For the past few decades, the USA has been grappling with an epidemic of its own making. In 2017, drug overdoses became the leading cause of death in people under 50, exceeding vehicle crashes and firearms. Opioids have played a huge role: between 1999 and 2018, these drugs were involved in 446,032 deaths. When overdoses dropped in 2018, many thought that a crackdown on prescription opioids was proving successful. New research, however, indicates that the epidemic is ongoing due to a market-driven shift to dangerous opioid synthetics.
Excessive hand-outs of prescriptions for pain conditions laid the foundations of the US opioid epidemic. ‘Since the 1990s, we’ve soaked the market with prescription opioids,’ explains policy expert Bryce Pardo. ‘Up until 2010, pain was treated very aggressively.’ As a result, many people became dependent. To constrain the supply, the Centers For Disease Control (CDC) started to encourage doctors to reduce the quantity of opioids being prescribed. ‘If you’re an opioid user, however, you need your opioids to avoid withdrawals,’ says Pardo.
The answer for many was to turn to heroin. Then, in around 2014, fentanyl – a synthetic heroin analogue – arrived on US streets. Synthetic opioids based on fentanyl soon superseded heroin. ‘Since then, synthetic opioids have by far been the leading cause of overdoses,’ says Pardo. According to the CDC, between 2013 and 2017, the rate of overdose deaths involving synthetic opioids increased from one to nine per 100,000 people.
Despite this, in 2018, there were signs that policies were working. By the end of 2017, 26 states had passed laws imposing limits on opioid prescriptions and in the following year, for the first time since 1990, the number of deaths involving prescription opioids and heroin fell by 13.5 per cent and 4.1 per cent respectively. Many were quick to see this fall as early signs of control. US President Donald Trump touted the success of regulation, claiming that ‘with unyielding commitment, we are curbing the opioid epidemic’.
However, scientists and policy researchers counselled more caution. ‘You have to scratch the surface to realise who’s dying from what,’ says Pardo. While there were fewer overdoses involving prescription opioids and heroin, deaths involving synthetic opioids had actually increased by ten per cent.
‘Synthetic opioid deaths have continued to rise year on year. We’ve now just got a synthetic opioid epidemic,’ says Pardo.
Close monitoring of the types of synthetics in circulation, specifically those that are causing overdoses, can help researchers understand the supply chain. Carfentanil, a synthetic opioid 10,000 times more potent than morphine, is one such drug. Its potency makes it hard for drug abusers to dose; its ease of production and cheap price tag make it easier for clandestine suppliers to distribute. Between 2007 and 2017, the National Forensics Laboratory Information System (NFLIS) recorded more than 150,000 seizures of synthetic opioids from street circulation. Carfentanil availability surged in 2016, but reports emerged of a reduction in 2018.
Health researchers at the University of Pittsburgh, noticing the correlation between carfentanil’s availability and overdose counts, have trawled through National Forensic Laboratory Information System seizure and overdose data for answers. They found evidence that seizures of carfentanil from street circulation matched the rise and fall in overdose deaths from 2016 to 2018. Tellingly, the dip in overdoses that many saw as the success of the federal response actually followed China’s listing of carfentanil as a controlled substance on 1 March 2017.
Before then, carfentanil was manufactured and sold legally within China. US citizens could order covert packages from Chinese distributors to arrive by mail. When this stopped, overdoses in the USA fell. In Michigan alone, overdose deaths involving carfentanil dropped from 33 per cent in February 2017 to three per cent in March 2017. ‘We are concerned that policy makers may have interpreted the one-year downturn in opioid overdoses in 2018 as evidence for an especially effective national response,’ say Hawre Jalal and Donald Burke, the study’s authors.
With many synthetics still available on the streets, tackling opioid addiction remains difficult. The Trump administration pushed for opioid prescriptions to drop by more than a third by 2021. However, a letter sent to the CDC in March, signed by more than 300 medical experts, argued that stringent prescribing guidelines may be forcing more patients with genuine need into withdrawal.
‘We’ve made good strides with prescription opioids. The tapering of treatment needs to be done carefully, however, because cutting off can leave [users] prone to withdrawal, increasing the likelihood that they will reach out to illicit opioid sources, such as street synthetics and heroin,’ says Pardo. He adds that efforts on the street to support addicted users, including pop-up tents where users can administer safer alternatives to synthetic opioids, and where staff are trained in the administration of the anti-overdose drug naloxone, are crucial.