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Treat the 'opioid epidemic' like an epidemic, with real-time surveillance

Reporter Andrea McDaniels on why health and law enforcement officials around the state are bracing for a potential uptick in drug overdoses as a synthetic opioid has hit Maryland streets. It's so strong a dose the size of a grain of salt can kill a person. (Baltimore Sun video)

"Opioid epidemic." Those two words are repeated over and over again in news coverage and political speeches about the deadly wave of drug use sweeping the country. But as a nation we are far from treating it the way an epidemic should be treated.

As public health practitioners, we are taught that the very first step in an epidemic is to get an understanding of the factors contributing to the outbreak. Imagine if an outbreak of a contagious disease hit Maryland, killing an average of five people each day. If those trying to identify the source of the outbreak received just one report on who died every three months, the disease would spiral out of control with hundreds more people dying. Now imagine instead that reports of patient deaths were coming in as they occurred, enabling crisis response teams to target their resources quickly and strategically, getting ahead of the outbreak, rather than reacting too late.

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This is the issue we are facing in Maryland. While we have detailed quarterly reports on opioid deaths from Maryland's Department of Health and Mental Hygiene, these are simply not timely enough to prevent more deaths from occurring. It is clear that we need real-time information on this crisis if we want to stop it.

This is not a new idea but rather the core of "active surveillance, " an effective, time-tested method of controlling epidemics. It is routinely used by public health agencies such as the Centers for Disease Control, and it played a major role in our country's quick response to the arrival of the Zika virus. But we haven't treated the opioid crisis that way, and in the meantime, opioid overdoses claimed 1,468 lives in Maryland between January and September 2016 — the equivalent of 62 yellow school buses filled with people.

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Obtaining detailed information about the location and trends of opioid overdoses can be done with collaborative, real-time data collection. The recent passage of the Heroin and Opioid Prevention Effort (HOPE) and Treatment Act in Maryland signals the beginning of a proportional response to an epidemic. But it will be difficult to target resources effectively and efficiently without a centralized data collection system telling us where naloxone is being administered for overdose reversal, or what patient population is being frequently admitted to emergency rooms.

Law enforcement, first responders, health care providers, pharmacists, public health workers and others need this information, and they need it now. For example, if paramedics are able to report that they have responded to multiple overdoses within a given neighborhood, police may be able to quickly identify the parties responsible for drug trafficking in that area. This surveillance system would be incredibly useful for tracking drugs tainted with fentanyl, which is 50 to 100 times more potent than heroin, or carfentanil, which is 10,000 times as powerful as morphine and a rapidly growing cause of overdose death.

Creating this system may be a tall order. Current systems for tracking drug and health information do not allow for real-time surveillance. But in this age of instantaneous communication, real-time surveillance is possible.

Maryland's Prescription Drug Monitoring Program (PDMP) provides an example of effective and timely reporting of crucial health information. Currently, it tracks prescriptions of opiates and other drugs in a secured database that requires authentication for access. A similar system tracking where and when overdoses occur, as well as what drugs were used and how much naloxone was given, would provide the information necessary to take swift, preventive action on the most pressing public health and safety issue facing our state.

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A secure, comprehensive database that is accessible to authenticated personnel could make the difference between life and death for Marylanders struggling through this crisis. Further, it would allow for targeted public health education efforts, smarter law enforcement strategies and initiatives, and better allocation of medical resources.

This is indeed an epidemic, and it is time we treated it as such, shifting our frame of thinking from "response" to "prevention," and putting in place the real-time surveillance that epidemics require.

Madeline Jackson (mjacks88@jhu.edu), Charlotte Kaye (ckaye1@jhu.edu) and Akachimere Uzosike (auzosik1@jhmi.edu) are all masters of public health students at the Johns Hopkins Bloomberg School of Public Health, as is Brian Smith (briansmith@jhu.edu), who also contributed to this op-ed.

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