Friday, March 1, 2019

Opioid Crisis

The opioid crisis seems to me one of those issues everyone knows exists, but also an issue that our political system and society really hasn't come to grips with. Molly Schnell provides a useful short overview in "The Opioid Crisis: Tragedy, Treatments and Trade-offs," written as a Policy Brief for the Stanford Institute of Economic Policy Reseach (February 2019). She writes: 
Overdose deaths have increased by more than 1,000 percent since 1980, with each of the past 28 years surpassing the last. With over 70,000 fatal overdoses in 2017 alone — an average of 192 deaths per day — drugs now kill more people than HIV/AIDS at the height of the epidemic in 1995.

When the AIDS epidemic peaked in 1995, it was (appropriately) a major center of public focus and discussion. For example, the best-selling book by Randy Shilts, And the Band Played On: Politics, People, and the AIDS Epidemic, had been published in 1987. Kushner's Angels in America had premiered on Broadway four years earlier in 1991, winning a Pulitzer and a Tony. While I've read some insightful writing on America's opioid crisis, it does not seem to have led to the same intensity of discussion.

Schnell illustrates some key patterns with this figure. The blue bars show the pattern of opioid prescriptions since 2000. Notice that the sharp rise in prescriptions is also tracked by the red line showing a rise in overdose deaths from commonly prescribed opioids. Then when the level of prescribed opoids levels out around 2010, overdose deaths from heroin start rising quickly, then followed by deaths from synthetic opioids like fentanyl a few years later.

Of course, this rise in deaths is an understatement of the costs of the opioid crisis. Addition has lots of costs other than early death.

As I've argued in the past, the opioid crisis is a problem that was created by the US health care industry. There isn't any particular reason in terms of underlying health why opioid prescriptions roughly quadrupled from 2000-2010, and since then have dropped by a quarter.  But it seemed like a good idea at the time, and now tens of thousands of people are dying every year.

The rise in overdose deaths from heroin and fentanyl shouldn't obscure that deaths from prescription opioids--over overprescribed by the health care industry and then passed along or re-sold--remain part of the problem. Schnell writes:
Non-medical use of prescription opioids remains the second most common type of federally illicit drug use, second only to marijuana, and is over 12 times more common than heroin use (SAMHSA, 2018). And while overdose deaths involving prescription opioids leveled off in 2016, they remain at four-and-a-half times their level from 2000 and account for at least 40 percent of all opioid-related mortality.
Some steps seem to have moderate but real effects. For example, when an average doctor is told that a patient overdosed from their prescription, that doctor cuts back on prescribing opioids by about 10%. Some states have mandatory "prescription drug monitoring programs." which make it harder for someone to take one prescription for an opioid and have it filled at several different pharmacies.

 Schnell writes: "Any single policy in unlikely to be sufficient to address the current crisis. Policies aimed at reducing prescriptions should be paired with broad access to treatment for those with problematic opioid use. And policies must be designed so as to not prevent providers from using opioids as a tool to help manage their patients’ pain." All fair enough, btut the rising body count calls for dramatically more, and it's not clear what would work.The health care industry dramatically raised its opioid prescriptions, and in doing do has opened Pandora's box.