The United States is knee-deep in what some experts call the opioid epidemic’s “fourth wave,” which is not only placing drug users at greater risk but is also complicating efforts to address the nation’s drug problem.
These waves, according to a report out today from Millennium Health, began with the crisis in prescription opioid use, followed by a significant jump in heroin use, then an increase in the use of synthetic opioids like fentanyl.
The latest wave involves using multiple substances at the same time, combining fentanyl mainly with either methamphetamine or cocaine, the report found. “And I’ve yet to see a peak,” said one of the co-authors, Eric Dawson, vice president of clinical affairs at Millennium Health, a specialty laboratory that provides drug testing services to monitor use of prescription medications and illicit drugs.
The report, which takes a deep dive into the nation’s drug trends and breaks usage patterns down by region, is based on 4.1 million urine samples collected from January 2013 to December 2023 from people receiving some kind of drug addiction care.
Its findings offer staggering statistics and insights. Its major finding: how common polysubstance use has become. According to the report, an overwhelming majority of fentanyl-positive urine samples — nearly 93% — contained additional substances. “And that is huge,” said Nora Volkow, director of the National Institute on Drug Abuse at the National Institutes of Health.
South Dakota is home to 3 of the 5 counties with the highest percent of cigarette smokers. We’ve written about one of those counties, Oglala Lakota County, severaltimes before as it has the lowest life expectancy of any county in the US (residents die at 67 on average), and median income is $30,347. Meanwhile, Utah is home to 6 of the 10 counties with the lowest percent of cigarette smokers. American Inequality has coveredseveral of these counties before. For example, Summit County has the highest life expectancy of any county in the US (residents die at 87 on average), and median income is 2.5x higher than in Oglala.
Cigarette smoking is 50% higher than in the following 12 states compared to the rest of the nation: Alabama, Arkansas, Indiana, Kentucky, Louisiana, Michigan, Mississippi, Missouri, Ohio, Oklahoma, Tennessee and West Virginia. An average smoker in these 12 states goes through about 53 packs in one year, compared with an average of 29 packs in the rest of the US. Life expectancy is 3 years lower in these states compared to the national average.
In 1998, California became the first state to implement a smoke free law prohibiting smoking in all indoor areas of bars and restaurants, as well as in most indoor workplaces. As we can see from the map above, California now has one of the lowest percent of adults smoking in the country.
Looking a bit more closely you see why Grail’s test is actually useless, or dangerous, or both. Let’s start with the sensitivity of the test. For a cancer screening test to work, it must find disease before it has caused symptoms — when it is in an early or premalignant stage. Say what you want about lung cancer screening, mammography, PSA, and colonoscopy (I’m talking to you Drs. M and P) but at least they look for, and succeed at finding, early stage/premalignant disease. Here is the sensitivity of the Galleri test by stage: stage 1, 16.8%; stage 2, 40.4%; stage 3, 77%; stage 4, 90.1%.
The test is nearly worthless at finding stage 1 disease, the stage we would like to find with screening. The type of disease that is usually cured with surgery alone.
How about specificity? Let’s consider a fictional, 64-year-old male patient who presents to his internist worried about pancreatic cancer. I pick pancreatic not only because it is a scary cancer: we can’t screen for it, our treatments stink, and it seems to kill half the people in NYT obituary section. I also chose it because it is the anecdotal disease in the WSJ article.
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Working through the math (prevalence 0.03%, sensitivity 61.9%, specificity 99.5%), this means our patient’s likelihood of having pancreatic cancer after a positive test is only 3.58%. For our patient, we have caused anxiety and the need for an MRI. You almost hope to find pancreatic cancer at this point to be able to say, “Well, it was all worth it.” If the MRI or ERCP is negative, the patient will live with fear and constant monitoring. (You will have to wait until next week to consider with me the impact of this test if we were to deploy it widely).
If the evaluation is positive, and you have managed to diagnose asymptomatic, pancreatic cancer, the likelihood of survival is probably, at best, 50%.
