What's causing the increase in opioid overdoses in Northeast Ohio?

Two men overdosed in separate instances on Cleveland's west side, on a recent Sunday in October of 2021.

One man's overdose was fatal. The other overdosed on heroin, but emergency responders gave him naloxone, an overdose reversal medication, and he survived, according to a report from the Cleveland Police Department.

While COVID-19 deaths have continued to dominate headlines this year, the opioid epidemic has continued to take lives. Overdoses are reported frequently in daily police reports.

In Cuyahoga County, drug deaths are already trending higher this year than they were at the same point in the past three years.

At least 356 people have died this year from heroin, fentanyl, or a combination through August 2021, according to the Cuyahoga County Medical Examiner. That number jumps to at least 446 deaths when including cocaine as well.

This graph from the Cuyahoga County Medical Examiner's Office shows the increase in overdoses in 2021. [Cuyahoga County Medical Examiner]

It has been widely reported that the opioid epidemic started, in part, because many doctors were overprescribing pain pills which led to dependence and abuse by some patients. After years of medical institutions trying to correct this practice, opioid prescriptions have declined significantly. 

The American Medical Association (AMA) issued a report recently showing a 44.4% decrease in opioid prescribing nationwide over the past decade. In Ohio, opioid prescriptions decreased by 54% between 2011-2020, including an 8.7% decrease from 2019-2020.

At the same time, Ohio saw a nearly 7% increase in drug overdose deaths from 2018 to 2019, according to the CDC. 

The graph from the AMA report shows that even as opioid prescriptions are decreasing, overdose deaths are increasing. [American Medical Association]

Policy changes and a greater awareness of the addictive nature of pain medications are some of the reasons for the decrease in prescriptions, according to the AMA.

The AMA would like to see more done to help those with substance abuse disorders, like using opioid settlement money for only public health purposes. 

Currently, several  phamacy chains are in court over their responsibility in the opioid epidemic. CVS, Giant Eagle, Walgreens, and Walmart are all in federal court in Cleveland this month, arguing they did nothing wrong in dispensing pain pills. 

But critics argue pharmacies ignored red flags as people became addicted, reaping financial gains instead of monitoring the highly addictive substances. 

Fentanyl driving increases in overdoses and deaths

As the litigation continues, more people are dying of opioid overdoses in Ohio. 

According to CDC data, 73% of opioid-involved overdose deaths involve synthetic opioids, like fentanyl. 

In 2020, the number of people who died in Cuyahoga County from heroin, fentanyl, or a combination was 273. In 2019, that number was 287, and in 2018, 265 people died, according to the medical examiner's office.

Synthetic opioids are the main reason for the increase in overdose deaths at the same time opioid prescriptions are going down, said Beth Zietlow-DeJesus, director of external affairs for the Alcohol, Drug Addiction, and Mental Health Services (ADAMHS) Board of Cuyahoga County. 

"Fentanyl right now is found in every illicit drug on the street that you can think of. It’s in cocaine, it is in methamphetamine, and there are reports of it being in pressed pills that look like Xanax or Percocet or Oxycontin, but they aren’t those drugs, they are actually fentanyl, and so that opioid is driving the overdose deaths and fatalities in Cuyahoga County," she said. 

After people became addicted to pain pills and could no longer find a prescription, many of them turned to street drugs, without realizing they would be laced with much more dangerous fentanyl, Zietlow-DeJesus said. 

Others are using stimulants without realizing they are laced with any opioids, including fentanyl, she said. 

“The reason that we believe fentanyl is used is because it is cheap. It is cheap and made in a lab, and so it is easy to add into drugs," she said. 

Fentanyl is one of the reasons the opioid epidemic seems to have no end, Zietlow-DeJesus said. 

“Historically speaking, if you look back over substance epidemics, an opioid epidemic is often followed by a stimulant epidemic," she said. "However, right now, our opioids and our stimulants are mixed, and so it’s just prolonging this opioid epidemic, addicting additional people.”

Opioid-related deaths might be even higher than those reported

People are also dying from opioids who aren't overdosing. Some of these deaths might not even make it into the CDC's data for drug deaths, if another cause of death was the primary reason, according to a new Ohio State University study, published in the journal Drug and Alcohol Dependence.

"The way that the CDC codes overdoses, it has to be the primary cause of death, but the coroner and medical examiner can list up to 10 additional causes," said Mike Vuoloco, co-author of the study and associate professor of sociology at Ohio State University.

"We just sort of came to the revelation that there must be deaths that doctors are saying are caused by drugs that don't get captured by overdoses," he said. 

There are two types of deaths Vuolo looked at: medical and external. External deaths include car accidents, drownings, and other situations where drugs didn't directly cause the death but if the person didn't have drugs in their system, they might still be alive. 

For medical deaths, Vuolo said the primary cause of death was cardiovascular death. 

This study is one of the first to point out that drug deaths might even be higher than what's being captured by CDC data, said Dr. Joan Papp, Director of Office Opioid Safety at MetroHealth. 

"I think we kind of had a sense that the numbers were greater than the opioid poisonings, simply because we know from the decades-long research on the effects of drinking and driving," she said. "Very few people die of alcohol poisoning, but millions of people die from drinking and driving and trauma related to alcohol use, and so it's not surprising that the same trend happens with psychotropic drugs like opioids."

Papp said medical complications from using drugs include heart attacks, strokes, and endocarditis, which can be caused by people getting a blood infection after injecting drugs. 

The future of the opioid epidemic

The long-term effects of fewer opioid prescriptions written will eventually lead to some good news, Zietlow-DeJesus said. 

"We're going to see a healthier, less addicted population when it comes to people whose addiction began on prescription medication," she said. "Some people are still going to become addicted, even based off of a prescription maybe that had been given safely, just because they may have a propensity for addiction."

But over time, fewer people will be addicted, Zietlow-DeJesus said

To stop overdoses, the ADAMHS Board and other organizations are working on education around fentanyl and synthetic opioids. They also give out free kits that include the overdose reversal drug naloxone and test strips that allow a person to test their drugs for fentanyl, hopefully preventing future overdoses.