Why overdose deaths have increased

Tthe American crackdown on drugs that started the modern opiate overdose epidemic-prescription opioids– largely succeeded. According to the American Medical Association (AMA) on September 8opioid prescriptions have dropped out in every state over the past decade, falling nearly 50% nationally.

However, efforts to prevent overdose deaths have failed miserably. Annual opioid overdose deaths more than tripled between 2010 and 2020, according to federal data. Drug overdose deaths in a 12-month period exceeded 100,000 for the first time in April 2021, with about 75% of those deaths involving opioids.

Many factors contributed to this, but the main problem is that the development of the drug market has outpaced efforts to stop drug overdoses. “The prices of these drugs have never been cheaper. And the efficacy of these drugs has never been higher,” said Dr. Daniel Ciccarone, a professor who studies the opioid crisis at the University of California, San Francisco.

If prescription pills were the first wave of the opioid epidemic, the second wave began in the late 2000s amid growing awareness of the risks associated with prescription opioids, according to Ciccarone. Because states and the federal government run programs like prescription monitoring, health care workers quickly reduced the number of opioid prescriptions they dispensed to protect their patients and their medical licenses. However, this rapid turnaround meant that many patients were suddenly weaned off prescription opioids. They didn’t get adequate help to taper off opioid medications or deal with persistent pain, and many turned to the market for illegal drugs, including heroin, says Nabarun Dasgupta, who studies opioid overdose and substance use disorder at Gillings School of Global Public Health at the University of North Carolina.

Why overdose deaths have increased

Many people continue to be abandoned, he says: “There are many abandoned people who have been on painkillers, who no longer have access to adequate pain management, and so they are increasingly turning to the streets. We hear these stories every day.

In the late 2010s, however, the US appears to have reached a tipping point: overdose deaths appear to be leveling off nationally, even declining in states like Minnesota, Rhode Islandand Massachusetts, after aggressive prevention efforts. A wide range of new programs have spread, including public education, expanded access to opioid use disorder medications such as buprenorphine, and naloxone distribution programs, which may have led to fewer deaths, says Thomas Stopka, Associate Professor of Public Health and Community Medicine at Tufts University School of Medicine. The decline may also be due to carfentanil rise and fall– an opioid more potent than fentanyl– in the late 2000s, says Ciccarone.

During this period, the illicit drug market continued to change. First, there was the advent of the synthetic opioid fentanyl, which in its legal form is often used to relieve pain during and after surgery, but on the illegal market is prized because it is cheap to produce, easy to move and results in a high that is more -more powerful (but shorter lasting) than heroin. The drug-making industry also became more fragmented after the crackdown on poppy cultivation and fentanyl production, Dasgupta says, with much of the production moving to Mexico, where there were more “small producers who have less interest in controlling quality and trying to make a quick buck.”

Fentanyl and its analogues (chemically similar drugs), which appeared first on the East Coast and gradually moved west, also play a major role in the increasing number of deaths. The strength of different variations can vary dramatically, making it difficult for drug users to regulate their dosage. This becomes an even greater threat when substances are mixed together.

Drug supply and use also became riskier. Fentanyl is increasingly being used alongside stimulants such as methamphetamine and cocaine. At the time the substances were sold, they were often combined with other drugs. Many experts, including Ciccarone, say it’s unclear whether this was intentional. However, the result is that many drug users and even drug sellers have no idea what is in the drugs they buy. This is particularly dangerous because it means users cannot adjust the level they consume to their individual opiate tolerance. People who do not regularly use opiates and have not developed a tolerance may also accidentally use the drug. Plus, in addition to fentanyl and its analogs, medications can contain a variety of other chemicals, including the animal tranquilizer xylazine and new psychoactive substances such as opioids nitazine.

The COVID-19 pandemic made the situation even worse. Some experts say the drug supply has become even more corrupt in the past few years as drug distributors favor substances that are more potent by volume. The pandemic also cut many people off from their social safety net, career and everyday life, exacerbating the mental health issues and feelings that play a role in substance use disorder. “People were hurt,” says Ciccarone. “We isolated ourselves, we got scared. Our social networks were broken, our safety nets were broken. And that just leads to more deaths.

Going forward, the AMA and substance abuse experts say the key will be to remove barriers that prevent people from accessing substance use disorder treatments, including opioid use disorder medications such as buprenorphine. It will also be critical to expand access to tools that save lives, including overdose reversal drugs naloxone (also known as Narcan)changing syringes and fentanyl test strips.

Saving lives will require a large investment of both financial resources and public attention, Cicarone says. Although overdose deaths will wax and wane, he says, the factors that drive many people to use drugs — trauma and suffering — are not going away. “There are no magic bullets,” he says. “You need bold, robust Marshall Plan-level attention to America’s drug use problem.”

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