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ClaudiaClaudia A. Merandi

Claudia Merandi, retired court reporter/author, of East Providence, RI, is a patient advocate and the founder of the national/international Don't Punish Pain Rally Organization. READ MORE
5 Chedell Avenue / East Providence, RI 02914 / USA 1.401.523.0426

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Advocate. Educate. Defend.

The Doctor Patient Forum is here to advocate, educate, and defend the rights of patients; to protect all providers, who tirelessly work to treat their patients, and to bring awareness to the general public regarding restrictions upon medical providers.
  • Elminate patient fear
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A new publication from the Trust for America’s Health[i], TFAH.org, a non-partisan public health policy, research, and advocacy organization, shows that deaths from alcohol, drugs, and suicides have leveled off for the first time since when records were first kept in 1999.

In 2018, more than 150,000 Americans died from alcohol, drugs, and suicide combined.[ii] The 2018 death rate of 46.4 deaths per 100,000 is level with the 2017 rate of 46.6 per 100,000. This is the first time since 1999 when there hasn’t been an annual increase in the combined figure and the first time in years that there hasn’t been a sizable increase.

However, the stabilization of alcohol, drug, and suicide deaths was not uniform. Some causes, places, and populations had positive or stable trends, many had a decline in the magnitude of the increases, and others are continuing to rise too quickly.

Of the two major takeaways cited in the report from 2018, Drug-Induced deaths, and Alcohol-Induced deaths, the source data remains controversial, both in content and interpretation. This is in large part due to how the data is collected, categorized, and reported by the CDC. For a more detailed review of how death data is collected, reported, and why it remains controversial, refer to this four-part series, How Prescription Opiate Overdose Data is Collected– Part 1[iii].

With regard to the source data, the CDC has been about three years behind on each evolution of the opioid overdose problem. While the opioid problem may have begun in 1999 with prescription medication, a reasonable assumption which still lacks sufficient data, in 2010 the CDC was still reporting overdoses as a prescription-based problem. Looking backward, it’s now known that heroin had become the leading source of overdoses by 2010, see “Today's Heroin Epidemic[iv], in large part to how toxicology testing was performed. It’s known that a single dose of heroin converts to morphine in the human body after 30 minutes, leaving no trace to the original substance. Consequently, postmortem tests reveal morphine as the cause of death and it receives an ICD-10 code that reflects a prescription medication on a death certificate. Unless death investigation includes findings of the original raw substance, these deaths go into the CDC WONDER system as a prescription medication, when in fact they were a street drug.

Combined with an inability to distinguish and report the true sources of these substances is a known fact that 63% of all Opioid Overdose Deaths also involve other drugs.[v] Yet the data submitted to CDC WONDER rarely if ever makes a distinction in the primary substance which attributed to death. Therefore, each substance found in the individual is counted as the primary substance responsible for the individual's death. All of which greatly over-inflates each substance category, and allowing researchers with an ideological bent, to inflate the underlying causes.

Further clouding this picture was a DOJ sponsored report, “2017 Medical Examiner-Coroner Office Survey Report[vi] which showed that most State and County medical examination facilities were grossly understaffed and under-budgeted throughout the period covering the opioid overdose problem. This resulted in a backlog of investigative work to determine the cause of death. Of particular concern was the absence of equipment for toxicology testing and trained staff for interpreting the results, which undoubtedly led to pigeonholing the actual cause of death in the most generic terms, which in this case is a prescription opioid-related death.

Again in 2016 when the CDC was reporting the leading cause for overdoses deaths as prescription related, looking backward from 2013 – 2018 the leading cause was IMF (illicitly manufactured fentanyl), see “Fentanyl analogs and opioid overdose deaths, the story mainstream media won’t cover[vii]. Combine this delayed response with the fact that there are more than 50 known fentanyl analogs manufactured outside the US, each with its own unique signature, and the lack of equipment for identifying these substances due to budget and staffing difficulties, and again, our nations ability to pinpoint the real sources of opioid deaths is compromised, leading to the default assumption that they are prescription medications.

This decade long string of mischaracterization on the sources of opioids has led to severe consequences for doctors who prescribe and the patients who were treated. A review of opioid prescribing behavior conducted by the CDC between 2010 and 2016 showed only 1% US physicians were responsible for 63% of the excessive prescribing from 1999 -2012.[viii] Yet knowing this fact, our nations leading health agency goes to great lengths to minimize these issues while they continue to point a finger at doctors and prescription medications. Changes made to root out such prescribing, which began around 2007, led to a greater than 33% reduction in prescribed opioids across the nation by 2013. And still the number of overdoses deaths continued to climb, setting new records each year up through 2018.

Any rational person who makes the effort to dig into these details, can’t help but come back and ask the question, are we as a nation really addressing the root cause? Twenty years since its start, and still reports like this one from TFAH, while closer to identifying the real sources and causes, continue to report the previous twenty years as a prescription-based problem as seen in this quote from the opening paragraph.

“Drug-induced deaths declined, driven by reductions in overdoses involving prescription opioids and to a lesser extent heroin-related overdose deaths. A number of other drug types—namely synthetic opioids, cocaine, and other psychostimulants (e.g., methamphetamine)—continued to increase, albeit mostly at a slower pace than in prior years. Likewise, certain populations did not see the same reductions or stabilization in drug-induced deaths.”

And why is this, the report itself provides the answer, the data is from one source, CDC WONDER. Like so many government systems cobbled together at a time of crisis, they are rarely thorough and complete enough to be all-encompassing and therefore fully reliable. Yet in regards to the drug problems facing this nation the wheels of misinformation, driven by ideology and politics have worked tirelessly to convince us all that our doctors are to blame. Therefore, we must take prescribing out of the hands of doctors and place it in the hands of bureaucrats and law enforcement.

