15.3 Overdosed: The 2nd Wave: Heroin and IV Drug Use

[00:00:00] Okay, welcome back everybody. We're going to cover today the third installment in Overdosed, the Worst Drug Epidemic in World History, which I'm now realizing I could have just said in history.

[00:00:13] In the last couple episodes we reviewed the scope of the problem, showing how the underrepresented annual numbers of fatal overdoses or drug-related deaths,

[00:00:24] then investigated the evolution of the first wave of the epidemic, the increase in prescription opiate prescribing, primarily OxyContin, in the late 1990s into the 2000s.

[00:00:38] And today we're going to delve into the next or second wave of the epidemic, the emergence of a widespread increase in the availability of black tar heroin for Americans,

[00:00:49] as well as the massive increase in the number of people injecting drugs.

[00:00:57] Somebody get this guy some help!

[00:01:08] So, as the prescription OxyContin and Opiate Pain Pill Crisis worsened,

[00:01:15] and drug overdose deaths rose quickly year over year, the government scrambled to intervene.

[00:01:22] They worked to shut down the pill mills, installed PDMPs or prescription drug monitoring programs,

[00:01:31] that restricted so-called doctor shopping or visiting multiple doctors in a day for the same problem or the same desired prescription,

[00:01:40] and users hitting up multiple pharmacies in a day by copying their prescriptions.

[00:01:46] With some pharmacies probably knowing what they were doing and not caring because, hey, they were profiting from increased drug sales too.

[00:01:54] Many states had PDMPs installed prior to the opiate epidemic.

[00:02:00] However, not all states implemented them expeditiously or created legal mandates for their use by doctors and pharmacies.

[00:02:08] So, for several years in the mid to late 2000s, states would gradually adopt and utilize PDMPs, but it was a slow and incomplete process.

[00:02:20] For example, in 2010, only five states had mandatory PDMP query laws, while today 40 states have mandatory PDMP laws.

[00:02:33] 70% of all current prescription drug monitoring programs were developed in the first 15 years of the 21st century.

[00:02:42] Now, Florida was one of the last states to implement a PDMP in 2009, but didn't start mandating providers to query it until 2011.

[00:02:52] And, like most state or federal run programs, it takes time to enforce new laws with providers and pharmacies.

[00:03:01] Most states that were hit hardest by the prescription opiate epidemic already had PDMPs in place by 2009, 2010.

[00:03:13] Paired with a backlash against providers with a resultant hesitance in prescribing opiates by many primary care doctors,

[00:03:20] this led to a lot of patients being abruptly cut off from their Oxycontin and other opiate supplies.

[00:03:28] People's brains that struggle with addiction are really savvy at finding ways to get their desired substances.

[00:03:35] For Appalachians, they started to make what were called hillbilly pilgrimages down to Florida,

[00:03:44] scooping up addicted persons on the way, providing transportation and their co-pays,

[00:03:50] then siphoning half or more of their prescriptions and bringing back hundreds to thousands of pills to their local community for resale.

[00:04:00] With demand as high as ever and supply limited, entrepreneurs were making a lot of money,

[00:04:08] and some users couldn't afford the increasing prices of illicit opiates or didn't have access to them any longer.

[00:04:15] Within a couple of days, users started to experience acute opiate withdrawal symptoms,

[00:04:21] consisting of a severely heightened sensitivity to pain and flu-like symptoms like chills, fevers, body aches, diarrhea, insomnia, nausea.

[00:04:33] And when those acute symptoms started to fade, later psychological and emotional symptoms would take their place.

[00:04:40] Depression, anxiety, irritability, restlessness, insomnia.

[00:04:46] And many users couldn't stomach those symptoms and sought relief from other means.

[00:04:52] By 2012, right around the time PDMPs and other government regulations were really taking hold and reducing,

[00:05:00] or at least stagnating the number of opiate prescriptions being doled out like candy from a concession stand at a youth baseball game,

[00:05:08] the cost of heroin per gram hit an all-time low, the cheapest it had been since the 1970s.

