With opioids, death is a symptom and unity is the cure

With opioids, death is a symptom and unity is the cure
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Opioid deaths reached record peaks in 2016. New demographic breakdowns show startling rises among African-Americans, and the cumulative effect of opioid deaths has driven down overall life expectancy for the second consecutive year, something not seen since the 1960s.  A baby born today can expect to enjoy two fewer months of life than one born just a few years ago.  

It is important to understand, however, that we as a nation did not make some terrible mistake in 2016.  That last year of the Obama administration was not marked by gross negligence or stupidity. Likewise, when 2017’s numbers roll in and likely shatter these recent records, one should not presume that Trump administration policies deserve blame.

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Rather, these deaths are a symptom of a 20-year accumulation of opioid dependence and addiction. I say that not to minimize what is happening now, but in hope that our country can avoid counterproductive finger-pointing and come together to focus on the work at hand.

 

The broad history is familiar.  Heroin spread to many American cities in the late 1960s, but then stabilized. From the mid-1970s to the mid-1990s, the pool of chronic, problem users was stable.  Premature deaths struck roughly 1 percent each year, mostly from overdose but also from violence, accidents and assorted other causes, with initiation offsetting departures from death or recovery.

That stability was broken when opioid prescribing expanded beyond traditional indications to also include treatment of chronic pain in patients who were not near the end of life.  Taking opioids for acute pain rarely leads to addiction, but a distressing proportion of long-term pain patients became addicted and, after some time, began “trading down” to cheaper black market heroin.  (Selling prescription pills into the black market and buying cheaper heroin effectively triples the amount of opioids one can take.)  

That swelled the number of people struggling with opioid addiction, probably at least fourfold.  Deaths rose roughly proportionately before soaring in 2014 when drug traffickers began supplementing heroin with fentanyl. Black market fentanyl wasn’t some sick form of revenge cooked up by Mexican traffickers. It’s more bad luck than conspiracy.

The technology for producing fentanyl spilled over from Chinese factories that were supplying pharmaceutical companies to rogue Chinese chemists who supplied drug trafficking organizations. The traffickers bought because fentanyl cut their cost of packing a given kick into a dime bag, and that would have happened with or without the expansion in heroin demand.

Here is a metaphor: Imagine that after 20 years of overeating and under-exercising, you moved to the mountains from a flat state in the Midwest. Being overweight and out of shape causes problems even in Nebraska but it suddenly becomes more pronounced at high altitude when walking up steep slopes. The opioid problem and fentanyl is like that.

What should we do?  We can’t move back to Nebraska; in all likelihood fentanyl is here to stay. Clearly we’ve got to make lifestyle adjustments. First responders need to carry naloxone to reverse overdose and taxpayers need to underwrite a massive expansion in treatment — costing closer to $10 billion per year than $1 billion. But just as clearly, we need to address the root causes by staunching the flow of people into opioid dependence.

If you break your arm, a health care provider can fix it and your arm will be good as new. Addiction is not like that. Of course some recover completely, but at the population level, providing treatment does not make people whole. Dropping out and relapsing is more common than graduating and remaining drug-free.

Long-term studies following people who were already receiving treatment find premature death rates remain elevated by a factor of ten, and not just in the United States. Those results have been replicated around the world, including in countries with well-funded treatment systems.  

The nation will be dealing with its two decades-long expansion of opioid prescribing and dependence for decades to come. It demands a unified national effort analogous to Roosevelt’s New Deal, but next year’s death statistics are as much a product of opioid prescribing practices 10 years ago as they are of what political leaders do today.

To paraphrase Winston Churchill, even if we do everything right in the new year, 2018 will not be the end or even the beginning of the end — but if we stop the flow of people into opioid addiction, it can be the end of the beginning.  

The nation needs a Churchillian leader who can bring us together in determination, generosity and compassion to deal as best we can with what will be the defining challenge of this generation. Yet today’s crisis has been decades in the making, so we need to refrain from hastily judging today’s interventions based on year-to-year changes in what is ultimately a symptom of a longstanding condition.  

Jonathan P. Caulkins is the H. Guyford Stever University Professor of Operations Research and Public Policy at Carnegie Mellon University’s Heinz College. His research includes modeling the effectiveness of interventions related to drugs, crime, violence, delinquency and prevention.