On Wednesday, President Trump announced the establishment of the President’s Commission on Combating Drug Addiction and the Opioid Crisis, to be headed up by noted public health addiction expert…New Jersey Governor Chris Christie.
The commission has fairly minimal tasks, with overall aim to “make recommendations to the President for improving the Federal response to drug addiction and the opioid crisis.” In other words, produce yet another commission report few will read and fewer will take action on – like the 2016 surgeon general’s report which covered much the same ground.
In promotion of this, the White House convened a “listening session,” in which it became clear the point of the commission was less about finding reasonable solutions to the supposed opioid crisis and more about sustaining popular (and wrong) mythologies about drug use, abuse, addiction and opioids.
During the gathering, Trump, alongside Christie, Education Secretary Betsy DeVos and Attorney General Jeff Sessions, heard stories by former addicts and family members, who told horror stories about their encounters with opioids. The stories were essentially the same: they took pain killers, became addicted and went on to become homeless and/or went to jail.
Throughout the session, various assertions were made, including that people become “immediately hooked” and that narcotics are “cheaper than candy,” the latter an assertion Trump has made in the past, without evidence.
But ultimately, as feel-good as the listening session may have been, the dominant narratives about the so-called opioid epidemic on display at listening session, and throughout the mainstream media, do more to obscure reality than to accurately describe it.
Opioid overdoses aren’t (just) opioid overdoses
There is no disputing that increasing numbers of people have lost their lives to opioid overdoses over the past several years. More than 33,000 Americans lost their lives to opioid overdoses in 2015, according to the Center for Disease Control and Prevention, including 12,989 deaths involving heroin.
But there’s a missing element to these numbers. Opioid overdoses usually involve more than just opioids – and often entail the mixing of multiple drugs, like alcohol, benzodiazepines, cocaine and fentanyl, either by choice (as is typically true of the first three substances) or due to unscrupulous black market dealers tainting their product (with fentanyl). This occurs so often, “opioid overdose” is virtually a misnomer – and many, if not most opioid overdoses are better described as “polydrug toxicity,” as suggested by a 2003 paper in the Journal of Urban Health.
Based on an evaluation of privately insured patients in the United States, research published on March 14 by the British Medical Journal determined that concurrent benzodiazepine and opioid use increased by 80 percent between 2001 and 2013, from 9 percent of opioid users to 17 percent of opioid users over that time period.
Noting that 30 percent of fatal opioid overdoses involve benzodiazepines and that those who use both are at a tenfold greater risk of overdose than those who don’t, the researchers concluded that the rapid growth in concurrent benzodiazepine/opioid use “significantly contributed to the overall population risk of opioid overdose.”
This is consistent with prior research. According to a 2014 report, nearly 60 percent of long-term opioid users took a combination of drugs that could potentially be fatal – with benzodiazepines being particularly common.
But how often do we hear from politicians or pundits about the reality that opioid overdoses tend to involve more than just opioids? Or that greater emphasis must be made on warning doctors and patients about the risks of concurrent use?
Educating people about the risks of drug mixing is a simple but overlooked undertaking that could save lives. Perhaps education and communication are too subtle to grab headlines – and there’s no money to be made from it. Or perhaps this lack of emphasis on drug mixing is because politicians, anti-drug crusaders and do-gooders are less interested in encouraging safer drug-taking practices and more interested in fostering hysteria.
Opioids (probably) won’t destroy your life
While there are certainly people who develop addictions to opioids, becoming so addicted one turns to a life of crime and homelessness to support a drug habit because they happened to use Percocet is exceedingly rare.
While mainstream outlets like CNN trot out claims that “prescription and illegal opioids are commonly abused because they are so addictive,” abuse of and addiction to opioids is the exception, not the norm.
According to the 2015 National Survey on Drug Use and Health, approximately 97 million Americans had used prescription pain relievers. Of them, nearly 12.5 million were estimated to have misused prescription pain relievers during the year, while about 3.8 million reported misusing them in the prior month. This alone tells us that the vast majority of users does not misuse pain relievers, and even among those who do, most don’t even do so long enough to have done it in the prior month.
