New Study from American Action Forum Adds to the Argument Against Present Supply-Side Opioid Policy

On April 11 the Washington Post cited a new study from the American Action Forum that reinforces arguments I have made here and here, that despite a dramatic reduction in the opioid prescription rate—a 41 percent reduction in high-dose opioid prescriptions since prescriptions peaked in 2010—the overdose rate continues to climb, as nonmedical users have simply migrated to more dangerous substitutes like fentanyl and heroin while the supply of diverted prescription opioids suitable for abuse continues to come down.

I have a minor quibble with the study’s finding that “the annual growth rate of prescription opioid-involved overdose fatalities significantly slowed from 13.4 percent before 2010 to just 4.8 percent after.” In fact, the Center for Disease Control and Prevention end-of-2017 Data Brief No. 294 reported:

The rate of drug overdose deaths involving natural and semisynthetic opioids, which include drugs such as oxycodone and hydrocodone, increased from 1.0 [per 100,000] in 1999 to 4.4 in 2016. The rated increased on average by 13% per year from 1999-2009 and by 3% per year from 2009-2016. (Emphasis added)

As an aside, it is worth mentioning that four researchers working in the CDC’s Division of Unintentional Injury Prevention reported in the April 2018 American Journal of Public Health that the CDC’s method for tracking opioid overdose deaths have over-estimated the number due to prescription opioids, calling the rate “significantly inflated.” Many overdose deaths actually due to fentanyl are folded into the “prescription opioid” numbers since, technically, fentanyl is a prescription drug even though it is rarely prescribed outside of the hospital in a form suitable for abuse. 

The AAF report understates the significant role that the abuse-deterrent reformulation of OxyContin and other opioids have played in driving nonmedical users to heroin and fentanyl. The researchers “suggest” abuse-deterrent formulations “could be a major factor driving the rise in heroin fatalities.” But evidence of the connection is much more powerful and convincing, as I presented in the Cato Policy Analysis “Abuse-Deterrent Opioids and the Law of Unintended Consequences” in February of this year.

The Washington Post says Ben Gitis, the lead investigator, stated that “many people became dependent on prescription opioids, and when the narcotics became difficult to obtain, people turned to whatever alternative they could find. The cartels saw that market and filled it rapidly.” He suggests in his study that overprescribing by doctors in the late 1990s and early part of this century was the driving force behind opioid abuse and addiction. This is another area where I have to disagree.

While there were undoubtedly unscrupulous doctors operating “pill mills,” some doctors who prescribed opioids too liberally with the best of intentions, and dishonest and overzealous pharmaceutical sales reps falsely representing the safety of their product, these factors were exceptions to the rule, and peripheral rather than central to the opioid overdose problem. 

It must be remembered that numerous studies throughout the 1970s, 1980s, and 1990s documented that patients were being undertreated for pain because of an irrational fear of opioids. In 1989, Charles Schuster, the Director of the National Institute on Drug Abuse, stated. “We have endowed these drugs with the mysterious power to enslave that has been overrated.” The “opiophobia” of the time gradually—and correctly—gave way to a more rational and humane approach to patients in pain. Furthermore, numerous studies, including Cochrane systematic analyses in 2010 and 2012, as well as a report this past January in BMJ by researchers at Harvard and Johns Hopkins show that opioids have an addiction rate of roughly 1 percent or less in the medical setting. And Dr. Nora Volkow, the current Director of NIDA, in a 2016 New England Journal of Medicine article, stated, “addiction occurs in only a small percentage of persons who are exposed to opioids — even among those with preexisting vulnerabilities.”

The National Survey on Drug Use and Health repeatedly finds that less than 25 percent of nonmedical users of prescription opioids obtain them from a doctor. Three-quarters obtain them from a friend, family member, or dealer. The NSDUH also found that nonmedical use of prescription opioids peaked in 2012, and total (medical and nonmedical) opioid use in 2014 was less than in 2012.

Studies repeatedly show upwards of 90 percent of opioid overdose victims have multiple drugs on board. In New York City in 2016, 75 percent of opioid overdoses were from heroin or fentanyl, and 97 percent also were found to have multiple drugs in their system at the time—46 percent of the time it was cocaine. And a November 2017 study from Washington University found 33.3 percent of heroin users entering rehab in 2015 stated that their gateway drug was heroin—as opposed to 8.7 percent in 2005. These numbers do not describe the profiles of patients victimized by doctors who were too liberal in their prescription of opioids. These are nonmedical users seeking drugs in the illicit and dangerous market that results from drug prohibition. 

And the problem is not confined to the US. In the European Union, where doctors historically have been “stingy” in prescribing opioids, expecting stoicism from their patients (and where it is much harder to “doctor shop”) there is an opioid crisis as well.  EU overdose rates have increased for the last three consecutive years for which data have been collected. It seems to be worse in the UK, Spain, and Sweden. And the distribution of drugs follows the same pattern as in the US: predominantly heroin and fentanyl. The same is happening in Australia.

Overdose deaths from methamphetamine and other stimulants have also been surging in recent years and now are at record levels. And recent reports from New England point to a surge in deaths from fentanyl-laced cocaine, the latest version of the “speedball.”

The reasons behind the rise in the illicit use and abuse of mind-altering drugs in the developed world is a subject worthy of serious investigation. The causes are most likely multifactorial. But policymakers need to disabuse themselves of the notion that the prescription of opioids to patients by doctors is at the heart of the problem. That notion has made too many patients suffer needlessly as the old “opiophobia” of the 1970s and 1980s has returned. 

The American Action Forum study provides yet another reason for our policymakers to end their focus on the supply-side. If they lack the political will to re-examine drug prohibition, they should at least put the focus on harm reduction programs, such as needle exchange and supervised injection facilities, medication-assisted treatment for addiction, and making naloxone available over-the-counter.