Commentary

As Fentanyl Floods the Streets, Don’t Blame Doctors, Patients

U.S. Food and Drug Administration Commissioner Scott Gottlieb announced a one-day “Online Opioid Summit” to be held in June to discuss “the compelling ease with which average Americans can now purchase illicit opioids online.” According to the federal Drug Enforcement Administration, while Mexican cartels play a role by using its well-established heroin and methamphetamine distribution networks, most of the fentanyl comes into the U.S. from China.

The overdose crisis has always been primarily due to nonmedical users accessing drugs in the dangerous black market that results from drug prohibition. While some unethical and unscrupulous doctors used their medical degrees to disguise their drug dealing operations in the form of “pill mills,” these were extreme exceptions to how doctors practice medicine and have been largely eradicated. Yet their behavior played into the false narrative to which misguided policymakers stubbornly cling.

For nearly 10 years, policymakers have been deluded into thinking that reducing prescriptions will reduce overdose deaths. State-based prescription drug monitoring programs already contributed to reducing the prescription of high-dose opioids by over 41 percent since 2010, the peak year of opioid prescribing. And opioid production quotas, set by the DEA, were cut 25 percent last year and another 20 percent this year. It was hoped that reducing the number of opioids in circulation would leave less available for diversion into the black market.

Fighting the war on drugs is like playing a game of Whac-A-Mole. Doctors and patients are the wrong targets.

The prescription cutdown has made many pain patients suffer needlessly and cruelly. Some have turned to suicide. Others access the black market for substitutes like heroin or fentanyl. As is always the case with prohibition, purveyors of illicit substances find new ways to satisfy market demand. Sometimes that involves substituting old drugs with new, more powerful ones. This was seen during alcohol prohibition as well, when bootleggers pushed whiskey over beer and wine. And so the overdose rate continues to climb.

Dealers are responding to market forces. Online distributors throughout China frequently sell fentanyl over the “dark web,” often shipping the products to the U.S. via the U.S. Postal Service or United Parcel Service. This is the way most fentanyl makes it on to the street, according to the DEA. The U.S. Centers for Disease Control and Prevention reports fentanyl caused 26,000 overdose deaths in 2017. For the past few years, fentanyl and heroin have been the major causes of opioid overdose deaths. The National Survey on Drug Use and Health reports nonmedical use of prescription opioids peaked in 2012, and total prescription opioid use in 2014 was lower than in 2012.

Last week, Nebraska State Patrol confirmed its spectacular drug bust of April 26 turned out to be “entirely fentanyl.” A total of 118 pounds of the white powder was seized, more than 26 million lethal doses. Last January, two men were sentenced to prison for smuggling nearly 100 pounds (roughly 18 million lethal doses) into the New York/New Jersey region in mid-2017.

Many dealers use pill presses to make counterfeit OxyContin or Vicodin pills and trick nonmedical users into thinking they are buying the real thing. That’s how Prince died. The singer/songwriter abused Vicodin. Records show he never got prescriptions from doctors. He died from ingesting counterfeit Vicodin pills he obtained on the black market that turned out to be fentanyl. Policymakers remain fixated on the false narrative that the overdose crisis is the result of doctors overprescribing opioids to their patients in pain, who then get hooked on opioids and become trapped in the web of addiction. But Prince’s tragic death actually typifies what is really happening.

A 2009 University of Pennsylvania study of OxyContin abusers found 78 percent of them had not received a prescription for any medical reason, 86 percent said they used the drug to “get high or get a buzz” and 77 percent gave a history of prior rehab for substance abuse. According to the National Survey on Drug Use and Health, less than 25 percent of nonmedical opioid users obtain prescriptions from a doctor. Three-quarters obtain them from a friend, relative or dealer.

Meanwhile, like a broken record, policymakers are intent on further reducing opioid prescriptions, as if that will do anything other than exacerbate matters. Columbia University researchers last month found evidence that the present restrictive opioid policy is not lowering overdose rates, but merely pushing nonmedical users to more dangerous drugs, making patients suffer in the process. This comes after two earlier studies came to similar conclusions. Drug dealers are quickly responding to the reduced supply of “diverted” prescription opioids with deadlier substitutes.

Fighting the war on drugs is like playing a game of Whac-A-Mole. Doctors and patients are the wrong targets. Until drug prohibition is recognized as the culprit, don’t expect the death rate to go down.

Jeffrey A. Singer practices general surgery in Phoenix and is a senior fellow at the Cato Institute.