Let’s end this week with two thoughts. First the data for the Galleri test is not good, yet. The test characteristics are certainly not those we would like to see for a screening test. Even more importantly, good test characteristics are just the start. To know that a test is worthwhile, you would like to know that it does more good than harm. This has not even been tested. The WSJ article scoffs at the idea that we would want this data.5
The Term Guy’s hobby is collecting antique insurance books. Here we’ve scanned many of our out of copyright books for your enjoyment and perhaps research purposes. Stay tuned, more books coming as I have time to scan them!
We have extracted table data from many of these books and made the information available as excel spreadsheets. In the download of spreadsheets we have also included a high def image of each of the pages containing the tables. The image filename for each page and the excel spreadsheet have the same name, i.e. image0001.jpg.xlxs contains table data from image0001.jpg. You may download and use the data unrestricted, but we would ask that you consider giving us a link from your website so that others can find this information as well.
Estimates suggest that the world population in 1918 was 1.8 billion.
Based on this, the low estimate of 17.4 million deaths by Spreeuwenberg et al. (2018) implies that the Spanish flu killed almost 1% of the world population.9
The estimate of 50 million deaths published by Johnson and Mueller implies that the Spanish flu killed 2.7% of the world population. And if it was in fact higher – 100 million as these authors suggest – then the global death rate would have been 5.4%.10
The world population was growing by around 13 million every year in this period which suggests that the period of the Spanish flu was likely the last time in history when the world population was declining.11
The Post reported that some politicians pointed to the rising death toll from “lethal drug overdoses” as a significant factor in declining U.S. life expectancy. The Post did, however, acknowledge that drug deaths “are not solely responsible for the decline in life expectancy.” It is worth noting that opioid overdose deaths began truly soaring after 2010 when users turned to illicit heroin and fentanyl after the introduction of Food and Drug Administration–approved abuse-deterrent formulations.
So how much do drug overdose deaths contribute to the recent decline in U.S. life expectancy? A 2021 comprehensive review of factors affecting mortality trends in the U.S. between 1999 and 2018 found that average life expectancy would “have been 0.3 years greater were it not for increases in unintentional drug poisoning.” In a 2023 preprint article, two Johns Hopkins University researchers calculated that opioid overdose deaths between 2019 and 2021 reduced U.S. life expectancy by 0.65 years. If politicians and policy makers really want to make increasing life expectancy a priority, one huge step would be to actually end the war on drugs. A cease-fire in the drug war would likely reduce gun deaths too.
Destatis yesterday published deaths figures for the whole of 2023. In order to obtain a reliable assessment of the situation, I calculated the weekly time series of life expectancy, applied an ARIMA forecast from the reference epoch 2016-2020 and compared it with the actual values. In this way, results are now available for all 4 pandemic years to date (Fig. 1)
Even more, the health professionals who administer methadone — and another commonly used treatment drug called buprenorphine — say the medications enable people to find new jobs, to regain custody of their children and to more easily recover from the mind-altering effects of opioids.
Lugo is just one of the tens of thousands of people who benefitted from a methadone treatment program in Connecticut in recent years, but state officials want to see that number increase even more to combat the state’s ongoing epidemic.
A special advisory committee, set up to manage roughly $600 million in opioid settlement funds for Connecticut, published a report earlier this year that laid out several key strategies for curtailing opioid overdoes in the state, and it argued that increasing the accessibility and use of methadone and buprenorphine would be the most effective approach to stemming the mounting death toll.
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Sharfstein, who also cowrote a book titled “The Opioid Epidemic: What Everyone Needs to Know,” said treatment programs that incorporate methadone and buprenorphine meet both of those principles.
The effectiveness of medication-assisted treatment, Sharfstein said, has been reviewed by the American Medical Association, the American Psychiatric Association and the National Academies of Sciences, Engineering, and Medicine.