[00:05:17] And a group of sons of subsistence Mexican sugarcane farmers, the Jalisco boys, took advantage of users to spare,

[00:05:28] and the fact that the poppy plant grew very well in their region, the Nyarit state of Mexico.

[00:05:35] They started cultivating poppy and making black tar, very potent black tar heroin,

[00:05:43] and transporting it to the United States in droves,

[00:05:46] forming what is now the second most powerful and well-known drug trafficking cartel in Mexico, the Jalisco Cartel.

[00:05:57] So, heroin coming into the United States around the mid-2010s, early 2010s,

[00:06:07] started to shift from primarily a South American influx to a near monopoly by Mexican cartels within a few years,

[00:06:17] jumping from about 50% to more than 90% between 2013 and 2019.

[00:06:26] They methodologically targeted one town or one city at a time,

[00:06:32] starting in the United States West and gradually branching out in every direction.

[00:06:38] Cartel leaders would send dozens of mules across the border,

[00:06:42] expecting that some of them would be caught.

[00:06:44] But those who were caught knew they couldn't cooperate with the authorities due to the risk of backlash on their families from the cartel leaders.

[00:06:53] And they didn't have enough heroin on them to gain lengthy prison sentences.

[00:06:59] They would serve their time or be deported and return home as a hero.

[00:07:04] If somebody was caught, they'd be easily replaced and not get caught with enough supply to spend very much time in prison.

[00:07:13] This system continues to operate today with hundreds to thousands of drug mules crossing the border every day,

[00:07:23] now with primarily fentanyl, but also heroin, methamphetamine.

[00:07:28] And thinking that we can catch everyone or even the majority of them is wholly unrealistic.

[00:07:38] Now, I throw this back up here just to emphasize the change that occurred between 2009 and 2012.

[00:07:47] It's important to note that many older Americans who were previously receiving opiate prescriptions for chronic pain

[00:07:56] did not have as hard of a time obtaining their prescriptions from doctors.

[00:08:00] But 20 year olds and 30 year olds had more and more of a difficult time convincing their doctors that they had painful conditions that indicated the need for Oxycontin.

[00:08:14] So while Appalachians were still relying on secondary market prescriptions and the second wave of heroin was starting to cause its own epidemic in the West,

[00:08:26] in pockets of the Pacific Northwest, it was young people who used drugs who really got hit the hardest.

[00:08:32] And the cartels were savvy as fuck, conquering one market at a time, starting in New Mexico and Colorado, moving into Arizona and California, Seattle, then traversing East across the United States.

[00:08:49] You can almost even see the or imagine the route of cities that they conquered one by one in the dark red areas of the Midwest seen in this 2012 graph.

[00:09:03] Now, the local law enforcement and DEA officials would catch criminals here and there.

[00:09:11] It took years for the DEA to realize these were not isolated small business operations as initially conceptualized.

[00:09:19] They've these were interconnected national networks with agents sworn to silence if arrested or convicted.

[00:09:30] New outposts were established by providing free samples to addicted persons outside of homeless shelters, outside of halfway houses, detox facilities, something that still happens today.

[00:09:44] And to users, heroin was 10 times more potent in a quarter of the cost of prescription Oxycontin.

[00:09:53] The number of deaths took a drastic upturn.

[00:09:58] It still blows my mind that nearly 11 years ago, I was starting medical school and this was the picture.

[00:10:07] And now, we've more than doubled this number in overdoses alone.

[00:10:14] Here, you can see the drastic increase in heroin overdose deaths until roughly 2015, 2016.

[00:10:22] And by 2017, the crisis evolved again with the increased availability of China produced fentanyl, an odorless and colorless synthetic opiate that was 100 times more potent than morphine.

[00:10:39] Now, if you want to learn more about just how the heroin epidemic emerged in the United States, I highly recommend journalist Sam Quinones' book, Dreamland, which follows the progression of the epidemic from prescription opiates to heroin and offers multiple firsthand perspectives and experiences on the topic.

[00:11:03] Including what it was like to become addicted from users' perspectives, what it was like to operate a pizza delivery system for heroin from drug trafficker perspective, how disconnected different branches of the DEA were, but eventually discovered the connections between multiple arrests in different towns, and also from experts in medicine.

