If this is an epidemic, why don’t we treat it as such?

William L. Spence

The greatest concentration of bald eagles in the Lower 48 states used to take place along a single creek in Montana, until one tiny shrimp upended the entire ecosystem.

The introduction of non-native mysis shrimp into the Flathead River drainage has been a cautionary tale for 30 years now. Montana Fish, Wildlife and Parks personnel expected the small crustacean to become a supplemental food source for kokanee, a land-locked salmon species that was a popular game fish in Flathead Lake.

Instead, the shrimp fed on the same zooplankton that the kokanee preferred. They also became a food source for lake trout, which increased in number and began eating the smaller kokanee.

Less than a decade after the shrimp first appeared in Flathead Lake, the kokanee fishery had collapsed. Spawning runs along McDonald Creek, near the entrance to Glacier National Park, dwindled from 100,000 or more per year to nothing. The hundreds of bald eagles that used to feed on salmon during their fall migration — with 20 or more birds sometimes perched in a single tree beside the creek — found other places to go.

Biologists refer to these combined changes as a “trophic cascade.” It describes how the introduction or removal of one species can send ripples throughout the entire food chain.

The ongoing opioid crisis strikes me as a similar situation: It resulted from a single change — the aggressive marketing of opioids for chronic pain — which prompted a series of failures throughout the health care industry.

Drugmakers chose profit over public safety. Federal regulators rushed to approve the new drugs and authorized ever-increasing manufacturing quotas. Doctors prescribed them in greater and greater numbers, despite mounting evidence of harm. Pharmacists and distributors rushed to fill the orders. Insurers refused to approve alternative pain management methods, such as acupuncture or massage. And patients themselves demanded a pill to take away their pain, rather than make difficult lifestyle changes that might yield more lasting benefits.

For 20 years now, the opioid crisis has been a long, cascading system failure — one that has undermined confidence in the medical professionals and regulators who were supposed to keep us safe, and that still today lacks a means of self-correction.

And that, perhaps, is the most disturbing thing about it: We call it an epidemic, but we don’t treat it like one.

Granted, opioid addiction isn’t the same as infectious disease. You can’t contain it by blockading roads or flooding a community with vaccines.

But there’s tons of data that could help address the problem. You could look for hot zones — areas with high prescription and overdose death rates. You could go there, dig deeper, find out what’s really going on.

Maybe you don’t find anything. Maybe, given the demographics of our region, there are perfectly rational explanations why Nez Perce County or Lewis County had the highest per-capita opioid prescription rate in Idaho every year from 2006 through 2017, or why Asotin County had the highest rate in Washington six times during that same period.

But if we’re going to call it an “opioid epidemic,” shouldn’t someone at least take a look?

Turns out that isn’t happening — certainly not by me, and apparently not by the health care professionals.

Until I stumbled upon the Centers for Disease Control prescription rate maps while doing research for an earlier story, I was oblivious to the data. I never imagined this region would rank so high.

As I spoke with others in the public health field, many were as surprised as I was. More to the point, several told me they had only recently seen the numbers — meaning it isn’t something they regularly track.

Opioid deaths are even harder to follow. Idaho coroners aren’t required to report the type of drug involved in an overdose death, so figures are understated to begin with. Overdoses that result in emergency room visits aren’t necessarily reported either, so public health officials may not even know if there’s a problem in their community.

What is known is that overdose deaths in Idaho have nearly quadrupled in less than two decades, from 64 in 1999 to 236 in 2017. In Washington, the numbers more than doubled, from 555 to 1,169. According to the National Institute on Drug Abuse, a majority of those cases are believed to be from legal and illegal opioid use.

That situation isn’t going to self-correct. To reverse the trajectory, there needs to be continuous monitoring and feedback, as well as intervention when things go wrong. Those are basic components of any quality improvement system.

Absent such proactive measures, the cascade continues and the predators just keep getting bigger.

Spence covers politics for the Tribune. He may be contacted at (208) 791-9168 or bspence@lmtribune.com.

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