnel who saw combat and responded to the DOD survey. Before 2013, women were not allowed to take up many frontline positions.

Injury, easy supply and peers

The authors reason that soldiers might start using opioids for their original medical purpose: when warzone service members are injured, opioids can help manage their pain.

Post-traumatic stress disorder also explains a big chunk of the relationship between combat exposure and painkiller abuse, Resul says. Traumatic events that military personnel experience, even among those who don’t serve directly on the front lines, can increase opioid misuse, according to the paper. In the authors’ DOD survey sample, 10% of active-duty deployed service members had PTSD.

Another reason for opioid misuse among military personnel who saw combat could be that cheap, high-quality opioids were available in the very places service members were deployed in the 2000s. Opium poppy cultivation in Afghanistan grew steadily in the years after 9/11, according to data from the United Nations Office on Drugs and Crime.

“Opium production in Iraq was much rarer than in Afghanistan, but production in Iraq began to grow in the aftermath of Operation Iraqi Freedom,” the authors write. “Production appears to have accelerated during the period just before and during the so-called ‘surge’ of U.S. Armed Forces to Iraq in 2007-2008.”

There may also be peer effects at play.

“People go to combat zones and then see their colleague is using opioids because he is stressed,” Cesur says. “So that may be another pattern. Humans are social creatures and we copy from each other.”

Veterans at risk

Programs aimed at reducing painkiller prescriptions to soldiers and veterans appear, so far, to be working.

Opioid prescriptions from Department of Veterans Affairs doctors fell more than 40% from 2012 to 2017, according to the authors. This coincides with the VA’s Opioid Safety Initiative, which began in 2013 and aims to educate healthcare providers on the benefits and risks of prescribing opioids.

The authors note that, “the reduction in opioid prescriptions to curb abuse may have the unintended consequence of reduced pain abatement for opioid users who do not suffer from addiction,” and that “sudden negative shocks to prescription painkillers could induce veterans to more dangerous, and perhaps deadly, forms of opioid use such as heroin or fentanyl if these drugs are substitutes.”

Despite fewer painkiller prescriptions, the opioid overdose death epidemic among veterans is still very real — and appears to be getting worse. After troop surges in Afghanistan and Iraq in the late 2000s, opioid use disorders among veterans rose 55%, according to data the authors cite from the VA.

Veterans broadly are twice as likely to die from accidental drug overdoses, according to one widely and recently cited study analyzing data from 2005 and published in 2011 in the journal Medical Care.

More recent research in the American Journal of Preventive Medicine bolsters the premise that veterans remain particularly vulnerable to addiction. The rate of opioid overdose deaths among veterans in 2016 increased 65% from 2010, according to that paper — even as the percentage of veterans who received prescriptions for opioids in the three months before their deaths fell from 54% in 2010 to 26% in 2016.

The authors of the new NBER paper cite evidence suggesting that medical marijuana could be an effective substitute for opioids in treating chronic pain. Medical marijuana may not play a straightforward role in easing the broader opioid epidemic, however. Research in the Proceedings of the National Academy of Sciences from just a few months ago found — contrary to prior research — that opioid overdose death rates increased by nearly a quarter in states with legal medical marijuana.

Can medical marijuana really play a role in easing the nation’s opioid epidemic? Here’s what the most recent research says. Plus, see the parts of the country where opioids are prescribed the most. And, America’s other drug epidemic. Last but not least, don’t miss these 10 rules for reporting on war trauma survivors, created in collaboration with our friends at The War Horse.

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A recent study challenges the role that legalizing medical marijuana might play in easing the opioid epidemic.

The paper, published in the Proceedings of the National Academy of Sciences in June 2019, indicates that a previously reported relationship between medical marijuana laws and declining opioid overdose deaths has not held up over time.

The paper uses the same research methods as a 2014 study published in JAMA Internal Medicine, which found that states that had legalized medical marijuana during the study period — 1999 to 2010 — had 24.8% lower annual opioid death rates, on average, compared with states that had not legalized medical marijuana.

The authors of the 2014 study found this association by examining opioid overdose death rates by state using data from the U.S. Centers for Disease Control and Prevention. The data included all overdose deaths in which an opioid was involved, including those that involved other drugs such as heroin. The authors used regression analysis to estimate the relationship between states enacting medical cannabis laws and opioid overdose death rates over time.

This new study replicated the original paper’s findings and extended the investigation through 2017, adding 32 states that legalized medical marijuana between 2010 and 2017 to the sample. When the authors examined the relationship over this longer period, they found that the relationship did not hold. In fact, it reversed direction — opioid overdose death rates increased by 22.7%, on average, in states that had legalized medical marijuana.

“To me, as a public health researcher working in drug policy and epidemiology, this idea that medical cannabis is a very important solution to the opioid overdose crisis is really salient,” explains Chelsea Shover, a postdoctoral research fellow in psychiatry at Stanford University who’s the lead author of the 2019 paper. “It’s just a pervasive idea, and it’s one that I, in the past, had found really compelling, even knowing the limitations that the authors of the first paper mentioned.”

The authors of the original study listed the following as limitations:

• The study is ecologic — that is, it’s concerned with trends at the population-level, such as at the level of the state or the country. This means that it does not and cannot account for what is happening at the level of the individual.
• The death certificate data used by the researchers could be inaccurate. Also, states may differ in how they classify opioid overdose deaths.
• Other factors that could explain the association might not have been accounted for in the model.
• The relationship between medical marijuana laws and opioid overdose death rates may change over time.

Despite this, the original article made a big — and lasting — splash. “That research received substantial attention in the scientific literature and popular press and served as a talking point for the cannabis industry and its advocates, despite caveats from the authors and others to exercise caution when using ecological correlations to draw causal, individual-level conclusions,” the authors of the follow-up study write.

In fact, the original article has been cited in over 400 scientific journal articles and 370 news articles.

