Journalists have primarily depicted the overdose issue as a narrative of three interlinked and maybe inevitable waves. First, pharmaceutical corporations, spearheaded by Purdue Pharma, the producer of the infamous OxyContin, persuaded doctors to prescribe unnecessary opioids. In the 1990s and 2000s, this resulted in hundreds of thousands of new addictions. Opioid prescription has been associated with more significant disability and lower productivity in observational studies.
As a result, the number of people dying from overdoses began to climb.
The second wave of this story started in 2011 when governments began cracking down on so-called “pain clinics” that were pill mills selling dosages for a dollar. Prescriptions were scarce, costs climbed, and addicts turned to heroin, which was cheaper and now had a large enough pool of clients to draw cartels to previously untapped markets. Overdose deaths have risen again more.
Dealers finally started the third wave around four years later. They began cutting heroin with illicitly made fentanyl and other synthetic opioids, which are cheaper to prepare and more powerful, seeing an opportunity to earn even more money. Addiction has deteriorated yet further. In 2020, about 100,000 individuals were estimated to have died from an overdose, making it the worst year in American history. This is the tale being conveyed in the ongoing lawsuits against Purdue Pharma and other opioid makers and distributors. It’s being recounted right now in West Virginia in a case against three large pharmacy wholesalers that are being hailed as a watershed moment for thousands of similar instances.
However, although the media has concentrated on the suffering caused by Big Pharma, it has generally overlooked the enormous suffering caused by legislation designed to address the problem.
Advocates, spearheaded primarily by Physicians for Responsible Opioid Prescribing, presented the case to policymakers and legislators that decreasing medical usage would address the problem since overprescribing produced the pandemic. And they were successful in dramatically reducing the medical supply: opioid prescriptions have decreased by more than 60% since 2011.
However, between 2011 and 2020, the overall number of overdose deaths more than quadrupled, owing to a reduction in medicinal usage. Indeed, even before the epidemic, more overdose fatalities after prescription began to decline than when medical opioid use was at an all-time high.
The possibility of worsening the situation by limiting medical supplies did not seem to enter the minds of those who supported this strategy. However, this effect was entirely predictable—so much so that the occurrence has been dubbed “the iron law of prohibition” by academics.
Activist Richard Cowan coined the phrase in 1986 to describe the consequences of cutting drug supplies while doing little to reduce demand. Because of a fundamental physical fact: hiding small items is simpler than hiding larger ones, it almost always ends in the growth of a more hazardous substance. As a result, because illicit drugs must be hidden, prohibition encourages more powerful and potentially lethal chemicals.
Even during prohibition, when hard liquor was chosen for sale over lower-alcohol wine and beer, this was evident. Whisky is nearly eight times stronger than beer, making it considerably simpler to conceal. As a result, we refer to alcohol traffickers as bootleggers rather than “barrel hiders” because they could hide flasks in their boots.
When persons with addiction lost access to medications like oxycodone (the active ingredient in OxyContin), the iron law meant that they developed a tremendous demand for street opioids. Historically, heroin has been the most popular. Still, with the help of the internet, traffickers quickly discovered a cheaper and more potent alternative: fentanyl and comparable synthetics, which may be hundreds to thousands of times more powerful.
It’s unclear what policymakers were thinking here: did they expect that merely taking medications away would cure addiction? Or is it suffering? Drug traffickers, on the other hand, were considerably more agile than the authorities, often scouring the streets for consumers outside of closed pill mills.
There’s another reason why this supply-side program was unavoidably risky.
Genuine drugs must adhere to a strict dose and purity standard, ensuring that users are aware of how much they are taking and whether it is higher or lower than typical. Contrary to popular belief, street narcotics are uncontrolled. It’s tough to know what’s in that mysterious tablet or powder, let alone what dosage is adequate.