[00:11:26] I just wanted to include this slide to emphasize just how deadly heroin addiction is.

[00:11:33] This is one of the only longitudinal studies of heroin addicted persons, with about 600 addicted people followed between 1964 and 1997, a 33 year period.

[00:11:47] And it found that half, and likely significantly more than half of them were dead, as 10% status unknown.

[00:11:56] Only one fifth of the original sample was abstinent from heroin, with another 21% still using heroin, 14% in jail, and 10% who refused to be tested.

[00:12:09] And that's of the survivors.

[00:12:12] Now, as the heroin epidemic moved eastward, it eventually reached Kentucky, where emergency rooms started filling up with heroin and IV drug use related visits.

[00:12:24] It wasn't just overdoses and deaths or problems that emerged from slowing breathing, not enough to kill a person, but to cause significant or even permanent brain damage, but also that sequela of IV drug use.

[00:12:39] It's a common method intravenously that many users progress toward from snorting, eating, or smoking due to the immediate and 100% availability of the substance via injection.

[00:12:53] So, in general, IV drug users have a 22 times higher mortality rate than age-adjusted controls.

[00:13:07] There are more than a million intravenous drug users in the last year alone in the United States.

[00:13:13] And for those who don't have compassion for these drug users, they're not that much different than you.

[00:13:19] They are products of their genetics and their life experience.

[00:13:23] And having worked in multiple different psychiatric and addiction facilities in my career, many of them have survived traumatic experiences that you can't even fathom, that you cannot empathize with, and that would make you want to escape via using drugs too.

[00:13:44] Now, this is a comprehensive list of complications of intravenous drug use from an emergency medicine textbook.

[00:13:54] We're going to focus on infectious complications here, especially HIV, which can progress to AIDS if not treated appropriately.

[00:14:06] Hepatitis C, which causes liver disease, including liver failure and liver cancer.

[00:14:13] And endocarditis, or infection of the heart valves, which can occur with any type of injection into the circulatory system.

[00:14:21] And is why healthcare providers always use clean needles and clean the area of the skin where the injection is taking place beforehand.

[00:14:32] So, people who inject drugs are 22 times more likely to contract HIV.

[00:14:40] Of the 12 million people living globally who inject drugs, 2 million are living with HIV.

[00:14:47] There's roughly 30,000 estimated new cases of HIV annually in the United States, with about 10% or 3,000 who contract it from injection drug use.

[00:14:59] There's roughly 15,000 to 20,000 deaths annually in the US due to HIV, with a spike during COVID as HIV knocks out a person's immune system.

[00:15:10] And we manage HIV better than most countries, with a global annual death number hovering around 700,000 deaths due to mostly lack of access to good care, such as antiretroviral drugs, which are extremely effective at preventing HIV from progressing to AIDS and preventing transmission.

[00:15:37] Preventing transmission is paramount in our fight against HIV and AIDS.

[00:15:42] So, while needle exchange programs and increased education have reduced the number of new cases caused by IV drug use, that wasn't necessarily the case in 2015.

[00:15:53] About 30 miles north of Louisville, where I live, Louisville, Kentucky, is a county called Scott County in Indiana, which in 2015 had quite possibly the worst local outbreak and spread of HIV in US history.

[00:16:16] With the epicenter being the town of Austin, Indiana.

[00:16:20] Austin had a population of roughly 4,000 people, and in 2015 registered most of the 142 new cases of HIV in Scott County.

[00:16:32] With over 215 new cases by 2017 related to this same outbreak, the prior record high of HIV cases per year in Scott County was 5.

[00:16:46] Scott County saw a total of 3 new HIV cases from 2009 to 2013.

[00:16:54] Now, nearly 250 people in the county are infected with HIV.

[00:17:00] Today, the local community is still reeling from the epidemic, with some obstinate folks who think maybe that they're better than IV drug users still restricting access to needle exchange programs.

[00:17:16] That's absolutely absurd.

