WCSAD | Historical, Recent Data Empower Clinicians to Better Educate, Support SUD Patients

Fentanyl and methamphetamine use has increased significantly during COVID-19 and knowledge of the trends can help clinicians better serve their patients, said Kelly Olson, PhD, Associate Director of Clinical Affairs, Millennium Health, San Diego, California, in a session Friday at the West Coast Symposium on Addictive Disorders (WCSAD).

Dr Olson walked attendees through the trends in drug overdose deaths, the risk factors for substance use disorders (SUD) in older adults, and the scope of the problems that come along with SUDs. She also discussed the history of methamphetamine, heroin, and fentanyl and how that history connects to current trends, including how the COVID-19 pandemic has affected the distribution and use.

Drug Overdose Deaths Before the COVID-19 Pandemic Declaration

• In the United States (US), drug overdose deaths reached a record high in 2019 at about 70,000 reported deaths and are projected to reach a new record in 2020.
• Drug overdose deaths “continue to be the leading cause of accidental death” in the US, surpassing deaths due to firearms, motor vehicle crashes, and suicides.
• From 2019 to 2020, overall drug overdose-involved deaths in total increased by 29.5%. Deaths involving opioids increased by 37.2%, synthetic opioids by 54.9%, prescription opioids by 21.2%, cocaine by 21.8%, and psychostimulants by 46.8%.
• Overdose deaths are increasing in all age groups. The rate among the 65-and-over population has increased over 200% over the past 2 decades.

Almost 20.5 million people over the age of 12 had a substance use disorder in 2019, and 89.7% of those did not receive treatment, according to the National Survey on Drug Use and Health. “During COVID-19, some had difficulty accessing these lifesaving treatments for SUD. We've already got a big group or a significant group of people not receiving care, but now you throw on the pandemic, and you see that it's even harder for a lot of folks to get that care,” Dr Olson told attendees.

Despite the barriers to care and increased need for support due to the pandemic, Dr Olson urged attendees to see the positives where possible. “Take heart in knowing that you understand the problem, or at least as much as we possibly can. Across the nation, we understand that there are challenges for our patients and clients to get care, but we also know that we are doing our very best one on one with our patients, with our clients, to educate them.”

To orient the audience to the modern-day issues, Dr Olson gave a brief history and production methods of some of the “key players” in the non-prescribed and illicit substances realm.

Methamphetamine

Methamphetamine was first synthesized around 1893 and was later used by soldiers in World War II to keep their energy high. In the 1940s, it was socially acceptable to use as a diet pill due to its ability to decrease appetite while keeping the user energized and busy, Dr Olson told virtual attendees.

Methamphetamine was not classified as a Schedule II drug until the early 1970s, and that is when gangs began to manufacture and traffic the drug. By 2017, methamphetamine became the most common drug identified by law enforcement.

Most methamphetamine in the US originates in Mexico, despite the widespread belief that it is primarily made in the US. High levels of drug are seized at the border. Cartels have been increasingly skillful with how they traffic drugs into the US. Before COVID-19, tablets were pressed and sold to look like MDMA or the prescription medication Adderall using pill presses.

Fentanyl and Fentanyl Analogues

• Fentanyl is 50-100 times more potent than morphine.
• Carfentanil, a fentanyl analog, is 10,000 times more potent than morphine, allowing for a greater return on investment but more deaths among users.
• A fatal dose of fentanyl is 2mg vs carfentanil at .02 mg.
• Carfentanil is traditionally used in veterinary medicine to put down large animals.

Profitability for Drug Trafficking Organizations

• Since 2007 methamphetamine has become exponentially more potent and profitable. In 2007, the purity averaged 56.4% pure at $152 per gram compared with 2017 at 96.9% pure at $56 per gram.
• Heroin purchased from Columbia costs $5,000 to $7,000 with a revenue of $80,000 per Kg.
• Pure fentanyl (99%) purchased from China costs $3,300 to $5,000 with a revenue of $1.28 million to $1.92 million per Kg.

Recent Data Surrounding COVID-19 Emergency Declaration

Dr Olson and her colleague recently conducted a retrospective analysis of 3.5 million de-identified, definitive urine drug test (UDT) results collected from patients seeking treatment between January 2013 and December 2020. The study consisted of 2 analyses: fentanyl, methamphetamine, cocaine, and heroine positivity rates and a positivity rate comparison between the “pre-COVID-19” (March 13, 2019) and COVID-19 (March 13, 2020 – December 31, 2020) time periods. Participants were excluded if they reported prescriptions.

The study found that heroin positivity rates remained consistent. Cocaine increased after the declaration but decreased back to the pre-covid level. Fentanyl positivity rates saw a “massive increase” after the emergency declaration and continues to rise. Methamphetamine was found to steadily increase from 2013 to 2019 and continues to increase post-emergency declaration.

The study broke down the positivity rate change for US census divisions between the 2 studied periods. As a whole, the US saw a 78% increase in fentanyl positivity rates, 29% for methamphetamine, and 9% for heroin. Cocaine saw a 2% decrease in positivity rates.

“As we look at this, COVID-19 is having quite an effect on things,” Dr Olson said.

Dr Olson noted that after the declaration the of COVID-19 emergency, carfentanil positivity rates have dropped to almost zero, but in its place, acryl fentanyl is starting to rise.

“Keep in mind these keep in mind these substances, these fentanyl analogs, are being utilized either known or unknown to our clients and patients. So, educating them in knowing what these substances are as best as they possibly can is really going to be helpful,” she said. “Certainly, if something unexpected comes up, if you do any kind of testing for these substances, it’s something that you can then take time to have a conversation with your patient.”

Data from August 2021 shows that methamphetamine and fentanyl positivity rates continue to rise. While these drugs have increased in the country as a whole, fentanyl rates have increased significantly in the western US and methamphetamine have increased significantly in the northeast.

Tips for Clinicians Moving Forward

“This education gives us a shot in the arm in order to be able to go forward and help our clients and our patients better,” Dr Olson concluded.

The knowledge of the presented data allows clinicians to understand which regions are reporting higher positive test rates for each drug and how they can more effectively help their patients. Understanding the drug trafficking trends and the impacts of the pandemic emergency declaration allows for an educational opportunity with patients who may not otherwise know what is in the drugs they are taking and how they affect their health and well-being.

Dr Olson is hopeful that this knowledge will help clinicians align with patients, build rapport and trust, and better serve them and their needs.

Reference

Olson, K. Shifts in illicit drug use heighten the COVID-19 health crisis. Presented at: West Coast Symposium on Addictive Disorders; September 29-October 1, 2021; Virtual.