T he US is in the grip of the worst drug crisis in its history. An estimated 64,000 Americans were killed by overdoses in 2016, more than in the Iraq and Vietnam wars combined. A year earlier, drug overdoses accounted for more deaths than gun violence and car crashes.
Two-thirds of overdoses in 2015 were linked to opioids - from prescription pain medicine, such as OxyContin or Percocet, to more potent substances like heroin and fentanyl. It shows no sign of abating. A recent forecast by STAT, a health-oriented news service, concluded that 650,000 people will die from opioid overdoses in the US over the next decade if nothing is done.
President Donald Trump recently declared the crisis a “national emergency”, and has established a White House commission to address the epidemic. Nonetheless, critics say that Washington must do more. Congress has passed just one major bill confronting the opioid epidemic, wherein it set aside $1 billion to drug treatment over a two-year period, far removed from the tens of billions of dollars which studies suggest are necessary to truly deal with the crisis.
Yet, even if money was no obstacle, combating opioid addiction is a thorny issue which continues to divide opinion. The World Weekly spoke with several drug policy and public health experts about America’s opioid epidemic, what is causing it and what can be done to solve it.
‘An epidemic of overprescribing’
Throughout the 1990s, consensus dictated that opioid-related deaths were the result of “bad apples”: doctors who acted like drug dealers, and people pretending to be patients who were really drug abusers. Such an approach, experts say, is misleading.
“If you frame it as an addiction epidemic, then what you need to do about it becomes a lot clearer,” explains Andrew Kolodny, an opioid policy expert at Brandeis University. “You do the same things as you would do for other disease epidemics: reduce its incidence, and make sure that the people who have the disease have access to effective treatment.”
Reducing the rate of opioid addiction means staving off new cases of the disease; central to doing that is understanding where the opioid epidemic has come from.
A common misconception is that the recent spike in opioid-related deaths is a result of what The Economist terms “white working-class despair”. In the US, deaths are highest in the Midwest and northeast, among middle-aged men, and among whites: what some call ‘Trump’s America’. Dramatic social and economic change in ‘Trump Country’, some argue, has led to an increase in suicides, alcohol poisonings and drug overdoses.
The impact of socio-economic dislocation should not be dismissed entirely, but the alarming recent upturn in opioid-related deaths is largely due to trends within the drug industry itself. “This opioid epidemic is first and foremost an epidemic of overprescribing,” says Anna Lembke, an addiction doctor and author of a new book on the opioid crisis.
Major pharmaceutical companies, like Purdue Pharma, the makers of OxyContin, “infiltrated medical watchdog organisations, to convince doctors that prescribing more opioids was good not just for their bottom line, but also for their patients,” Dr. Lembke told TWW. “The result was a massive paradigm shift within medicine, wherein opioids became the first line of treatment for all types of pain.”
‘Big Pharma’ is taking its controversial playbook into the developing world. A recent LA Times investigation showed that Mundipharma, an international drug conglomerate under the same ownership as Purdue Pharma, is using the same controversial marketing strategies which shot OxyContin to prominence in the US in Latin America, Asia and elsewhere. Experts fear the opioid crisis could spill across borders as a result.
Americans consume more opioids than any other country in the world. In 2015, the amount of opioid prescribed in the US was enough for every American to be medicated around the clock for three weeks.
According to Keith Humphreys, a drug policy expert at Stanford University, the first task in combatting the opioid epidemic is to “shift the level of prescribing in the US to what it is in other developed countries”, a move which would actually save the government money.
That is easier said than done. Reducing opioid prescription rates in the US requires a “culture change”, explains Daniel Ciccarone, professor of Family and Community Medicine at the University of California San Francisco.
Across the US, doctors regularly prescribe their patients too many opioids. Consequently, overall rates of prescription are up to four times higher than they were in the 1990s. Addressing this issue, Professor Ciccarone told TWW, requires providing “better education on opioid prescribing to medical students and residents.”
‘Cheaper to get high than help’
Preventing new generations of drug users from misusing opioids is only one side of the coin. If overprescription is curtailed but nothing is done to expand the treatment of addiction, then users will turn to heroin and fentanyl instead, and overdose deaths will remain at unprecedentedly high levels. The central problem with treating the opioid epidemic, Professor Kolodny says, is that it is much cheaper and easier for an opioid addict to get high than to get help.