[00:17:19] So, Kentucky is, unfortunately, also notorious for their HIV rates, with 8 out of the 10 most at-risk counties in the nation for HIV and hepatitis C being located in Kentucky, with 36 out of the top 100 counties.

[00:17:39] Now, part of that is due to the fact that Kentucky has too many counties.

[00:17:45] But, you'll notice that many of these counties are centered around the mountains that surround Appalachia.

[00:17:53] There are still local municipalities that continue to restrict access to needle exchange programs, despite widespread evidence that they help to reduce potentially fatal transmission of multiple different infections, including HIV,

[00:18:12] including hepatitis C, and endocarditis, with close-minded local government administrators and officials in some of the worst afflicted areas, creating this moral divide between those who use drugs and those who don't.

[00:18:29] That's a very, very, very, very, very, very, very, very, very much.

[00:18:59] turnover like the GI tract which is particularly prone to bleeding almost

[00:19:05] half of IV drug users are positive for hepatitis C and 90% of new cases of

[00:19:12] hepatitis C are related back to IV drug use as you can see here the hepatitis C

[00:19:21] death rate map from 2017 looks just like the map of drug overdose deaths further

[00:19:28] showing that overdose deaths are a non total percentage of overall drug related

[00:19:33] deaths if these people don't contract hepatitis C from their IV drug use not

[00:19:39] nearly as many of them end up dying early luckily we have a recent adjunct to

[00:19:44] previous treatment that was FDA approved in July of 2015 and now hepatitis C

[00:19:51] treatment is extremely effective with an over 90% remission rate after 8 to 12

[00:19:58] weeks of treatment but it requires future abstinence from IV drug use or at a

[00:20:05] minimum abstinence from sharing needles and we've seen annual deaths attributed to

[00:20:11] hepatitis C fall from close to 20,000 in 2014 to less than 14,000 in 2021 by 2013

[00:20:23] Kentucky rose to number one in hepatitis C rates and as you can see the other most afflicted states

[00:20:32] in the country all border Kentucky in the Appalachian Mountains West Virginia Indiana

[00:20:38] Tennessee Kentucky saw a 730% increase in hep C rate from 2007 to 2013 and again hepatitis C is

[00:20:50] primarily caused by direct blood to blood transmission between one infected user and the next like HIV this

[00:21:00] transmission can be prevented with using clean needles on every injection drug use according to

[00:21:08] the University of Washington you can see the annual cases of H or of hepatitis C from 2010 when injection drug

[00:21:18] use was not as prevalent and hepatitis C infections were just north of 10,000 annually to 2021 where new hepatitis C cases per year nearly surpassed 70,000 and more importantly than the 700% increase over 11 years is the fact that the number of infections has risen year over year.

[00:21:43] Also the highest number of new hepatitis C infections occurred in people aged 30 to 39.

[00:21:51] So again, we're talking about relatively young people with their whole lives ahead of them being afflicted with a potentially deadly viral infection from IV drug use.

[00:22:03] This 2019 World Drug Report graph shows a side by side of the number of hep C attributed deaths and probably an even more important statistic the DALYs or disability adjusted life years.

[00:22:20] A time based measure that combines years of life loss due to premature death and years of life loss due to time lived in states of less than full health.

[00:22:32] Globally as of 2018 hepatitis C actually kills more people at this point primarily due to lack of access to effective treatment in lesser developed nations than direct opioid overdoses.

[00:22:48] But hepatitis C also leads to millions of years of health life lost.

[00:22:53] If you combine HIV and hepatitis C, it amounts to nearly 350,000 global deaths annually and 10 million plus years of healthy life lost.

[00:23:07] So sharing needles is the primary cause of infection in IV drug users for hepatitis C especially in a major cause of HIV transmission as well and is totally preventable with clean needles.

[00:23:23] This graph shows how common syringe sharing is especially in younger and more naive IV drug users.

[00:23:32] It also indicates that older IV drug users do learn through their experience and can be educated even if they continue to use drugs intravenously on ways to use them more safely and reduce their harm.

[00:23:48] Obviously, we've got to better educate our youths in regards to how to avoid these complications and not just harp on abstinence as the only way to reduce harm.

