The easiest, most effective step that the federal and state governments can take to stem the tide of deaths from opioid overdoses is to make naloxone easier to get …”

Megan McLemore of Human Rights Watch, as quoted in The Lancet[1]

 

[This is G. Sallust again. It’s said that more than 90 Americans die every day from opioid overdose.[2] That simple fact makes opioids truly blog-worthy, and worth an update, so I asked for volunteers to do the job.  Unfortunately I didn’t get any. Instead my loyal staff told me to write it myself. This isn’t a democracy; but everybody here is a volunteer, so I have to listen when they yell at me. And this time they made a good case.

It’s true that I’m uniquely qualified to talk about opioids. And no, that’s not because I’m a heroin addict. Actually I don’t take anything unless it’s prescribed by a doctor, and I especially I don’t like pain killers, no matter who wants me to take them, because they make us stupid.  I’m qualified because I (i) live in a rural area that has a horrible problem with opioids and (ii) am morally offended by the situation.

Actually they didn’t say it that way. Fred says I’m loud and abrasive, and an attention-getter, and that’s what’s needed. Phil says I often sound reasonable, even when I’m not, and that might help with some readers, the ones who are not too far gone in politics. And Larry, bless his heart, says that I can be persuasive when I stick to the facts, which isn’t always the case, and if I do that I might do a passable job. All of them had other pressing business, and none of them wanted to get involved. I call that mutiny, thinly disguised.

So I’m writing this myself. And speaking of politics, which I just did, let’s start by saying that in my opinion Donald J. Trump, is not responsible for the opioid epidemic. He’s been President only since January 20, 2017[3];  and the problem predates him by several years. Of course, the same could have been said of Barrack Obama, when he first took office in 2009. The economy had collapsed in the second half of 2008, and threatened to go belly-up. That pretty much gave the election of 2008 to the Democrats. Conservative pundits then argued that Obama, who wasn’t President at the time, was actually responsible for the 2008 crash, because the mere fact that he might be elected had upset the market. A few months later they followed up by complaining that the recovery was taking too long.

Well, that was then and this is now, and today we’re talking about crimes, the criminal law and public health, not about the economy. So far no one has blamed Trump for the opioid problem, but they will. At some point the loyal opposition is going to start asking why President Trump hasn’t done more to solve it. But before we go down that road, it might be best to take a look at where we are, medically speaking, in the battle to restrict opioids. Luckily there are a couple of recent articles, one in The Lancet[4] and the other in the New England Journal of Medicine[5], to help us understand the situation.]

The Lancet Says

Let’s take first things first. Heroin is an opioid, as are morphine, opium, and various synthetics, such as fentanyl and its numerous cousins.[6] One can overdose on any of these, but it’s more likely with street drugs because those are frequently mixed with one variety or another of fentanyl. Some versions of fentanyl (I don’t know how many) are extremely potent, and can kill with very, very small quantities. So if a dealer is an amateur, he can easily kill a lot of people.

Naloxone is an antidote that reverses the effect of overdose. (In my neighborhood it’s also called Narcan.) Many jurisdictions are equipping their first responders with it, so that they can treat an overdose on the spot, rather than cart the victim off to an ER. That’s a good thing, because [apparently] it saves lives. But that doesn’t necessarily reduce the addiction rate. In fact, one can speculate that the more addicts survive overdose, and if new addicts continue to enter the population at the usual rate [whatever that is], the total number of addicts will grow over time. And as the numbers increase, the addiction rate will as well.

So that brings us to the bigger problem: How do we, in the U.S., treat addicts to reduce their numbers? Well, the Administration resolved to study the matter, which sounds like a good idea, and interim recommendations are due the 27th of this month. That sounds like something we ought to read. In the meantime The Lancet reports that a policy is beginning to emerge. So far –

  • The president’s budget for the next fiscal year (FY 2018) calls for a $279.7 million increase in funding for drug control efforts;
  • That includes a $103 million increase to the Department of Justice’s budget to “fight against opioids and other illicit drugs”.
  • Last March, the new Attorney General said “we need to focus on…preventing people from ever taking drugs in the first place”. On May 13 he ordered federal prosecutors to utilize mandatory minimum sentencing for heroin offenses. This would “prescribe that possessing any amount of heroin would be a minimum fine of $1000 and 1 year in prison.”[7]

So far none of those initiatives sound like slam-dunk wins. Do they?

