Data drives the fight against opioid deaths in NC

But in North Carolina, state public health officials have for years been putting data collected on the local level to work fighting the crisis.

And experts say in many cases, that information has painted a clearer picture of how opioids spread across the state – and how the epidemic continues to change.

Nabarun Dasgupta has known about ARCOS for a long time.

An epidemiologist with the Injury Prevention Research Center at the University of North Carolina at Chapel Hill, Dasgupta worked with ARCOS data before the DEA closed it off to researchers. Since then, he's tried to access the database through the Freedom of Information Act with no success.

Analyzing ARCOS can show areas where pharmacies purchased the most pills per person, which Dasgupta says can be a red flag of sorts.

Dasgupta said communities with the highest dispensing rates also tend to have the highest overdose death rates. Yet that link is clear only for the extremes, meaning that even if a county has relatively high dispensing rates, it might not see a matching spike in deaths.

"The data can confirm that things are bad where there are a lot of pills are going out," Dasgupta said. "But for the vast majority of the country, the association doesn't hold."

Beyond what's public though, state officials acknowledge that they're putting ARCOS to use behind the scenes.

"We are pursuing many avenues, but the ARCOS data is an important part of our office’s investigation into the role various defendants played in fueling the opioid crisis," Laura Brewer, a spokesperson for the state attorney general's office, said in an email.

Dasgupta has largely used other sources of information in the 17 years he's studied the opioid crisis. Because ARCOS' tracking stops once the pills get to each pharmacy, he said, other sources can provide a more complete picture of the what's happening on the ground.

"When you see high numbers in a database like ARCOS, you're not sure why that's happening," Dasgupta said.

Some of those data sources are commercial. But in North Carolina, researchers with the Department of Health and Human Services have for years pulled together figures from the dispensing side – where the pills go when they leave the pharmacy – through the state's Controlled Substances Reporting System.

Some of the data goes back to 2000 and is updated quarterly.

That makes it much more complete than the public release from ARCOS, which contains data through 2012. But Dasgupta said there's historical value to that period.

"2012 was kind of like peak opioid in the United States," he said. "Since then, prescribing rates have come down. But because supply was cut off in an abrupt way, there was this market opportunity for heroin."

As heroin became easier to get than prescription pills, many suffering from addiction switched to the illicit opioid to cope.

State Opioid Coordinator Elyse Powell said 2013 was the "second wave" of the epidemic with the migration to heroin. About two years later, the crisis shifted again with the spread of fentanyl.

The vast majority of opioid deaths, Powell said, now involve illicitly manufactured fentanyl or its analogues. Yet health officials are now seeing another evolution of the crisis now, with far more complex substance abuse involving multiple drugs.

"It's not true anymore that primarily you are an opioid user or stimulant user," Powell said. "Folks use combinations of substances."

Finding a Fix

Experts say although both dispensing and shipments of legally prescribed opioids have dropped in response to the addiction epidemic, the reality is that the supply has merely shifted.

"The total amount of opioids right now, when you include heroin, might be higher than it was in 2012," Dasgupta said.

But he acknowledges that's a hard thing to know for sure. Unlike the prescription drugs tracked by ARCOS or the state CSRS, illicit drugs are almost impossible to track.

That keeps health policy analysts like Aaron McKethan up at night.

"Even though our data silos are silos, we can dig in and brute force them," said McKethan, an assistant professor of population health sciences at the Duke University School of Medicine and the former chief data and analytics officer. "But with the illicit side, there is no data."

That's why monitoring emergency department visits and overdose deaths, state health officials said, can be so valuable. Hospitals report such data in near real time, and they also track overdoses from all types of opioids – legal and illicit.

After several years of steep increases that built to 1,884 opioid-related deaths in 2017, state data show the figure dropped to a preliminary estimate of 1,785 for 2018. The 5 percent decrease was the largest drop since 2010.

But the agency acknowledges there are still gaps in the data.

"This is almost always going to be underreported," Powell said. "Whether or not you end up in an emergency department with an overdose depends on whether you have access to a hospital."

She said the agency also works closely with health officials and advocates on the ground, who can often identify trends long before lagging data begins to indicate a shift.

Beyond overdoses though, health experts stress treatment is a key component of tackling the epidemic.

To McKethan, that means increasing the supply of treatment providers across the state and expanding Medicaid coverage to ensure people can access that treatment.

"There is a chance that this gets worse before it gets better," McKethan said. "People who are addicted, it's impossible to cold turkey your way out of that."

Dasgupta says the solutions need to start even earlier – long before opioids even become a medical option for patients.

"We need to think about why people in the United States are in so much pain," Dasgupta said. "That's something we don't talk about."