[00:24:04] Though obviously it is the best way.

[00:24:07] Now, it's not just about using a clean needle in terms of infectious complications of injecting things into our bodies.

[00:24:16] There's another very important tool in combating other infectious risks and it's using alcohol swabs to clean the skin around the area of injection prior to injection.

[00:24:28] Same as we do in the hospital anytime an infection or injection is given.

[00:24:34] Endocarditis is maybe the most acute and serious of all IV drug use related infections.

[00:24:42] HIV and hepatitis C can be treated and the damage can be minimized as can endocarditis.

[00:24:50] But endocarditis has a mortality rate of about 50% if not treated and without proper imaging, it can easily be missed in somebody who is having a behavioral problem in the ER going through opioid withdrawal or methamphetamine intoxication.

[00:25:11] Let's take a quick virtual tour of how bacteria get to the heart during injection drug use and then where they can go from there.

[00:25:22] So it doesn't matter if someone uses a cleaner unused needle when injecting if they don't clean the area around the skin first.

[00:25:30] Our skin is covered with bacteria that acts as a protective layer against foreign pathogens.

[00:25:38] Staph aureus is a dominant skin bacteria that easily invades into our bloodstream and can infect our entire body from there.

[00:25:47] What happens is the needle pulls in Staph aureus or other skin bacteria and is injected into the vein with the substance heroin or meth among others.

[00:25:59] Because the bloodstream is like a flowing river that bacteria just bounces along through the venous system until it reaches the confluence of that venous river, the right atrium of the heart.

[00:26:14] One of the first places it sees where it can latch onto is the tricuspid valve or the valve between the right atrium and the right ventricle or the pulmonic valve, the valve between the right ventricle and its outflow tract to the lungs where the blood is then oxygenated and comes back to the heart.

[00:26:35] This bacteria multiplies on these heart.

[00:26:39] This bacteria multiplies on these heart valves creating what are called vegetations or clusters of bacteria.

[00:26:45] These can then break off and seed other areas of the body first traveling to the lungs and often causing what's called a double pneumonia and then back to the left side of the heart infecting the mitral valve and or the aortic valve.

[00:27:05] These valves have really important functions.

[00:27:09] Just like the valve on any hose, they need to be sealed in order for blood to travel in the direction it's meant to travel without back flowing.

[00:27:20] When there's a vegetation on a valve, it doesn't open or close as completely.

[00:27:25] It leads to a less efficient heart and a heart that has to now work harder and pump harder to effectively get blood to the rest of the body.

[00:27:36] It's a vicious cycle because as the heart works hard, as the heart works to beat even harder, that increased pressure works to spread the infection further into the systemic circulation, AKA the rest of the body.

[00:27:52] It can go into the coronary arteries, which branch off right after the blood leaves the heart causing a heart attack, or it can shoot into the brain causing what's called a septic cerebral emboli causing a stroke as the mixture of clotted blood and infectious materials plugs up arteries trying to provide oxygen and nutrients to brain cells.

[00:28:17] These clusters of bacteria also love to hide out in between the spinal vertebrae causing very painful abscesses.

[00:28:28] These symptoms can literally go anywhere else.

[00:28:31] These symptoms can go into the kidneys, the liver, the spleen, the colon, the skin, the joints.

[00:28:36] Now I didn't initially understand why my endocarditis patients had such poor insight and would try to go sneak out of the hospital in order to shoot up again.

[00:28:48] But imagine a heroin addicted person who develops endocarditis that goes to their spine.

[00:28:55] Now they have an even more painful primary condition with the secondary effect of going through opiate withdrawal when they're already more sensitive to the effects of that pain.

[00:29:08] As you can see in this graph, the national prevalence of endocarditis due to IV drug use increased drastically more than triple fold from 2003 to 2016 from about 5% to more than 15%.

[00:29:26] There are many other causes of endocarditis such as elderly folks getting dental work and that bacteria shooting into their venous circulation.

[00:29:36] But the incidence of endocarditis in young people is growing year over year and primarily related to IV drug use.

