The Other Opioid Crisis: False Narratives Are Hurting Patients

The number of accidental drug overdose fatalities crossed 100,000 in 2021, an increase of almost 15% over the previous year, which itself was an increase of 30% over the year before. The Centers for Disease Control and Prevention (CDC), in its press release, called these deaths “opioid overdoses.” This framing of drug overdose fatalities as an “opioid crisis” is both misleading and counterproductive. The term “opioid” evokes prescription medications in popular imagination and ramps up fear of medications that have been used for centuries. The overdose death numbers, however, mostly reflect street drugs, ranging from heroin to illicit fentanyl analogs; 85% of 2019 deaths were from these drugs, and the increase in 2020 can be attributed almost entirely to them.

The conflation of all opioids has resulted in an unwarranted focus on prescription opioids and medical use as the root cause of the “problem” of accidental drug overdoses, even though overdose deaths from prescription opioids are a small and decreasing fraction of the total. The result is policies that fail to address the problem they were intended to solve—illicit drug use and accidental drug overdoses. Further, these policies have harmed medically fragile patients with chronic, high-impact, intractable pain who need prescription opioid medication to maintain quality of life and basic function levels.

Why did a narrative that is at odds with science become dominant, despite the harm it causes to people with substance use disorder and to medically fragile patients? The answer lies in the complex incentives that face policymakers, law enforcement and families of overdose victims, particularly as illicit drugs have edged into upper-income suburbs. The result of the “opioid crisis” narrative has been disastrous for the most vulnerable and powerless: Americans struggling with complex medical conditions and constant pain.

The Tidy but Inaccurate Narrative

The dominant narrative runs something like this: Doctors overprescribed opioids from the late 1990s through approximately 2012, resulting in addiction to prescription painkillers. When prescriptions ran out, these patients turned to street drugs. This overprescribing was responsible for an increase in substance use disorder rates and overdose fatalities. The appropriate policy response was, therefore, to tighten restrictions on opioid prescribing. Very plausible, very straightforward—and almost entirely contradicted by the facts. (...)

Most overdose fatalities are caused by illicit fentanyl analogs; they were responsible for more than 70,000 of 107,000 such deaths in 2021. Fentanyl is a synthetic opioid that is available by prescription, but these “fentalogues” are not prescription opioids—they are never a part of the medical/pharmaceutical distribution system. They are street drugs, distributed through illicit channels. It makes no sense for the government to monitor physicians, patients, pharmacies and prescription records; it is akin to searching for keys lost in an alley under the streetlight, not because the keys are likely to be under the light but simply because it’s easier to search there.

by Nita Ghei, Discourse | Read more:

Image: Catherine McQueen/Getty Images
[ed. See also: Part 2: The Other Opioid Crisis: A Failure of Care; and, Part 3: How the Criminal Justice System Imperils Patients and Physicians (Discourse):]

The DEA continues this hunt for “drug-dealing doctors” even today, despite the fact that there is very little diversion of drugs from medical channels and almost none from patients. On the contrary, patients across the board are having their pain relief options limited, including patients with cancer where opioids are the first-line treatment.

The opioid problem today is a lack of access and even temporary shortages of some pain relievers. But in the 1990s, the DEA actually contributed to the rise of pill mills and the flow of prescription pain relievers to illicit markets. In what is probably a unique feature of the U.S., the DEA, a law enforcement agency, determines the quantities of the various Schedule II opioids—prescription medications—that manufacturers can produce in a year. The DEA increased the quota of oxycodone by about 3,900% between 1993 and 2015; the quota for fentanyl increased by 2,500%. While some increase was necessary as pain was significantly undertreated in the 1990s, opening the floodgates to this degree was a questionable call at best. The 1990s saw the rise of the pill mills and the first wave of the crisis, as a significant share of the new opioid production was diverted to nonmedical use.

The rates of substance use disorder have remained largely stable over the past several decades. The drug du jour has changed, though, with changes in the legal landscape. Sharp cutbacks in prescribing began in 2012, starting with the Veterans Administration, where prescriptions fell by two-thirds in eight years. The DEA started cutting opioid quotas in 2015. As the supply of prescription opioids in the illicit markets shrank, first heroin, then illicit fentanyl analogs filled the gap. The number of prescriptions fell rapidly between 2012 and 2022, but the number of fatal accidental overdoses rose almost as fast.

Today, opioid prescriptions are about 60% lower than their all-time peak in 2012. Fatal accidental overdoses, however, are at an all-time high, exceeding 100,000 last year. About 85% of these fatalities were caused by a combination of substances, including alcohol and illicit fentanyl analogs—substances that were never part of the medical materials supply chain. The DEA nonetheless continues to persist with its narrative of overprescribing doctors.