Why Overdose Deaths Increased After Prescriptions Dropped

The American crackdown on the drugs that kicked off the modern opioid overdose epidemic—prescription opioids—largely succeeded. Data released by American Medical Association on September 8 shows that prescription opioids in the United States have fallen nearly 50% over the past decade according to the AMA.

The attempt to stop overdose deaths has been a failure. Federal data shows that the annual number of overdose deaths from opioids has tripled since 2010. In April 2021, the number of drug overdoses in the United States surpassed 100,000. The majority of them were opioid-related.

Although there were many contributing factors, the problem lies in the fact that drug markets have evolved faster than efforts to reduce drug overdoses. “The prices of these drugs have never been cheaper. And the potency of these drugs has never been higher,” says Dr. Daniel Ciccarone, a professor who researches the opioid crisis at the University of California-San Francisco.

Ciccarone says that prescription painkillers were once the initial wave of the opioid crisis. However, Ciccarone claims the second wave began in 2000, with increasing awareness about the dangers of prescription opioids. As states and the federal government implemented programs like prescription monitoring, health care workers rapidly reduced the number of opioid prescriptions they issued in order to protect their patients—and their medical licenses. This quick change meant many people were abruptly cut off from prescription opioids. They received inadequate help tapering off opioid medications or coping with lingering pain, and many turned to the illegal drug market, including heroin, says Nabarun Dasgupta, who studies opioid overdose and substance use disorder at the University of North Carolina’s Gillings School of Global Public Health.

Many people continue to be left behind, he says: “There are a lot of abandoned people who were on pain medications, who cannot get access to adequate pain management anymore, and are therefore, increasingly, turning to the street. We hear those stories every day.”

The U.S. reached an important turning point in late 2010. Overdose deaths started to decrease nationally and even declined in some states like Massachusetts, Rhode Island, Minnesota, and Massachusetts. These were all due to aggressive prevention measures. Thomas Stopka is an associate professor of community medicine and public health at Tufts University School of Medicine. He believes that a wide variety of programs have proliferated. These include public education and expanded access to opioid abuse disorder medications like buprenorphine. The decline might also be attributable to the rise and fall of carfentanil—an opioid more potent than fentanyl—in the late 2000s, says Ciccarone.

During this time, the illegal drug market changed. First, there was the emergence of the synthetic opioid fentanyl, which in its legal form is often used to relieve pain during and after surgeries, but on the illicit market is valued because it’s cheap to manufacture, easy to move, and leads to a high that’s more powerful (but shorter lasting) than heroin. The drug manufacturing industry also became more fractured following crackdowns on poppy cultivation and fentanyl manufacturing, says Dasgupta, with a lot of the production shifting to Mexico, where there were more “little manufacturers who have less interest in quality control, and are trying to make a fast buck.”

Fentanyl, and its chemically related drugs (analogs), were first discovered on the East Coast. The drug played an important role in the rise of deaths. Different potencies can be very different, making it challenging for drug addicts to control their dosage. Mixing substances together poses a greater risk.

It became more risky to use and supply drugs. Fentanyl was increasingly used with other stimulants, such as methamphetamine or cocaine. Many substances have been sold in combination with other drugs. Many experts, including Ciccarone, say it’s not clear if this is intentional. The result, however, is that many drug users, and even drug sellers, have no idea what’s in the drugs they’re buying. This is particularly dangerous because it means users can’t adjust the level they consume to their individual opioid tolerance. People who are not regular opioid users and haven’t built up tolerance might also accidentally use the drug. In addition to fentanyl, and its analogues, drug might also contain novel psychoactive substances such as the opioid nitazine or animal tranquilizer, xylazine.

Even worse was the COVID-19 pandemic. Experts have suggested that drug distribution networks favoured more powerful drugs. Many people were cut off from their jobs, social safety nets, and normal lives by the pandemic, which in turn exacerbated mental health problems and led to substance abuse disorder. “Humans got hurt,” Ciccarone says. “We got isolated, we got afraid. We lost our social networks, and safety nets. And that just leads to more deaths.”

Experts on drugs use and the AMA argue that the best way to remove barriers to accessing treatment for substance abuse disorder is to eliminate the stigma surrounding opioid addiction. Expanding access to resources that can save lives is also crucial, such as naloxone, which reverses overdoses (also called Narcan), and syringe swaps.

Ciccarone states that it will take a large investment both in financial resources as well as public attention to save lives. While overdose deaths will go up and down, he says, the factors that drive many people to drug use—trauma and suffering—aren’t going away. “There’s no magic bullets,” he says. “You need bold, steady, Marshall-plan level attention to the drug consumption problem in America.”

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