[00:29:45] Another infection that is also disproportionately affecting and killing people under the age of 30.

[00:29:55] Another national study of IV drug use related infective endocarditis actually showed an increased incidence of close to 30% of total cases in 2015 with an estimated expenditure of nearly $2.5 billion and roughly $33,000 per hospitalization.

[00:30:20] Now, this information on this next slide is from a 2012 to 2017 retrospective or looking back in time study conducted using a database from about 800 private and academic hospitals, which represents about 20% of all US hospital discharges.

[00:30:44] It shows the rate of substance use related endocarditis more than doubled in just five years, concomitant with the amount of heroin that was flooding across the border and the subsequent increase in the number of people using drugs intravenously.

[00:31:02] But just to reemphasize, it's not just the heart that's affected.

[00:31:08] These infections can go into the bones causing osteomyelitis with the rate of those infections doubling over this timeframe as well.

[00:31:17] Osteomyelitis hospitalizations cost almost $22,000 per and usually involve, at least in the United States, a six week course of IV antibiotics, which is extremely burdensome.

[00:31:34] And if the patient is sent home runs the risk of easy intravenous drug use relapse.

[00:31:40] The rates of brain or spinal cord abscesses increased from 15 to 24% in this five year period.

[00:31:48] And the rate of skin and soft tissue infections, which is where the drug user is health wise lucky enough to have missed their vein and injected directly into the tissue in their muscle or in what's called the fascia.

[00:32:05] Um, where those bacteria don't have as easy of access to the rest of the body increased about 40% with an estimated $10,000 cost per hospitalization.

[00:32:20] Now this still runs the risk of the person becoming septic and dying though at a much lower rate than some of the other infections that we've discussed.

[00:32:29] So the point that I have been repeatedly hammering home to listeners, watchers, and anyone who crosses my academic path is that we are severely underestimating the number of deaths related to illicit drug use.

[00:32:47] While the heroin epidemic turned out to be relatively short lived once the more potent and more easily smuggled fentanyl rapidly became the most prevalent opioid involved in overdose deaths.

[00:32:58] Increasing in prevalence from 2015 to today heroin brought with it a huge surge in IV drug use with all of its related complications.

[00:33:10] This amounts to an additional 2000 deaths per year from HIV, another 10 plus thousand annual deaths from hepatitis C.

[00:33:21] And with five to 8000 deaths annually from endocarditis related to IV drug use in a progressive trend towards killing younger people,

[00:33:32] AKA IV drug users from those three infections alone.

[00:33:37] We're talking about somewhere around 15,000 additional deaths related to drug IV related to any sort of drug use.

[00:33:46] And we haven't even gotten into discussing the third wave of the epidemic involving the most potent opioid narcotics fentanyl, which is 20 to 50 times more potent and therefore lethal than heroin.

[00:34:03] And its cousin car fentanyl, which is used to tranquilize elephants and is nearly 100 times more potent than fentanyl and up to 5000 times as potent as heroin.

[00:34:15] Disclaimer, this podcast is for informational purposes only. The information provided in this podcast and related materials are meant only to educate.

[00:34:20] This information is not intended as a substitute for professional medical advice.

[00:34:23] While I am a medical doctor and many of my guests have extensive medical training and experience, nothing stated in this podcast nor materials related to this podcast,

[00:34:29] including recommended websites, texts, graphics, images or any other materials should be treated as a substitute for professional medical or psychological advice, diagnosis or treatment.

[00:34:35] All listeners should consult with a medical professional licensed mental health provider or other health care provider if seeking medical advice, diagnosis or treatment.

[00:34:42] Or put more simply, if you need help like this guy, call your own doctor.

[00:34:47] Thanks again for watching and or listening.

[00:34:50] If you're passionate about the subjects that I discuss on the channel, do me a favor and like comment, subscribe, do whatever you can to make your voice heard that these are problems that must be addressed in our society.

[00:35:07] If you have any questions, comments or concerns, I want to hear them.

[00:35:13] Feel free to reach out on social media or email us at renegadesike at gmail.com.

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[00:35:29] Thanks again for listening.