AMERICA’S opioid crisis has spiralled further out of control. The latest figures reveal that more people in the US are dying from opioid overdoses than from motor vehicle accidents. The country’s life expectancy has , thanks in part to drug overdose deaths.
“It is the highest level we’ve ever seen related to drug overdose deaths,” says , who served as director of the White House Office of National Drug Control Policy (ONDCP) under former President Barack Obama and now directs the Grayken Center for Addiction Medicine in Boston. “It has surpassed the peak of HIV deaths and the peak of gun deaths,” he says. “To say it is the defining health crisis of our time is no exaggeration.”
In October last year, President Donald Trump acknowledged the scale of the crisis by declaring a public health emergency. This temporary emergency period lasted only 90 days, and expired on 23 January. A renewal has already been announced, but during the first emergency period, the administration has achieved little, if anything.
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A report, commissioned by Trump and published in November last year, made , such as making treatment more accessible, sending people to drug courts rather than prison, and supporting affected families. None has yet been implemented, and no additional funds were made available for desperately needed treatment centres and prevention programmes.
It is no wonder, then, that one of the report’s authors, former Democratic representative Patrick Kennedy, described the administration’s approach as “a sham” and “tantamount to reshuffling chairs on the Titanic” in an .
Talk is cheap
That isn’t the only problem – even the unfulfilled promises made by the administration are problematic. “We’ve seen posturing that would actually have a significant detrimental effect,” says Botticelli.
Perhaps the most immediately obvious is Trump’s promise to repeal the Affordable Care Act (ACA) – a law implemented in 2010 to ensure that more US citizens have access to affordable health insurance. The policy has been a lifeline for people who are dependent on opioid drugs. The ACA lists substance use disorder services as .
“Without preservation of the ACA, it will be very hard to turn this epidemic around,” says Hillary Kunins at the New York City Department of Health and Mental Hygiene.
Another of Trump’s promises was for “really tough, really big, really great advertising”. This hasn’t yet materialised. If it were to, the success of any public health campaign depends on the message it promotes. It is easy enough to tell someone that taking drugs is bad. But the failure of the Reagan administration’s “Just Say No” campaign ought to serve as a reminder that these statements do nothing to reduce the impact of harmful drug use.
A similar approach used scare tactics in an attempt to warn teenagers off methamphetamine in the 2000s. The increased people’s awareness of the drug, but did nothing to reduce drug use, says , a provincial health officer in British Columbia, Canada. In fact, the advertising was associated with increased risk of drug use, says Kendall. “The campaign was so over the top that people dismissed it,” he says. Some teenagers might have started using the drug in order not to feel left out, he says.
Considering that Trump has said “it’s really, really easy not to take [opioids]”, it’s no wonder that public health officials are worried that the current administration might go down the same route.
Efforts in Canada show this is the wrong approach. There, advertising campaigns target people with addiction, offering advice on where and how to seek treatment. What’s more, they don’t paint drug dependence as a moral failing, and so avoid stigmatising people who need help.
“Treating people with substance use disorders as criminals is unlikely to help”
But adverts aren’t enough. Canada also has centres that offer people with opioid dependence a supervised, safe space to take their drugs. And it has ensured the large-scale distribution of naloxone, a drug that can reverse the effects of an overdose and can be administered by anyone after 10 minutes of training.
These measures have reduced opioid overdose deaths, says Kendall. “It means that very few people who overdose in public die,” he says. “The people that are dying are the ones that use in private and the reason they don’t want anyone around is shame and stigma.”
So treating people with substance use disorders as criminals, rather than people in need of medical treatment, is unlikely to help.
“Treating it as a crime is the worst thing you can do,” says at the Brigham and Women’s Hospital in Boston. “If we start to recognise it as the disease that it is, we can treat it and get people back on track. If you criminalise it, you take away a person’s chance of a normal life.”
But in November, US attorney general Jeff Sessions released funding and support to law enforcers, along with the development of a to tackle the crisis.
In the same month, the DEA moved to classify illicit versions of fentanyl as a schedule 1 drug – ranking it alongside heroin.
But the people most likely to be arrested for possessing it are those most in need of medical treatment, says Kendall. “Most law enforcement tends to go after the user rather than the importer or distributor. It ends up being pretty ineffective, because it picks up people who are sick.”
Some progress has been made in the US. Under the Obama administration, the ONDCP worked with the country’s Centers for Disease Control and Prevention to create new . Since then, many states have set their own prescribing limits, and prescriptions of opioids have reduced by between 12 and 19 per cent since 2012, says , director of the National Institute on Drug Abuse.
But this tactic, while ostensibly a good idea, may have backfired. As the legal supply of opioids has shrunk, people seem to have turned to illicit alternatives like heroin and synthetic drugs like fentanyl and carfentanyl. “The number of prescribed opioids is declining, but overdose deaths have been rising,” says Weiner. “It represents the shift from prescribed opioids to illicit opioids.”
These drugs are more potent, so are easier to accidentally overdose on. “Fentanyl is 100 times more potent than morphine, and carfentanyl is 100 times as potent as fentanyl,” says Kendall. They are thought to be responsiblefor the majority of accidental overdose deaths in the US today.
In December, the Trump administration with a list of planned and ongoing actions, including expanding access to naloxone and funding development of new pain treatments. But much of this is continuing Obama-era policy, and barely anything new has been done since the emergency was declared.
More success has been accomplished at state and local levels. In New York City, Kunins is seeking to distribute 100,000 naloxone kits, mainly to people living with others at risk of overdosing.
“Accidental drug overdose has surpassed the peak of HIV deaths and the peak of gun deaths”
Kunins and her colleagues have also set up a programme targeting people who are in emergency care after a non-fatal overdose. These people are offered support and counselling for three months, along with a supply of naloxone.
Similar schemes should be rolled out across the country, say health officers and academics. Treatment centres that offer supervised environments for the use of drugs, and replacements like methadone, have proved successful in other places, says Kendall.
Researchers are working on new treatments for overdose and addiction (see “The love drug that could draw people away from any addiction”), and also on ways to develop opioid drugs without the risk of addiction or overdose. One approach is to make drug formulations that are harder to abuse. In the past, some opioids have been crushed and snorted as a powder for a more powerful hit. Newer formulations turn to gel when crushed.
All of this shows that there are ways of tackling the US opioid crisis. But they require money and evidence-based treatments, not sound bites and law enforcement. “As Americans, we cannot allow this to continue,” said Trump as he announced the emergency in October. More than three months later, he is still allowing just that.
This article appeared in print under the headline “Emergency in name only”
