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.
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.
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 an effort to reduce the death toll from the use of opioids, New Mexico passed the first Naloxone Access Law in 2001. Under this law, trained responders, such as police and firefighters, were authorized to administer an opioid antagonist (naloxone) if they believed that someone was experiencing a drug overdose. The law also said that private citizens who administer opioid antagonists would not be subject to civil liability or criminal prosecution.
The adoption of a Naloxone Access law is associated with a 9% to 11% reduction in opioid-related deaths (removing criminal liability for possession of naloxone is associated with a 13% reduction in opioid-related deaths). Good Samaritan laws reduce opioid-related deaths involving alcohol.
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