OPIOID overdoses are escalating throughout the United States. As a mayor’s son, a sheriff’s wife and the legendary musician Prince overdose on heroin, fentanyl and other opioids, morgues fill and it becomes clear that nobody is sacred. Urged by the committee tasked with investigating the epidemic, President Trump has declared a national state of emergency.
The US’ Centre for Disease Control and Prevention (CDC) reports that of the roughly 52,000 overdose deaths in 2015, 33,100 were specifically down to opioids, rising by 4,444 in one year. Between 2010 and 2015, heroin deaths increased 20.6% and synthetic opioids (excluding methadone, a painkiller and heroin substitute) surged by 72.2%. This is in part attributable to a surge in illegal fentanyl laboratories: fentanyl is a synthetic opioid normally prescribed for severe pain or chronic pain in patients with opioid resistance and is between 50 and 100 times stronger than morphine.
What makes fentanyl so dangerous is that it binds to opioid receptors in the brain, in the region that controls pain and emotion. When bound to these receptors, dopamine stimulates the brain’s reward centres, which is what creates the relaxation and euphoria chased by users. Unfortunately, these receptors are found elsewhere in the brain, including where the breathing rate is regulated. High doses of opiates, or an opiate as potent as fentanyl, can stop the user’s breathing, resulting in death. Moreover, street fentanyl can be laced with cocaine or heroin, augmenting the danger.
But what’s behind this crisis? What could be driving greater numbers of people to take the hardest drugs available?
The longest running element is the over-prescription of opiate-based painkillers to patients. Accidents hurt. But medical opioids as a treatment risk reliance and are a significant factor in later addiction, especially in instances of chronic pain, which is dangerous and especially unfortunate for the patient. In the 20 years following 1991, opioid prescriptions rocketed from 76m to 219m. With the spreading of opioids came an increase in their potency, paving the way for an epidemic.
Once a user becomes addicted, however, they are forced underground to play a Russian roulette of unidentifiable pills to get a fix. Even heroin is a natural progression: the CDC found that painkiller addicts are 40 times more likely to be addicted to heroin. As previously mentioned, unregulated fentanyl has flooded the blacket market. Fentanyl’s obscene strength fetches it an eye-watering price: whilst a kilogram of heroin is valued at $50,000, a kilogram of fentanyl can rake in $1m, hence the desire to peddle it.
However, unknown tablets of opioid are rightly far less trustworthy than branded prescription painkillers and a tightening of prescriptions in recent years has presented a profitable opportunity for suppliers to counterfeit tablets. Of course these tablets contain fentanyl, but when only 0.25mg can kill, many batches easily overshoot the dosage, delivering deadly results. It’s likely most taking fentanyl are clueless they are doing so.
What can be done to ease the crisis?
Clamping down on the supply of counterfeit pills containing fentanyl is an obvious starting place. Shutting down the labs is easier said than done, as much of the supply originates from China. Chinese legislature is scrambling to keep up with the new fentanyl variants the clandestine labs are producing, and banning one form only prompts another to replace it. As of the 1st of March, 2017, China has banned four main strains of fentanyl for manufacturing and sale. This should help stem the tide, though for long the ban will remain effective is unknown.
Work on the root of the epidemic must start soon. Opioids must be prescribed far less frequently and in lower doses, especially for patients with chronic pain rather than short-term pain. Recent CDC guidelines for opioid usage suggest patients seek alternative treatments, be it non-opioid medications, physical therapy, electrical stimulation, acupuncture or an array of others. If opioids are to be prescribed, doses should “start low and go slow”, minimising the risk that patients build tolerance and seek higher doses elsewhere.
Existing users must be given greater access to treatments to detoxify and rehabilitate. By declaring a state of national emergency, President Trump has opened up some options. This could speed the government’s ability to adapt legislature, improve communication and co-ordination between charities and agencies, unlock funding and expand access to treatments.
Under state of emergency the US government could negotiate down the price of treatment drugs, as in the 2001 anthrax mania: the declaration, plus the threatening pharmaceuticals company Bayer with buying cheap generic alternatives allowed the government to stockpile several million Cipro tablets – the antibiotic treatment – at a discount of over 80%. Pharmaceutical treatments such as Suboxone exist to ease withdrawal symptoms and stave off the cravings. Naloxone can reverse the immediate effects of heroin and return regular breathing in overdoses. This would be a start: cheaper Suboxone in particular could help addicts wean themselves to sobriety and wider public holding of Naloxone could save lives.
To declare a national emergency for an ongoing health crisis is unprecedented. Previous declarations have been for short, immediate crises such as Hurricane Katrina or the September 11th attacks. Trump must use this vital period to act on the primary recommendations of the Opioids Committee to prevent future addictions. Tightening of opioid prescription policy is crucial to reforms. Only then will the bodies stop piling up.
Student Scribblings 