Opioid deaths in the U.S. keep climbing inexorably. However, at the same time, prescriptions for all opioids have decreased for four straight years (2013-2016), according to the Center for Disease Control, and prescriptions for high-dose opioids have decreased for seven straight years (2010-2016). Further decreases are expected when prescriptions are reported for 2017. How does the declining supply square with the increasing death rate? Contrary to popular belief, opioid prescriptions are not now and never were the cause of opioid overdose deaths. The causes are  complex, but they have everything to do with ill-fated efforts to regulate prescriptions and prohibit some opioids.

Fatal Fun

In this informative interview, Dr. Jeffrey Singer explains that 75% of opioid deaths occur among “recreational” users who have never obtained a legitimate prescription. The recent increases in overdose deaths have been dominated by “other synthetic opioids” like fentanyl and heroin, both of which are illegal (except for fentanyl in patches or anesthesia). Oddly, heroin is not legal for medical use in the U.S., despite the fact that it is less than half as powerful as Dilaudid, which Singer says is used fairly routinely to relieve severe pain.

Singer debunks a widespread notion about the dynamic underlying opioid deaths:

“…first of all the narrative that everyone has bought into, and this is very frustrating to us practitioners, is that the opioid overdose death problem is a direct result of doctors prescribing pain medicine for patients. So, the popular notion is that I’d write a prescription for an opioid for my patient for pain, my patient becomes a drug addict, and then starts resorting to all sorts of illegal behavior in search of the drug. He becomes a dope fiend, and then he eventually overdoses and dies. … That is not what’s going on.“

From the very beginning, the problem of opioid use was driven by an appetite for recreational drugs. Certainly there are people with legitimate medical needs who develop a dependence or addiction and ultimately turn to the black market for continuing supplies. Dr. Singer does not deny that. But there are also individuals who manage to use these drugs recreationally without ever compromising their lives or livelihoods (see Singer’s anecdote about the “Father of American Surgery”, William Halsted). Unfortunately, however, there are recreational users who become dependent or addicted, just as some do with alcohol.

Where do the opioid supplies come from? Of course, heroin and fentanyl make their way onto the market from overseas, and supplies of prescription opioids also make their way onto the black market. For a real buzz, a lot of oxycodone can be extracted from a OxyContin capsule to bypass its slow release. In fact, illegally-obtained OxyContin became a major source of recreational opioid use following its introduction in the 1990s. At the time, physicians were encouraged to be more aggressive in addressing pain management. But the increase in legitimate use for pain brought a concomitant increase in leakage of pills onto the black market. Rx pads are stolen, a few patients might sell legitimate prescriptions, and pills are stolen from medicine cabinets at parties or over at Grampa’s place, for example.

We’re Watching You, Herr Doktor

Efforts to reduce the availability of opioids have been underway for a number of years now. The DEA has mandated reductions in the quantity of opioids manufactured (25% in 2016 and 20% in 2017). The crackdown on so-called “pill-mills” might have helped stem the flow of opioids to the illegal market, especially in Florida, but the measures included strict supply quotas that have harmed those with legitimate needs for the medications. The DEA reclassified hydrocondone as a Schedule II drug, imposing maximum dosages that are too low to relieve the pain experienced by some patients. All 50 states now have prescription drug monitoring programs (PDMPs), which follow prescribing doctors and patients. Singer says PDMPs have a chilling effect on doctors even when their patients’ needs are legitimate. Finally, the FDA has supported pharmaceutical companies in developing “abuse-deterrent formulations” that can’t be crushed or liquified. And those companies have a strong incentive to do so as they can obtain new patents in the process! Some states have required insurers to cover the new formulations, ending the sale of cheaper generics. That is a nice crony deal for big pharma!

While Endangering Lives

The restrictive policies have led to substitution of heroin for opioid pills, as this Notre Dame study shows. The policies endanger: 1) patients with legitimate needs for pain management; 2) occasional users who are otherwise productive members of society; and 3) heavy recreational users. With greater reliance on black market heroin, there is no way for users to tell exactly what they’re getting: it’s probably impure and it’s often amped with fentanyl, or fentanyl sold as heroin. Fentanyl is 50 times as powerful as morphine and 7 – 8 times as powerful as heroin! Singer describes the severe information problem facing users of black market intoxicants:

“… when I go into the supermarket or liquor store to buy a bottle of liquor and I see on the label it says, let’s say, ’80 proof,’ or ‘15% alcohol,’ the thought never crosses my mind that it may not be that, that it could be adulterated with all sorts of impurities or laced with something that could kill me. I believe what it says on the label, because it’s legal, and in the legal market. 

