San Diego Union-Tribune (Sunday)
PRESCRIPTIONS FOR OPIOIDS ON RISE IN EAST COUNTY, BUT DECLINE ELSEWHERE
Santa Ysabel, Pauma Valley, Julian, Pala far exceed county rate
While physicians and other health care providers have become increasingly wary of offering addictive medications to fight pain, the number of opioid prescriptions has decreased regionally and statewide.
But people in some pockets of East San Diego County are using the same amount or more of the habit-forming drugs.
According to a decade of data compiled by state health officials, the rate of prescriptions in some rural, predominantly White communities in San Diego County is higher than it was before, or it has remained stagnant, even as the use of prescription opioids is declining across the county.
The reduction in opioid use overall can be seen by some as a good sign in the now decadeslong fight against pain medication addiction.
However, researchers caution that the trends in eastern parts of San Diego County may actually reflect long-standing disparities in who can access the medical care they need and who is forced to seek pain treatment through illegal street drugs.
The California Overdose Surveillance Dashboard, which tracks
opioid prescriptions, deaths and hospitalizations throughout the state, shows there were some 532 opioid prescriptions issued for every 1,000 residents in San Diego County in 2010.
By 2020, the most recent year data is available, the countywide rate had decreased to 304 prescriptions per 1,000 people, an average drop of 40 percent.
The decrease was not seen everywhere.
In Boulevard, the tiny desert community near the U.s.-mexico border, prescriptions for opioids soared more than 50 percent in 10 years, from 779 to some 1,200 for every 1,000 residents, state data show.
Santa Ysabel recorded 1,035 prescriptions per 1,000 people, almost three times the county rate. Pauma Valley, Julian and Pala also reported more than double the county average.
“We thought we were at the top of the arc in 2015,” said Luke Bergmann, the county’s director of behavioral health services. “No one could fathom that we would be looking at these numbers now.”
Bias or coincidence
According to Joseph Friedman, a PH.D. candidate at University of California Los Angeles who studies social medicine, demographics are among the many factors playing a role in prescription trends.
Friedman participated in a study published in the Journal of the American Medical Association in 2019 that found majority-white neighborhoods in California were obtaining opioid prescriptions at much higher rates than communities of color.
“Across drug categories, controlled medications were much more likely to be prescribed to individuals living in majority-white areas,” the study said. “These discrepancies may have shielded non-white communities from the brunt of the prescription opioid epidemic but also represent disparities in treatment and access to all medications.”
Estimates from the San Diego Association of Governments, or SANDAG, show many of the neighborhoods with high opioid prescription rates in the county are predominantly White or have more White residents than any other race.
Nearly 3 in 4 residents in Julian are White. SANDAG data show half of Pauma Valley’s population is White. In the 91942 ZIP code of La Mesa and Grossmont, which has the eighth highest opioid prescription rate in the county, more than half of the 39,500 residents are White.
An exception is the Boulevard area, which has a nearly even White and Latino population; its high prescription rate could be attributed to its small population of roughly 2,100 residents.
“There’s a lot of fear in the medical community about being prosecuted by the [U.S. Drug Enforcement Agency] so there’s this push to cut prescribing, and I think that in many cases hurts more vulnerable patients to a greater degree,” Friedman said, “where a patient with more resources or more privilege is probably more able to navigate the health care system and access the medications that they need to be comfortable.”
Income also played a role, the study found, with lower-income, White neighborhoods receiving more prescriptions than areas with higher-income populations of color.
SANDAG data show more than 65 percent of the households in the Boulevard area have an annual income of less than $75,000. Nearly 70 percent of households in Julian and about 62 percent of the 16,900 households in La Mesa and Grossmont earn less than $75,000 each year.
Meanwhile, areas with some of the highest incomes that are largely communities of color, have some of the lowest prescription rates.
In a Chula Vista community, more than 60 percent of households have an annual income above $75,000. Data show more than half of residents are Latino and 1 in 5 are Asian, yet the area has one of the lowest prescription rates in the county — some 200 prescriptions per 1,000 people.
“Consistently, for as long as we have data for, there have been long-standing disparities in access to needed medications,” Friedman said. “We know that minoritized individuals are less likely to receive pain control that they need for their health.”
Bergmann, the director of county behavioral health services, said racial demographics and income are certainly a factor in prescribing trends seen across the country, not just in San Diego County, and historical data show White populations are prescribed at higher rates than minority populations, particularly Black populations.
However, Bergmann said, other factors may explain the higher rates seen in the more rural areas of the county.
“It’s hard to make any causal assertion,” Bergmann said. “It’s possible more people in these areas work in certain fields that have higher rates of workplace injuries, which would lead to them requiring more pain-reliving medication.
“You’d need to control for a lot of complicating factors.”
For example, data show ZIP codes in Coronado, a mostly White and high-income city, have some of the lowest prescription rates in the county.
Mira Mesa also reports low prescription rates in 2020, yet SANDAG data show more than 36 percent of its 76,100 residents are Asian and nearly 1 in 5 are Latino.