To address this problem, he recommends copying the model that New York City implemented to reduce smoking in the early 2000s. Alongside making tobacco less accessible through banning smoking in public places and hiking taxes to make cigarettes much more expensive, the city also made alternatives to tobacco more accessible by opening a phone line that people could use to contact a clinic or access free nicotine patches and gum. It was a roaring success.
Preventative strategies have been employed in the US, with some state legislatures imposing limits on the lengths of prescriptions, for example. However, neither federal nor state governments have made a concerted effort to ease access to opioid alternatives such as counselling or Medication-Assisted Treatment (MAT).
Medicines like methadone, buprenorphine and naloxone have been proven to lessen opioid cravings and reduce dependence, yet in many places these remedies remain less accessible and less expensive than heroin. “Naloxone has a cost out of reach for many,” Professor Ciccarone says. “We need a massive expansion in availability of this lifesaving drug so that every person who uses heroin as well as their families peer, mates, partners has a dose on hand.”
Only 10% of Americans suffering from drug addiction receive specialised treatment, and there remains a stigma against using one drug to treat dependence on another, even in the West Wing. “If we’re just substituting one opioid for another, we’re not moving the dial much,” Tom Price, Mr. Trump’s health secretary, said earlier this year. “Folks need to be cured so they can be productive members of society and realise their dreams.”
Mr. Trump’s opioid commission has openly disagreed with Mr. Price. In its list of recommendations published last month, it encourages the White House to “immediately establish and fund a federal incentive to enhance access to MAT.”
Professor Kolodny agrees, suggesting that Congress should appropriate $60 billion over the next 10 years to systematise addiction treatment. “In every county in the US there should be a treatment centre where someone can walk in and on that same day, regardless of their ability to pay for it, have access to opioid addiction treatment with buprenorphine or methadone.”
Policy and policing
Mr. Trump’s opioid commission, observers agree, has been making the right noises. Yet the president himself has taken actions which undermine his own administration’s efforts to fight a problem “the likes of which,” he says, “we’ve never had.”
The Republican caucus has so far come up short in its efforts to repeal and replace the Affordable Care Act (ACA), President Obama’s signature health care bill. If the GOP were to eventually succeed in scrapping the law, it would likely have a drastic impact on opioid addicts’ ability to seek treatment.
“The biggest single advance in providing access to addiction treatment has been the ACA,” Dr. Lembke told TWW. “It made addiction treatment an essential health benefit, meaning insurance companies and other third-party payers are mandated to reimburse for addiction treatment. It also expanded Medicaid to millions of Americans who did not previously have access to treatment."
Mr. Trump’s policies, instead, seem more focused on law enforcement, and tightening up US border security to protect against illegal flows of drugs from Mexico. While this is certainly important, a single-minded focus south of the border is unlikely to solve the current crisis. “We need to understand the poisoning epidemic better,” Professor Ciccarone explains. Fentanyl, a synthetic opioid, has entered the heroin supply in much of the US, and is “acting like a poison.”
While deaths from prescription opioids alone are trending downwards, fentanyl deaths have increased by 540% in the last three years, reaching 20,000 in 2016. People who unknowingly take fentanyl can easily overdose; it is 50 times more potent than heroin, and just two milligrammes can constitute a lethal dose.
China is the primary source of fentanyl in the US, and Professor Humphreys suggests that Washington should work with Beijing to reduce its production, while simultaneously expanding its testing and surveillance of drug samples to alert consumers that fentanyl has entered the heroin supply.
Shedding the stigma
Much work lies ahead.
Mr. Trump has taken the significant step of declaring the opioid crisis a national emergency, but he is yet to actually set that declaration in motion. What’s more, the White House’s latest budget proposed deep cuts to the Department of Health and Human Services, which has been tasked with tackling the crisis.
Experts agree that a solution to the current epidemic is in reach, should lawmakers at both a state and federal level find the money and motivation to act. As of yet, that has not happened, and in many quarters there remains a stigma surrounding addiction in the US.
Outside the medical profession, a substantial portion of the population still sees addiction as some sort of moral defect. It is an opinion shared by some policymakers, too. Rob Schaaf, a Republican state senator from Missouri, once commented that when people die of overdoses, that “just removes them from the gene pool."
Until apathy gives way to action, the opioid epidemic will continue to decimate families and communities across the US.