Prescription Drugs, Economic Despair Challenged as Causes of Opioid Crisis

New studies are challenging the widely accepted idea that prescription drug abuse and economic despair are driving the epidemic of opioid drug abuse.

Writing at Politico, addiction psychiatrist Sally Satel argued that while the use of opioid-based prescription painkillers has certainly increased over the past three decades, medicinal use of these drugs is not leading to abuse on the scale implied by legislation such as the Opioid Addiction Prevention Act introduced by Senators John McCain (R-AZ) and Kirsten Gillibrand (D-NY).

Satel stated that her review of the data revealed that “only a minority of people who are prescribed opioids for pain become addicted to them, and those who do become addicted and who die from painkiller overdoses tend to obtain these medications from sources other than their own physicians.”

“Within the past several years, overdose deaths are overwhelmingly attributable not to prescription opioids but to illicit fentanyl and heroin. These ‘street opioids’ have become the engine of the opioid crisis in its current, most lethal form,” Satel added.

According to the studies Satel referenced, the addiction rate for prescription painkillers is much lower than commonly imagined, although the studies dramatically disagree about just how low the rate is. One problem with her contrarian analysis is that even the lowest estimated addiction rate of about 1 percent still translates to a lot of people, given how widespread the use of prescription painkillers has become. One or two million people who become addicted to prescriptions is not a trivial population, especially when added to those who follow other paths directly into abusing street drugs.

The highest addiction rates in the studies quoted by Satel are much higher indeed, and the average rate calculated by the New England Journal of Medicine in 2016 was “less than eight percent.” That would mean we’re talking about six or seven million people, which seems like a significant factor in the overall opioid crisis, contrary to Satel’s contrarian argument.

Satel addresses this by suggesting prescription drug addicts are often addicted to other substances already when they obtain opioid prescriptions, or they have other physical or mental health issues that cause them to become addicted when they take painkillers.

She also stresses that she believes opioids are overprescribed – a 300 percent increase in prescriptions since 1999 cannot be dismissed as a proportional response to increasing pain levels. This creates a secondary problem: precisely because most prescription users do not become addicted, or even use all of the pills they are given for temporary discomfort or post-operative recovery, the nation has accumulated an inventory of surplus drugs that finds its way into the hands of abusers and street dealers.

All of that seems a little counterproductive for the argument Satel wanted to make about prescription drugs getting a bad rap, but she counters with the interesting point that abuse levels continued to increase even after prescription volume began trending down in 2011. She argues that models of the opioid crisis that put excessive emphasis on prescription painkillers are overly reliant upon data from the first decade of this century when the second decade has been quite different:

Notably, more current heroin users these days seem to be initiating their opioid trajectory with heroin itself – an estimated 33 percent as of 2015 – rather than with opioid painkillers. In the first decade of the 2000s, about 75 to 80 percent of heroin users started using opioids with pills (though not necessarily pain medication prescribed by a doctor for that particular person). It seems that, far more than prescribed opioids, the unpredictability of heroin and the turbocharged lethality of fentanyl have been a prescription for an overdose disaster.

This leads to several problems in Satel’s estimation: the true causes of the opioid epidemic will not be addressed if legislation focuses too heavily on prescription drugs, effective treatment for people with addiction disorders will be impeded, and doctors are becoming reluctant to prescribe painkillers for people who really need them – to the point where a horrifying number of people in pain said they were contemplating suicide.

The high volume of people receiving prescription painkillers might be having a pronounced cultural effect that would be difficult to quantify in studies. If it becomes common knowledge that “everybody gets a pill” to deal with their discomfort, then people without access to prescription pharmaceuticals might feel more comfortable with borrowing surplus drugs from friends or turning to street dealers for relief. Satel mentions that street drugs are now frequently made to look just like prescription drugs and even given labels such as “Oxycontin,” which would support the notion of drug dealers marketing their wares to people who would not normally do business with them.

If painkiller prescriptions are not driving the opioid epidemic, then what is? Richard Florida at Citylab cites a study arguing that, contrary to widespread opinion, the primary factor is not economic despair.

The National Bureau of Economic Research study essentially argued that while drug abuse certainly surged in economically devastated areas like Appalachia and the Rust Belt, and nationwide opioid deaths spiked when the 2008 financial crisis hit, drug abuse kept getting worse even as the economy recovered.

This study also makes the point Satel did about separating deaths attributable to prescription opioids from those caused by street drugs. Deaths from prescription drugs leveled off and began to decline after 2010, while those caused by illegal drugs increased dramatically. The decline has been partially credited to lower prescription rates and tighter controls as awareness of the opioid crisis grew throughout this decade.

Another data point presented as an argument against the “death by despair” theory is that drug mortality rates for older people are leveling out, while the death rate for younger white men in skyrocketing. The idea is that access to illegal heroin products for young people is increasing, while the number of older people falling into prescription drug abuse as a result of economic despair has begun to decline.

“Curtailing this deadly epidemic means acting on both the supply of these drugs and the demand for them,” Florida contends. “On the supply side, it means addressing the flow of heroin in the United States and stopping the over-prescription of opioids, which is how many people who go on to use cheaper illegal drugs get hooked to begin with. On the demand side, it means raising awareness about their use among high-risk groups and developing better treatments for opioid users.”

The authors of these two contrarian pieces would seem to have an argument with each other, as Satel’s point is that over-prescribing opioids is not a major factor in getting people hooked on drugs and sending them to street dealers after their prescriptions run out.

As for interdicting the drug supply line, fentanyl is largely manufactured in China thanks to lax oversight from the Chinese government, shipped to Mexico, and smuggled into the United States through our porous southern border. As long as the U.S. has weak border security, that supply line will remain open. A frank discussion of the relationship between mass migration and the supply of illegal drugs seems completely beyond the American political system at the moment. Authoritarian control-freak China has been suspiciously reticent to crack down on the supply side of that chain.

There is also the question of exactly why so many young people, especially young white males, are jumping on the heroin bandwagon. Despair and economic anxiety cannot easily be dismissed as factors in their behavior merely because older people are becoming less likely to overdose.

Conversely, increased availability of cheaper drugs might not be the primary factor in rising abuse rates, especially when the lethality of illegal fentanyl is becoming so widely known. Among other things, fentanyl overdoses are not easily treated with the medication used for opioid overdoses, so people who unwittingly take fentanyl are dancing with death. It’s unsettling to consider that some portion of young abusers know they could die, and they either don’t care, or welcome the prospect. If that isn’t “despair,” than what should we call it?