Policymakers can reduce overdose deaths and other harms stemming from nonmedical use of opioids and other dangerous drugs by switching to a policy of “harm reduction” strategies. Harm reduction has a success record that prohibition cannot match. It involves a range of public health options. These strategies would include medication-assisted treatment, needle-exchange programs, safe injection sites, heroin-assisted treatment, deregulation of naloxone, and the decriminalization of marijuana.
Though critics have dismissed these strategies as surrendering to addiction, jurisdictions that have attempted them have found that harm reduction strategies significantly reduce overdose deaths, the spread of infectious diseases, and even the nonmedical use of dangerous drugs.
As a result, the value of all drugs seized by the average agent has fallen by 70% since FY 2013. Without marijuana coming in between ports of entry, drug smuggling activity now primarily occurs at ports of entry, where a border wall would have no effect. In FY 2018, the average inspector at ports of entry made drug seizures that were three times more valuable overall than those made by Border Patrol agents between ports of entry — a radical change from 2013 when Border Patrol agents averaged more valuable seizures. This is because smugglers bring mainly hard drugs through ports. By weight, the average port inspector seized 8 times more cocaine, 17 times more fentanyl, 23 times more methamphetamine, and 36 times more heroin than the average Border Patrol agent seized at the physical border in early 2018.
Study after study show a “misuse” rate of less than 1% in patients prescribed opioids for acute pain or chronic pain. And numerous large studies show an even lower overdose rate from opioids used in the medical setting.
Between 1999 and 2009, opioid death rates were rising rapidly, but heroin death rates were much lower and were increasing slowly. In 2010, this changed; over the next four years, heroin death rates increased by a factor of four while opioid death rates remained fairly flat.
Opioids are narcotic pain relievers and are available, legally, only by prescription. When used as directed, they are an important element of fighting acute and chronic pain. However, when taken in large quantities, opioids shut down the respiratory system and can lead to death.
Starting in the mid-1990s, medical groups argued that there was an epidemic of untreated pain, and they urged greater use of opioid pain medicines, especially for those with chronic conditions. The efforts changed prescribing practices considerably. Between 1991 and 2013, opioid prescriptions increased threefold. Opioids are addictive, and as their everyday use increased, so did abuse rates.
OxyContin became popular for recreational use and abuse because the drug offered much more of the active ingredient, oxycodone, than other prescription opioids, and because the pills could easily be manipulated to access the entire store of the active ingredient. In early August 2010, the makers of OxyContin, Purdue Pharma, took the existing drug off the market and replaced it with an abusedeterrent formulation (ADF) that made it difficult to abuse the drug in this fashion.
OxyContin prescriptions, deaths from opioids, fatalities reported to the makers of OxyContin, calls to poison control centers for opioids, and entrance into opioid treatment programs all have flatlined since the third quarter of 2010.
However, this change made the drug far less appealing to opioid abusers and led many to shift to a readily available and cheaper substitute, heroin.
For example, in the case of the OxyContin reformulation, opioid death rates were increasing rapidly across all groups before reformulation, but were flat afterward. That might seem like a success, but when heroin and opioid death rates are combined, there’s no evidence that total heroin and opioid deaths fell at all after the reformulation. Instead, there appears to have been one-for-one substitution of heroin deaths for opioid deaths.
In the past several years, the national movement to end drug prohibition has accelerated. Nine states and Washington, DC, have legalized recreational marijuana, with at least three more states (Connecticut, Michigan, and Ohio) likely to vote on legalization by the end of 2018. Dozens of others have decriminalized the substance or permitted it for medicinal use. Moreover, amid the nation’s ongoing opioid crisis, some advocates and politicians are calling to decriminalize drugs more broadly and rethink our approach to drug enforcement.
Drug legalization affects various social outcomes. In the debate over marijuana legalization, academics and the media tend to focus on how legalization affects public health and criminal justice outcomes. But policymakers and scholars should also consider the fiscal effects of drug liberalization.