Its widespread uptake stems from a few factors, Shover suggests. “There are a lot of people who really want this to be true,” she says. “It’s compelling because it just sort of makes sense on its face and it’s easy for people to understand.”

She maintains that there’s a problem with the way the research has been interpreted by academics and the media. Both studies are concerned with ecological-level associations — that is, population-level trends. These bigger picture associations don’t provide information about what’s happening from person to person. For example, the studies don’t shed light on whether, at the individual-level, people are (or aren’t) substituting medical marijuana for opioids.

Shover and her co-authors write in their paper that the relationship the original study found is likely “spurious.”

Chinazo Cunningham, an author on the 2014 paper, disagrees with using the term “spurious” to describe the association between medical marijuana legalization and decreases in opioid overdose mortality.

“To me, the findings are consistent,” Cunningham says. “The opioid epidemic has evolved. And what it was when we were looking at it, is now different,” she explains. Initially, people were overdosing on prescription opioids. In more recent years, they have died after using heroin and synthetic opioids like fentanyl.

“What we know is that medical cannabis helps with pain,” Cunningham continues. “And the prescription opioids were really around pain and pain management. And so as the epidemic has evolved, it’s become more around addiction. And there really are not data to support the use of medical cannabis to treat opioid addiction. I don’t expect that medical cannabis would treat opioid addiction. Ever. So that is really what I think the [original] findings are saying — medical cannabis helps with pain management, and there can be a reduction in opioid use, but it’s not going to treat necessarily addiction.”

However, Cunningham agrees that both studies are limited in that they cannot establish causality: “These studies also have limitations, definitely,” she adds.

Shover maintains that her work is agnostic on the role of marijuana in treating pain. “What does this study mean for how patients and families should treat their pain?” Shover asks. “The answer to that is nothing. It’s a study about policy; it explicitly is talking about population-level effects and not about the individual-level decisions.”

For now, it’s hard to study the individual-level due to federal marijuana policy that prevents national data collection and analysis, Cunningham points out. “The other really important thing here is, why are we talking about this? It’s about the data and the lack of causality. And that is because we can’t study cannabis in the way we want to study it,” she says. “If we could just change our federal policy to match more with what the states are doing, then we could actually do the studies and have the data that can inform this conversation in a much better way.”

But researchers might be able to get closer to understanding the crux of the issue through different kinds of studies, Shover says. To suggest how to understand the individual-level relationship between opioids and medical marijuana, Shover offers the hypothetical example of a study that looks at state-level medical marijuana registry data and corresponding medical records to see if people who had, prior to registering for medical marijuana, been prescribed opioids, were subsequently prescribed fewer opioids after joining the registry in comparison with people who received opioids for similar diagnoses but who hadn’t registered for medical marijuana. For now, Shover says it would be challenging to execute such a study due to issues with accessing the records involved.

Shover continues, “The relationship between two things can be really different on individual levels than on a population level, and so our work is not aimed at patients for making decisions about how to treat their pain. It’s not aimed at voters who are deciding whether to support decriminalization or legalization. It’s aimed at policy makers who are saying, ‘I could either spend my time trying to push for medical cannabis and then feel like I’ve really done something to address the overdose crisis, or I can say okay, medical cannabis is a separate issue, when I’m thinking of strategies about the overdose crisis I should be focusing on stuff we have better evidence for — like Narcan, like making it easier for people to get treatment and reforming incarceration policies to reduce vulnerability to overdose.’”

Lessons for journalists

This tale of two studies is a great example of why it’s important for journalists to stay close to the source material they’re covering — paying careful attention to the question the study is addressing, as well as the limitations of the research — and not extrapolate beyond the researchers’ findings.

Part of this has to do with framing the research accurately from the outset.

“Headlines help you stay in business, right?” Shover asks. “Well, whatever you go into in the actual article is really important. But it is undercut pretty easily by a headline that’s saying something that’s stronger than what the actual study would say.”

For example, these headlines overstate the 2014 study’s findings:

• “Marijuana Legalization Reduces Opioid Use, Studies Show”
• “Studies: Medical Marijuana Helps Ease Painkiller Addiction Crisis”
• “Despite the Skeptics, Legal Marijuana is Having a Positive Impact on the Opioid Crisis.”

Shover says some of the onus is on researchers, who must communicate their findings in a way that’s both accurate and understandable to the lay public.

Cunningham agrees. “I think that often, as researchers, we’re very specific in the ways that we talk about our findings, and not overselling it,” she says “But I think that gets lost by the media often because the media wants headlines.” But it’s not just on the media: “I do think there’s a dual responsibility of the researchers and the journalists,” she adds. “We have to discuss it in a way where the general public can understand the nuance. And I think that’s really a lot of where the challenge lies.”

From her own experience, Shover advises researchers to say yes to every interview. “Getting out in front of it, and being very forthcoming with reporters and being willing to talk to media has been helpful in that the content of the articles I see out there really do seem to capture what we found and to do a good job of communicating to what it does and doesn’t say,” she says.

Part of it, she says, has to do with putting a study into its proper context — as a contribution to a larger body of research, rather than the last word on a topic.

Shover suggests journalists bring in broader research perspectives beyond just the authors of the study on which they’re reporting. “Bring in basic scientists who are doing research on how it [cannabis] affects the brain, and then people who are doing clinical research, and just talking about it from angles and different levels like whenever possible,” she says. “Trying to get those perspectives is really helpful to understanding what you can and can’t learn from an individual study.”

For more on covering academic research responsibly, check out our tips on determining whether a medical study is newsworthy, pointers from scholars for journalists (and vice versa), suggestions for covering viral research and a useful reminder about the dangers of parachuting into and out of academic research papers.

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This tip sheet, originally published in 2018, has been updated to include more recent statistics and additional information.

