Opioids. Photo via Flickr, CC by 2.0.

By Emily Top
Capital News Service

Between 2006 and 2012, Maryland saw a large influx of prescription opioids, more of which, per person, were sent to suburban areas of the state than the urban or rural areas, according to a Drug Enforcement Administration database published by The Washington Post.

Much of the rest of the nation also saw suburban areas hit harder than rural or urban areas, but Maryland saw fewer pills per person on average than across the nation.

Additionally, urban areas in Maryland had the lowest number of pills per person—compared with rural areas and suburbs—whereas nationally, urban areas had the second-largest influx of prescription opioids per person.

Utilizing The Washington Post‘s Drug Enforcement Administration ARCOS database, Capital News Service found that counties on the Eastern Shore of Maryland, specifically Cecil and Kent counties, had some of the highest number of pills per person than other counties throughout the state. Cecil County led the state with 69.7 opioid pills per person in 2011, the highest number during this time period.

Additionally, Cecil County led the state in pills per person in 2010 with 68.8 pills per person that year.

In 2011, Kent County just trailed Cecil County with 68.0 pills per person.

Allegany County, home to Cumberland and Frostburg, had a large number of pills per person as well, reaching over 60 pills per person between 2009 and 2012.

Data for later years was not available; the information provided was the result of a lawsuit by The Washington Post, which published it.

The Maryland Department of Health referred Capital News Service to the Maryland Opioid Operational Command Center.

The center responded, in an email: “We are able to comment only on the policies and actions of the Hogan administration. Questions regarding the policies and actions of previous administrations may be directed to representatives of those administrations.”

In Maryland, counties are rarely uniform in population density. To address this issue, Capital News Service utilized census tracts and tract-type labels.

A census tract is an area that contains approximately 4,000 people, said David Kraiker, a data dissemination specialist, in a video published by the Census Bureau.

Census tracts allow for deeper analysis within a county. Instead of defining an entire county as rural, suburban or urban, a New York Times data analyst gave four definitions to census tracts; Capital News Service followed this model in its analysis. A census tract could be urban, inner ring, outer ring or rural. Inner and outer rings are more similar to suburban areas, but inner rings are closer to a metropolitan center than outer rings. Because of their similarities, inner and outer rings were combined into “suburbs.”

Below shows which areas of Maryland are considered rural (red), suburban (gray) or urban (yellow), according to The New York Times census tract definitions.

Utilizing these more specific definitions, suburban areas in Maryland had the highest number of pills per person on average between 2006 and 2012—61.1 compared to 45.0 in rural areas and 42.8 in urban areas.

This phenomenon is nearly replicated nationally, where suburban areas had the highest number of pills per person. However, nationally, urban areas had a greater number of pills per person than rural areas as defined by the census tracts. Nationwide, suburban areas had 71.4 pills per person whereas urban and rural had 59.5 and 51.7 pills per person, respectively.

Although it is not completely clear why non-urban areas had a higher number of pills per person in Maryland than urban areas, academics have found that medical standards may have led to an increase in prescribing.

In 2001, The Joint Commission on Accreditation of Healthcare Organizations, now just The Joint Commission, “introduce(d) standards that require(d) pain assessment and treatment,” wrote Hector Vila Jr., et al. in their study. As a result, many hospitals introduced numerical pain scales into their treatment plans.

The study authors found that this change increased opioid oversedation—that the overuse of opioids passed the amount needed for a therapeutic effect, per 100,000 inpatients from 11.0 to 24.5.

In 2011, The Joint Commission released a statement noting that “both pharmacologic and nonpharmacologic strategies have a role in the management of pain.”

And in 2017, The Joint Commission wrote that it is unclear whether their standards or other factors prior to their standards caused an increase in opioid prescriptions.

Dr. Gary Pushkin, former president of Maryland’s state medical society, MedChi, and current chair of the opioid committee, said The Joint Commission contributed to the problem. The commission was getting hospitals in trouble for undertreating pain, which led hospitals to put pressure on doctors.

Additionally, Pushkin said, doctors can’t tell whether a patient is at risk to become addicted to opioids.

“(There) are no signs to guide us,” Pushkin said.

Between 2006 and 2012, over 1.1 billion prescription opioid pills were supplied to the state, according to the DEA database.

Of these 1.1 billion pills, manufacturer SpecGx LLC was responsible for 549,303,798 pills, and McKesson Corp. distributed 384,635,325 prescription pills, according to the DEA data.

In May 2019, Maryland Attorney General Brian Frosh filed charges against the controlling owner-directors of Purdue Pharma.

In a May press release from the Attorney General, Frosh said, “the strategies allegedly used by Purdue and the Sacklers (the family members who own the company) were calculated, misleading, and extraordinarily effective.” Frosh continued, “According to the charges, sales were prized over safety, and sales representatives for Purdue referred to the highest dosage for OxyContin as ‘hillbilly heroin.’ In Maryland alone, thousands have died, many more have become addicted, and the costs to our state and its people have been staggering.”

Frosh in September said he would decline to participate in a proposed national settlement agreement, according to the Baltimore Sun.

In a tweet on Dec. 17, Frosh said, “The Sackler family took more than $10 billion out of Purdue Pharma since 2007. That’s why we have refused (to) take the $3 billion they have offered to settle our charges against them and Purdue.”

Purdue Pharma manufactured 60,872,936 pills that were sent to Maryland, ranked fourth for manufacturers between 2006 and 2012, according to the DEA data set.

Despite the problems in the past, Pushkin said, “physicians are getting the message,” and numbers of opioid pills and prescriptions are going down in Maryland.

Maryland’s opioid command center has said that prescription opioid-related deaths are down in recent years. From 2016 to 2018, these deaths fell from 418 to 379, according to state health department data. In the first six months of 2019, “the number of prescription opioid-related deaths was down approximately 3.5 percent when compared to the same period in 2018,” a center representative wrote in an email to Capital News Service.

In Maryland, State EMS Medical Director Dr. Timothy Chizmar said that, as of late, emergency medical services have not seen a difference in the location of overdoses.

“(Opioid Use Disorder) does not discriminate on ethnic or geographic lines,” Chizmar said.