Map of the world made up of pills

Stimulants and drug related deaths in America

 

News coverage of the drug overdose crisis gripping America has, for a large part, focused on opioid drug deaths. However, this represents a small part of the ever-shifting landscape of drug use. Away from the mainstream, stimulants – both prescribed and illicit – continue to claim lives at an increasing rate.

 

Joshua Black and Janetta Iwanicki from Rocky Mountain Poison and Drug Safety discuss their institutes role in tracking deaths, informing policy, and attempting to stem the tide of drug related deaths in America.

 

Read more: https://doi.org/10.1001/jamainternmed.2020.7850

 

The following transcript is automatically generated.

 

00:00:10 Will 

Hello I’m Will welcome to research pod. 

News coverage of the drug overdose crisis gripping America has, for a large part, focused on opioid drug deaths. However, this represents a small part of the ever-shifting landscape of drug use. Away from the mainstream, stimulants – both prescribed and illicit – continue to claim lives at an increasing rate.

 

Joshua Black and Janetta Iwanicki from Rocky Mountain Poison and Drug Safety discuss their institutes role in tracking deaths, informing policy, and attempting to stem the tide of drug related deaths in America. 

 

00:00:52 Will 

Joshua and Janetta hello to the both of you. 

 

00:00:54 Janetta 

Hello thanks for having us. 

 

00:00:56 Joshua 

Hello thanks. 

 

00:00:57 Will 

What is killing Americans? 

 

00:01:00 Joshua 

Well, I would say there’s certainly a lot of things. 

 

One of the things that have been there has been increasing for decades have been overdoses and drug overdoses. 

 

00:01:12 Janetta 

An important piece that goes with sad is certainly drug overdoses have been a problem for a long time in the United States, but historically we’ve seen a lot of deaths that have been related to Opioid. Both prescription opioid as well as opioid such that are obtained somewhat illicitly such as fentanyl and heroin. 

 

But in recent years, we’ve seen an increase in deaths that have been related to stimulants and I think that’s really set off a lot of alarm bells. Both within government agencies trying to figure out how to create safer policies around it. 

 

As well As for researchers such as ourselves who want to understand more about that phenomenon. 

 

00:01:57 Janetta 

So I’m the chief scientific officer here at Rocky Mountain Poison and drug safety. My background is as a physician so I’m trained in emergency medicine and medical toxicology and as I was going through my training I found that one thing. I really wanted to understand more about was an intersection between the clinical practise that I was seeing everyday working at the hospital and then also some of the data that we were seeing through the poison centre looking at things such as impacts of drug overdoses And toxicity from drugs. 

 

00:02:31 Janetta 

And so I became involved in research looking at the large scale Epidemiology of how prescription drugs are used as well as misused to understand that a little bit further, and that brought me here to the work that I’m doing now. 

 

So one of the things that we do is we look at trends both in the United States but also in other countries, including the.uk as well as Europe to understand patterns of prescription drug misuse. 

 

To be able to think about how do we make these drugs safer because we know they have important therapeutic uses but we also know that there are potential risks associated. That’s the context in which I get to work with Joshua. 

 

00:03:11 Joshua 

And I am one of the senior research scientist here at RMPDS. 

 

My background is an interdisciplinary scientist I trained in Biostatistics and biophysics actually and so moving into this field. I started to study Epidemiology and working with Ginetta and the folks here and what I want to really understand and really bring to the table is improved ways to answer questions and so. 

 

As we look at the data sources that we have? What can we do to look in the novel Ways and try to understand the data itself, so that it can answer the relevant questions. We need to answer to improve public health. 

 

00:03:50 Will 

Where do you find that you sit between policy and policing and medicine and any other fields of work? 

 

00:03:59 Janetta 

bit of a unique position here in that we are a part of a group called Denver Health, which is a public institution. Actually, a subdivision of the state of Colorado that provides medical care to people in the County of Denver. 

 

So we live in this public institution that’s really a government agency, but we also do research that is both funded by groups like the Food and Drug Administration as well as inform policy. 

 

And we really see our role often as providing the right data to have good conversations around how to Create better policy 

 

00:04:36 Janetta 

I would say that in general, you know, we’re on the side of the data and wanting to look at what it tells us and how we can do Things most safely. 

 

00:04:44 Joshua 

I’m just grateful that we have that position because then we can really pursue what the data are telling us and and tell the Storey of the data itself from a perspective that I think is as independent as as possible. 

 

00:04:59 Will 

And to get into some of the data and the people that it represents behind the paper that we’re discussing today national look at who is using drugs. 