Benzodiazepines, a class of anti-anxiety drugs, are commonly-prescribed medications with the potential for abuse, addiction and overdose. Sound familiar? The parallels to the opioid epidemic are apparent; some physicians have taken to calling it “our other prescription drug problem” as they warn of potential dangers.

“People don’t appreciate that benzodiazepines are addictive and that people abuse them,” said Dr. Anna Lembke, a psychiatry professor at Stanford Medical School. In a phone call with Journalist’s Resource, she said that, just as with alcohol, benzodiazepines can be taken to achieve a state of intoxication.

Lembke is the program director for the Stanford University Addiction Medicine Fellowship and chief of the Stanford Addiction Medicine Dual Diagnosis Clinic. She has published research in JAMA Psychiatry, Molecular Psychiatry, the Journal of Substance Abuse Treatment, Addiction and other journals. In 2016 she published Drug Dealer, MD: How Doctors Were Duped, Patients Got Hooked, and Why It’s So Hard to Stop, a book on the prescription drug epidemic. Journalist’s Resource spoke with Lembke to learn more about the drugs and factors that have spurred current prescribing trends.

For context, a few recent studies put numbers to these trends: A new study that focuses on Sweden finds that benzodiazepines and benzodiazepine-related drug prescriptions increased 22 percent from 2006 to 2013 among individuals aged 24 and younger.

A study published in 2016 in the American Journal of Public Health finds that from 1996 to 2013, the number of adults in the United States filling a prescription for benzodiazepines increased 67 percent, from 8.1 million to 13.5 million. The death rate for overdoses involving benzodiazepines also increased in this time period, from 0.58 per 100,000 adults to 3.07.

What are benzodiazepines?

Benzodiazepines are a class of drugs with sedative and anti-anxiety effects. A few of the most commonly prescribed benzodiazepines include diazepam (brand name: Valium), alprazolam (brand name: Xanax; street names: bars, xannies), clonazepam (brand name: Klonopin) and lorazepam (brand name: Ativan). These drugs differ with respect to how long they take to start working and how long they last, but all have similar effects, since they work by the same mechanism.

How do they work?

Benzodiazepines bind to gamma-aminobutyric acid (GABA) receptors in the brain. GABA is an inhibitory neurotransmitter; in other words, it inhibits brain activity. Turning the power down in the brain feels like sleepiness and calm.

What are they prescribed for?

They can be prescribed for a number of concerns, including anxiety, insomnia and seizures.

How can they be dangerous?

Benzodiazepines are accompanied by a number of side effects, including tolerance (reduced sensitivity) for the drug, cognitive impairment, anterograde amnesia (the inability to remember events that occurred after taking the drug), increased risk of Alzheimer’s disease, increased risk of falls (particularly among the elderly, who, according to a study in JAMA Psychiatry, comprise the age group in the U.S. most likely to use the drugs, and use them over the long term), and, most notably, dependence, abuse and overdose. Benzodiazepines are similar to opioids, cannabinoids, and the club drug gamma-hydroxybutyrate (GHB) insofar as the same neural mechanism underlies their addictiveness, according to research published in Nature.

Even taking benzodiazepines in adherence to a prescribing physician’s instructions can lead to dependence. Withdrawal symptoms are likely among patients who have taken benzodiazepines continuously for longer than a few weeks, according to a study published in Australian Prescriber.

For people who are looking to discontinue their use of benzodiazepines, Lembke noted that withdrawal could be potentially life threatening. “You can have full-blown seizures and die just from the withdrawal,” she said.

“The way that they’re prescribed and continued is contrary to the evidence in the medical literature,” Lembke said. She noted that the evidence indicates benzodiazepines are effective and useful only in the short term, and typically at low doses. “There’s no evidence that benzodiazepines taken long term work for anxiety,” she said. “Nonetheless, it is common practice to prescribe and continue those prescriptions for months to years to decades. Somehow there’s a disconnect between the evidence and what the practice is.”

Given these risks, why are prescriptions on the rise?

“No one knows for sure,” Lembke said. She did, however, offer a few possible explanations.

She mentioned changes over the past three decades in the way healthcare is delivered.

As more physicians have shifted from private practice into integrated health care centers, they might feel pressure to adhere to standard protocols or perform procedures and prescribe pills like benzodiazepines, because “that’s what pays.”

She added that the way medicine is currently practiced separates patients into parts: “Patients have a different doctor for every body part … The right hand doesn’t know what the left hand is prescribing.”

Frequent changes in insurance coverage, or churn, means that individuals bounce from one coverage source (and care provider) to another. This eliminates the possibility of a sustained, caring and trusting relationship that might allow for more efficacious, long-term health interventions, Lembke added.

Other changes to the health care system have also occurred: “In many ways, doctors are like waiters and patients are customers,” Lembke explained, adding that some doctors feel the need to respond to patients’ requests and provide short-term relief or “customer satisfaction.”

A cultural shift might be at work here, too, “Patients expect it,” Lembke said. “We now think pain in any form is dangerous … We’ve also got a whole generation of individuals raised on Prozac, Adderall, Xanax thinking there isn’t anything wrong with using chemicals to change the way you feel.”

Benzodiazepines and opioids

As Lembke pointed out, rising pharmaceutical use isn’t limited to benzodiazepines. And as the United States grapples with widespread opioid use, research points to a dangerous link between these drugs and benzodiazepines.

A study of over 300,000 patients receiving opioid prescriptions between 2001 and 2013 finds that by 2013, 17 percent also received benzodiazepine prescriptions — up from 9 percent in 2001.

Moreover, a study that looked at U.S. veterans who received opioid prescriptions finds that those who received benzodiazepines as well experienced increased risk of drug overdose death; the risk increased along with the dose. Another study finds that the overdose death rate among patients receiving opioids and benzodiazepines was 10 times higher than among those receiving opioids alone.

