Tracking Trends in the Opioid Epidemic in North Carolina : Early Results from the Opioid Action Plan Metrics

Discussion

Between 2010-2012 and 2015-2017, there was a significant increase in the opioid-related death rate for North Carolina overall, and also for many individual North Carolina counties, but the increases were not uniform across counties. Some counties that had low opioid-related death rates in 2010-2012 experienced very large increases over the five-year period, such as Jones, Chowan, Davie, Caswell, and Cumberland (Figure 2). Others that had low rates early on (or no deaths at all) remained low (Washington, Hertford), and some with high death rates remained high (Mitchell, Wilkes). But there were others with very high rates in the early period that experienced a decrease later on, particularly several counties in the far west of the state, such as Cherokee, Swain, and Graham. This pattern suggests that at least some counties may have found successful strategies for addressing the epidemic, or at least curtailing deaths.

A key part of North Carolina's strategy for addressing the epidemic has been to limit the supply of prescription opioid pills [3, 16]. Opioid-related deaths include deaths due to both prescription and non-prescription opioids. While reducing the supply of prescription pills may prevent people from becoming addicted, those who become addicted may gravitate toward non-legal drugs like heroin and fentanyl, which can be more lethal [18]. A correlation between prescription opioid pills and mortality rates has been noted in numerous other studies, including studies focused on North Carolina [4, 5, 16]. Our results did not show a statistically significant relationship between the per capita pill rates and death rates at the county level. Our trend results showed an increase in the overall eight-year statewide trend for opioid pills per capita, but a decrease in the rate since 2015. There have been policy actions at the state and national level that have likely helped to bring down the number of opioid prescriptions. At the national level, the CDC released guidelines for prescribing opioids for pain in 2016, which likely influenced prescribing patterns [18]. The Comprehensive Addiction and Recovery Act (CARA) and the 21st Century Cures Act, both signed in 2016, authorized and funded a range of actions to address the opioid epidemic, including support for state prescription drug monitoring programs (PMDP) to track prescriptions of controlled substances [19]. The NC CSRS tracks prescriptions of controlled substances in North Carolina [15], and the 2017 North Carolina Strengthening Opioid Misuse Prevention (STOP) Act requires prescribers to review it before prescribing opioids [20, 21, 22]. The STOP Act also limits initial opioid prescriptions to no more than five days of medication (seven for post-surgical patients). The North Carolina Heroin and Opioid Prevention and Enforcement (HOPE) Act, signed in 2018, also increased tools for law enforcement to better curtail the illegal diversion of prescription opioids [23, 24]. The decrease shown by the data in the number of opioid pills per capita suggest progress; it is modest so far, but bears watching in the future.

Another strategy for reducing opioid-related overdose deaths has been to increase the availability and use of naloxone [3, 25]. Naloxone is a prescription medication that reverses the effects of an opioid overdose and can save lives. Naloxone has been used by EMS providers for many years. The North Carolina Good Samaritan Act, passed in 2013, changed the law to allow non-medical personnel to also administer and dispense the drug to reverse an overdose without fear of criminal prosecution or liability [26, 27, 28, 29]. Subsequent legislation in 2016 allowed naloxone kits to be purchased from a pharmacy without a prescription under a statewide standing order [26, 30]. At the federal level, CARA and the Cures Act provided funding for naloxone education, training, and distribution [19]. In North Carolina, naloxone has been distributed to some law enforcement agencies and to family and friends of opioid users as a preventive and emergency response measure. The North Carolina Opioid Action Plan metrics include two measures related to naloxone—the number of community administrations and the number of EMS administrations. The community data is only available for 2013 and later and is based on self-reports, so for our analysis we only used the rate of EMS naloxone administrations. We found a positive correlation between mortality rates and EMS naloxone rates; where EMS naloxone administrations are high, death rates tend also to be high. EMS naloxone administration rates are likely high for those counties where the opioid problem is greatest, therefore the mortality rates in these counties are also high. We might have found a different relationship if we had community naloxone data. EMS naloxone use may be an indicator of the problem; for an individual with an overdose event, naloxone can be a life saver and, without its availability, death rates might be even higher.

Our results showed a small but significant relationship between the use of buprenorphine and a reduction in the opioid-related death rate in some counties. For individuals with an opioid dependency or substance use disorder, treatment typically involves a combination of medication to suppress withdrawal effects and counselling to help adjust habits and behaviors, hence the term medication assisted treatment [18]. The Substance Abuse and Mental Health Services Administration (SAMHSA) certifies opioid treatment centers (OTCs) and approves them to dispense controlled opioid treatment medications such as methadone and buprenorphine [31, 32, 33]. Under the provisions of the Drug Addiction Treatment Act of 2000 (DATA), buprenorphine can also be prescribed outside of an OTC, in a doctor's office setting, so long as the physician has received a waiver from SAMHSA (buprenorphine can be prescribed for pain without a waiver) [34]. The DATA Act also reduced record keeping requirements for physicians who prescribe buprenorphine, and recent additional legislative changes raise the number of patients a physician can treat at any one time [34]. Provider training for MAT has also become more available, and the number of newly certified practitioners who can prescribe the medication has increased every year since 2002 in North Carolina [35]. The increasing number of buprenorphine prescriptions indicates an increased need for the medicine, but also indicates greater use of MAT for opioid use disorders. Our results suggest that increased availability and use of MAT may have a significant effect on reducing opioid-related deaths in North Carolina. A qualitative evaluation would be useful for identifying other strategies and factors involved where mortality rates are decreasing.

We did not find a relationship between the number of Certified Peer Support Specialists and the opioid-related death rate. Certified Peer Support Specialists are individuals with a personal recovery history who have completed a 40-hour training program [36, 37]. They act as mentors, advocates, patient navigators, and counselors and work at opioid treatment centers, as well as in other settings. Peer Support Specialists can receive their training through a number of different organizations in the state, but are certified through the North Carolina Certified Peer Support Specialist Program at UNC-Chapel Hill. As of December 2018, there were 3,386 peer specialists statewide in North Carolina, although their numbers are growing [37]. A number of counties have none at all, so it may be too early to expect this form of peer support treatment to yield measurable results. Further study of the program and its impact on opioid recovery is warranted.

Our study is an initial attempt to demonstrate how the Opioid Action Plan data can be used to track progress in reducing opioid-related deaths. The major limitations of this analysis relate to the data themselves. Opioid-related mortality data are derived from death certificates, and underlying cause of death may be difficult to ascertain where multiple substances may be involved or the intent of the individual is difficult to determine. The buprenorphine data and the prescription opioid data are from the NC CSRS, and the quality of this data is unknown. Further, some buprenorphine prescriptions may be for pain, not for MAT. Also, medications dispensed in OTCs are not captured in the NC CSRS reporting system. EMS naloxone administration data are entered at the county level, and there may be variations in data quality from county to county. There have also been changes to the EMS data system that could impact data consistency from year to year. All the data metrics are indirect, and serve as proxy measures for the underlying health changes in the populations studied.