 

00:05:10 Janetta 

When we talk about people who use drugs. I think it’s a really large very heterogeneous group that represents really a large swath of Americans, an particular it all depends on what types of drugs. People are using how they’re using them and it’s really just not one group and it’s actually not even just one drug that people are often using? 

 

00:05:34 Janetta 

When we think about sort of the numbers that we’re going to talk about today and who they represent I think that’s something really important to keep in mind as this is not just one set of people. This is multiple different populations that were really thinking of here. 

 

00:05:48 Joshua 

Yeah, I think that’s that’s probably the most salient point is that the people who choose to use drugs are going to use them for a variety of different reasons. 

And it isn’t necessarily one clear path that’s dominated by the drug itself. It’s more about the person who uses than it is about the substance, they are using.

 

00:06:10 Will 

where the kind of difference between a medical approach and the pathology of stimulant use disorder and the criminal approach of a drug offender comes into your work. 

 

00:06:36 Janetta 

So I would say that we, we come at this predominantly from the medical and data perspective and I think our angle on this is really understanding both the patterns of use. 

Some of the reasons for use as well as looking at the sub populations, so that we can better understand how to create policies that make things safer for everyone. 

You know, we’re really looking at this from that angle of how do we create safer drugs safer drug use patterns? Safer access to treatments and how? Do we have good data that helps us inform those choices. 

 

00:07:00 Joshua 

Yeah, from the individual perspective. It’s those. I like to think of it as what risk factors are present for an individual that could lead to a more harmful outcome. 

You know, obviously fatal overdose being the worst, but there’s other Unflawed comes that could occur from drug use. And so we really come at it. 

From that perspective of how to the risk factors play into an individual and what where they could lead them. 

 

00:07:24 Janetta 

I think we focus so much on individual substances and. 

You know problem drugs whether we say it’s heroin. That’s the problem or methamphetamine. That’s the problem or oxycontin that’s the problem. 

And I think that really misses the individual who is at the heart of those outcomes and misses a lot of those important factors that place that person at risk. 

 

00:07:54 Will 

And from there, it’s a pretty clear aligned to the paper that brings us all together. Today, if you tell us a little bit more about the specifics behind how the data for this one was gathered and kind of some of the theory behind it. 

 

00:08:06 Joshua 

Sure, this paper came about because… Opioid’s have dominated the conversation for a long time, and action has been taken to help kind of control the availability and prevalence of those, and so over the last say 5 years for things that we’ve been thinking about. We’ve been thinking about what other substances could individuals start to use instead of the squeezing of balloon idea is that as you push on one part of the drug landscape say one substance it. 

 

00:08:41 Joshua 

 

Drives people maybe to a different substance that they may choose to use and so that’s again coming back to that. 

 

You know patient centred perspective of why a person chooses to use it not the substance that they choose to use. 

 

Specifically, for this paper, we really wanted to drill into which substances are present at death because the 

 

Typical reports that are put out there kind of lump all stimulants together and so there’s a very big difference between cocaine and say methylphenidate. 

 

So, too, sis stimulant substances, but they have very different ways that they change the body and what what it causes a person to to react to and so we wanted to drill into which substances are present at death. 

 

00:09:24 Janetta 

You know one thing that we know certainly impacts the choice of which substances someone uses. 

 

Availability is certainly one of those pieces substance use is really deeply intertwined with a lot of other characteristics. Whether that combination of genetic factors heredity along with psychosocial factors early childhood trauma, um. 

 

Socio economic status poverty things like that, we all know we’re very deeply intertwined. 

 

And so often the substance of choice might be related to some of those physiological characteristics that Joshua was mentioning. 

 

But sometimes the substance that’s accessible or readily available may not always be that substance of choice and so that interplay between what substance is available? How accessible it is what the societal impact of choosing to use that substances as well as all those other factors really all come into play as we look at some of these broader trends on that bigger scale. 

 

00:10:31 Joshua 

So the data itself comes from death certificates, so in the United States when when someone dies. That person has a certificate that’s a standardised form filled out for them. In certain parts of the form when it said regular related death. The medical examiner coroner will list which substances were. 

 

Causally involved in the death and so they’ll say this person died of drug overdose, but then in the free text part of the form. They list the substances that were discovered, either through toxicology report or some other knowledge of the case that will make it into the official report of why someone died. 

 

This analysis analyses that field that says. What substances an individual died from we looked at how frequent different specific substances were present or involved in the death for stimulant substances. 

