At more than twice the age-adjusted opioid-related death rate compared to the U.S. average, the Commonwealth of Massachusetts represents one of the states hardest hit by the opioid epidemic. Additionally, as the most populous state in New England, MA in many ways typifies the situation as it unfolds in the Northeastern United States.
Opioid Usage Trends in Massachusetts
According to data collected by the MA Department of Public Health Bureau of Substance Abuse Services, one third of admissions to substance abuse treatment programs were opioid related in 2000. By 2015, this number increased to more than 50%, overtaking alcohol as the most prevalent substance used at intake. A similar shift was seen in the state’s Health Policy Commission record of hospitalizations and emergency room visits.
The View From Emergency Services
Since 2013, the Massachusetts Ambulance Trip Reporting System (MATRIS) has starkly illustrated the course of the opioid crisis. This system found a substantial 37% increase in the number of opioid-related incidents during the first three quarters of 2016, compared to first three of 2015. In 2013, opioid-related calls made up between just 1 and 1.5% of all incidents in the first quarter of 2013. According to MATRIS data, this figure more than doubled over the last few years, hitting between 3 and 3.5% in the third quarter of 2016. Additionally, incidents where Naloxone was administered are on the rise, as well as instances where more than one dose of this life-saving drug was necessary.
However, when considering the nature of MATRIS, this trend may not be wholly negative. Some of these additional incident reports may be a function of overdose victims receiving better care than they did a few years ago. The MA government has recently implemented a number of programs, such as State Without StigMA (11) and Make the Right Call, with this goal in mind through encouraging more people — and their loved ones — to seek help and medical attention when needed. In particular, Make the Right Call is an educational campaign highlighting the Massachusetts Good Samaritan Law that was originally passed in 2012. Increasing awareness that this legislation protects third parties who place opioid-related calls to EMS from possession charges may mean that these health emergencies are being addressed at a higher rate.
The Drugs Making the Biggest Impact in MA
While the epidemic is a widespread national problem, the specific opioids being used, how they are obtained, and the impact of these factors often vary greatly by region. Consequently, the understanding of local situations is an ongoing process where details can change rapidly.
As has already been heavily reported, the general roots of the opioid crisis can be traced to the dramatic uptick in prescribing practices, tripling the number of prescriptions for this group over just two decades. In MA specifically, this number increased by roughly 7% per year from 2000 to 2015 — to a point where one in six residents obtained a prescription for opioids in 2015. However, with a crackdown on pill mills and greater scrutiny being given to prescribers, today’s diverted medications now represent a relatively small piece of MA’s opioid problem, and one that may be in decline. For example, prescription medications were found to be present in just 16.2% of opioid-related overdose deaths in the third quarter of 2016, compared to the 24.8% in the beginning of 2014.
Unfortunately, combined with ever-increasing mortality rates, this trend does not paint a rosy picture for MA residents: Many people with existing opioid addictions are simply making the transition from prescription medications to heroin and other illicit sources. This is often directly attributed to increased awareness and stricter regulations, which have the intended effect of reducing the amount of prescription medications into consumer hands. But it also comes with the unintended effect of nudging patients towards different sources and increased dangers.
Between 2007 and 2014, New England — including Massachusetts — had the highest percentage of law enforcement respondents reporting the easy availability of illegal opioids for each year of one large-scale DEA study. And, while also available as a prescription drug, illegally produced and supplied fentanyl (rather than diverted pharmaceutical sources) are dominating the MA landscape. In 2016, 75% of opioid-related deaths where toxicology was performed were positive for fentanyl, up from approximately 30% in the first quarter of 2014. Only 3% of those who had fentanyl in their systems had a prescription for the drug at the time of their death. In contrast, the presence of heroin in such screens has decreased by roughly 50% since 2014. However, the state notes that many heroin-related deaths may not be classified as such, since the drug is rapidly metabolized into morphine.
A Quickly Rising Death Toll
And it is a major upswing in opioid-related deaths among Massachusetts residents that is making headlines. Recently, the average number of such deaths in MA reached a startling five per day. For perspective, car accident fatalities in the same area are roughly half that rate.
A majority of opioid-related deaths between 2011 and 2014 occurred among patients who had a legal prescription at some point within this time period. One in 12 opioid-related deaths occurred where the patient received one such prescription the month prior to overdosing, a statistic that helped compel prescribing and monitoring reform.
However, the surge in opioid-related mortality in MA began with a sharp increase in 2012. Despite the established link to opioid prescribing practices, this climb did not correspond with a similar increase in prescriptions — a testament to the complexity of the opioid crisis. With many different intersecting factors in health policy, standards of care, and social determinants coming together over decades, effective policies will likely be ones with an eye towards long-term changes in addition to triage for current victims.
As of February 2017, the data compiled and released by the Massachusetts Department of Health and Human Services for 2016 indicates that the state’s opioid crisis has not yet reached its peak. The DPH reported between 1,465 and 1,979 unintentional opioid-related deaths in 2016, a 26% increase compared to 2014–2015. Of course, both periods are a dramatic rise from 355 in 2000 and 698 in 2012.
Massachusetts residents of all ages, races, ethnicities, and genders are currently struggling with increasing rates of opioid addiction. However, certain groups are disproportionately affected by the current crisis.