Though proponents of medical supply cuts say that prescription opioids are mere “heroin tablets” and should be treated as such, this overlooks an important distinction. There would be no need for authorities like the FDA if pharmaceutical and street versions of medications were equally safe. Sure, individuals may abuse both, but they may do it more controlled manner, at least with drugs. This fact makes utilizing illegal substances much more dangerous.
Furthermore, it’s not as if policymakers couldn’t intervene on the demand side. Buprenorphine (Suboxone) and methadone are two drugs that have been shown to reduce overdose death rates by 50% or more. When rogue physicians were brought down, we could have made them instantly available to addiction sufferers.
And it would have been significantly easier to hunt down and treat those who use illicit substances when their sources were apprehended. Doctors, unlike street traffickers, must have a list of the true identities of the patients to whom they prescribe. In contrast, pharmacies require an official ID such as a driver’s license to distribute prohibited medications.
When these individuals lost their doctors, they might have been notified and provided prompt access to appropriate therapy for their medical concerns if the purpose of reduced prescription was genuinely to help addicted individuals and enhance pain management. Dealers would have had much fewer customers as a result.
Instead, the supply was simply shut off, leaving thousands of patients to endure withdrawal symptoms simultaneously. Even physicians who saw their patients benefiting from opioids began to cut dosage or cease prescribing altogether as the campaign continued for fear of being pursued by police and medical boards. Half of all general practitioners are now refusing to take on new patients who have lost their physician yet want to continue receiving opiate therapy.
When pain clinics close, health agencies can anticipate a problem. Some even issue warnings about the possibility of an increase in overdose call these days. But, if the purpose is to save lives, why are these patients being put in danger without ever being assisted? (The only recorded incident of law enforcement attempting to help patients in this position I’ve discovered was during a large 2019 raid; why is this the exception rather than the rule?)
Furthermore, none of this considers the increased impairment and suicidal thoughts that can arise when pain patients are denied access to the single medicine that has brought them respite. Even though opioids were misused, some intractable pain sufferers benefit from them, and only lip service has been paid to assisting them. Hundreds of thousands of patients have had their opioid drugs lowered or discontinued as a consequence, regardless of whether this has helped or damaged their lives.
And research shows that these cuts don’t always benefit those who are in agony. One analysis of millions of medical records indicated reducing opioids linked to increased disability, less productivity, higher medical expenditures, and more pain. Another research revealed that 9 percent of veterans who had their opioids discontinued involuntarily felt suicidal, with 2 percent attempting suicide. Worse, other data suggest that restricting access to medicinal opioids roughly triples the chance of overdose mortality among those in pain rather than reducing it.
Journalists continue to repeat the three-wave narrative, which disproportionately blames pharma. The second and third stages, on the other hand, did not spontaneously happen; policy decisions influenced them.
Few have advocated for those responsible for the medical supply crackdown that fueled the surge of fentanyl to be held accountable.
So, where is the accountability for policymakers, from the DEA to the CDC to Congress and state legislatures, who shut down pill mills and drafted rules, recommendations, and rules to reduce prescription while failing to treat any of the abandoned patients, whether they were addicted, in pain, or both?
Why are we still spending hundreds of millions of dollars on police and restricting medical supplies when more than 80% of individuals with opioid use disorder still lack access to good treatment, and the great majority of overdose deaths are now caused by street fentanyl and its chemical relatives, rather than prescriptions? Why do we overlook the reality that most opioid addictions begin when people use medications that were not prescribed to them?
Of fact, many policies might have harmful consequences, and lawsuits aren’t the most effective approach to keep policymakers responsible. Furthermore, unlike Purdue Pharma, many of these attempts were made with good intentions.
But, if we want to put the money we get from suing pharma companies to good use, we can’t overlook the reality that the supply-side “treatment” we’ve implemented so far has made the sickness worse. Naturally, pharma companies would want to be punished for the actual harm they’ve caused. To improve, however, we must base policy on fact rather than emotion.