 

00:11:30 Joshua 

We broke it down to several different substances. The 2 most common being cocaine and methamphetamine. A smaller subset, but a rising subset was medically related stimulants, so amphetamine and methylphenidate. A smaller subset, but a rising subset was medically related stimulants so amphetamines Which are your Adderall in your Ritalin were also listed so those were much smaller in terms of prevalence of the other 2 but were rising across the study period, which began in 2010 and went up through 2017, which is the latest year we had for the free text. 

 

00:12:05 Janetta 

And this data from these death certificates all goes into the centres for disease controls, national vital statistics system. So the national data set that gives us essentially all of the deaths that were reported during that time frame. So it’s pretty comprehensive and gives us a way to look at this pretty holistically from a national. 

 

00:12:28 Will 

How do these deaths fit in with a national picture of drug use and drug mortality and what kind of conclusions about the drug use and drug death landscape? Can we see over the last 10 or so years. 

 

00:12:42 Joshua 

The trend that we’ve observed over the last 10 years with opioid s’s that drug overdose continues to rise and. It isn’t necessarily one substance that is, it is present with these. We found multiple different substances involved. 

 

Independently and then we found that many of the substances were also present with other entire classes of deaths, and so stimulants frequently weren’t found present by themselves. They could have been found with. 

 

Hope yours with with other sedatives or or even antidepressants. So I think some of the biggest things that we saw at the study was that the conversation being only around opioid XI think misses a huge part of the picture and the changing part of the picture for. 

 

What people choose to use and unfortunately what they ultimately die of. 

 

00:13:33 Janetta 

Just to go off that a little bit further, you know when I think about how do we save peoples lives and how do we decrease mortality? 

 

Unfortunately, I think it’s not a simple answer because simply changing opioid’s hasn’t solved the problem, and looking at this data, while stimulants are an important part of this picture, they’re not the only part either. What we’re really seeing here is an epidemic of polysubstance deaths with stimulants and opioid being important parts of that. But I think that has major implications. 

 

As we think about how to create better policy, we need to be thinking about this from that polysubstance perspective. 

 

00:14:14 Will 

And in terms of the usage demographics of age, ethnicity national origin location where there any trends within that that you could see that there were at risk people or populations or anything that leapt out against the kind of comprehensive national picture. 

 

00:14:30 Joshua 

Yeah, I think the race profile would certainly interesting when you looked at all drug deaths. Any deaths with drug mention it was predominantly white and around 86% and smaller percentages for the other races. When you look specifically stimulants. The seasons had a smaller percentage of white, around 75%, and the number of the percentage of decisions who were black was about twice as high as they were for all drugs mentioned… 10% for all drugs to 20% for stimulants. So I think there’s certainly a racial difference of those involving stimulant deaths. 

 

00:15:12 Joshua 

Comes to age. It also tend to be younger. All deaths with any drug mentions were around 55. Was the median age. Deaths involving the stimulant drugs were 45, so the profile tended to be younger and less white. When it comes to sex disparity, it wasn’t as different between the two. Drug tests tend to be more male than than female and involving stimulus. That percentage was pretty similar. 

 

00:15:42 Janetta 

It’s the assumption that all people who use drugs are the same, and I think that that is a really stereotypic. Colon probably pretty narrow sighted view, whatever assumption it is that people have, that somebody who uses drugs is an the answer really is. 

 

Number one, you probably know people who use drugs. You might not know it, and two, they often look very different from one another. 

 

They may have similar risk factors, but there are so many different populations of people within that larger group that understanding that nuance is really crucial to being able to provide good care. 

 

00:16:17 Joshua 

We tend to focus on the drug because it’s probably easier to focus on the drug. It’s a lot easier to rein in safe prescribing or control the supply. 

 

Then it is to try and address the need or the demand for drugs. So I think it’s harder to approach it from that more holistic individual perspective, but I think it’s better and it provides more log lasting health to individuals to take that approach. 

 

00:16:47 Will 

And is there any data connecting drug use amongst survivors connecting that to the death data that is seen there. Is that something that I can imagine would be very hard to gather and get honest numbers about? Who is alive and using these drugs compared to who has died with these drugs in their system. 

 

00:17:05 Janetta 

So that’s the topic of some of our future work. We have a grant called broad Agency announcement, funded by the US FDA to better understand the population of people who use stimulants and particularly prescription stimulants. So we’ll be doing some work around understanding that population in more detail, trying to look at, you know, what does this group look like prior to you know these outcomes of unfortunate? 

 

That’s an I think you know a big part of what we’re seeing so far and very preliminary work is that there’s multiple different sub populations within this group, all of which look a little bit different, and a really interesting step, but one that would be really challenging would be to truly connect these death cases back to what we saw prior to death. 

