The nation’s opioid crisis is real and it is serious. As Christopher Caldwell recently pointed out, “those who call the word ‘carnage’ an irresponsible exaggeration are wrong.” And so, too, are those playing politics with the crisis. Even beyond the politicization—or, perhaps, because of it—there is still a great deal of misunderstanding as to what is driving this crisis.
As for the first problem, the politics: Senator Claire McCaskill (D., MO) has announced that she is initiating an investigation of several opioid manufacturers, and is requesting “reams of information” from them. But note the one manufacturer she did not target and from which she did not request information—Mallinckrodt. Mallinckrodt, after all, is headquartered in Missouri, her own state. Odd, that. And it’s not as if Mallinckrodt is a bit player in the manufacture and sales of opioid drugs. Indeed, “it is one of the nation’s largest” producers, responsible for nearly 20 percent of the market share of opioid prescriptions. The companies McCaskill has targeted are responsible for a total market share of 5.25 percent combined. Odd, that. If she were serious about investigating pharmaceutical companies, she most certainly would be investigating the one based in her own home state which also happens to be the one responsible for most opioid sales in America.
But all of this is not even the beginning of the beginning in addressing America’s opioid crisis. For when political leaders like Senator McCaskill are not playing politics with the issue, they are too often misunderstanding it. Some of that is not their fault.
Part of the problem in addressing the opioid crisis is that the terminology can be confusing or misleading. People hear “opioid” or “prescription opioid” or “fentanyl” and begin to lump the problems all together as a crisis driven by legitimately prescribed drugs. No doubt, that is a part of the problem, but it is nowhere near the biggest part of it. Take a look at the best statistics available (taken from the Office of National Drug Control Policy and the CDC):
- In 2015, there were 33,091 opioid overdose deaths.
- Heroin deaths constituted 12,990 of those deaths.
- Synthetic opioids (mostly illegal fentanyl) constitute another 9,580 deaths.
Because opioid deaths usually involve the use of more than one drug, percentages and raw numbers will not neatly add up to 100% or the 33,091 deaths. As the White House Website puts it: “A portion of the overdose deaths involved both illicit opioids and prescription opioids.” But what we can see from the above is that over 68 percent of the problem is from the use of illegal drugs. Or, as the CDC put it in December of 2016: “[T]he increase in opioid overdose death rates is driven in large part by illicit opioids, like heroin and illicitly manufactured fentanyl, a synthetic opioid.”
As for the prescribed opioids, the majority of overdose deaths from those come from the diversion and illegal distribution of them. As the CDC notes: “Most people who abuse prescription opioids get them for free from a friend or relative.” The people “at highest risk of overdose” “get opioids using their own prescriptions (27 percent), from friends or relatives for free (26 percent), buying from friends or relatives (23 percent), or buying from a drug dealer (15 percent).” Thus, for the population that overdoses from opioid prescriptions, 64 percent abuse them from a diverted or illegal source. In other words, the abuse of opioid prescriptions that leads to overdose deaths involving a patient acquiring a legal prescription and misusing that prescription on himself is less than 30 percent of the prescription problem and constitutes about 15 percent of the overall opioid overdose problem.
This is backed up, as well, by the most recent testimony of the Director of the National Center for Injury Prevention and Control at the CDC, Dr. Debra Houry. Just last month, she testified to Congress stating,
Although prescription opioids were driving the increase in overdose deaths for many years, more recently, the large increase in overdose deaths has been due mainly to increases in heroin and synthetic opioid (other than methadone) overdose deaths, not prescription opioids. Importantly, the available data indicate these increases are largely due to illicitly manufactured fentanyl.
Again, the main driver of our current crisis is the use and abuse of illegal drugs, not legally prescribed drugs. Indeed, there is some common sense to this. Almost anyone who has had a surgical procedure was likely given a legal opioid like fentanyl. As one prominent anesthesiologist recently wrote: “To an anesthesiologist, fentanyl is as familiar as a Philips screwdriver is to a carpenter; it is an indispensable tool in my toolbox. It is the most commonly used painkiller during surgery. If you’ve had surgery, it is more likely than not that you have had fentanyl.” And yet the vast majority of people who have had surgical procedures do not have substance abuse or opioid abuse problems.
Yes, there is a popular reverse gateway theory regarding heroin abuse—i.e., that high percentages of heroin users started by abusing prescription opioid drugs. But that is misleading and, indeed, looks at the problem from the wrong direction.
As Dr. Robert DuPont from the Institute for Behavior and Health has put it:
[W]hile 80% of heroin users used a prescription opioid before they first used heroin, the vast majority, over 96%, of people who have used a prescription opioid non-medically [i.e., illegally] have not transitioned to using heroin. Five years after the initial nonmedical use of a prescription opioid, only 3.6% ever used any heroin. Among prescription opiate users, the people most vulnerable to switching to heroin are those who are also abusers of other drugs including alcohol.
In other words, the vast majority of prescription opioid patients do not transition to the use of an illegal drug like heroin.
Other data bear this out, as well. For example, according to an important article in the January 2016 issue of The New England Journal of Medicine, it was found that “[A]lthough the majority of current heroin users report having used prescription opioids non-medically before they initiated heroin use, heroin use among people who use prescription opioids for non-medical reasons is rare, and the transition to heroin use appears to occur at a low rate.”
The numbers and factors detailed here are not meant to diminish or emphasize any serious or particular effort to address the variety of opioid issues contributing to the present crisis but, rather, to detail the full picture of the problem in sharp relief. Playing politics with this crisis will get us nowhere and waste a lot of time, energy, and resources. Public confusion about what is leading the epidemic and behind the majority of cases driving the crisis is another problem altogether, made worse by playing politics with it. It is time, past time, to get serious about this issue and take it on in a serious manner.
There are a great many efforts aimed at dealing with pill mills and irresponsible and rogue sales of prescription opioids. That is all to the good. But those efforts will not solve the problem or even get to the roots of the largest parts of it. A responsible and successful prevention campaign is needed and must be combined with serious drug education policies and messages along with a greater border and law enforcement effort. For concerned Americans, first and foremost, it is our duty to become educated about the issue.