As the US battled the Covid-19 pandemic, it got lost in the shuffle that the country endured record numbers of drug overdose-related deaths in 2020; approximately 93,000. Moreover, from May 2020 to April 2021, the figure rose to 100,000. Furthermore, preliminary data from the Centers for Disease Control and Prevention (CDC) estimates that more than 107,000 people will die from a drug overdose in 2021, with 75% of those deaths involving an opioid. Illegal fentanyl is the primary culprit.
While the federal government is spending billions to pursue various supply-side and demand-side strategies to combat the problem, it is behind the eight ball when it comes to this ever-growing crisis. Similarly, state and local authorities are not doing enough.
In the past 10 years, where local, state and federal governments have acted in concert, there appears to be an inordinate focus on legal prescription opioids, which are in many ways easier to control than illegal opiates.
But it is important to properly distinguish between the role of illicit and prescription opioids in the current opioid crisis. Contrary to public perception, the problem of abuse, misuse and diversion of prescription opioids has been much less of a factor than illicit opioids in recent years. A picture of a bottle of prescription painkillers often accompanies articles about drug overdose deaths, creating the wrong impression.
Shortly after the peak of opioid prescribing in 2012, about a third of the 44,000 drug overdose deaths reported in 2013 were attributable to the inappropriate use of prescription opioids. Since 2013, the percentage of drug overdose deaths attributable to the inappropriate use of prescription opioids has decreased, in part because fewer are being prescribed. Reductions in prescribing are based on more restrictive regulatory policies enacted in individual states and counties, and reinforced by federal guideline recommendations outlined by CDC in 2016.
Some experts have suggested that a number of improper restrictions have caused the pendulum to swing too far in the direction of severely restricting prescription opioids — even increasing forced tapering — since such medications do have legitimate uses for certain persons suffering from acute and chronic pain.
There appears to be a correlation between the move to draconian limits on opioid prescribing and the increase in the use of illegal opiates. Of course, correlation is not causation. Nevertheless, it is striking that heroin and illegal synthetic fentanyl now account for the vast majority of drug overdose-related deaths, with fentanyl being by far the biggest driver.
Federal government efforts to stop supply
The US federal government has emphasized stopping the supply of illegal opioids. Successive administrations have pursued policies aimed at reducing illegal imports of such substances.
Most illegal fentanyl in the US is smuggled from Mexico. Even fentanyl originating in China is often diverted through Mexico.
The Obama, Trump and Biden administrations have increased the number of Border Patrol agents to more than 20,000. Yet the smuggling continues; mostly by US citizens smuggling through official ports of entry along the border.
And while the federal government has also provided significant counternarcotics assistance (resources and manpower) abroad to countries such as Colombia and Mexico, the effects have been minimal at best.
Demand side initiatives
Although the attempt to cut off supply is a logical step to tackle the problem, the success of such policies is extraordinarily limited.
What is problematic is that the federal government has only recently acknowledged that much of the problem exists on the demand side.
According to dr. Rahul Gupta, director of the White House Office of National Drug Control Policy, says only about 10% of people in the US who need addiction care receive treatment.
The good news is that federal, state and local officials have shifted some of the emphasis to prevention and treatment.
For example, continued expansion of the Affordable Care Act under the Biden administration has been instrumental in making available public health resources essential to combating substance use disorders, particularly for those on Medicaid.
The Biden administration also eased restrictions on the use of buprenorphine, a drug used specifically for opioid use disorders.
Furthermore, in October 2021, without much fanfare, the Biden administration proposed a new set of policies to stem the rise in drug overdose deaths. These demand-side measures are based in a building consensus around the expansion of federal support of harm reduction strategies for people who actively use illegal drugs; for example, wider distribution of fentanyl test strips, which help users avoid street drugs contaminated with the deadly synthetic opioid.
More controversially, the Biden administration’s plan embraces expansion of needle exchange programs, which for several decades have shown effectiveness in reducing the spread of infectious diseases such as HIV and hepatitis.
At the municipal level, we are observing gradual implementation of programs designed to reduce harm in those who use illegal drugs. New York City has authorized the establishment of two supervised injection sites for drug users in Manhattan. The facilities will provide clean needles and administer medications, such as naloxone, to reverse overdoses. At the same time, users are offered different options for addiction treatment.
Other city and local governments, particularly on the West Coast of the US, have launched large-scale programs focused on limiting HIV virus transmission and overdose by promoting safer drug use.
All in all, however, the US response is inadequate and out of proportion to the scale of the problem. The Biden administration has invested more than $5 billion in increasing access to mental health care and preventing and treating opioid addiction. Although this seems like a substantial sum, it is relatively meager. The federal government has spent more than $18 billion on Operation Warp Speed to develop Covid-19 vaccines, with tens of billions more going towards procuring Covid-19 tests, vaccines and treatments. In the US, the household response to HIV has risen to more than $28 billion per year. There is not the same kind of funding regarding the opioid crisis, or even determination on the part of authorities to systematically address the issue.
Observers say the federal government is not providing sufficient sustained funding to quell the crisis. Additionally, state Medicaid programs vary widely in their coverage of recovery support services and pharmaceutical interventions.
Recently, the shortage of beds and resources for psychiatric patients, many of whom have substance use disorders, has accelerated in all states. This has led to serious bottlenecks in hospitals and very long waiting times for admissions.
Even relatively simple solutions are not pursued to the greatest extent possible. To illustrate, naloxone, which can reverse an opioid overdose, is still not as widely available as it should be. While naloxone can be purchased without a prescription in all 50 states, it is not officially an OTC product. The ability to purchase naloxone OTC does not apply to organizations that purchase naloxone in bulk from drug manufacturers. States do not have the authority to designate naloxone as an OTC product. Only the federal government can do that. The Food and Drug Administration (FDA) says it doesn’t because drugmakers don’t initiate a switch from prescription to OTC status. While this is usually the way to go for switches, there is precedent for the FDA to step in and authorize a switch without the consent of the drug manufacturers.
In addition to the issues mentioned, there was poor public health messaging and a general lack of public education. Experts believe that the federal, state and local governments need to direct much more resources to educating the public about the risks of illegal opioids and the availability of treatment and other services. Evidence of flawed public health messaging is not hard to find. The scarce services offered are only exploited by a very small minority of drug-using patients.
Perhaps lessons can be learned from overseas experience. Two decades ago, Portugal adopted a systemic, nationwide harm reduction drug policy that decriminalized possession of drugs for personal use and emphasized treatment (adopting a plethora of options tailored to individual patients’ needs) instead of incarceration. By 2018, Portugal had the lowest rate of drug-related deaths in Europe.
In the 1990s, the Netherlands began offering heroin addicts free of charge as part of professionally supervised recovery support services. The rate of high-risk or “problem” use has halved from 2002 to around fourteen thousand cases in 2012, according to the European Monitoring Center for Drugs and Drug Addiction.
Of course, there are no panaceas that will magically solve the fentanyl disaster, or abuse of other illegal drugs for that matter. And international efforts to address the opioid crisis do not necessarily translate to the American context. Nevertheless, it would appear that from the insufficient budgets allocated to the problem, the chronic shortages of services and the limited scope of the programs that do exist, much more could be done in the US