Could Better Data Collection Bring Down Opioid Overdose Deaths?

Drug overdoses are the leading cause of death for Americans under 50. Death rates began to spike a decade ago, as the supply of illicitly manufactured fentanyl grew. Fentanyl exposures have since taken on new dimensions. EMTs and emergency room physicians scramble to stay ahead of health emergencies caused when fentanyl is combined with other drugs to augment its effects. Now, unexpected new compounds are entering the mix.

In 2022, more than 260 people in Florida died from accidental overdoses which involved xylazine, a horse tranquilizer. All but two of those cases also involved fentanyl. (Combining the two drugs can extend a high.) Now, just as the treatment community is beginning to get a handle on xylazine and develop ways to deal with it, other additives are making headlines.

In mid-May, another veterinary tranquilizer, medetomidine, was associated with an increase in drug overdoses in Chicago. The drug has also been detected in counterfeit pharmaceuticals in Canada. It’s not the only newcomer: N-pyrrolidino protonitazene, a synthetic opioid that may be 25 times more powerful than fentanyl, is also being detected in drug supplies in Canada and several U.S. states.

Illicit drug makers are technologically sophisticated and users are constantly searching for new experiences, says A. Thomas McLellan, who has spent 50 years doing drug research and served as deputy director of the Office of National Drug Control Policy during the Obama administration.

Despite all efforts, standard drugs of abuse are readily available, enabling the creation of an almost limitless variety of chemical combinations that can produce euphoric, hallucinogenic or other effects desired by users. “I don’t think it’s going to stop,” says McLellan. “Much of this is not beyond what a reasonably talented college chemist, possibly even a high school chemist, could concoct.”

Flying Blind

Data is a first-line defense in the face of novel and unpredicted risks, a hard lesson the country learned as it scrambled to shore up data systems during the pandemic. “In terms of adulterants, we’re flying blind,” says Bradley Stein, director of the RAND-USC Schaeffer Opioid Policy Center.

The drug supply has always evolved in terms of primary drugs and adulterants alike, he says, and this is difficult to prevent. Change can be tracked, however, and data gathered to inform response to shifts in drug supply and use. Stein was lead author of a 600-page report RAND produced in 2023, America’s Opioid Ecosystem, which included several recommendations for this kind of data collection.

“The United States urgently needs to improve the data infrastructure for understanding people who use drugs, drug consumption, and drug markets,” the report states. It recommends bringing back “some version” of a program discontinued in 2013, the Arrestee Drug Abuse Monitoring Program (ADAM). Persons arrested for any offense were offered the opportunity to volunteer to be interviewed and to provide a urine sample for analysis.

This was at least one way to monitor which drugs were in a community and how use was evolving. “It’s not perfect — nothing’s perfect,” Stein says. “But it gave us some important information, and it wasn’t that expensive compared to other federal spending for things like that.”

RAND also recommends wastewater testing to measure trends. “We’ve seen more uptake of wastewater monitoring in Australia and in some European countries,” Stein says. “We’re lagging behind doing this at all in the United States. If you have the infrastructure in place to test for COVID, that same sort of sampling could be used for drugs and illicit substances.”

In the meantime, says McLellan, ER doctors and public health nurses have to depend on the best information available and share what they are learning as rapidly as possible, as has been done with viruses. “I can’t think of what else you can do in the here and now,” he says.

More data regarding treatment systems is also important, not only to understand what’s working but to connect the dots between use patterns and health impacts.

Learning from Medicaid

Medicaid is the largest payer for mental health and substance abuse services, accounting for as much as a quarter of all behavioral health spending. Variations in screening and recording practices make an exact estimate difficult, but the Centers for Medicare and Medicaid Services (CMS) estimates that almost 12 percent of Medicaid enrollees over the age of 18 have a substance use disorder.

States are required to report certain measures of opioid use disorder treatment delivered through Medicaid, based on the programs in which they participate. Researchers for the Pew Charitable Trusts recently looked at the state-by-state status of this data collection and talked to state officials about how they are using it to improve the delivery of opioid use disorder services.

It’s not enough to simply report data, says Frances McGaffey, an associate manager of Pew’s substance use prevention and treatment initiative. “People on the ground need to be empowered to use the data to improve care,” says McGaffey. “That requires being really thoughtful about creating infrastructure to get the right data together to look at the data and decide how to act on it.”

McGaffey points to a public data dashboard launched in Ohio last year as an example. It incorporates Medicaid treatment data as well as data points from other agencies, searchable at state and county levels. Access to this data is step one. “This means that state officials can get together and make a plan,” McGaffey says, “and so can county officials who are making a plan for how to spend their opioid settlement [dollars].”

The Medicaid data is vital to understanding how systems of care are functioning, what’s working and what’s not. It’s not real-time data, however, as it’s derived from claims that can take up to 30 days to submit and process. If states could collect data about use trends that comes closer to a real-time snapshot and incorporate that in their data infrastructure, that could also help improve treatment.
As big as the challenges are, McLellan believes they can be overcome if monitoring and treatment are accompanied by redoubling prevention efforts that involve all sectors of a community. This includes schools, police, medicine, clergy and parents. Currently, prevention is everybody’s business and nobody’s business, but there are evidence-based ways of approaching it that can work. “I don’t see public willingness to treat this as a preventable but often chronic illness,” he says.

McLellan says the most successful public health story of his lifetime involved a highly addictive substance that was a tremendous source of profit, subsidized by the government and supported by all levels of society even though it was associated with devastating health effects. Against seemingly insurmountable odds, a 70 percent reduction in use was achieved.

“I’m talking about cigarettes,” he says.