According to statistics from the National Institute of Drug Abuse (NIDA), from 1999 to 2017, there was a 10-fold increase in the number of overdose deaths involving benzodiazepines in the United States — a rise from 1,135 in 1999 to 11,537 in 2017. Most of the increase has been driven by the use of benzodiazepines in combination with opioids (since 2014, the number of overdose deaths involving benzodiazepines but not any opioids has held steady). As opioids contribute increasingly to benzodiazepine overdose deaths, benzodiazepines too are increasingly present in opioid overdose deaths — the powerful combination of drugs is present in over 30 percent of opioid overdoses, NIDA reports.

Benzodiazepine abuse on its own can lead to overdose and death, but overdose deaths typically occur in combination with other substances — generally other central nervous system depressants, which, like benzodiazepines, can lead to the life-threatening effect of slowed or stopped breathing.

In August 2016, the Food and Drug Administration issued a requirement that opioids and benzodiazepines carry a black-box warning about the risks associated with using these substances together.

Now that you have the background, here are some story ideas, courtesy of Lembke:

Look into the latest wave of benzodiazepines: super-potent, designer, synthetic varieties made in illicit labs.

Investigate the growth of benzodiazepine-related patient advocacy organizations as a phenomenon.

Probe Big Pharma’s role in prescription trends and look at socioeconomic variations in benzodiazepine prescriptions (e.g., Medicaid prescribing rates).

Journalist’s Resource also has explainers on other drugs, including fentanyl and meth.

This photo, property of the United States Department of Justice, was obtained from Wikimedia Commons and used under a Creative Commons license.

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This tip sheet, originally published in 2018, has been updated to include more recent statistics. The numbers show that the problem has grown significantly.

Amid the United States’ ongoing opioid crisis, government agencies are documenting the rise of another highly addictive drug: methamphetamine.

Data from the U.S. Centers for Disease Control and Prevention shows that from 2011 to 2016, the number of drug overdose deaths involving methamphetamine more than tripled, jumping from 1,887 to 6,762 (opioid-related overdose deaths are an order of magnitude greater).

The U.S. Drug Enforcement Administration’s 2018 National Drug Threat Assessment suggests that methamphetamine availability is high in the U.S., with many states reporting greater availability in recent years.

The DEA substantiated these reports using purity (the amount of methamphetamine present compared to other substances), potency (how much of the drug is needed to have an effect) and price data. The price of methamphetamine per gram has decreased (it stood at around $70 in March 2017) as its purity has increased.

“Use and treatment numbers still remain higher than lows seen in previous years,” the 2018 National Drug Threat Assessment states. “Significantly, deaths from psychostimulants (the majority being methamphetamine) are rising.”

In light of these trends, Journalist’s Resource collected recent research and resources to answer questions reporters new to the topic might have.

What is methamphetamine?

Methamphetamine is an addictive drug classified by the DEA as a Schedule II stimulant. It affects the central nervous system, stimulating dopamine receptors in the brain and producing euphoric effects. It can be smoked, snorted, injected or taken by mouth. One form of the drug is crystal methamphetamine, which resembles clear or bluish glass shards. Methamphetamine and crystal methamphetamine are commonly called by slang names including ice, crystal, meth, speed, crank and chalk.

How is it made?

Methamphetamine is a synthetic drug, which means it’s made in a lab, not grown in a field like marijuana or opium poppies. Producing meth thus depends on the availability of the ingredients needed to create it, also called precursors, including ephedrine, pseudoephedrine, and phenyl-2-proponone (P2P). These first two ingredients might ring a bell from trips to the pharmacy. Pseudophedrine is a decongestant used to alleviate cold and allergy symptoms. Ephedrine was commonly used in weight-loss products. Dietary ephedrine products were banned by the FDA in 2004, but the drug is available over the counter for some conditions, like asthma. P2P is a schedule II controlled substance not commonly available in consumer products. The household availability of some meth precursors, though, fostered small, domestic laboratory operations in the early 2000s.

The Combat Methamphetamine Epidemic Act (CMEA), signed into law in 2006, attempted to curtail these efforts by regulating the sale of over-the-counter ingredients, including ephedrine, pseudoephedrine and phenylpropanolamine. Some producers skirt these regulations, martialing teams of people to obtain legal quantities of these ingredients (sometimes repeatedly, through the use of false identification documents), which together net sufficient quantities for production. This practice is often referred to as “smurfing.” (The term, a nod to the cartoon characters, has been used at least since the 1980s in the context of money laundering to describe a process through which droves of people break up larger transactions into smaller ones so as to avoid suspicion.)

These restrictions might also drive manufacturers to synthesize meth with other ingredients. Much of the methamphetamine found in the U.S. today is produced in Mexico using phenyl-2-proponone and trafficked across the border, according to the DEA’s report. This reflects a broader decline of domestic production of methamphetamine since the passage of CMEA and an increase in international production. Domestically, however, conversion laboratories are popping up, particularly in California. These labs transform smuggled methamphetamine into a saleable product.

What are some of the effects of the resurgence of methamphetamine?

Methamphetamine has been linked to a number of health risks, including hepatitis C infection, stroke, psychosis and other forms of psychological distress. A longitudinal study of 278 people who were dependent on methamphetamine but not schizophrenic or manic, published in Addiction in 2014, found that violent behavior increased after subjects used methamphetamine. Methamphetamine users also face a higher risk of death than people who use other drugs, including cannabis, cocaine and alcohol.

A study published in the American Journal on Addictions in 2014 suggests that certain social outcomes, including homelessness, drug dealing, being a victim of violence and prostitution are associated with crystal methamphetamine use.

