New Hampshire’s chief medical examiner recently leased the state’s latest opioid overdose death totals for 2018. As in most of the country, prescription opioids are not propelling the death rate in New Hampshire. For the last several years, more and more non‐medical users have been dying from heroin and fentanyl, with fentanyl accounting for more than 83 percent of overdose deaths in the Granite State.
But you won’t hear about the Fentanyl crisis, because all anyone seems to talk about is the opioid crisis. It’s a false narrative which holds that the serious number of overdoses nationwide is the result of greedy drug makers manipulating gullible doctors into overtreating patients in pain and hooking them on drugs.
And even then, it’s not Fentanyl that’s at the root of our nation’s overdose problems. The real source of our woes is drug prohibition.
The fact is, the overdose crisis has always been primarily the result of non‐medical users accessing drugs in the dangerous black market that results from prohibition. As the supply of prescription opioids diverted to the underground gets harder to come by, the efficient black market fills the void with other, more dangerous drugs. Lately, the synthetic opioid fentanyl has emerged as the number one killer. The DEA reports that the overwhelming majority of seized fentanyl is “illicit fentanyl” — fentanyl made in a powdered form (unlike prescription grade fentanyl) in underground labs in Asia and Mexico and smuggled in often by mail, Fedex, or United Parcel Service. This drug is 50 times more potent than heroin. Some fentanyl analogs designed by inventive drug dealers are even more powerful than that.
Drug prohibition fuels this lucrative enterprise. Prescription surveillance boards and government‐mandated prescribing limits have pushed prescribing down dramatically. High‐dose prescriptions were down 41 percent between 2010 and 2016, another 16.1 percent in 2017, and another 12 percent this year. But the overdose rate continues to climb. Estimates place the 2017 overdose rate related to opioids at 49,000 deaths.
Moreover, the black market for drugs is full of dangerous uncertainty. Dealers with pill presses turn the powder into counterfeit prescription pills and sell them to unsuspecting users—sometimes to desperate patients who’ve been cut off from their pain meds by doctors terrorized by surveillance boards—causing them to asphyxiate from an overdose. That’s what happened to Prince. He liked to use Vicodin (hydrocodone) to get high. Records show he never went to a doctor for a prescription. His dealer scored him some counterfeit Vicodin that turned out to be fentanyl. Prohibition killed Prince, not prescription opioids.
There is a stark difference between the U.S., with its strict prohibition, and other countries which have liberalized drug policy. Portugal, in 2001, recognized that prohibition was driving the death rate. At the time it had the highest overdose rate in Western Europe. It decriminalized all drugs and redirected efforts towards treatment and harm reduction. Portugal saw its population of heroin addicts drop 75 percent, and now has the lowest overdose rate in Europe. It has been so successful that Norway is about to take the same route.
If the political will is not yet there to consider decriminalization, then at a minimum policymakers in the U.S. should turn to harm reduction. They should expand syringe exchange and supervised injection facilities, lighten the regulatory burden on health care practitioners wishing to treat addicts with medication‐assisted treatments such as methadone and buprenorphine, and reschedule the overdose antidote naloxone to a truly over‐the‐counter drug.
It’s time to stop calling it an “opioid crisis.” The term is misleading. One particular opioid, fentanyl, is the primary killer. But even calling it a “fentanyl crisis” would be inaccurate. The real killer is prohibition.