Bergmann acknowledged that biases among doctors and prescribers are a long-standing issue in the health care community. He said the problem goes beyond the relationships doctors may have with their patients.
“Across the world of health care there are longstanding biases baked into the data we use to create protocols and guidelines doctors follow,” he said. “When we develop clinical practices using data that already has biases baked in, there is a risk of those biases becoming perpetuated simply by the numbers.”
“There’s a lot of fear in the medical community about being prosecuted by the (U.S. Drug Enforcement Agency) so there’s this push to cut prescribing, and I think that in many cases hurts more vulnerable patients to a greater degree.”
Joseph Friedman • UCLA PH.D. candidate
Unforeseen consequences
More than 808 million oxycodone and hydrocodone pills were shipped and distributed to San Diego County from 2006 through 2014, the secondhighest quantity in the state, according to data from the U.S. Drug Enforcement Agency.
The data, which was obtained by The Washington Post and the company that owns the Charleston Gazette-mail in West Virginia, traces the path of pills from manufacturers and distributors to pharmacies across the country. More recent distribution records are not yet available.
Opioid distribution increased by 35 percent in San Diego County over the nineyear period, data show. In 2006, county pharmacies purchased nearly 73 million pills. By 2014, the number jumped to 98 million pills.
The largest spike in San Diego County — as well as in other large areas including Los Angeles, Alameda, Sacramento and Riverside counties — began in 2010 and continued to rise over the next three years.
Bergmann said this was the beginning of what experts call the “first wave” of the opioid crisis, which began around 2010 and continued through 2015, and was largely driven by the initial consumption of opioids throughout the country.
There was also an increase in opioid-related overdose deaths. Data show there were 42 opioid deaths in San Diego County in 2001. Ten years later, the county reported 428 deaths.
By 2015, doctors and prescribers were more aware of the addictive properties of the drugs, such as oxycodone and hydrocodone.
The Centers for Disease Control and Prevention in 2016 released guidelines on best practices for initiating opioid treatments and how best to prescribe patients with chronic pain, recommending treatment should begin at the lowest effective dosage. Clinicians should then use caution when increasing doses equaling 50 morphine milligrams, or MME, the CDC said, and avoid increasing doses of 90 milligrams per day or more.
Bergmann said this decrease in opioid prescriptions led to an unforeseen “second wave” in the epidemic, where many who were already addicted to opioids or those who couldn’t get access to prescriptions they required transitioned to illicit street drugs.
“There was a shift of people who had initially gotten hooked and then transitioned to illicit drugs,” he said. “They were available and they were much cheaper.”
Eventually there was yet another shift to a “third wave” involving the use of fentanyl, a synthetic opioid that’s roughly 80 to 100 times stronger than morphine.
A fourth wave
According to Friedman, who studies social medicine at UCLA, the latest and “fourth wave” in the opioid crisis is the use of fentanyl mixed with unprecedented levels of stimulants, such as methamphetamine and cocaine.
Researchers also have seen massive shifts in the demographics of those using these drugs during the coronavirus pandemic.
“We’re seeing really sharply rising racial disparities in overdoses now,” he said. “In 2010, the White overdose rate was double the Black overdose rate. By 2020, the Black overdose rate has exceeded the White overdose rate for the first time since the ’90s.”
Dylan Aste, an assistant U.S. attorney who was appointed in 2018 as the civil opioid coordinator for the Southern District of California, said his office is proactively investigating and prosecuting doctors who carelessly prescribe opioids or do not adhere to recommended dosage levels.
“When a doctor or other prescriber breaks the law by over-prescribing or prescribing in dangerous combinations, there’s a high likelihood that patients will be harmed,” Aste said. “There’s also a possibility that patients are seeking to abuse the drugs ... and we do everything we can to stop that.”
Aste said his office, as well as agencies throughout the district, have been coordinating in recent years to stop the surge of opioid abuse. They’ve had multiple civil settlements against doctors and pharmacies.
For instance, in a September press statement, Aste’s office announced a $200,000 settlement with a San Diego pain clinic doctor. The physician did not return calls and messages seeking comment.
Prosecutors accused the doctor of writing opioid prescriptions to patients without a legitimate medical purpose for more than five years. He also was accused of prescribing opioids in combination with benzodiazepines, such as Xanax and Valium, along with muscle relaxants — a dangerous combination known to significantly increase the risk of addiction, abuse and overdose.
“There’s a deterrent effect,” Aste said. “When prescribers or doctors see that others are paying civil penalties, they might spend a little extra time with patients, ask more questions, try other modalities, or make sure to give the patient the proper care that is medically necessary.”
All data from the California Overdose Surveillance Board analyzed by the San Diego Union-tribune use an age-adjusted and weighted rate of prescriptions in each ZIP code. Opioid prescription rates exclude prescriptions for buprenorphine, which treats pain as well as addiction to narcotic pain relievers.
Data from The Washington Post only tracks the number of pills imported to each county and does not indicate whether pills were actually distributed to people who live in that county or whether each pill was consumed.