The Opioid Crisis Has Not Peaked

The opioid crisis is far from over.  It has merely morphed, and it may be getting worse in some areas.  Without diminishing President Trump's exuberance that the death rate has peaked, caution is more in order.

Ahead of a 2020 race already focused on health care, President Trump is boasting that his administration played a huge role in achieving the first annual drop in overdose deaths in three decades.  The drop, he crowed recently, is "tremendous."

The problem is that deaths from opioid overdoses may be a flawed metric to consider.  The drop in deaths can be attributable to wider use of naloxone, an opioid antidote that has saved countless lives, rather than a decrease in usage.

Prescriptions of the overdose-reversing drug naloxone are soaring, and experts say that could be a reason overdose deaths have stopped rising for the first time in nearly three decades.

In some states, Naloxone is now sold over the counter.

41 states have legalized its sale without a prescription, according to CVS. The states not on the CVS list are Delaware, Hawaii, Kansas, Maine, Michigan, Nebraska, Oklahoma, South Dakota and Wyoming.

Now everyone and his grandfather can be equipped to assist those who collapse from an overdose.

None of this necessarily translates into a decrease in usage, nor a lessening of the problem.  All that may have peaked are the immediate consequent deaths — not that that isn't a good thing.  But the problem is persisting.  Even then, the data are inconclusive and not uniform.  Connecticut has had a frightening increase in opioid deaths.

A record high 1,200 fatalities in 2019 is an 18% jump[.]

The number of people who died in Connecticut from drug overdoses in 2019 was the most the state has recorded in a single year, even after a dip in deaths in 2018.

So has San Francisco.

Deaths resulting from overdoses of Heroin, Fentanyl or combination of the two drugs more than doubled in 2019, the San Francisco Chronicle reported on Wednesday.

According to preliminary statistics compiled by city authorities, deaths from overdoses of Fentanyl, a synthetic painkiller 100 times more powerful than morphine, alone reached 234 in 2019, up from 90 in 2018.

The real crisis now is with fentanyl, a synthetic opiate, easy to produce and powerful enough to be effective in extraordinarily low doses — so that only small volumes need to be smuggled.  It is easy to get past the authorities.

We all have an idea of how this started.

Purdue Pharmaceuticals had made an earlier claim (1998) that opiates used for pain management are not that addictive.  This claim was based on just one letter to the 1980 New England Journal of Medicine.

Recently, we examined our current files to determine the incidence of narcotic addiction in 39,946 hospitalized medical patients who were monitored consecutively.  Although there were 11,882 patients who received at least one narcotic preparation, there were only four cases of reasonably well documented addiction in patients who had no history of addiction.  The addiction was considered major in only one instance.  The drugs implicated were meperidine in two patients, Percodan in one, and hydromorphone in one.  We conclude that despite widespread use of narcotic drugs in hospitals, the development of addiction is rare in medical patients with no history of addiction.

That is not much to go on.  It certainly did not constitute an adequate controlled study.  Yet that is what Purdue Pharmaceuticals used to push the claim of opiate safety.  And the marketing of its signature product, Oxycontin, certainly jump-started a great degree of this present opioid problem.

Oxycontin created a generation of addicts who got started with legitimate medication.  By the mid-aughts, the damage was clear.  Oxycontin was forced to pay $600 million in fines.

By 2010, Purdue Pharmaceuticals reformulated the drug to discourage abuse.  Simultaneously, the government started cracking down on doctors who overprescribed opiates.

Suddenly, those addicted to Oxycontin — some were middle-class patients — were cut off from a legitimate supply, and even if they could get Oxycontin, it could no longer be crushed and injected, or nasally inhaled, for a quick rush.  The addicts then switched to street heroin.

From there, it was a shot and a jump to fentanyl, a drug orders of magnitude more powerful than morphine.

New York State set up the I-STOP program to require doctors prescribing opiates to check in a state-run database to make sure that patients are not doctor-shopping for duplicate prescriptions.  Many states will now require doctors to foward prescriptions electronically to a pharmacy rather than have them written on script, which can be easily forged.