In MA, young people are perhaps at greatest risk for opioid addiction and its consequences. Opioid overdoses accounted for 24.6% of all deaths among residents ages 15 through 24, 38.6% for ages 25 through 34. This is in contrast to 27.1% for ages 35 through 44 and 10.3% for ages 45 through 54. Younger opioid users are more likely to be introduced to these drugs through peers and recreational use, rather than starting from prescriptions. This means that efforts to reign in over-prescription will likely have less of an impact on those belonging to such high-risk age groups.
These high levels of addiction and mortality among young adults in their prime will also likely have a negative impact on future generations for years to come: Massachusetts is already reporting extreme strain to its foster system. Children are frequently removed from parents struggling with addiction due to abuse and neglect. Making up a third of such allegations, opioid abuse was the most common reporting factor between March and September 2016. Additionally, many of these children continue to permanently lose parents and guardians to overdose deaths.
Race and Ethnicity
While the media focuses on the climb in opioid use among whites, with the CDC estimating overdose rates for this group as more than double those seen in the Black community on average, the crude number of deaths in MA are roughly proportional based on the state’s population. However, age-adjusted data does show white non-Hispanics with an opioid-related death rate of roughly twice that of Black non-Hispanics and 50% greater than Hispanics of all races. These adjustments account for the younger age of the Hispanic and Black populations in MA, which — with the added risks already noted among young adults — can cause these groups to be overrepresented in the crude data. As in many other parts of the country, this is hypothesized to be an unexpected protective effect of racism in prescribing practices. Additionally, Black and Hispanic residents in general have less access to medical care, and thus fewer opportunities to be given initial opioid prescriptions.
In 2016, 73% of unintentional opioid-related deaths in MA were male, 27% female. Additionally, heroin was more likely to be found through a toxicology screen for men, while prescription opioids were more likely to be detected in women. MA health officials have posited this is caused by the fact that women are more likely to use the health care system.
According to MATRIS reporting, greatest number of opioid-related incidents in 2016 occurred in males 25 to 34, who made up 25% of all suspected opioid overdose incidents.
Notably, the opioid crisis is making it even more difficult for previously incarcerated MA citizens from achieving a better life. The risk for opioid-related death in this group was found to be 50 times greater than that of the general population. Additionally, these deaths are much more likely to occur during the first month following release. In MA, opioid-related deaths made up 40% of those who were released and died from 2013 through 2014. Those ages 18 through 24 had an risk some ten times greater than those over 45.
While efforts to address the opioid epidemic in MA go back many years, the Chapter 55 report released in September 2016 represents a more recent strategy. It consists of an analysis of multiple datasets from five different government agencies that, according to related laws, may directly guide future policies (1). Other public initiatives have worked to educate MA citizens and to increase the number of beds in substance-abuse treatment facilities.
MA Prescription Monitoring Program
Originally established in 2009, the MA Department of Public Health (PMP) is a statewide repository of data on all prescription medicines. Through it, doctors and pharmacists can access a patient’s prescription history to make informed decisions regarding their care.
The MA PMP is used to combat a risk factor identified early on during the MA opioid crisis: three or more prescribers designated for a single person. The MA PMP helps clinicians identify patients in this risk group, using additional data to determine whether or not the patient is in a situation where this is appropriate, such as being cared for by a single practice with numerous physicians.
The most recent significant piece of MA legislation has been Chapter 52 of the Acts of 2016, An Act Relative to Substance Use Treatment, Education and Prevention, which was signed into law in March 2016. It contains an extensive list of provisions, which include those that:
- Instruct licensing and registration boards to require prescribers to complete training in pain management and addiction.
- Require physicians to query the state’s PMP database before prescribing all Schedule II and III narcotics, while also allowing for exceptions under certain specific circumstances.
- Introduce a seven-day limit for patients being prescribed opioids for the first time. However, it includes exceptions for cases involving chronic pain, cancer, palliative care, and acute medical conditions.
- Establishes a voluntary non-opiate directive form for use with certain patients who have a history of substance abuse.
- Promote education on the topic in many forms, such as substance abuse prevention in public schools and drivers education programs, as well as training courses for municipal police on drug-related overdoses.
- Require the Board of Registration in Pharmacy to establish a treatment program for pharmacists, interns, and technicians who have substance abuse issues.
While such dramatic and proactive action by MA officials and residents may prove effective in dealing with the opioid crisis, these policies also make it more difficult for chronic pain sufferers to find relief. According to members of the Massachusetts Pain Initiative, a patient advocacy group, many doctors and pharmacists are incorrectly interpreting new state and federal regulations. As a result, many chronic pain patients are finding themselves cut off from the medications they relied upon and safely used for years. Some MA doctors and residents with chronic pain have expressed concern for a possible upswing in suicides as a direct result. MA health professionals need better education about these laws to ensure that pain patients don’t become casualties of the opioid crisis.
While MA may be headed in the right direction with increased focus on prevention, treatment, education, and battling social stigma, it will likely take years for datasets assessing the success of these programs to mature. In the mean time, public health policy is at risk of lagging behind when it comes to this rapidly evolving crisis.