Short Answers to Hard Questions About the Opioid Crisis By Josh Katz
On Thursday, President Trump said he intended to declare the opioid crisis a national emergency, as previously recommended by his opioid commission.
With the death toll from drugs rising faster than ever, you might feel that you could use a little catching up. For a quick refresher, and more on the practical effects of a formal declaration of an emergency, here are answers to 12 critical questions.
1. How bad is it?
Drug overdoses are the leading cause of death for Americans under 50, and deaths are rising faster than ever, primarily because of opioids.
Overdoses killed more people last year than guns or car accidents, and are doing so at a pace faster than the H.I.V. epidemic at its peak. In 2015, roughly 2 percent of deaths — one in 50 — in the United States were drug-related.
Overdoses are merely the most visible and easily counted symptom of the problem. Over two million Americans are estimated to have a problem with opioids. According to the latest survey data, over 97 million people took prescription painkillers in 2015; of these, 12 million did so without being directed by a doctor.
2. What is an “opioid”?
That’s not really a helpful answer.
The first such drug, and the one from which the opioid receptors get their name, was opium. Opium, a narcotic obtained from a kind of poppy, has been used in human societies for thousands of years. From opium people derived a whole host of other drugs with similar properties: first morphine, then heroin, then prescription painkillers like Vicodin, Percocet and OxyContin. Opium along with all of these derivatives are collectively known as opiates.
Then there are a handful of compounds that act just like opiates but aren’t made from the plant. Opiates along with these synthetic drugs — chiefly methadone and fentanyl — are grouped together into the category of substances called opioids.
Opioid receptors regulate pain and the reward system in the human body. That makes opioids powerful painkillers, but also debilitatingly addictive.
3. So is this crisis about prescription painkillers or heroin?
The crisis has its roots in the overprescription of opioid painkillers, but since 2011 overdose deaths from prescription opioids have leveled off. Deaths from heroin and fentanyl, on the other hand, are rising fast. In several states where the drug crisis is particularly severe, including Rhode Island, Pennsylvania and Massachusetts, fentanyl is now involved in over half of all overdose fatalities.
While heroin and fentanyl are the primary killers now, experts agree that the epidemic will not stop without halting the flow of prescription opioids that got people hooked in the first place.
4. Show me one way the epidemic has changed.
The latest iteration of the opioid epidemic has been especially deadly among adults in their 20s and early 30s.
In 2000, the most common age for drug deaths, including those not involving opioids, was around 40. This was the generation that first grew addicted to prescription opioids in large numbers — white people especially so. Now there’s evidence that the opioid epidemic is dividing into two waves, with a new group of younger drug users growing addicted to, and dying from, heroin or fentanyl rather than prescription pills.
5. Where is the worst of the problem?
There’s a lot of geographic variation in the rate of drug deaths, with the highest overdose rates clustered in Appalachia, the Rust Belt and New England.
Teasing out the reasons for the geographical differences is not easy. In certain places, the ways in which people use drugs could be more dangerous (you’re more likely to die from injecting heroin than you are from smoking it, for example).
But it’s clear that a significant portion of the variation in deaths, if not necessarily in use, is being driven by the appearance of fentanyl in the drug supply. Fentanyl, a highly potent opioid, affects heroin users and pill users both, the latter often falling victim to counterfeit pills that look like prescription painkillers.
So far, the white population has been hardest hit, but this is beginning to change. Several critics have been quick to point out that the country’s response was not nearly as public-health-oriented during the crack cocaine epidemic in the 1980s, which disproportionately affected African-Americans.
6. Why has this problem gotten so much worse in recent years?
Addiction to opioids goes back centuries, but the current crisis really starts in the 1980s. A handful of highly influential journal articles relaxed long-standing fears among doctors about prescribing opioids for chronic pain. The pharmaceutical industry took note, and in the mid-1990s began aggressively marketing drugs like OxyContin. This aggressive and at times fraudulent marketing, combined with a new focus on patient satisfaction and the elimination of pain, sharply increased the availability of pharmaceutical narcotics.
Pill mills began popping up around the country as communities were flooded with prescription opioids. Over the next decade, a growing number of people grew addicted to the drugs, whether from prescriptions or from taking them recreationally. For many, what started with pills evolved into a heroin addiction.
At the same time, the heroin market was changing. The price plummeted. Newly decentralized drug distribution networks pushed heroin and counterfeit pharmaceuticals into suburban and rural areas where they had never been. Everywhere the suppliers went, they found a ready and willing customer base, primed for addiction by decades of prescription opiate use.
Then in 2014, fentanyl began entering the drug supply in large amounts.
7.What is fentanyl and why is it killing people?
Heroin is derived from opium, a plant. That means its growers need fields and labor to harvest the crop. They are tied to land, weather and time.
Fentanyl is purely synthetic. Think chemistry, not agriculture. It’s commonly used for surgical anesthesia and is prescribed to treat pain, but almost all of the fentanyl on the streets is illicitly manufactured. According to the Drug Enforcement Administration, the majority of illicit fentanyl in the United States is manufactured either in China or in Mexico using precursors bought from China. And at least some portion of it comes to the United States in the mail, ordered from dark web sources like the recently shuttered AlphaBay. But we don’t know how much.
