Experts: Shifting opioid landscape demands new approaches

Published: Wednesday, February 1, 2023 - 4:43pm
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NYU Grossman School of Medicine.
Magdalena Cerdá directs NYU Grossman School of Medicine's Center for Opioid Epidemiology and Policy.
The Washington Post.
Sari Horwitz covers the Justice Department and criminal justice for The Washington Post. She co-led the Post’s “The Opioid Files” series, a 2020 Pulitzer Finalist for Public Service.
The Washington Post.
Scott Higham has investigating the opioid industry since 2016 and co-led “The Opioid Files.” He the co-author of “American Cartel: Inside the Battle to Bring Down the Opioid Industry.”

Apache Junction police are looking into the death of a 3-year-old who ingested fentanyl.

It’s the latest tragedy in Arizona, where five people a day die from opioid overdose, and in the U.S., a world leader in such deaths.

It also exemplifies the changing opioid landscape.

“At the beginning of the overdose crisis, the response focused on regulating opioid prescribing and tightening the prescription opioid supply,” said Magdalena Cerdá, who directs the Center for Opioid Epidemiology and Policy at NYU Grossman School of Medicine. “But now, what we're talking about is a crisis characterized particularly by illegal opioids.”

Today, the opioid crisis has mutated from medication misuse to deadly mass poisonings, as people unwittingly ingest fentanyl while using other drugs.

“What we're increasingly seeing across the country are something called mass poisonings, where several people at a party or a gathering who are using cocaine, meth, heroin, oxycodone, Xanax, Adderall, all kinds of different things, don't realize that what they're using is laced with fentanyl, and they all die,” said Sari Horwitz, who co-led the Washington Post’s investigative “The Opioid Files” series.

The social burden of opioids, too, has shifted: from rural whites to minority groups, especially Black communities. Through it all, Native Americans have ranked among those hardest hit.

“Across the country, from 2006 to 2014, Native Americans were nearly 50% more likely to die of an opioid overdose than nonnatives,” said Horwitz.

In lawsuits, tribal leaders have repeatedly blamed drug companies for targeting their communities.

More generally, the COVID-19 pandemic significantly worsened the opioid crisis. Following an initial peak, usage and deaths leveled off, but remained higher.

“In 2021, more than 100,000 people died of an overdose, mostly involving opioids,” said Cerdá. “That was the highest number ever in recorded history.”

Fentanyl is tailor-made to drive up such grim statistics. The synthetic drug is cheap to make, immensely profitable and easy to smuggle.

But Scott Higham, another Post reporter who led “The Opioid Files” series and has covered opioids since 2016, says — despite the protestations of politicians — trafficking has little to do with immigration.

“Very little fentanyl is being carried by people,” he said. “It's mostly being stuffed into cars and into trucks by drug-trafficking organizations, the cartels, and by their smugglers, and just driving it right through the ports of entry.”

Or those on the receiving end, the drug Naloxone can be a lifesaver. But research shows only 15% of U.S. counties offer community-based distribution programs, and fewer than 50% have treatment centers that provide the medication.

Indeed, overdose interventions are increasingly handled by law enforcement agents, who are increasingly focusing instead on trying to save lives over trying to stem the fentanyl tide.

“They are overwhelmed; they are beleaguered; they are sad; they can't do their job and all around them people are dying,” said Higham.

Meanwhile, he says, the crisis has relocated uptown.

“At first, it was small towns in Appalachia and Ohio and West Virginia, Kentucky, New Hampshire; then it became big cities, Chicago, New York, San Francisco, LA, San Diego — places that we would never expect to be walking downtown and walking into a place that looks like a set from a zombie movie,” he said.

Cerdá says the shift in the landscape demands a change in focus and approach, one dedicated to reducing harm and death. That means providing Naloxone, shielding people who report overdoses from criminal prosecution and improving access to treatment that works.

“We found that 87% of people with opioid use disorder do not receive evidence-based treatment,” she said.

But inequities in access to medications used to treat opioid use disorder also split along racial and ethnic lines. Black and Hispanic residents have greater access to burdensome methadone clinic treatments than to buprenorphine, which can pharmacists can prescribe for home use.

Studies suggest expanding Medicaid might help.

“What we saw is that, indeed, states that expanded Medicaid not only experienced an increase in access to treatment, but they also experienced a decline and overall opioid overdoses, particularly overdoses involving heroin and illegal and manufactured synthetics,” said Cerdá.

Whatever approaches are implemented, their success or failure will remain difficult to track so long as impact estimates and predictions continue to lag behind.

“Looking at deaths that took place a year ago and trying to predict what's going to happen on the ground next month is almost impossible,” said Higham. “It's like one of the former drugs czars we interviewed said: ‘It's like trying to track the overdose epidemic by visiting cemeteries; it just doesn't work.’”

If you suspect someone is having an overdose, call 911. For less urgent help, the state health department offers a free, confidential opioid assistance and referral hotline at 888-688-4222.

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