The nation recently reached the halfway point in its effort to spur the replacement of easily stolen or forged paper prescriptions with electronic prescribing.  With the recent signing of bills in both Florida and Texas, more than half of all states are on their way to requiring that prescribers use e-prescribing for opioids, controlled substances, or all prescriptions.

These are all wonderful ideas — albeit with some downsides — and might have stopped the crisis had they been implemented around 2000, but they weren't.   The government is fighting the last war.

Big Pharma is being sued into bankruptcy.  Oxycontin declared a pre-emptive bankruptcy a few months ago.  Worst of all, patients who do need pain medication are having a hard time getting it.

But the danger now is fentanyl — cheap, easy to hide, and super-powerful.  Naloxone is keeping these addicts alive but not unaddicting them.

Obviously, what worked before will not work now.

A lot of it is coming from China — where nothing happens without government oversight.  So smuggling in fentanyl seems to be a government policy.  Maybe revenge for the Opium Wars.  As the undercover journalist Ben Westhoff found out:

"I actually went undercover into a pair of Chinese drug operations, including, I went into a fentanyl lab outside Shanghai. And I was pretending to be a drug dealer."

He continued: "What I learned was that these companies making fentanyl and other dangerous drugs are subsidized by the government.  And so when they work in these suburban office parks, for example, the building, the costs for research and development, they have these development zones, they get export tax breaks."

Not only can fentanyl be mailed out from China in small letters, but it can be smuggled over the border from Mexico in drones.  Or distributed by the difficult-to-trace dark web.  They even sell it on Craigslist.  At some point, society will have to admit that this cannot be controlled from the producer side of the equation.

A) This opioid crisis is not peaking.  It is merely changing.  Given that these substances are so addictive, a get-tough policy may not work.  These drugs change the brain and emasculate the willpower to get off the substances.  Getting tougher on addicts may only create an over-incarcerated society.

B) A hands-off policy may not work, either.  San Francisco's disaster with the homeless shows that when all rules are removed, the situation does get worse.

C) Portugal has had some success with the decriminalization of drug use — and it is being suggested in Canada — but the addicts are clearly monitored, similar to our methadone programs.  Drugs are not legal, but the addicts are given health options.

However, less us not be fooled.  Portugal is a mono-ethnic, almost mono-racial culture, where almost everyone subscribes to a basic set of given social rules.  Muslims are less than one-half of one percent of the population.  Ninety-five of the population is ethnic Portuguese.  Essentially, everyone is extended family.  Such a generous attitude would not work in a society where diversity is everywhere and litigious lawyers abound.

To that end, the USA, if it adopts a Portuguese course of decriminalization, may have to modify it considerably.  Education should be stressed, but frankly, it already has been and hasn't worked that much, has it?
Addicts are here to say, and given fentanyl's rise, they will be for a very long time.  I do not like the idea of imprisonment, nor hampering them with criminal records, but a modification of their civil rights might in order.

When caught with illegal drugs, the addicts might be given a choice: cold turkey withdrawal in jail or admittance into a drug control program, where they will get safer drugs, but...they lose the right to vote.  Their movement is restricted and monitored by ankle bracelet.  They cannot visit certain parts of town.  They lose the right to drive.  They lose custody of their be permanent after a year.  Not until they test clean for one year can these rights be restored to them — and the loss of children may be permanent.

Many will think I am too soft on drug addicts, but too many middle-class people have fallen into this trap.  We can no longer ascribe addiction to a pure moral failure.  One can get addicted, even from proper use of painkillers after surgery.  Therefore, legal remedies may not always be proper.  This has not peaked, nor will it go away.  Naloxone is helping to prevent deaths but is not saving lives.

Controlling the producers is impossible.  A moral regeneration of the public might be the only solution.  Dry up the market on the buyer's end.  Until then, a modified version of civil rights restriction might be preferable to incarceration for many of these cases.

Notice that I am not asking for legalization — a policy that I think was wrong for marijuana.  I am in favor of a modified decriminalization.

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