The epidemic began with painkillers. As such, government agencies, regulators, doctors, and medical groups have pulled back on prescriptions for the drugs. Some states have limitedhow many opioids doctors can prescribe. The federal government put some opioids on a stricter regulatory schedule. Law enforcement has threatened doctors with incarceration and the loss of their medical licenses if they prescribe opioids unscrupulously. And the CDC released guidelines that, among other proposals, ask doctors to avoid prescribing opioids for chronic pain except in some circumstances.
This has had a steady effect on painkiller prescriptions, with total opioid prescriptions falling since 2010. But there’s still a lot of work to be done: In 2016, there were enough pills prescribed to fill a bottle for every adult in the US. And in 2015, the amount of opioids prescribed per person was more than triple what it was in 1999, according to the CDC.
There are risks to the pullback: With the existing population of opioid users, cutting them off from painkillers could be dangerous. Although they shouldn’t be a first-line treatment, opioids can be the only source of relief for a few chronic pain patients. If someone is suddenly yanked from a high dose of opioids, she could undergo painful withdrawal. (This is why experts say careful tapering is necessary for a patient getting off opioids — to ensure the process is as painless as possible.) And people who lose access to painkillers could decide that rather than deal with pain from withdrawal or chronic conditions, they’re going to get other opioids — such as heroin and fentanyl, which are deadlier than painkillers and would likely lead to even worse outcomes.
The shift to heroin and fentanyl is one reason experts emphasize the need for access to addiction treatment on top of efforts to pull back on painkillers.
“Let’s say you only focus on curtailing overprescribing to prevent people getting addicted, but you do nothing to expand treatment,” Kolodny said. “Then heroin and fentanyl will keep flooding in, and overdose deaths will remain at historically high levels until the generation that became addicted ultimately dies off.”
But based on the 2016 addiction report by the surgeon general, comprehensive treatment still remains out of reach for many.
While the federal government has added some spending to addiction care (including $1 billion over two years in the 21st Century Cures Act), it’s nowhere near the tens of billions every year that Kolodny and other experts argue is necessary to fully confront the crisis. For reference, a 2016 study estimated the total economic burden of prescription opioid overdose, misuse, and addiction at $78.5 billion in 2013, about a third of which was due to higher health care and drug treatment costs. So even an investment of tens of billions could save money in the long run by preventing even more in costs.
For opioids, much of that funding needs to go to medication-assisted treatment (MAT), when medicines like methadone, buprenorphine, and naltrexone are used to combat opioid cravings. Several studies have found that MAT can cut mortality among opioid addiction patients by halfor more. The CDC, the National Institute on Drug Abuse, and the World Health Organization all acknowledge its medical value, and experts often describe it as “the gold standard” for opioid addiction treatment.
But MAT remains inaccessible, in large part due to strict policies surrounding it. For example, the federal government still caps how many patients doctors can prescribe buprenorphine to, with strict rules about raising the cap. A HuffPost analysis found that even if every doctor who can prescribe buprenorphine did so at the maximum rate in 2012, more than half of Americans with opioid use disorders could not get the medication.
Even if all of this is fixed, however, the reality is some people will still misuse and get addicted to drugs. That’s one reason experts have also called for harm reduction efforts: Prescription heroin, which has been tried successfully in Canada and Europe, could let people access a clean supply of the drug. Supervised injection facilities could provide a space for drug users to inject illicit substances, with medical staff ready in case something goes wrong. Needle exchange programs could let people trade in used syringes for new ones, reducing the risk that a needle will carry HIV, hepatitis C, or some other disease. The opioid overdose antidote naloxone could be made more accessible across the country.
One concern with harm reduction strategies, echoed by anti-drug groups like the Drug Free America Foundation, is that removing some of the risk to using harder drugs will perhaps make some people more likely to use dangerous substances.
But this simply has no foundation in the evidence. For example, a 1998 study from researchers at Johns Hopkins University found needle exchange programs generally reduced the spread of HIV without increasing drug use. A 2004 study from the World Health Organization, which analyzed two decades of evidence, produced similar results.
Harm reduction efforts will not prevent all deaths. They won’t make all heroin use safe. But they will reduce the amount of harm done by these drugs.