Number one, they have competitors and number two, I have recourse if I’ve been defrauded and injured. But, when were dealing with the illegal market, you go to somebody in a subterranean way who says, ‘Yeah, I have what you want.’ And you don’t know if it’s the dose, you don’t know if it’s pure, that’s what’s happening. In fact, what we’ve learned, because of the narrative that it’s a doctor’s prescribing, since about 2010, 2011, all of the policies of both the federal government and the state governments have been aimed at curtailing the amounts of opioids prescribed.“

Prohibition always creates more danger for users. Adulteration of is one side of it. In “Legalizing Opioids Would Dramatically Reduce Overdose Deaths“, Harvard economist Jeffrey Miron adds that prohibition leads to mixing with other legal or illegal substances:

“In 2013, 77 percent of deaths involving prescription opioids involved mixing with either alcohol or another drug. If opioids are easily accessible, people tend to use the substance they desire; when access is limited, however, some consumers obtain an insufficient quantity and therefore improvise with alcohol, benzodiazepines, and other drugs. Taking these drugs together increases the risk of overdose, especially when dealing with depressants like opioids ….“

Miron and Singer both discuss the risks created by prohibition for users who have developed tolerance to the drugs. Miron says:

“[Tolerance] makes usage less dangerous as the body develops resistance to opioids’ respiratory-depressing effects. … [but] under prohibition users who have developed tolerance get cut off, whether by legal or medical restrictions or by being forced into non-[Medically-Assisted Treatment] treatment. Tolerance then declines, according to medical experts in drug rehabilitation, so users who resume use are more prone to suffer an overdose.

One study proposes that environmental factors also influence tolerance, and that ‘a failure of tolerance should occur if the drug is administered in an environment that has not, in the past, been associated with that drug.’ Therefore, prohibition may increase the chance of overdose by driving users out of their routine into unfamiliar settings in which their tolerance against the respiratory effect of opioids is diminished. “

Finally, by encouraging the development of a black market, prohibition drives up prices, prompting some users to engage in crime to finance their highs. Prohibition itself cedes the market to underworld elements, whose competition culminates in gangsterism and violence.

Medically-Assisted Treatment

Singer believes resources should be redeployed: less drug regulation and interdiction efforts and more harm reduction programs and medically-assisted treatment (MAT):

“… when you take [Methadone] orally, it gets absorbed from the gut. It levels that bind with your opioid receptors enough so you won’t experience withdrawal symptoms. … And the idea behind methadone maintenance is that you get used to not, it’s sort of, behavior modification. You’re blunting withdrawal symptoms, but you’re getting used to not feeling the high. And then it’s hoped that over time, you can be tapered off the methadone. And now you don’t crave the high anymore, and you’re over your addiction problem. That’s the idea behind medical-assisted treatment, whether it’s methadone or Suboxone or others.“

While doctors, within limits, can prescribe drugs to treat pain, they aren’t authorized to prescribe Methadone or Suboxone to treat addiction. But MAT can actually prevent people from dying! In addition, Singer mentions needle exchange programs to prevent the spread of hepatitis and HIV, and safe injection rooms:

“…you go into the room, you inject there, and then you leave. The needle is then discarded by the people who run the place. And not only that, but you have the bonus of somebody being around there with Narcan so if you overdose, because again, you’re using an illegally obtained substance, so you don’t know really what’s in it. … in Switzerland, they reported that teen heroin use has come down, because when the kids see these people going in and out of the clinic to get their injection, it doesn’t look cool.“

Conclusion

There are solutions to the deadly nature of the opioid epidemic, but prohibition is not one of them and never will be. If anything, prohibition in varying degrees has aggravated the dangers of opioids. To truly solve the problem, we should eliminate restrictions on the production and distribution of legal opioids for pain management, legalize heroin, and stop interfering in markets. That would be merciful for patients in real pain, make recreational use of opioids dramatically safer, and put an end to the gangland violence associated with underground competition. Second, redirect those resources into MATs and other harm reduction programs. Miron notes that legalization has worked in other countries, like Portugal and France, to reduce overdoses and opioid deaths. As a political matter, however, these steps might not be feasible unless we get over the cultural bias stigmatizing recreational opioid use as “evil”, and the idea that laws and enforcement can actually prevent people from trying to get high.