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May 12, 2016

Public health class advises how to intervene in the opioid epidemic

Injection needle with prescription pills blue background

When agent Brian Dempsey of the local Drug Enforcement Agency office made his first visit to Pitt’s Law in Public Health Practice course in mid-semester, he told the students that Pittsburgh is now one of the epicenters of the heroin epidemic — and that the “feeder system” of prescription opioid pain medications is to blame.

The students already had been working for weeks in small teams to research, formulate and present to the Allegheny County Health Department a proposal for the law, and the public health system, to intervene in the opioid epidemic. The interdisciplinary class included a student in the Graduate School of Public Health’s master of public health program; another working toward a PhD in genetics; medical students; an undergraduate aiming for a bachelor’s degree in economics; and even a Carnegie Mellon University (CMU) master of public policy student. Public health faculty member Elizabeth Van Nostrand, director of the school’s JD/MPH program and associate director for law and policy in the Center for Public Health Practice, was the instructor for the course.

Dempsey explained to the class how the U.S. — Pittsburgh more recently than many other regions — got to this point:

Physicians first prescribed opioids to alleviate pain in the worst cases — severe, often terminal illnesses. But then in the 1990s doctors began giving opioids such as oxycodone (marketed alone as OxyContin, or as an ingredient in other drugs) for less severe, often routine, pain relief. “All this was pushed out into the public” by pharmaceutical companies, Dempsey said.

“I’m not trying to deny anyone’s pain,” he added. But there is wide agreement that this medication was being over-prescribed, and it led to addictions. Eighty percent of all heroin users started out on opioid medications, he said, then turned to heroin because it was cheaper and more readily available.

Since 2011, drug overdoses have overtaken traffic accidents as one of the top causes of death in the U.S., with more than 45,000 such fatalities in 2015 — half from opioids.

Recent Pitt public health studies have confirmed the epidemic’s local impact, showing that drug OD deaths have climbed 1400 percent in the state over the past 35 years, especially among young white women, and that western Pennsylvania has some of the counties with the largest recent increases in OD deaths.

Most of the heroin the DEA sees in western Pennsylvania is being cut with fentanyl, Dempsey said. Fentanyl is another pain medication, which increases heroin’s potency and its chance of killing users. If the DEA gives publicity to a particular stamped “brand” of heroin with fentanyl — responsible for the most fatal overdoses — it only encourages users to seek out that particular high, he said. It seems that, no matter what the government tries to stem the epidemic of opioid deaths, it is stymied.

Questions came quickly at Dempsey from all sides of the room, based on the students’ earlier research for the class: Are local police forces being educated about Good Samaritan laws, what they allow fellow drug addicts to do for overdosing friends without themselves getting arrested, for instance? Would decriminalizing all drug use help, as has been done in Portugal, which since taking that step has seen a decrease in drug use and drug-related deaths and diseases? Doesn’t Mexico’s main heroin manufacturer, the Sinaloa cartel, worry about decreasing its customer base by killing them?

“The demand is so high …” Dempsey began.

In 1995, western Pennsylvania had six methadone clinics, which were designed to help heroin users wean themselves from the drug, he told the students. Today the area has 29 such clinics that treat opiate addicts as well as those addicted to heroin, along with 700 doctors who can prescribe Suboxone, another opioid addiction treatment.

Illegally obtained Suboxone is the local DEA’s third most confiscated drug today. “Are we just helping people to stay addicts?” Dempsey asked. “It’s something the government is struggling with today. I wonder if you can help us?”

After Dempsey left the class, Van Nostrand lectured on how legal statutes work, and then the students got to work as a group. They had decided to study where naloxone — the emergency injection for reviving overdose victims (and one of the ingredients in Suboxone) — might be most effectively available to addicts, their friends and families. The class considered possible naloxone distribution to three vulnerable populations: Addicts just released from prison, who overdose more frequently than any other group; Veterans Administration facility patients, since veterans may need pain medication more often than the general population; and adolescents in schools, because Gov. Tom Wolf had signed an order allowing public high schools to stock naloxone.

The students debated what form their project report would take, and eventually settled on a white paper, as opposed to new regulation proposals, which the county health department might have found untenable. They set their own deadlines after Van Nostrand warned them: “We could research this for the next three years. There has to be a cut-off date.”

Then they traded updates on the progress of their small research teams: literature and case study review; economic impact; legal analysis; and others. Their reports were both enthusiastic and heavy with raw data that was yet to be chewed over: the locations of pharmacies stocking naloxone versus overdose deaths in Allegheny County, for instance, or what research had to say about naloxone’s effectiveness in each of their three target populations.