Fentanyl is a fine-grained powder, meaning that it’s easy to mix into other drugs. This is how most people are exposed to illicit fentanyl: It will be mixed into, or made to look like, powdered heroin or it will be used to produce counterfeit prescription pills.
It’s super potent, meaning you’re dealing with very small quantities. That makes it almost impossible to control supply. Though most of the fentanyl in America is thought to originate in China, the fact that it’s synthetic means it’s much harder to know where the drugs are coming from. With heroin, investigators could rely on regionally specific chemical markers to indicate where the drugs had been produced. With drugs synthesized in a lab, it’s harder to tell.
8. Why would people take fentanyl? It does not sound fun.
From a dealer’s perspective, fentanyl is easier to get and more profitable to sell. Some law enforcement officials argue that drug users will seek out batches of drugs that contain fentanyl or that are known to have killed people, as that demonstrates the drugs’ potency.
While that is certainly true for some number of drug users, research suggests that they are a minority. Most are exposed to fentanyl inadvertently — it’s difficult to know just what is in the drugs they are buying (many dealers don’t know themselves), one more risk in a dangerous pursuit of a high.
For long-time drug users, their continued use underlines the grip of addiction and the agony of withdrawal: They know it could kill them but do it anyway. Casual drug users are also at risk of fentanyl poisoning, particularly with increased reports of fentanyl-adulterated cocaine.
9. So shouldn’t we just stop prescribing opioids?
Opioids are a vital component of modern medicine that have measurably improved the quality of life for millions of people, particularly cancer patients and those with acute pain. But their efficacy in treating chronic pain is less clear, especially when weighed against the risks of overdose and addiction.
Though prescription opioid consumption has been decreasing in the United States since 2010 or 2011, it remains high. According to the International Narcotics Control Board, if the amount of opioids prescribed per year were averaged out over each person living in America, everyone would get about a two-week supply. (Or a three-week supply, according to the C.D.C. Different ways of measuring what counts as a daily opioid dose give different values.) Either way you count, it’s higher than anywhere else in the world.
At the same time, some chronic pain patients now struggle to fill their prescriptions. Solving the opioid problem requires controlling prescription opioid distribution while maintaining access for patients with legitimate medical needs. Suddenly removing access to opioids from those who are dependent on them to function could easily push people to illicit opioid sources, like heroin or counterfeit pills.
10. What can be done?
Experts agree fixing the opioid epidemic will take a combination of solutions. But it’s a question of priorities: Which approaches will be most effective and most efficient? What is the best use of resources?
Officials want to use state prescription drug monitoring programs to reduce the supply of prescription opioids that end up being used recreationally while maintaining adequate access for current chronic pain patients. More broadly, experts say we need to improve the way our medical system manages pain. Remember the 12 million people we said took prescription painkillers outside of medical use? Roughly two-thirds of those did so to relieve physical pain. A more holistic approach to pain treatment would lessen the need for opioids.
On the treatment side, experts stress the importance of having treatment readily available for those who are already addicted. Often that means going to where the people are, not waiting for them to seek out treatment themselves. And addiction treatment doesn’t just mean counseling or an inpatient clinic. Studies show the most effective treatment for opioid addiction often requires opioid medications like methadone or buprenorphine.
In the meantime, widespread distribution of naloxone — an overdose antidote — will save lives in acute cases.
There isn’t agreement about other possible measures that could help. Public health experts advocate things like safe injection sites, where people could use drugs under medical supervision, and drug checking services that people could use to test drugs for fentanyl, but many in law enforcement remain reluctant to adopt such measures.
11. Will the commission’s recommendations help?
The commission laid out a series of recommendations in its interim report, with a final report expected in October.
Some of the recommendations — like enhancing prescription drug monitoring programs and mandatory physician education on the dangers of opioids — are aimed at prevention. Some — expanding access to and funding development of medication-assisted treatment, eliminating Medicaid barriers to in-patient addiction treatment and enforcing laws that prevent health insurance companies from limiting mental health coverage — are aimed at treatment. The commission’s report also called upon the president to mandate that naloxone be carried by every American law enforcement officer.
Of course, these are only recommendations. It’s up to the president and the various executive agencies to implement them. Experts know how to attack the problem. It’s just a matter of having the will to put those policies into practice.
12. What does declaring a national emergency actually do?
The commission’s “most urgent recommendation” was for Mr. Trump to declare a national emergency. One way this could work is through the National Emergencies Act and a law called the Public Health Service Act.
During a public health emergency, this law gives the secretary of health and human service broad authority to make grants, conduct investigations and waive or amend a variety of health regulations.
For example, the opioid commission argued that the H.H.S. secretary would be able to waive the I.M.D. exclusion, an obscure rule that bars Medicaid reimbursement for patients in mental health facilities with more than 16 beds. Since Medicaid pays for a significant portion of inpatient drug addiction treatment, the exclusion is a major obstacle.
Many states have been granted waivers from this regulation, but the onus is on each state to prove that it qualifies for one. The commission asserted that an emergency declaration would give the H.H.S. secretary the power to grant a waiver to any state that requests one, but it’s not clear that this is the case.
Katz, J. (2017, August 10). Short Answers to Hard Questions About the Opioid Crisis. Retrieved from http://www.nytimes.com/