Hospitals are working hard to ameliorate the situation by asking medical staff to use prescription opioid pills such as oxycodone and OxyContin instead of injectables, but many patients are unable to take oral medication due to their acute illness or post-operative condition. In those cases, hospitals use injectable acetaminophen, muscle relaxants, or non-steroidal anti-inflammatory agents, but those drugs fail to give adequate relief. Some hospitals have even resorted to asking nursing staff to manually combine smaller-dose vials of morphine or other injectable opioids that remain in-stock as a replacement for the out-of-stock larger dose vials. Dose-equivalents of different IV opioids vary and are difficult to accurately calculate. This increases the risk of human error and places patients at risk for overdose.
“Abuse-deterrent” opioids have done nothing to address the surge in deaths from opioid overdoses — but they have made the problem much worse…
The United States has seen a surge in deaths from overdoses of opioids, including both prescription drugs and illegal opioids such as heroin. Nonmedical users and abusers often obtain prescription opioids diverted from the legal to the illegal market. In the hope of reducing opioid use, abuse, and overdoses, policymakers have focused on developing and promoting tamper-resistant or abuse-deterrent formulations (ADFs) that render diverted opioids unusable if individuals attempt to use them for nonmedical (i.e., recreational) purposes.
Government at all levels should stop promoting ADF opioids. Congress should end or limit the ability of pharmaceutical manufacturers to impose higher costs on pain patients by using ADFs to “evergreen” their opioid patents (evergreening is a practice by which pharmaceutical manufacturers extend or renew the patent protection before the current patent expires by tweaking the formula slightly or repurposing the product)/
In Los Angeles, for example, the city council cited crime in its 2010 decision to cap the number of dispensaries in the city. On June 7, 2010, roughly 70% of the nearly 600 shops operating in the City of Los Angeles were ordered to close. The shutdown came after years of concern and indecision over how to handle the burgeoning medical marijuana dispensary business in the city. In September 2007, the city adopted an Interim Control Ordinance, placing a temporary moratorium on new dispensaries and requiring existing dispensaries to register with the city by November 13, 2007.
Given the limited time that dispensaries had to submit a registration form along with the required city business tax registration certificate, registration was quite ad hoc. How the city would use the registrations was unclear, and the market continued to grow for several years despite the moratorium. In January 2010, final regulations, including closure orders, were adopted. The new ordinance set the number of dispensaries in the city at 70. Dispensaries that had registered between September and November 2007 and had been operating legally since that time were grandfathered, meaning that the number of legal dispensaries in the city could exceed 70 in the short term.
Closure orders were not correlated with observable dispensary characteristics (including the level of or trend in crime around specific dispensaries) that might have otherwise made them of specific interest to law enforcement.
Contrary to conventional wisdom, there is no evidence that closures decreased crime. Instead, there was a significant relative increase in crime around closed dispensaries. Like compliance with the closure orders themselves (which was at first high, then fell off with legal challenges, and finally collapsed after a December 2010 injunction), the increase in crime is temporary. Relative crime rates return to normal within four weeks. The increase is also very local—the estimated crime effects decrease rapidly with distance around dispensaries.
Both Mexican and U.S. officials basked in satisfaction when Mexican marines captured Joaquin “El Chapo” Guzman Loera, leader of the notorious Sinaloa drug cartel, in January 2016. The cartel kingpin was subsequently extradited to the United States.
Authorities on both sides of the Rio Grande heralded El Chapo’s removal as a major victory in the war on illegal drugs, but matters have not turned out at all the way drug warriors and other optimists assumed.
Under Guzman’s leadership, the Sinaloa cartel became Mexico’s most powerful drug trafficking operation, controlling nearly 50% of drug commerce. Although considerable violence accompanied that consolidation of market share, as the Sinaloa organization’s grip on the trade grew tighter, the turmoil ebbed modestly after 2012.
Killings began to edge upward in 2015 when Guzman was briefly in custody following more than a decade of freedom after his original escape in January 2001, dipped slightly when he escaped again, and rose noticeably with his recapture and extradition.
The May total was a new record, and it brought the total number of deaths in 2017 to 9,906. That was an increase of 33% over 2016, which had already seen a worrisome rise.
The current drug war policies that Washington has pushed and Mexico City has accepted is creating havoc for our southern neighbor.
Punitive measures will not succeed in eliminating consumer demand or overcome other economic realities. Cartel leaders and their bank accounts may benefit from that policy, but no one else on either side of the Rio Grande is doing so.
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