The Administration's Fundamental Flaw on Opioid Addiction: Talk of Progress Is Greatly Exaggerated

Jeffrey A. Singer

The White House plans to stage an event this week celebrating its accomplishments addressing the opioid overdose deaths crisis. The event will come a year after the President declared opioid-related overdoses a national public health emergency, and a little over a week since the Senate passed and sent to the President’s desk a bill, H.R. 6, aimed at further combatting the problem. But Congress and the White House have nothing to boast about. The policies in place for the past several years, and on which the new legislation generally doubles down, have only served to drive up the overdose rate while making patients suffer needlessly in the process.

Sadly, all that Congress and the White House have to brag about is a policy that is driving non-medical users to more dangerous drugs and causing desperate pain patients to turn to the black market or to suicide for relief. They should refrain from uncorking the champagne.

Last December the Centers for Disease Control and Prevention reported that the overdose rate increased 21% from 2015 to 2016. This month the CDC reported provisional numbers showing another 10% increase in 2017. All of this is happening despite federal and state efforts, using practice guidelines and prescription surveillance programs, that have led to a drop in high-dose opioid prescribing of 41% from 2010 to 2016, and another 16% in 2017. Those same policies have caused heroin and illicit fentanyl (largely smuggled in from Asia employing drug cartel infrastructure) to become the predominant causes of opioid-related overdose deaths as non-medical users migrated over to those cheaper and more available drugs. Yet the new legislation provides funding to augment and enhance prescription surveillance programs.

That’s because the opioid overdose crisis was never really about doctors treating their patients in pain. It has always primarily been caused by non-medical users accessing drugs through the dangerous black market that results from drug prohibition. The overwhelming majority of those overdose victims have multiple drugs in their system when they overdose. The New York City Department of Health reported in 2016 that three-quarters of all overdose deaths were either heroin or fentanyl, and 97% of those overdose victims have multiple drugs onboard – 46% of the time that drug included cocaine. This hardly fits the profile of a patient receiving medical treatment for pain.

This should come as no surprise to policymakers. The National Survey on Drug Use and Health has been reporting for years that less than 25% of non-medical users of prescription opioids ever obtain them from a doctor. They get them from a dealer, a friend or a relative.

As a report last month by researchers at the University of Pittsburgh Medical Center shows, death rates from drug overdoses by non-medical users have been on a steady increase since the 1970s. At different points in time different drugs come in and out of vogue. In the opening years of the 21st century, the media reported on a “meth epidemic.” In 2005, restricting Sudafed sales along with SWAT team hits on meth labs slowed down the death rate for about a year, and then overdoses from prescription opioids became the new cause of concern. Heroin and fentanyl are now the primary killers, although one should keep their eyes on meth, which is making a big comeback. Meth deaths were up 30% in 2015 alone, as alternative production methods were developed by the drug cartels that filled the void after home-grown meth labs were destroyed.

Sociocultural forces drive this decades-long trend of self-medication with licit and illicit drugs, and prohibition makes them dangerous and deadly. You never can be sure of what you are getting when you get it on the black market.

HR 6 throws more money toward addiction rehab programs, but not all non-medical users are addicts, and the fear of being treated as a criminal deters those who need help from seeking it.

Congress and the White House have their eyes on the wrong target. If they can’t answer the hard questions surrounding the unintended consequences of drug prohibition, they should at least put their efforts into reducing the harm that comes from using drugs in the black market. The just-passed legislation does make it somewhat easier for health-care providers to prescribe buprenorphine as a form of Medication-Assisted Treatment for opioid addiction. But it doesn’t go far enough. It should also allow providers to prescribe methadone in the same manner – as they’ve done in Canada, Australia and the UK for decades. Federal law must be changed to legalize supervised injection facilities, used successfully in virtually the entire developed world since the 1980s, to reduce overdose deaths and the spread of infectious diseases. And the overdose antidote naloxone should be made truly over-the-counter, so it gets more widely used.

Sadly, all that Congress and the White House have to brag about is a policy that is driving non-medical users to more dangerous drugs and causing desperate pain patients to turn to the black market or to suicide for relief. They should refrain from uncorking the champagne.

Jeffrey A. Singer practices general surgery in Phoenix, AZ and is a senior fellow at the Cato Institute.