Research exploring connections between methamphetamine use and criminal behavior indicates that meth users “have more extensive criminal records and are more likely than other drug users to commit property crimes.” Kentucky Department of Corrections data indicates that the percentage of offenders who used methamphetamine in the 12 months before their incarceration has increased sharply over the past five years. In 2012, 23.5 percent of offenders in the state reported using illicit methamphetamine in the 12 months before their incarceration; by 2017, this figure was 43.9 percent.

Are there treatments for methamphetamine addiction?

A number of treatments exist for methamphetamine addiction, including cognitive behavioral therapy and other drug counseling and addiction support services. Unlike treatment for opioid misuse, there aren’t medications that specifically block the effects of or curb cravings for the drug.

Other resources:

The National Institute on Drug Abuse (NIDA), run by the National Institutes of Health, funds and publishes research on methamphetamine and other drugs.

The DEA summarized key findings related to methamphetamine from the report cited in this piece in a one-page document. Additional resources are available on the DEA’s website.

The U.S. Sentencing Commission has a backgrounder on methamphetamine trafficking and a sourcebook of federal sentencing statistics that can be sorted by drug type.

Journalist’s Resource has covered research and resources on other substances, including fentanyl, prescription opioids and marijuana.

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Are workplace recovery programs successful in helping people to quit abusing drugs and avoid relapsing? A growing field of research suggests the answer is yes, though their success may have more to do with incentives than the nature of work itself.

There are a few ways that scholars have studied the relationship between employment and recovery, according to Matthew Walton, an instructor at the University of Louisville’s Kent School of Social Work. He is also the author of “The Effects of Employment Interventions on Addiction Treatment Outcomes: A Review of the Literature,” which looks at 12 studies on workplace recovery programs and concludes that they tend to be effective.

Walton described the two dominant approaches: one views employment as benchmark of successful recovery. The other area of research focuses on whether being employed is a therapeutic intervention in and of itself.

Paid work as an incentive to abstinence

Kenneth Silverman, professor of psychiatry at Johns Hopkins Medicine in Baltimore, is a leading researcher in this latter field. Silverman has developed an experimental therapeutic workplace that offers paid employment to poor, unemployed people with opioid dependencies and other substance use disorders — with the understanding that the researchers will be studying them.

“We’re studying access to paid work as reinforcer or incentive to abstinence,” Silverman explained.

In this model, which has been the subject of study since 1996, participants have to provide drug-free urine samples to keep their jobs and/or avoid a dock in pay.

The model has proven effective in promoting and maintaining abstinence from heroin and cocaine among people who have been unable to stop on their own, he said.

Silverman was careful to say that his research shows that work alone does not keep employees from using drugs. Money and accountability matter, too.

“When we randomly assign people to just work and get paid, but they don’t have to provide drug-free samples to obtain maximum pay, they work a lot, but they continue to use heroin or cocaine,” he said. Only when paid work is contingent on abstaining does it serve as powerful incentive to maintain sobriety.

“I’m not sure that it’s right to say that work is a powerful incentive. Paid work is a powerful incentive,” Silverman said. “It’s probably the money that’s the most important thing.”

Doctors with opioid addiction

Anthony DeFulio, an assistant professor of psychology at Western Michigan University who studies workplace recovery programs, offered a similar perspective regarding treatment for physicians with opioid addictions.

DeFulio cited research on the national system of Physician Health Programs, which involves outpatient treatment and random drug testing over a period of five years. The results of these tests are reported to employers, insurers and state licensing boards, and if participants test positive, they can lose their license to practice medicine. These programs are quite successful, with only 22 percent of physicians testing positive at any point in the five-year follow-up screening period, according to a 2009 study involving 49 medical directors in charge of their state-run programs.

“When someone has a lot to lose, then that alone seems to be sufficient,” DeFulio said in a recent phone call.

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More newborn babies suffer from drug withdrawal in counties where there are shortages of mental health care providers, higher rates of long-term unemployment and higher proportions of manufacturing jobs, according to new research published in JAMA.

The study looks at rates of neonatal abstinence syndrome (NAS) — a form of withdrawal that newborns can experience if their mothers used drugs, including opioids, throughout pregnancy. As opioid use has increased in the United States, the number of infants born with NAS has increased, too. The authors write that the number of infants born with NAS in the U.S. jumped from 1.2 hospital births per 1,000 in the year 2000 to 8.0 per 1,000 in 2014.

With this study, researchers were interested in determining the specific characteristics of counties that have particularly high rates of NAS.

“What inspired us to do this work was actually my clinical work — taking care of newborns who have opioid withdrawal, and their families,” lead author Stephen W. Patrick, a pediatrician and professor of pediatrics and health policy at Vanderbilt University, said in a call with Journalist’s Resource. Patrick added that this outcome — NAS — “represents a whole slew of events that happened before they got to the delivery room.”

“A better understanding of the association among community characteristics such as health care infrastructure and macroeconomic conditions and NAS is needed to inform community-level interventions aimed at improving opioid-related outcomes for these vulnerable populations,” the authors write.

The researchers looked at 6,302,497 births occurring between 2009 and 2015 across 580 counties, both urban and rural, located in eight states — New York, Massachusetts, Kentucky, Tennessee, North Carolina, Washington, Florida and Michigan. They examined the associations between county-level NAS rates and the following factors: primary care and mental health care shortages and long-term unemployment rates.