Even among heroin users, the national survey estimated 5.1 million Americans had used the drug in their lifetimes, while just over 800,000 had used it in the past year and 329,000 had done so in the past month. Notably, though there were fewer past year and past month heroin users in 2015 than in 2014, the number of deaths attributed to heroin overdoses increased in 2015 over 2014. This likely has something to do with the dangers of drug prohibition pushing heroin underground and subject to the whims of the black market – causing wide variations in potency and the deliberate cutting of heroin by drug producers and dealers with potent drugs like fentanyl.
But the relatively low rate of misuse, abuse or addiction hardly makes for inspiring political rhetoric. It is much more convenient to use the stories of the relative few who destroyed their lives than it is to talk about opioids realistically. Likewise, as is the case with resistance to talking about drug mixing, politicians simply don’t want to acknowledge the fact that it is drug prohibition which has made heroin as dangerous as it is.
Doubling down on failed policies won’t work
Politicians have responded to increases in opioid use and misuse by restricting access to prescription pain relievers and punishing physicians and pharmacists. Overdose deaths have climbed despite these efforts, as abusers and those with legitimate needs, especially those who deal with chronic pain, find themselves criminalized, stigmatized and/or forced to either deal with the black market or suffer from what ails them.
Donald Trump has suggested his border wall will help solve the problem of accessibility to opioids. Jeff Sessions has stressed criminal enforcement and interdiction efforts. Chris Christie, meanwhile, stressed his view that addiction was a disease that can be treated.
Whatever the merits of the disease model of addiction – and there are plenty of reasons to find it an inadequate, incomplete understanding of addiction – Christie’s record reveals a mixed, if convoluted, record.
“We will end the failed war on drugs that believes that incarceration is the cure of every ill caused by drug abuse,” he said during his 2014 inauguration. “We will make drug treatment available to as many of our non-violent offenders as we can and we will partner with our citizens to create a society that understands that every life has value and no life is disposable.”
To his credit, as Governor of New Jersey his state enacted a Good Samaritan law protecting people from arrest if they report an overdose while using drugs themselves and made anti-overdose drug naloxone available.
But as recently as February, Christie signed into law a bill limiting prescriptions for acute pain to just five days. It’s the sort of overreach by government into what should be between a doctor and their patient that has contributed to the current state of affairs in the first place.
This was an insight even President Obama seemed to have – though his policies didn’t actually reflect his apparent ideas. “If we go to doctors right now and say ‘Don’t overprescribe’ without providing some mechanisms for people in these communities to deal with the pain that they have or the issues that they have, then we’re not going to solve the problem, because the pain is real, the mental illness is real,” Obama said during a meeting with state governors in 2016. “In some cases, addiction is already there.”
Christie has also been a vocal opponent of marijuana legalization, believing it to be a gateway drug and taxes on it to be “blood money,” despite the fact that there’s growing evidence that marijuana and increased accessibility to it may help many with pain and help reduce deaths associated with prescription pain relievers.
Still, his talk of treatment presents some opportunities for reformers. However, as important as “treatment” in the abstract might be, it is hardly a cure-all to the problems of the opioid overdose problem. And as psychologist Stanton Peele recently observed, “no other country in the world provides as much disease-oriented addiction treatment (i.e.,12-step and vaguely biomedical treatment—‘vaguely’ since no treatments actually directly address supposed brain centers of addiction) as does the US. Yet North America, as a global harm reduction report notes, has the ‘highest drug-related mortality rate in the world.’”
The drug war is the problem, not opioids
Making clear the dangers of drug mixing, removing politicians from doctor-patient relationships, emphasizing harm reduction, supporting the expansion of medication-assisted treatment and permitting legal access to heroin and other drugs would do more to save lives than even the most soft-hearted drug prohibition.
Messages that opioids are especially likely to ruin peoples lives, that they are especially dangerous and that government intervention is needed to save people from themselves is just a rehashing of the same old prohibitionist attitudes that enabled the growth in prison populations, overdose deaths and discord all around the world in the first place.