Then, of course, there are the current Congressional efforts to repeal and replace Obamacare. That effort, if successful, might throw many of the addicted into the ranks of the uninsured. “The American Society of Addiction Medicine, a professional society of physicians, warned that [if so] a ‘critical lifeline for people with addiction’ would be severed.”[8] That’s interesting, but speculative. So far Congress hasn’t really done anything. I’m going to wait until there’s actual legislation on the table before I start an argument.

Science from the NEJM

OK, from what little we know of President Trump’s program, he doesn’t seem to be counting on any scientific breakthroughs to solve the opioid problem. How about the scientists? What do they think? Well, the National Institutes of Health say that since April of this year they have been working with pharmaceutical industry in three important areas:

  • Overdose Treatment. Naloxone is good, and has saved lives, but other, more effective overdose treatments are possible. The NIH/ industry objective is to develop “better overdose-reversal and prevention” therapies[9];
  • Curing Addicts. Currently “sustained treatment over years or even a lifetime is often necessary to achieve and maintain long-term recovery.” There are only three medications available for treating Opioid Use Disorder. These are methadone, buprenorphine and extended-release naltrexone. We need more and better medicines in this area.[10]
  • Managing Pain. For many, addiction starts with opioids prescribed by a doctor to relieve chronic pain. If we develop “safe, effective, non-addictive interventions” to deal with pain, we can greatly restrict the use of opioids in medical practice. That should reduce the rate of addiction as well.[11]

The NIH expect “some advances” may occur rapidly, “such as such as improved formulations of existing medications, opioids with abuse-deterrent properties, longer-acting overdose-reversal drugs, and the repurposing of treatments approved for other conditions.[12]” Others may take longer. Nevertheless, the goal “is to cut in half the time typically required to develop new safe and effective therapeutics.”[13]

Conclusion

To date the new Administration seems to have focused primarily on law enforcement to control the opioid crisis. That’s short-sighted. Addiction is a problem for doctors and scientists, as well for the police. I’m not in a position to judge the validity of the initiatives the National Institutes of Health have proposed, but they are our experts; so perhaps we should fund their initiatives, or over-fund them if necessary, to see what they can do for us. The problem with addicts is that they’re, well, addicted. There’s no talking them out of their addiction, and locking them up doesn’t seem to be helpful. Speaking for the public, we need a damned cure!

[1] See The Lancet, Reinl, Trump administration and the opioid epidemic in the USA (June 17, 2017), available at http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(17)31543-X/fulltext?elsca1=etoc (The proper citation for this, I think, is Reinl, Trump & Opioids at 389 World Report 2181 (June 3, 2017). We’ll just call it Trump & Opioids, until someone corrects us. To access this article [apparently] you need to register with The Lancet. Do that [it’s free] and you can download a pdf version.

[2] See New England Journal of Medicine, Volkow & Collins, The Role of Science in Addressing the Opioid Crisis (May 31, 2017), available at http://www.nejm.org/doi/full/10.1056/NEJMsr1706626#t=article There are no page numbers; henceforth we will cite this as Opioid Crisis at __ and reference the § in which the quote appears.

[3] See the President’s inauguration speech at https://www.nytimes.com/video/us/politics/100000004863342/donald-trump-full-inaugural-address-2017.html

[4] See n. 1.

[5] See n. 2.

[6] For a more full discussion of the subject, take a look at the Wikipedia entry at https://en.wikipedia.org/wiki/Opioid .

[7] All quotations are from Trump & Opioids.

[8] Id.

[9] See Opioid Crisis at Overdose-Reversal Interventions.

[10] See Opioid Crisis at Treatments for Opioid Addiction.

[11] See Opioid Crisis at Nonaddictive Treatments for Chronic Pain .

[12] See Opioid Crisis at Public-Private Partnerships.

[13] Id.

Advertisements