“Dynamic” Drug Crisis Demands Data-Driven Federal Action

With methamphetamine and cocaine having contributed to over 33,000 and 26,000 of the record 108,000 drug overdose deaths for the most recent 12-month period on record, several federal officials discussed the strategies being pursued by their respective agencies during a session presented at the Cocaine, Meth and Stimulant Summit on Thursday afternoon.

Rahul Gupta, MD, MPH, MBA, FACP, director of the Office of National Drug Control Policy (ONDCP), told attendees that the current drug supply environment is the “most dynamic” in the nation’s history, with increases in overdose deaths involving synthetic opioids, as well as stimulants, on the rise.

“The days of large-volume production of plant-based drugs are fading, and small volume, high-potency, synthetic drug production is rising,” Dr Gupta said. “And this has opened a pandora’s box. These synthetic substances ultimately infiltrate our most vulnerable communities. This has been unraveling the very social fabric of our state and our nation and destroying American lives and livelihoods.”

Faced with a complex crisis involving national security, law enforcement, and public health, Dr Gupta said the national drug control strategy being crafted by the administration of President Joe Biden is focused on 2 main drivers of the epidemic: untreated addiction and drug trafficking profits. In particular, Dr Gupta said, the administration’s methamphetamine response plan builds on this approach.

The federal government is disrupting transnational criminal organizations and their illicit financial networks and supply chains, and border patrol agents’ seizures of meth, cocaine, and illicit fentanyl are up significantly, Dr Gupta said. Defending the border is only part of the equation, though, he added. The administration is also addressing the challenge of drug precursor chemicals coming from China, as well as the activities of domestic drug trafficking organizations.

On the public health side, ONDCP is expanding access to harm reduction and recovery support services. The administration aims to ensure universal access to medications for opioid use disorder by 2025, Dr Gupta said. This is a key part of the stimulant response as well, Dr Gupta explained, because of the frequent presence of illicit fentanyl in stimulant-involved overdose deaths.

As researchers work to develop medications to treat stimulant use disorder, Dr Gupta advocated for the use of contingency management and cognitive behavioral therapy. Dr Gupta cited a motivational incentives pilot program and evaluation for patients with stimulant use disorder that has proved to be successful in California. Dr Gupta encouraged more states to follow suit and apply for Section 1115 demonstration waivers to fund similar initiatives.

FDA Builds Overdose Prevention Framework

Robert Califf, MD, MACC, commissioner of the Food and Drug Administration (FDA), told Stimulant Summit attendees that while overdose deaths, including deaths from stimulants, are increasing across all demographics, the surge is especially pronounced among Hispanic, non-Hispanic, Black, and Alaska Native populations, as well as among those living in rural areas. While prescription stimulants are a vital treatment option for conditions including attention-deficit/hyperactivity disorder (ADHD) and narcolepsy, prescription stimulants can also be used for non-medical reasons and have a high potential for abuse.

“We must strike a balance between promoting appropriate treatment and preventing the consequences of non-medical use,” Dr Califf said. “This is especially critical given that Schedule II stimulant use has increased nationally over the past 30 years in that telehealth flexibilities make prescription stimulants easier to access during the COVID-19 pandemic. Likewise, we need to pay attention to how these medications are being diverted.”

In response, the FDA has developed an Overdose Prevention Framework that is based on 4 priorities:

Support primary prevention by eliminating unnecessary initial prescription drug exposure and inappropriate prolonged prescribing. The FDA has taken steps to increase access to digital and non-stimulant pharmacological alternative therapeutics options.

Encouraging harm reduction. With opioids and stimulants being used together, expanding the availability and access to the opioid overdose reversal medication naloxone has been critical, Dr Califf said.

Advancing the development of evidence-based treatments for substance use disorders. In October 2021, the FDA partnered with the Regan-Udall Foundation and the National Institute on Drug Abuse (NIDA) to hold a virtual public workshop to discuss treatment development for stimulant use disorder. The FDA is now building on these efforts by exploring a draft guidance on development of treatments, while recognizing that accessible treatment may come in the form of digital devices, medications, or behavioral therapies.

Protecting the public from unapproved, diverted, or counterfeit drugs. Although counterfeit products are often sold on the dark web, they are finding their way through resellers onto college campuses and other places where unsuspecting populations are exposed to them. “It's essential that patients work with their qualified clinicians to safely obtain the medications they need and not seek out drugs of unknown origins on the internet, which might be unapproved, counterfeit, or laced with a fentanyl or meth,” Dr Califf said, adding that one particularly useful resource is the FDA’s BeSafeRx tool.

CDC: Good Data Bolsters Overdose Response

Timely, high-quality data is helping public officials and other stakeholders understand the overdose crisis and make informed decisions on how to deploy resources, said Debra Houry, MD, MPH, acting principal deputy director, Centers for Disease Control and Prevention (CDC). Recently, the CDC has released 2 drug overdose data dashboard that represent the most up-to-date fatal and nonfatal overdose statistics.

“The first dashboard uses the state unintentional drug overdose reporting system and provides comprehensive data on unintentional drug overdose deaths from 29 funded jurisdictions,” Dr Houry said. “The dashboard includes annual counts, percentages, and rates of drug overdose by substance, including stimulants.

“The second dashboard uses the drug overdose surveillance and epidemiology data, which includes monthly and annual data from syndromic surveillance systems and 42 states including the District of Columbia.”

Dr Houry concluded her segment by offering 3 takeaways for preventing overdose deaths:

• Increase access and reduce barriers to proven treatment and recovery services for all people with substance use disorders and to include culturally tailored practices.
• Raise awareness about illegally manufactured fentanyl and polysubstance use, and reduce stigma around treatment, recovery, and harm reduction.
• Reduce harms by expanding distribution and education around naloxone, harm reduction services, and education of substance use risks and populations disproportionately impacted.

“Through years of data, research, and practice, we know what works,” Dr Houry said. “Each one of you have made critical advances in this field, and the work presented on during this conference gives me hope.”

Reference

Gupta R, Califf R, Houry D, et al. Federal government voices – policy updates. Presented at Cocaine, Meth and Stimulant Summit. November 2-4, 2022; virtual.