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Is opioid abuse down in Minnesota, or just getting harder to track?

The widespread availability of naloxone may mean some overdose victims never come in contact with the health care system.

While the number of people dying from opioid use has gone down, death rates are still high.
REUTERS/George Frey

This month, the Minnesota Department of Health announced the number of deaths caused by opioids went down instead of up. That’s kind of a big deal, since opioid deaths have climbed up and up, almost without exception, for the last two decades.

Data from the Department of Health show 331 opioid-related deaths in 2018, down from 422 in 2017.

Public health officials are treating the good news with caution. While the number of people dying from opioid use has gone down, death rates are still high — and it’s unclear whether the number of people abusing the drugs has substantially declined.

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Life-saving drug

The decline in opioid deaths is only the second drop the state has seen since 2000, according to data from the Minnesota Department of Health. Deaths related to prescription opioids decreased from 195 to 134 between 2017 and 2018, while heroin-related deaths declined from 111 to 85. The number of deaths involving synthetic opioids, primarily fentanyl, are up. (Numbers from 2018 are considered preliminary as of now.)

Opioid-related deaths in Minnesota by year, 2000-2018
Source: Minnesota Department of Health

In a press conference announcing the new numbers, Minnesota Department of Health Commissioner Jan Malcolm said the data suggest efforts by the state and its partners to reduce the number of opioid deaths are helping to make a dent.

Minnesota has monitored the amount of some controlled substances, including opioids, prescribed in the state since 2010. Soon, the system will alert prescribers if patients are potentially abusing opioids. The state is now also notifying providers who serve Medicaid and MinnesotaCare patients if their prescription rates are higher than peers’ and has developed opioid prescription guidelines.

“I think these different avenues have provided tools for providers to prescribe more cautiously,” Malcolm said.

But not all people who become addicted to opioids first come into contact with the drugs through prescriptions, and increased monitoring and education of providers is only part of what may have caused the drop in opioid deaths.

In 2014, Minnesota passed a law to allow first responders, police and drug prevention staff to carry naloxone, a drug that can bring people back from an otherwise fatal overdose. The law also protected someone calling 911 about opioids from liability. In 2016, Minnesota passed a law expanding access to naloxone by allowing pharmacists to distribute the drug, making it available to opioid users and their families.

In Hennepin County, law enforcement officers carry naloxone and are trained in its use. So are security staff in several of the county’s libraries, said Julie Bauch, opioid response coordinator for Hennepin County.

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“I think that’s step one to this public health intervention, is to flood our community with a lifesaving medication,” Bauch said. “I’m not saying we’ve done that completely — we still have a lot of work to do. But the overwhelming feeling is that is what’s turning the tide, more and more people have access to this life-saving drug.”

“If you were to use this as a corollary to other chronic disease models, I think you could say … that we’re preventing mortality in people who are having heart attacks, but we’re not preventing heart attacks,” said Dr. Joseph Lee, the medical director at Hazelden Betty Ford Youth Continuum.

Obscuring numbers

It’s not just overdose deaths that are down. Health department data show the number of non-fatal emergency room visits related to opioid overdoses dropped from 2,037 in 2017 to 1,946 in 2018. Treatment admissions are also down, according to data from the Minnesota Department of Human Services.

Treatment admissions for opioids, 1995-2018
Source: Minnesota Department of Human Services

But while naloxone makes it less likely people will die of an overdose or potentially end up in the emergency room, its widespread availability makes some of the numbers used to measure the opioid epidemic harder to interpret.

When only certain professionals carried naloxone, its use was usually associated with a 911 call or a hospital visit, which could be counted. Today, people are often revived without making contact with the system.

“We know that the preliminary data says that deaths are down, but what we’re concerned about and what we think about is we still can’t estimate the true prevalence of how common opioid use disorder is and how many people and families are still suffering,” Bauch said.

Still, Bauch said, when you piece data together, things are encouraging.

Hennepin County has seen a decrease in autopsies for deaths related to opioids. Preliminary data shows fewer people using the county’s opioid withdrawal management facilities.

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“All of those things kind of corroborate and validate that we do think there’s a downward trend,” Bauch said. But, “We still have to use caution with the interpretation of this data because while we might see deaths decreasing, we still have a massive epidemic in our community.”

Challenges remain

The statewide reduction in deaths from opioids isn’t being felt everywhere. St. Louis County had its worst quarter in terms of opioid deaths yet in the first three months of 2019, said Jess McCarthy, opioid program technician for the Duluth Police Department. It also had high nonfatal opioid overdose numbers.

That’s despite that there are resources available for people who need help.

“Here in Duluth, even for being a smaller city, we have a ton of resources for people,” she said. But, “I can’t tell you how many of my clients I’ve met with who are like, ‘I’ve been wanting to go to treatment forever, I just didn’t know how to do it.’”

The stigma of substance abuse is still an impediment to some in seeking treatment, McCarthy said. She had just met with a mother who felt that she was being judged for drug use and court involvements.

“She was talking about how all of these people must think I’m a total piece of shit,” McCarthy said. It’s different, than say, alcoholism, which she thinks has come a long way in terms of stigma reduction.

“I don’t want to say a majority, but a large percent of the general public still sees it as a moral failing as opposed to a mental health issue,” she said.“We don’t have the same get behind that we do for substance abuse disorder as we do for alcoholism.”

Racial disparities remain another barrier to reducing opioid deaths, Lee, of Hazelden, said: African American and Native American Minnesotans are much more likely to die of drug overdoses than are white Minnesotans.

“In that racial disparity there are major issues with access,” Lee said.