 

Unfortunately, in the United States, health records aren’t well linked often, and so that’s often really difficult. So what we end up doing is trying to look separately at those two questions. And then draw some inferences about those relationships. 

 

00:18:16 Will 

How does this investigation contribute to decision-making on those national those federal levels in terms of what could be done with this information and curve moving forwards to help us understand fatalities. 

 

00:18:31 Janetta 

So I think if we look at the opioid epidemic as an example of how this kind of data can be helpful. A few important pieces come out. One is the more that we understand how people are dying. The more we can work backwards from that to look at those populations and to look at some of those risk factors that may place people at risk that can help inform things such as education around substance, use education around safe use as well as harm reduction action. 

 

So that’s one. I think major piece of the puzzle. A second piece of the puzzle is. Are there different ways to think about how we either prescribed or regulate drugs such as stimulants in order to increase that safety? 

 

So not just improving safety for those who do use them, but also are there ways to either change the supply in a way that’s helpful, or redirect some of that education towards people who may not otherwise hear it. 

 

I think one thing that’s particularly challenging around prescription stimulants is that because they are prescription drug, people often think it’s safer than other types of drugs, such as those you might purchase on the street, and so finding ways to do public education around that is a really big and, I think, important goal, sort of somewhere down the road to improve that safety there. 

 

00:19:52 Joshua 

One other notable thing that when it comes to stimulants different than opioid is that we don’t have as many tools to prevent overdose with stimulants. There’s no no reversal agent. We talk about Narcan for opioid. We don’t have something similar for stimulants. 

 

00:20:06 Janetta 

And I think that’s a really important point, because I think a major goal, both in academia and in public policy right now is to find ways to create more tools, and so the better we understand the risks and better understand the population, the more we can inform that. 

 

I think a lot of this does come back around to that idea of Poly substance use as well. While we’re talking about stimulants here. 

 

The more that we’re learning about how use of multiple substances interact with one another, the more that can also impact things, such as how do we create better tools and better therapy with that knowledge that very rarely is somebody using a single substance. 

 

00:20:46 Will 

To look forward to an idealised outcome of your work and say, 1015 years down the line? What would you like to see  

 

Could take all of the lessons about working with people and not just drugs and working with health systems and not just silos of information? What would be the perfect drug landscape in America in 2035. 

 

00:21:12 Janetta 

In my mind, the perfect world is one that allows us to balance the benefits of having therapeutic options with different kinds of drugs. Whether those are opioid sourced. 

 

Alliance or other drugs that have an important use, but we know how to use them safely in the right patients. And we know how to keep track of what our trends look like on a broader level so that we can tell when policy changes are needed. 

 

00:21:38 Janetta 

I think those two pieces would be really important to my ideal state because the answer isn’t just to say we don’t need these drugs because you know if if somebody has attention deficit activity. 

 

I think those two pieces would be really important to my ideal state because the answer isn’t just to say we don’t need these drugs because you know if if somebody has Attention deficit hyperactivity disorder, or they have severe acute pain from a broken bone. As a physician, I want to be able to give them the medicine that they need, but I also want to be able to do it in the safest way possible. 

 

And then I think the second piece that goes with that. And this is beyond the scope of this research and I will own is just my personal opinion, but I think transitioning from a more punitive approach to a more therapeutic approach in how we treat substance use disorders is another crucial step. 

 

00:22:23 Joshua 

I would say from my perspective, the data perspective you know. In 2035, I’d love to have much more integrated systems to study this stuff. Death certificates, Aurora, siloed data source and I don’t have a lot of knowledge for individuals with history, so I can’t study very well what led to that point. 

 

There are other systems elsewhere that have much more integrated ways of connecting a person’s medical history to say the vinyl records from the vital records offices at these States and so to be able to connect the data in a more kind of holistic way to see an individual’s path. 

 

Would give us a lot of power to answer questions that we need to answer. 

 

You know you don’t even need to really delve into one individual very deeply just to get a wide collective sense of what people engage with now without having to add a bunch of burden to them, I think would give us a whole new perspective on health in The United States. 

 

00:23:26 Janetta 

So our research can be found at radars.org. We are also actually in the process of creating a public data dashboard which will be accessible from that site. 

 

It will give readers an opportunity to look at rates of use, not just for stimulants, but for other substances as well on a state level as well as national levels, and it will be an interactive site that will be up and running in June of 2021. And then in addition to that, we are working on several publications related to the grant to describe the population of those who use prescription stimulants in more detail. 

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