President Trump recently declared the opioid crisis a national public health emergency. It’s still unclear how much funding, if any, is tied to that declaration, but whatever resources are marshaled will likely fund work done by people most commonly thought of as fighting on the front lines of the epidemic, like social workers, addiction counselors and physicians.
But another group of people is crunching the numbers to better understand the hows and the whys of the crisis: mathematicians, epidemiologists, data scientists and statisticians.
As a roomful of these kinds of scientists from across the country gathered at the University of Pittsburgh for a workshop, the Centers for Disease Control and Prevention's Sarah Bacon made her ask.
"I'm the person who needs your science to do the work that I do," Bacon said.
That work is helping to determine how the CDC can most effectively use its resources, and Bacon wants researchers to focus on three main areas: predicting overdose deaths, finding the most effective treatment strategies and understanding the social forces behind the epidemic.
Predicting Overdoses Is Getting Harder
"What if we could find a precursor in law enforcement data or another untapped source to predict overdose outbreaks and build an early warning system... how many lives could we save?" asked Bacon.
Right now, by the time a sudden cluster of overdose deaths is realized, it's too late to stop. In large part, that's because reporting of overdose deaths can be unreliable and slow, according to Allegheny County Medical Examiner Karl Williams.
Neil Capretto, medical director of the Gateway Rehab program, said it used to be that the presence of fentanyl, often mixed with heroin, would indicate that a rash of deaths was about to occur.
"We’ll hear of a couple cases of people who are ‘experienced’ heroin users, let’s say they’re using 15-20 bags a day, often three or four at once, and we will hear that they overdosed and went out or maybe died on one or two bags," said Capretto.
Fentanyl is a synthetic opioid about 100 times more powerful than heroin, and now, it's so common, Capretto said this is the middle of a prolonged spike in overdose deaths that started in the Pittsburgh area in 2014.
“Unfortunately, over the last year and a half, two years, that’s just been more the norm. A high percentage of what is sold as heroin on the street is actually fentanyl or another synthetic,” said Capretto.
According to online database OverdoseFreePA, from 2013 to 2016 the number of fatal overdoses from fentanyl and related substances in Allegheny County rose from 8 to 425.
Recently, even deadlier substances have started to surface.
"We had quite a few people die and they found out they were mixing heroin with elephant tranquilizer," said Dean Robinson, a member of the street outreach team at North Side ministry Light of Life, which helps people struggling with addiction and homelessness. Robinson himself is in recovery from heroin addiction.
Those elephant tranquilizers are made with a synthetic opioid called carfentanil, which in turn is 100 times more potent than fentanyl.
Synthetics are so common now that their mere presence can't predict sudden upticks in overdose deaths; rather, their introduction has increased the average rate of overdose deaths overall. Researchers will have to look deeper into the data to find new ways to predict when the next spike in overdoses might occur.
Preventing Addiction And Treating The Disease
The CDC needs more evidence of what works well in terms of prevention, intervention and treatment, said Sarah Bacon.
"It is very hard to compel policy makers and other partners to enact a new policy or implement a new program or a practice if we don’t have evidence of effectiveness," said Bacon.
Neil Capretto said most opioid addictions start with a prescription. He said the CDC is on the right track with one of its biggest projects: working with states, like Pennsylvania, to develop prescription drug monitoring programs. These let government officials, law enforcement and health professionals see who is getting prescribed opioids, how much and by which doctors.
But Capretto also said caregivers need to treat addiction like the chronic disease it is.
“We often treat it like it’s a sprained ankle or it’s the flu. You go to a rehab for 14, 20 days and you’re supposed to live happily ever after. That’s just the beginning, you really need to be managed,” said Capretto.
Caprett0 said addiction is often tied to mental health issues, which in turn frequently originate from trauma.
When Dean Robinson was growing up, his mother was verbally and physically abusive towards his father. Robinson said he started drinking and using other drugs as a coping mechanism, which eventually led to his heroin use.
Robinson said the key to staying clean for good after detoxing was addressing those traumatic events from his early life. He went to therapy and started opening up to people. And, like many others in recovery, he found an anchor in a higher power.
"God is a big factor. Praying in the morning, praying at night, asking God for guidance, allowing him to speak into my life," said Robinson.
The Bigger Forces At Work
The CDC also wants researchers to consider the underlying causes of the epidemic. Sarah Bacon described it as more a question of "why?" than "how?"
"If we want to prevent the seeds of this epidemic from being sown into the next generation, then this work is vital," said Bacon.
According to Pitt’s Graduate School of Public Health, overdose deaths in the US across all drug types have increased nearly 20-fold since 1979. That year it was about 2,500. In 2015, it was 44,000.
Capretto worries about a snowball effect from one generation to another.
"We have more people, probably, going through trauma, raised often by parents who were less than ideal because of their addiction," said Capretto.
A 2016 study from Harvard Medical School found about 1 in 5 kids live in a home where an adult has a substance use disorder. The same study shows that those kids are more likely to abuse drugs themselves.
Opioids are highly addictive, powerful pain relievers that produce an intense euphoria. The advent of OxyContin in the late 1990s made opioid prescriptions more common than ever before. But the cost of the pills were starting to be too much for patients with prescriptions. "You have these people not being able to get the prescription drugs because of the price of them, which makes them move to heroin," said Dean Robinson."That, plus the growing tolerance of patients addicted to pills, led a lot of people to the street and launched an illegal market with a cheaper, more powerful alternative. According to a 2016 report from the Drug Enforcement Agency, officials seized about 6,700 kilograms of heroin in the US in 2015, more than twice what they seized just five years earlier.
Of course, this is all historical data. The CDC needs to know what could happen in the future, if, for instance, they dedicate more resources toward treatment or a more potent type of opioid takes hold.
"(We need) to think about where we need to go next, to think about where to invest, where to develop partnerships and who to beat over the head with the findings," said Bacon.