One of the best methods for making such a tactic so successful is to keep every American running as fast as they can, to stay ahead of the next crisis just over the horizon. In the last fifty years, we’ve gone from a middle-class income and lifestyle that could be managed by one income earner to having the same standard of living but requiring two income earners.

Now in the midst of a viral pandemic, we’re hearing more talk about keeping as many jobs as possible as work-from-home positions. And while that appears attractive to many, it also comes at the cost of being more isolated from your employer. More of a number on a ledger than a valued resource for the success of the company. To wrap your head around this just imagine mass layoffs when the next crisis comes along in the form of an email or a text message. In a world that lives on the backbone of the internet and the anonymity that comes with that, will a work-from-home position offer us a better income when we must provide the space and equipment for doing so out of our own pocket? Will it offer us more job security?

This report also found that deaths of despair increased in some minority communities during the same time period and separately alcohol-related deaths were up 4% and suicides were up 2%. Will working from home improve these numbers or simply add another layer of anonymity that gives both employer and employee greater leverage for acting outside the boundaries of civility? Will drug and alcohol-related deaths increase given this new level of anonymity, with no one looking over your shoulder, will more of us be tempted to do while working, what we previously did after work before going home?

This report goes on to say, "We've seen unemployment rates go higher than what we were anticipating, which means that some of the estimates on those deaths could actually increase substantially," Ben Miller, a psychologist, and the chief strategy officer for the Well Being Trust said.

"But what makes it all different and why I think that people do need to be paying attention to this is that the social issues, the sheltering in place, the isolation, the loneliness -- those are major, major risk factors for people not doing well psychologically, as well as potential premature mortality due to suicide or overdose," Miller said.

The pandemic is triggering opioid relapses across Appalachia

The study, which analyzed numbers from the US Center for Disease Control and Prevention since 1999, also found that while some drug-related deaths declined for the first time in a decade, including for whites and those between 18 and 54 years old, deaths from other drugs increased. Raising the question, is prescribing the real culprit in this story, or is the problem more diffuse and more difficult to identify because it’s lurking behind our choices of finding an easier and softer way to live our lives? And when we can’t find this, weary from our efforts to do so, will we do what our ancestors before us did, look for an escape from the hell we’ve created for ourselves? Humans are by nature social beings; we need that interaction in order to be whole and healthy. And how can we guarantee responsibility and accountability when we don’t have face to face interactions with our co-workers?

I was already deep into technology when the internet was born and like so many, the benefits it offered were irresistible. But over the last forty years I’ve seen how something that held so much promise has in fact, become a dredge on society, a major contributor to a lack of civility and social order. And for no other reason than, this is our nature. This is how we compete and survive, but now it's hidden behind a shield of anonymity, with a temptation to take our inhumanity even further. Driven by a profit at all cost mentality, and our competitive natures, we may lack the moral center we had forty years ago, to manage what we’ve built.

As long as profit alone remains the primary motivation, those things which are necessary for a whole and completely balanced life will evade us. With it will come wider and deeper levels of dysfunction as we seek ways to fill that hole in our souls created by our poor choices. Without better leadership to steer us towards civility with neighbors, we may eventually tear ourselves apart.

Studies like this that measure our propensity towards mind-altering substances and acts of despair such as suicide, are essential to monitoring our decline, but they offer no real answers to the core problems. Take away our guns and we will simply fashion our own. Close the bars, and we will brew our beverages in the basement. Isolate us the social environment at work and we will gather at someone’s home in order to have a social experience. Deny us the medication we need to manage our pain, and someone will figure out a way to sell it to us on the street.

This is our true nature; we want what we want when we want it and sometimes, we actually need it as a means to escape the hell we've created or had forced upon us. Better to manage these essential elements of our nature, than to ban them altogether or isolate the control of such issues in the hands of a few.


End Notes

[i] Pain in the Nation Series Update – Alcohol, Drug and Suicide Deaths in 2018, https://www.tfah.org/

[ii] “CDC WONDER.” In: Centers for Disease Control and Prevention, April 29, 2020. https://wonder.cdc.gov/

[iii] CERGM, “How Prescription Opiate Overdose Data is Collected– Part 1”, https://cergm.carter-brothers.com/2019/02/20/how-prescription-opiate-overdose-data-is-collected-part-1/

[iv] CERGM, “Today's Heroin Epidemic”, https://cergm.carter-brothers.com/2019/12/18/todays-heroin-epidemic/

[v]CERGM, “63% of all Opioid Overdose Deaths also involve other drugs”, https://cergm.carter-brothers.com/2019/12/23/63-of-all-opioid-overdose-deaths-also-involve-other-drugs/

[vi] US Department of Justice, “2017 Medical Examiner-Coroner Office Survey Report”, https://www.nflis.deadiversion.usdoj.gov/DesktopModules/ReportDownloads/Reports/NFLIS-

MECSurveyReport.pdf

[vii] CERGM, “Fentanyl analogs and opioid overdose deaths, the story mainstream media won’t cover”, https://cergm.carter-brothers.com/2020/04/15/fentanyl-analogs-and-opioid-overdose-deaths-the-story-mainstream-media-wont-cover/

[viii] CERGM, "Opioid Prescribing Behaviors — Prescription Behavior Surveillance System, 11 States, 2010–2016",

https://cergm.carter-brothers.com/2020/04/23/opioid-prescribing-behaviors-prescription-behavior-surveillance-system-11-states-2010-2016/

The Doctor Patient Forum

Claudia A. Merandi 5 Chedell Avenue / East Providence, RI 02914 / USA 1.401.523.0426