“I have never in my lifetime seen people step up to the plate like these students,” Van Nostrand said after the class. “Not only are they working well collaboratively but they are going beyond the assigned tasks. From a teacher’s perspective that is so nice to see it play out this way.

“There have been a lot of lessons learned… The more buy-ins students have in class, the better the outcomes are.”

Lauren Torso, a student in the DrPH program in epidemiology in the Graduate School of Public Health, was group leader for the class that day. Previously, she had worked as a full-time epidemiology researcher with the Allegheny County Health Department (ACHD); she still works there half-time, and hopes to continue her research career with government agencies upon graduation.

She was part of the class’s legal analysis team, and investigated how well current Good Samaritan laws work in individual states. “We were surprised to find that even with this very exploratory analysis, we were able to find a relationship between having a Good Samaritan law and the overdose mortality rate, by state.” Without a Good Samaritan law, her team found, overdose mortality rates increased by a statistically significant 18 percent.

“I think it was a great learning experience, especially for real-world applications,” Torso said of the class. “It seemed a bit more like real work” than the average course, she added.

Her classmate Andrew Cobb is a student in the master of public policy and management program at CMU’s Heinz School and a nine-year military law enforcement veteran in the Marines, where he worked with trauma patients at military hospitals in Germany, seeing that opiate abuse was all too common. His team mapped heroin and other opioid ODs 2005-13 against pharmacies registered with Allegheny County to carry naloxone (which was first allowed in 2013). They found that OD locations were fairly consistent across the years (including a high incidence in Oakland), and that the pharmacies carrying the emergency drug — all small and independently owned — generally were nearby, including four in the 15213 ZIP code.

He hopes that larger chain pharmacies, which have developed protocols to allow their outlets to carry naloxone but are not actually carrying the drug, may be encouraged by the class’s data to carry it, once the county health department is able to muster their data as proof that, frankly, there is a market.

Naloxone has a very limited shelf life and is expensive, Cobb added. Pharmacies may be stocking the drug, but if they aren’t able to distribute it to those who need it, the drug may expire, discouraging pharmacies from continuing to carry naloxone. Such pharmacies may need subsidies to encourage them to maintain their stocks, and more insurance companies may need to cover the treatment as well, he said.

“We were able to look at a subset of the problem and find a way to help in a small corner of this issue,” Cobb concluded, “which could potentially be used to address the larger problem.”


Other guest lecturers for the class included, via Skype, Los Angeles writer Sam Quinones, whose nonfiction book “Dreamland” is an account of the opioid epidemic in both Mexico and the United States. Class members quizzed him about the complexities of the epidemic, Van Nostrand said, and asked where they should recommend the health department put its limited resources.

“He basically said you can’t arrest your way out of this problem and you also can’t treat your way out of most of this problem,” Van Nostrand said.

The class’s conclusions, presented to ACHD officials last month, recommended changes to naloxone availability in the county, proposing:

• Naloxone and appropriate training on naloxone use and overdose intervention should be offered to inmates with a history of opiate abuse upon release from the Allegheny County Jail;

• Opiate-addicted Allegheny County Jail inmates should be offered opiate-specific medication-assisted treatment (MAT) and community-based MAT referral upon release;

• ACHD should work to ensure opioid overdose prevention for Allegheny County veterans by collaborating with the local VA hospital system and community partners on third-party naloxone distribution;

• ACHD, in conjunction with the Allegheny County Department of Human Services, should conduct a large-scale in-person naloxone distribution and training program for first responders and Allegheny County bystanders; and

• ACHD should expand data-sharing initiatives with community and governmental partners as well as expand publicly available data sources specific to the opioid epidemic.

ACHD head Karen Hacker and others on the county health department executive team heard the students present these recommendations.

“They do a great job; they really take it seriously,” Hacker said afterwards. “Some of the recommendations they made, we’re actually already starting,” such as working to provide medically assisted treatment in jails. She was particularly pleased with the students’ economic and legal analyses “that we don’t normally have the bandwidth to do.” Even if the county doesn’t follow all the class’s recommendations to the letter, she added, the research will prove tremendously useful in bolstering their understanding of the epidemic and their future moves.

The conclusion that freshly released prisoners should be the top target for a public health intervention is a smart conclusion, Van Nostrand said.

“Even if they’re not using in prison, they are being forced to quit. It’s just putting their addiction on hold for a while, until they are released.

“They’re released and their bodies are not used to the level of drug they were using before … so they are more prone to overdose,” she explained. “You’ve got to keep people alive to get them into treatment. A lot of society looks at addicts getting what they deserve, but that is not the attitude of public health.”

—Marty Levine

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