Here’s what they found:

• Counties with high 10-year unemployment rates also had high rates of NAS. Across the sample, unemployment rates ranged from 4.1 percent to 15.8 percent in 2015. In the highest unemployment quartile, rates of NAS were 20.1 per 1,000 hospital births, whereas in the lowest unemployment quartile, NAS rates were 7.8 per 1,000 births. Counties with high unemployment and NAS rates tended to be rural, and were concentrated in the following regions: rural Appalachia (parts of the states of Kentucky, New York, North Carolina and Tennessee), southeastern Massachusetts, northern Michigan and southwestern Washington.
• Considering the overlap between unemployment rates and the number of babies experiencing withdrawal at birth, the authors suggest that both prior and current economic hardship might contribute to NAS rates.
• Rural counties with a higher proportion of manufacturing jobs also had higher rates of NAS. The authors suggest that the risks of injury, disability and chronic pain associated with manufacturing industries — which in turn can lead to opioid use — might explain this association.
• There was no link between NAS rates and primary health care provider shortages. However, metropolitan counties experiencing mental health care provider shortages saw higher rates of NAS. In mental health care shortage areas, for every 1,000 hospital births, an average of 14.0 infants were born with NAS, compared with 10.6 per 1,000 births in areas where there were no shortages. Adults with mental health conditions are already three times as likely to use opioid painkillers as compared to their peers without mental health disorders, the authors write, adding that “untreated and undertreated mental health disorders increase the risk of opioid misuse and abuse.” Mental health care provider shortages are widespread – between 2009 and 2015, the proportion of counties in the sample that were designated as mental health professional shortage areas jumped from 79.5 percent to 88.2 percent.

Next steps for journalists and policy makers

“While the opioid crisis has gotten a lot of attention by the press, pregnant women and infants are often left out of the conversation,” Patrick said. He suggested journalists increase their coverage of the link among economic hardship, the opioid epidemic and maternal-child health. He also suggested an increased focus on rural communities, which have been hit hardest by these interrelated issues.

On the policy side, Patrick suggested that economic revitalization programs similar to the Depression-era Works Progress Administration might help to address the long-term economic downturn at the root of the opioid epidemic.

“To really solve the opioid crisis, you need to think beyond the hospital walls,” Patrick said.

Looking for more resources? We have a tip sheet on reporting on fentanyl and synthetic opioids and a research roundup on the role safe injection sites might play in the opioid epidemic. We also have summaries of research on rural Americans’ views about economic issues and the opioid epidemic, geographic opioid prescribing trends and racial trends associated with prescription opioid use.

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Three days after the mass shooting in a Pittsburgh synagogue on Oct. 27 — and eight days before the mass shooting at a Thousand Oaks, Calif., dance bar on Nov. 7 — journalist German Lopez spoke at the Shorenstein Center on Media, Politics and Public Policy on the issue of gun violence in America. Lopez is a senior correspondent at Vox focusing on criminal justice, guns and drugs.

Following his talk, Lopez sat down with Journalist’s Resource to discuss gun violence in the U.S., where mass shootings are occurring with alarming frequency, and what journalists can do to improve their coverage.

Though definitions of what constitutes a mass shooting vary, Lopez prefers the simplicity of the Gun Violence Archive’s categorization, which considers an event in which four or more people are shot in a single incident a mass shooting. Under this definition, there’s nearly one for every day in the year, Lopez said.

U.S. law considers “mass killings” to mean three or more killings in a single incident. The FBI takes a narrower definition for “active shooter incidents,” which they consider to be “one or more individuals actively engaged in or attempting to kill people in a populated area.”

Critics say wider definitions of mass shootings may distort the public’s understanding by conflating incidents of gang violence, domestic abuse and robbery with indiscriminate public attacks.

The news media also might be partly responsible for what Lopez labeled a “self-perpetuating” aspect of mass shootings, according to research. “There is evidence that when there’s a mass shooting that gets widespread coverage, mass shootings become more likely shortly thereafter, just because there are copycats out there,” he said.

To deter fame-seeking copycat mass shooters, Lopez offered a few suggestions.

First, think twice before publishing the names of mass shooters. Lopez recommended asking yourself, “Is there a news value in getting this person’s name out there?” If not, then don’t.

He also suggested avoiding non-stop broadcast coverage of mass shootings. “What you see on cable news a lot is just non-stop coverage of the specific mass shootings and the very particular details that come out of it,” Lopez said.

“That seems to perpetuate the glorification of this mass shooting, instead of just focusing on the issues at large that a lot of people are thinking about in that moment,” like gun control, and other forms of gun violence.

Lopez continued, “If you do want to focus on mass shootings in particular, there’s a lot of work you can do there. You can talk to experts about why these keep happening, you can start walking through … not even just gun control policies, but other policies that might be effective for preventing mass shootings. There’s a lot of journalism you could do there that doesn’t focus just on the latest mass shooting to happen and the specific details that came out of that.”

Lopez also suggested zooming out to discuss other gun violence issues rather than focusing on details of a particular mass shooting. “It’s a moment to cover all the gun violence in domestic violence, or in minority communities, that often goes ignored,” he said.

Even while examining links between different types of gun violence, it’s important for journalists to maintain distinctions, too, Lopez said. He suggested breaking down gun violence in the U.S. by type – for example, homicide, suicide, mass shootings, accidents, violent injuries. “You can then start walking through those categories, and how they’re connected, and what the different solutions for them are, while still educating people in general on gun violence,” he said.

“Domestic [gun] violence is something that, particularly [in light of] the #MeToo movement, if you put it in that context, still gets a lot of attention, and that’s a way that you can continue focusing on gun violence and giving those issues attention,” Lopez said.

Lopez pointed out a few other angles for journalists to pursue in their coverage of gun violence:

• Stories about interventions launched by cities, states and countries that have lowered their suicide rates. For example, the Economist wrote about Japan, which saw success after a 2007 intervention aimed to reduce suicide rates by 20 percent over ten years.
• More comprehensive coverage of the trend of “deaths of despair,” focusing on suicide and alcohol rather than the opioid epidemic. Alcohol is linked to 88,000 deaths each year in the U.S. – more than all drug overdoses combined, according to the Centers for Disease Control and Prevention (CDC).
• Covering research that highlights possible solutions to gun violence that don’t focus on gun control. For example, focused deterrence policing (in which efforts are targeted on specific issues within a community), higher alcohol taxes and programs that eliminate blighted housing or raise the age at which students can drop out of school.

