News That Matters

Federal, State, And Local Governments Aren’t Doing Enough To Combat It


While the U.S. has been battling the Covid-19 pandemic it’s gotten lost in the shuffle that the nation endured record numbers of drug overdose-related deaths in 2020; approximately 93,000. In addition, from May 2020 through April 2021, the figure rose to 100,000. Furthermore, provisional data from the Centers for Disease Control and Prevention (CDC) estimate that more than 107,000 people died of a drug overdose in 2021, with 75% of those deaths involving an opioid. Illicit fentanyl is the primary culprit.

While the federal government is spending billions pursuing different supply- and demand-side strategies to combat the problem, it is behind the eight ball when it comes to this ever-growing crisis. Similarly, state and local authorities aren’t doing enough.

In the past 10 years, where governments at the local, state, and federal levels have acted in concert, there appears to be a disproportionate focus on legal prescription opioids, which in many ways are easier to control than illegal opiates.

But, it’s important to properly distinguish between the role of illicit and prescription opioids in the current opioid crisis. Contrary to public perception, the problem of misuse, abuse, and diversion of prescription opioids has been much less of a factor in recent years than illicit opioids. A picture of a bottle of prescription painkillers often accompanies articles on drug overdose deaths, which creates an erroneous impression.

Soon after the peak of prescription opioid prescribing in 2012, roughly a third of the 44,000 drug overdose deaths reported in 2013 were attributable to inappropriate use of prescription opioids. Since 2013, the percentage of drug overdose deaths that can be traced to inappropriate use of prescription opioids has diminished, in part because fewer are being prescribed. Reductions in prescribing have been based on more restrictive regulatory policies instituted in individual states and counties, and reinforced by federal guideline recommendations put forth by CDC in 2016.

Some experts have suggested that a number of undue restrictions have caused the pendulum to swing too far in the direction of severely limiting prescription opioids – even forced tapering – as such medications do have legitimate uses for certain persons suffering from acute and chronic pain.

There appears to be a correlation between the switch towards draconian limits on prescribing of opioids and the rise in the use of illegal opiates. Of course, correlation is not causation. Nevertheless, it’s conspicuous that heroin and illicit synthetic fentanyl now account for the vast majority of drug overdose-related fatalities, with fentanyl being far and away the biggest driver.

Federal government efforts to stop supply

The U.S. federal government has emphasized stopping the supply of illicit opioids. Successive Administrations have pursued policies aimed at reducing illegal importation of such substances.

Most illicit fentanyl in the U.S. is smuggled from Mexico. Even fentanyl originating in China is often being rerouted through Mexico.

The Obama, Trump, and Biden Administrations have increased the number of border patrol agents to more than 20,000. Yet, the smuggling continues; mostly by U.S. citizens trafficking contraband through official ports of entry along the border.

And, while the federal government has also provided substantial counter-narcotics assistance (resources and manpower) abroad to countries like Colombia and Mexico, the effects have been minimal at best.

Demand-side initiatives

While attempting to cut off supply is a logical step in tackling the problem, the success of such policies has been extraordinarily limited.

What’s problematic is that the federal government has only recently acknowledged that a large part of the problem exists on the demand side.

According to Dr. Rahul Gupta, director of the White House Office of National Drug Control Policy, only around 10% of people in the U.S. who need addiction care receive treatment.

The good news is that federal, state, and local officials have shifted some of the emphasis toward prevention and treatment.

Continuing expansion of the Affordable Care Act under the Biden Administration, for example, has been pivotal in making available public health resources that are essential for combating substance use disorders, particularly for those on Medicaid.

The Biden Administration has also eased restrictions on the use of buprenorphine, a drug used specifically for opioid use disorders.

Further, in October of 2021, without much fanfare, the Biden Administration proposed a new set of policies to stem the rise in drug overdose deaths. These demand-side measures were grounded in a building consensus around expanding federal support of harm reduction strategies for people who are actively using illicit drugs; for example, wider distribution of fentanyl test strips, which help users avoid street drugs contaminated with the deadly synthetic opioid.

More controversially, the Biden Administration’s plan embraces expansion of needle exchange programs, which for several decades have demonstrated effectiveness in reducing the spread of contagious diseases such as HIV and hepatitis.

At the municipal level, we’re observing gradual implementation of programs designed to reduce harms in those who are using illicit drugs. New York City has authorized the establishment of two supervised injection sites for drug users in Manhattan. The facilities will provide clean needles and administer medication, such as naloxone, to reverse overdoses. At the same time, users are offered different options for addiction treatment.

Other city and local governments, especially on the West Coast of the U.S., have launched large-scale programs focused on limiting HIV virus transmission and overdoses through the promotion of safer drug use.

All told, however, the U.S. response is inadequate, and not proportionate to the enormity of the problem. The Biden Administration has invested more than $5 billion in increasing access to mental healthcare and to prevent and treat opioid addiction. While this seems like a sizable sum, it’s comparatively paltry. The federal government spent more than $18 billion on Operation Warp Speed to develop Covid-19 vaccines, with tens of billions more going towards procurement of Covid-19 tests, vaccines, and treatments. In the U.S., the domestic response to HIV has risen to more than $28 billion per year. There isn’t the same kind of funding with respect to the opioid crisis, or even determination on the part of authorities to systematically address the issue.

Observers say the federal government does not provide sufficient sustained funding to subdue the crisis. Moreover, state Medicaid programs vary widely in their coverage of recovery support services and pharmaceutical interventions.

Recently, the shortage of beds and resources for psychiatric patients, many of whom have substance use disorders, has accelerated in all states. This has led to serious bottlenecks in hospitals and very long admission wait times.

Even comparatively simple solutions aren’t being pursued to the fullest extent possible. As an illustration, naloxone, which can reverse an opioid overdose, is still not as widely available as it ought to be. While naloxone can be purchased without a prescription in all 50 states, it is not officially an OTC product. Ability to buy naloxone OTC doesn’t apply to organizations which purchase naloxone in bulk from drug makers. States don’t have the authority to designate naloxone as an OTC product. Only the federal government can do this. The Food and Drug Administration (FDA) says it is not doing so because drug manufacturers aren’t initiating a switch from prescription-only to OTC status. While this is normally the path for switches, there is precedent for the FDA to step in and authorize a switch without drug makers’ consent.

Besides the issues mentioned, there has been poor public health messaging and a general lack of public education. Experts believe the federal, state, and local governments should direct far more resources toward educating the public about the risks of illicit opioids and the availability of treatment and other services. Evidence of deficient public health messaging isn’t hard to find. The scarce services that are being offered are only being tapped into by a very small minority of substance use disorder patients.

Perhaps lessons can be learned from overseas experience. Two decades ago, Portugal has adopted a systemic, country-wide harm-reduction drug policies that decriminalizes the possession of narcotics for personal use and emphasizes treatment (adopting a plethora of options tailored to individual patients’ needs) instead of incarceration. By 2018, Portugal had the lowest rate of drug-related deaths in Europe.

In the 1990s, the Netherlands began offering addicts heroin at no cost, as part of professionally supervised recovery support services. The rate of high-risk or “problem” use was halved from 2002 to some fourteen thousand cases in 2012, according to the European Monitoring Centre for Drugs and Drug Addiction.

Of course, there are no panaceas that will magically solve the fentanyl disaster, or abuse of other illicit drugs for that matter. And, international efforts to address the opioid crisis don’t necessarily translate to the U.S. context. Nevertheless, it would seem from the insufficient budgets allocated to the problem, the chronic shortages of services, and the limited reach of the programs that do exist, that much more can be done in the U.S.



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