And research has suggested that the use of methadone and buprenorphine in treating opioid use disorders can substantially reduce people’s chances of fatally overdosing — some studies suggest by up to 50%.
“For a disease that is killing many Americans, that is a significant reduction in mortality that you can get with appropriate treatment that includes medications,” Sharfstein said. “And that I think is just an incredibly important point to keep in mind as officials are thinking about expanding access to treatment.”
Many countries, including the UK, have continued to experience an apparent excess of deaths long after the peaks associated with the COVID-19 pandemic in 2020 and 2021. Numbers of excess deaths estimated in this period are considerable. The UK Office for National Statistics (ONS) has calculated that there were 7.2% or 44,255 more deaths registered in the UK in 2022 based on comparison with the five-year average (excluding 2020). This persisted into 2023 with 8.6% or 28,024 more deaths registered in the first six months of the year than expected. The Continuous Mortality Investigation (CMI) found a similar excess (28,500 deaths) for the same period using different methods. Several methods can be used to estimate excess deaths, each with limitations which should be considered in interpretation, however the overall trends tend to be consistent across the various methods.
The causes of these excess deaths are likely to be multiple and could include the direct effects of Covid-19 infection, acute pressures on NHS acute services resulting in poorer outcomes from episodes of acute illness, and disruption to chronic disease detection and management. Further analysis by cause and by age- and sex-group may help quantify the relative contributions of these causes.
Since July 2020, the Office for Health Improvement and Disparities (OHID) has published estimates of excess mortality based on a Poisson regression model for England week by week, overall and decomposed by age, ethnicity, region and cause. This model finds that in the period from week ending 3rd June 2022 to 30th June 2023, excess deaths for all causes were relatively greatest for 50–64 year olds (15% higher than expected), compared with 11% higher for 25–49 and < 25 year olds, and about 9% higher for over 65 year old groups. While the median age of these groups has changed since 2020, age-standardised mortality analysis breaking down death rates by sex find clearer age differences still. The age-standardised CMI found similar patterns with the largest relative excess deaths for 2022 observed in young (20–44 years) and middle-aged (45–64 years) adults. These findings should be interpreted carefully because of greater than usual delay in registration of deaths in the latter part of 2022.
Several causes, including cardiovascular diseases, show a relative excess greater than that seen in deaths from all-causes (9%) over the same period (week ending 3rd June 2022–30th June 2023), namely: all cardiovascular diseases (12%), heart failure (20%), ischaemic heart diseases (15%), liver diseases (19%), acute respiratory infections (14%), and diabetes (13%).
For middle-aged adults (50–64) in this 13-month period, the relative excess for almost all causes of death examined was higher than that seen for all ages. Deaths involving cardiovascular diseases were 33% higher than expected, while for specific cardiovascular diseases, deaths involving ischaemic heart diseases were 44% higher, cerebrovascular diseases 40% higher and heart failure 39% higher. Deaths involving acute respiratory infections were 43% higher than expected and for diabetes, deaths were 35% higher. Deaths involving liver diseases were 19% higher than expected for those aged 50–64, the same as for deaths at all ages.
Looking at place of death, from 3rd June 2022 to 30th June 2023 there were 22% more deaths in private homes than expected compared with 10% more in hospitals, but there was no excess in deaths in care homes and 12% fewer deaths than expected in hospices. For deaths involving cardiovascular diseases the relative excess in private homes was higher than all causes at 27%. Deaths in hospital were 8% higher and deaths in care homes only 3% higher.
The greatest numbers of excess deaths in the acute phase of the pandemic were in older adults. The pattern now is one of persisting excess deaths which are most prominent in relative terms in middle-aged and younger adults, with deaths from CVD causes and deaths in private homes being most affected. Timely and granular analyses are needed to describe such trends and so to inform prevention and disease management efforts. Leveraging such granular insights has the potential to mitigate what seems to be a continued and unequal impact on mortality, and likely corresponding impacts on morbidity, across the population.