There’s a common notion that there’s no recent academic research on gun violence because Congress banned the CDC from funding research projects that “may be used to advocate or promote gun control.” The National Rifle Association had lobbied for the ban, put in place by a provision authored by former Republican Congressman Jay Dickey of Arkansas. Adopted in 1996, it became known as the Dickey Amendment.

Lopez, who relies heavily upon research in his reporting, said there are still some institutions producing “good work” on the subject, including the Injury Control Research Center at Harvard, Johns Hopkins University’s Center for Gun Policy and Research and the Violence Prevention Research Program at the University of California, Davis.

It’s part of Lopez’s job to share this research with the public. While he acknowledges that he “definitely” takes a stance, often in favor of gun control, he doesn’t consider himself an advocate.

“I am reporting what the research shows and then trying to translate that to a more readable format, because a lot of these studies just frankly are unreadable for lay people,” he said. “I think doing that responsibly, I do have to come to the conclusion sometimes that this research does land on a certain answer.”

The image in this post by Mathias Wasik was obtained from Flickr and is published under a Creative Commons license.

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The Kensington neighborhood of Philadelphia is a hub for heroin dealers and users on the East coast.

The city tried to clean up the area but did little more than move the problem around. After residents complained of yards strewn with used needles and the smell of dead bodies, the city evicted drug-addicted homeless people from underpasses and abandoned lots, only to have them resettle down the block.

Kensington has suffered more than most areas, but many towns and cities in the U.S. have struggled to cope with a rise in heroin overdoses. Many of their residents are wondering how this happened and what they can do about it.

A paper in the November issue of the American Economic Journal: Economic Policy identifies one important driver of heroin overdoses across the U.S.: the reformulation of OxyContin.

Doctors liberally prescribed opioids throughout the 1990s in the U.S., leading Americans to consume more opioids than any other country. Dependency and abuse grew at the same time.

OxyContin became one of the most widely abused opioids due to its “extended-release” formula, one large dose that lasted for 12 hours. People who abused the drug were able to chew, snort, or inject the pill to ingest a full dose of oxycodone — the main ingredient in OxyContin — all at once.

“There was a major shift in the opioid epidemic around 2010 when people shifted from primarily abusing prescription opioids to then abusing heroin and later fentanyl,” Abby Alpert, co-author of the paper, said in an interview with the American Economic Association.

Alpert and her co-authors, David Powell and Rosalie Liccardo Pacula, began looking for the factors behind the change. They suspected that a reformulation of OxyContin in 2010 could be an important reason for the sharp rise in heroin deaths.

Purdue Pharma reformulated OxyContin in 2010 to make it more difficult to crush and dissolve. It was so effective, the authors found, that misuse of OxyContin declined by about 40 percent over the four years following the reformulation.

The researchers also noticed that states that saw a large increase in heroin overdoses — like Pennsylvania — had high rates of OxyContin misuse prior to the reformulation. Likewise, states which saw a small increase in heroin overdoses had low rates of OxyContin misuse.

Using these state differences in OxyContin misuse prior to the reformulation, the researchers showed that nearly all of the rise in heroin deaths was the result of users switching from OxyContin to heroin. Factors like the price of heroin and state level initiatives against prescription opioid abuse seemed to play very little role.

In short, users found the reformulated OxyContin hard to abuse and heroin a ready substitute, according to Alpert.

Nevertheless, Alpert said the reformulation may still prove beneficial in the long run. “While the reformulation may have led existing users to switch from OxyContin to heroin in the short run,” Alpert cautioned, “this reformulation might also reduce the initiation of abuse and might have potential future benefits down the road.”

This isn’t the only paper to argue that the OxyContin reformulation ignited the heroin epidemic. And it’s one of many studies to show that narrow supply-side interventions into drug markets have done little more than shift the problem.

It’s a problem that occurs so frequently it’s been dubbed the “balloon” effect by drug-policy experts. Put pressure on the problem in one place, and it reappears in another. Consumers and producers of drugs regularly find substitutes.

There are signs, though, that the epidemic is abating. National heroin overdoses have dropped slightly over the past year. And more resources are being directed toward programs that Alpert believes could help bring relief.

“Just simply disrupting the supply of a single drug may be inadequate for addressing the opioid epidemic,” Alpert said. “A potentially more effective strategy is to treat the underlying demand through substance abuse treatment and medication-assisted treatment.”

“Supply-Side Drug Policy in the Presence of Substitutes: Evidence from the Introduction of Abuse-Deterrent Opioids”  appears in the November issue of the American Economic Journal: Economic Policy.

This piece was published with permission of the American Economic Association, which first published it as a Research Highlight. 

The accompanying photo, created by Psychonaught and obtained from Wikimedia Commons, is a public domain image. 

For more research on opioids, see our write-ups on opioid treatment and the criminal justice system and the narrowing race gap in prescription opioid use.

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American patients in the rural South are more likely to receive opioid prescriptions than patients in the urban North, according to two new studies from Harvard University and the University of Pennsylvania.

In one new analysis of data from 2016, researchers found that opioid prescribing rates per 100 people vary across congressional districts, from a high of 166 in Alabama’s Fourth Congressional District to a low of 23 in New York’s Ninth Congressional District. It’s important to note these rates can include multiple prescriptions written for one individual.

According to their analysis, the areas with the highest opioid prescribing rates are in the South, Appalachia and the rural West. The districts with the lowest prescribing rates are located in New York City and urban areas in California and Virginia.

A full ranking of all congressional districts is available as a supplemental table to the paper.

The researchers had legislators in mind when they chose to study prescribing rates by congressional district rather than by county or state. The paper, published in the American Journal of Public Health, indicates that analysis at the congressional district level might facilitate targeted policy interventions.