Author(s): Jonathan Pearson-Stuttard Sarah Caul Stuart McDonald Emily Whamond John N. Newton
Publication Date: 1 Dec 2023
Publication Site: The Lancet Regional Health Europe
Many black women report feeling silenced or ignored by healthcare providers during their pregnancy journey.
“It is 2023 almost 2024, and in this time, we should not be dying in birth. Period. You may be the medical professional, and you may have great textbook knowledge and you may have many degrees, but nobody is in my body but me, and nobody can tell me that this pain that I’m feeling is not there,” King said.
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This month New York Governor Kathy Hochul called the issue a crisis and a disgrace. Hochul announced more than $4 million in funding for regional perinatal centers and said doula services will now be covered for all Medicaid enrollees beginning January first.
In a statement, Governor Hochul said, “as the first mom and grandma to serve as Governor of New York, I’m committed to doing everything in my power to tackle the disturbing rise in infant mortality.”
Esther is hopeful the attacks on this issue from all fronts will lead to better outcomes for women and babies in the future.
It’s not the orgy of pink that reminds me of breast cancer. It’s the Nobel Prize in Physiology or Medicine. I have a rooting interest, and so far I’ve been disappointed. I want the prize to go to UCLA cancer researcher Dennis Slamon, who in recent years has been on the Great Mentioner’s short list (an improvement since I started paying attention a decade or so ago).
Slamon’s work did two things: Beginning with HER2+ breast cancer, it demonstrated that cancers could be identified by specific genetic variants, rather than merely where they occur in the body. Then it showed that those variations could be targeted and treated with specific antibodies. The first practical result was the drug Herceptin, which treats the roughly 25 percent of breast cancer patients with an especially aggressive form.
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The usual sources were still not interested in paying for research. But in 1989, Slamon was treating Hollywood honcho Brandon Tartikoff, best known for his stint as president of NBC, for Hodgkin’s lymphoma. Tartikoff’s wife Lilly was grateful for the care and asked Slamon what she might do to help him. He told her about the idea of finding a drug to treat HER2+ breast cancer. Soon thereafter, in a classic Hollywood moment, she ran into Ronald O. Perelman, who owned Revlon, at Wolfgang Puck’s original Spago restaurant. She gave him the pitch: You own Revlon. Revlon sells to women. Women get breast cancer. You and Revlon should support this research. He agreed to let his representative meet with Slamon.
At the meeting, Slamon was accompanied by his colleague John Glaspy, who is a notably blunt-spoken person. Even if they got government funding, Glaspy warned, it would take several years and by then “we’ll have a Rose Bowl full of dead women” from breast cancer. The pitch worked.
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In 1998, the drug was approved for treatment of Stage 4 HER2+ breast cancer and in 2006 it was approved for treating early stage cancers. A year later, it saved my life.
Author(s): Virginia Postrel
Publication Date: 9 Oct 2023
Publication Site: Virginia Postrel’s newsletter at Substack
Her pleas for help were shrugged off, she said, and she was repeatedly sent home from the hospital. Doctors and nurses told her she was suffering from normal contractions, she said, even as her abdominal pain worsened and she began to vomit bile. Angelica said she wasn’t taken seriously until a searing pain rocketed throughout her body and her baby’s heart rate plummeted.
Rushed into the operating room for an emergency cesarean section, months before her due date, she nearly died of an undiagnosed case of sepsis.
Even more disheartening: Angelica worked at the University of Alabama at Birmingham, the university affiliated with the hospital that treated her.
Her experience is a reflection of the medical racism, bias and inattentive care that Black Americans endure. Black women have the highest maternal mortality rate in the United States — 69.9 per 100,000 live births for 2021, almost three times the rate for white women, according to the Centers for Disease Control and Prevention.
Black babies are more likely to die, and also far more likely to be born prematurely, setting the stage for health issues that could follow them through their lives.