“We are interested in congressional districts because they have a certain level of political accountability, they have an elected representative, in the way that counties do not,” said Jack Cordes, an epidemiologist at the Harvard T.H. Chan School of Public Health and an author on the paper, in a phone interview. The data he and his co-authors collected, he continued, “makes it easier for representatives to understand what their particular constituents are going through, and it makes it easier for advocacy — for certain interventions and polices.”

Moreover, analysis of prescribing rates at the congressional district level might reveal trends that aren’t evident at the state level, the paper notes. For example, Virginia is noteworthy in that it contains districts in both the top and bottom 10 for opioid prescribing rates; in the rural, western part of the state, opioid prescriptions are high, whereas in the metropolitan north of the state, near Washington D.C., rates are low.

To create the map, the researchers looked at prescribing rates for opioids provided by the U.S. Centers for Disease Control and Prevention and population data collected by the U.S. Census Bureau.

Cordes noted that while the findings reveal important geographical trends in the prescribing rates of opioids, the results don’t reveal whether the patients actually use these prescriptions, or whether they are tied to overdoses or deaths.

“These are areas that we identified as [being] at higher risk because of oversaturation of opioids, but it’s not a particular health outcome,” he told Journalist’s Resource.

A new paper in Annals of Emergency Medicine offers further detail on similar trends, presenting links between receiving opioid prescriptions for minor injuries and increased likelihood of prolonged use.

Researchers at the University of Pennsylvania analyzed opioid prescribing rates among patients who showed up to the emergency room with ankle sprains between 2011 and 2015. The data was collected from a sample of privately insured people across the United States; this sample resembled the U.S. population of commercially insured people in terms of demographics. The sample included over 30,000 patients who had not received opioids in the six months prior to their E.R. visit.

“Ankle sprains are a minor, self-limited condition for which there is likely to be little clinical benefit from opioids,” the authors write. Nonsteroidal anti-inflammatory drugs are the recommended treatment for ankle sprains and are shown to be as effective as opioids in reducing pain.

Despite this, nearly 20 percent of the studied ankle sprain patients in 2015 received a prescription for opioids. While this was a decrease from the overall prescription rate in 2011 of 28 percent, more than 140,000 opioid tablets “could have been prevented from entering the community if opioids had not been prescribed for our study sample,” the authors write.

Patients with ankle sprains who received prescriptions for longer courses of opioids (more than 30 tablets) had a 6.3 percent likelihood of developing prolonged use, as compared to a 1.2 percent likelihood for those who received 10 tablets or less — a nearly five-fold increase.

Moreover, most of the patients who received subsequent prescriptions got them for reasons unrelated to sprains and strains or joint disorders.

“This suggests that association between larger prescriptions and increased likelihood of prolonged use could be due to other factors such as patients requesting opioids as default pain control, or the development of dependence or misuse,” the authors write.

As with the congressional district analysis, certain geographical trends held. Prescribing rates varied drastically across the country, with above-average rates concentrated in the South and below-average rates in the North. North Dakota had the lowest prescribing rates: 2.8 percent of patients with sprained ankles received opioids. By contrast, in Arkansas, 40 percent of patients with sprained ankles were prescribed opioids. The authors indicate that their findings present “multiple opportunities for clinical, health system and state-level interventions.”

Journalist’s Resource has also covered research that shows how the race gap in prescription opioid use is narrowing and a paper that highlights how unlikely it is for opioid users referred for treatment by the criminal justice system to receive evidence-based treatments.

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While the nation’s ongoing opioid epidemic is often discussed as a white issue, new research indicates that prescription opioid use in black adults is just as high.

The powerful painkillers have a high potential for abuse — across the literature, rates of misuse average between 21 and 29 percent. Moreover, prescription opioids can pave the way for future use of illegal drugs like heroin. Eighty percent of people who have used heroin have previously misused prescription opioids.

Policies have been enacted across the nation to modify opioid prescription practices, but the effects of such policies are not fully understood. Researchers at the University of Pennsylvania, University of Michigan and Dartmouth sought to identify how pain medication prescription trends are changing over time across racial and ethnic groups.

The researchers looked at nationally representative survey data from 2000 to 2015. They estimated the percentage of adults who received a prescription for pain medication for reasons other than cancer pain for four racial groups — white, black, Hispanic or Latino, and other or multiple races/ethnicities. They broke these results down by pain medication type, including opioids, nonsteroidal anti-inflammatory drugs, COX-2 inhibitors and muscle relaxants.

They found:

• The greatest increase in prescription opioid use occurred in white adults. Over the 15 years studied, the scholars noted a 78 percent increase.
• Both black and white adults, however, had similar rates of prescription opioid use by 2015 — around 23 percent.
• Whereas white adults experienced increases in the percentage reporting poor or fair health, from 24 percent to 34 percent, the percentage of black adults reporting poor or fair health decreased from 52 percent to 41 percent.
• The researchers do not reconcile this “somewhat paradoxical” finding or explain why opioid prescriptions have increased among black adults.
• For all types of pain medications, across all racial groups studied, there were not large differences in the likelihood of receiving medication over the 15-year time period — about 30 to 35 percent of adults in the sample received something.

While the paper does not discuss the use of non-prescription opioids or overdose rates by race, new data from the U.S. Centers for Disease Control and Prevention add further nuance. The data show that overdose rates for all drugs have increased among black Americans since 2011. In particular, overdose rates for heroin, fentanyl, and other synthetic opioids have risen dramatically for black Americans.

Other resources:

• The National Institute on Drug Abuse offers information on drug addiction treatments.
• The World Health Organization has resources for the management of substance abuse.
• The U.S. Centers for Disease Control and Prevention offer data on drug and opioid overdose deaths.
• We have a tip sheet on reporting on fentanyl and synthetic opioids and a research roundup on the role safe injection sites might play in the opioid epidemic.

Federal report: Prescription drug abuse, 2011

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