The controversial Purdue Pharmaceuticals settlement agreement announced on September 1, 2021 comes at a critical moment in the US drug overdose crisis: 2020 is the worst year on record, with more than 93,000 Americans suffering from fatal drug overdose. Killed. Since 1999, over 20 years of drug overdose epidemics have claimed the lives of more than 840,000 people. Current estimates indicate that approximately 2.3 million people in the United States use heroin and 1.7 million people use opioids without a prescription.
Since 2016, I have been studying the drug overdose crisis, focusing on understanding its root causes and consequences. As a sociologist, I came to this field of research to find meaning, because every year I bring more funerals to my former classmates and friends. I found that for drug users, the drug environment is becoming more and more dangerous, and policies that are not based on research and attitudes to harm the affected often make the situation worse.
How bans fuel dangerous markets
Research shows that the illegal drug market adapts to demand and drug law enforcement.
The first consequence of increased demand is that medicines become cheaper over time. For example, the prices of heroin and cocaine have been declining for decades. Political economists explained that the combination of demand and globalization has increased efficiency and competition. The result is that there are more drugs on the illegal market, which in turn lowers prices.
Second, as a response to drug control, drugs have become more effective. Stronger products in smaller packages are easier to transport and harder to detect. The US drug overdose crisis has become a case study of the destructive interaction between demand and bans.
OxyContin was released in 1996 and sold on a large scale as a revolutionary intervention for pain medical treatment. Its manufacturer Purdue Pharmaceuticals deliberately downplayed its addictive potential. As an opioid and central nervous system depressant, OxyContin acts similarly to morphine or heroin. Not surprisingly, research shows that from 1999 to 2008, opioid prescription patterns were directly related to the surge in overdose deaths.
As concerns about overdose of opioids intensify, doctors’ prescribing behavior is under scrutiny. In 2010, Purdue Pharma replaced the original OxyContin with an “abuse deterrence” formula that is more difficult to crush and inhale. As a result, many people addicted to OxyContin turned to cheaper and more easily available heroin. This has stimulated a surge in fatal heroin-related overdose, which is often referred to as the second wave of the overdose crisis.
The growing heroin market has paved the way for fentanyl to enter the illegal drug market in the United States. Fentanyl is a medicine used to treat severe pain in a medical setting, and its effectiveness is 50 times that of heroin. From the perspective of transportation and trafficking efficiency, fentanyl is easier to transport and sell than heroin. Fentanyl’s entry into the illicit drug market, especially in combination with heroin, caused overdose deaths to double and triple between 2012 and 2013.
Since then, fentanyl has contaminated the illicit drug supply in the United States: it is not only found in heroin, but also in cocaine, ecstasy (often called ecstasy), methamphetamine, and counterfeit prescription drugs. The result is that most people do not know the potency or content of the drugs they use.
As the overdose crisis evolves, communities of color in particular have experienced a surge in fatal overdose—these deaths are usually preventable. Recently, a disruption in the COVID-19 supply chain has caused people to use whatever is available, leading to mixed drugs and overdose.
Drug users are often bombarded with information that has not been supported by research, thereby exacerbating the harm.
Public health officials and community leaders urge people to seek treatment and emphasize that recovery is within reach. However, approximately 70% of people seeking treatment cannot get treatment. Treatment barriers include health care costs, lack of available treatment options, and social stigma. Research also shows that some people are not ready for treatment or do not want to stay awake.
Sober is touted as the ultimate goal of drug addicts. However, studies have shown that addiction is a recurrent brain disease, and it is very likely to relapse. Most drug users take drugs in a sporadic manner, which is characterized by controlled and uncontrolled use and sobriety. There is also ample evidence that the fear of arrest and shame encourages people to hide their drug use in ways that increase the risk of fatal overdose. This is because when people use it alone, if an overdose occurs, no one can call 911 or perform CPR.
In terms of effective treatment, medical aids are considered the gold standard for opioid use disorders, but they are still underutilized. Buprenorphine is an opioid with a “ceiling effect”, which means that it is not as intoxicating as morphine or heroin, but can satisfy the craving for opioids. Buprenorphine helps people get rid of uncontrolled use and reduces their body cravings. The person who prescribes is usually able to work, receive treatment, and re-enjoy daily life.
Nevertheless, the availability of buprenorphine varies from state to state, and prescriptions for this life-saving drug for people of color have been insufficient. Methadone has been used to treat opioid use disorders since the 1950s, but it has been difficult to obtain for a long time. Researchers point out that stigma plays a sustained role in the underuse of these two drugs.
A better way forward
Public health officials, harm reduction activists and concerned citizens across the United States are working to ensure safer injection sites where people can use drugs in the presence of medical staff. These sites promote the prevention of fatal overdose by ensuring an adequate and timely medical response and open the way for further medical care and addiction-related treatments. In response to the pressure on inpatient care facilities caused by the pandemic, the supply of methadone has been expanded in new ways—some therapists hope that this change will be permanent.
For drug users, the potency and content of their drugs are usually unknown. The drug inspection program allows people to use simple test strips to check the ingredients of fentanyl at home. Such plans have recently gained attention with the support of the federal government. States are also continuing to expand the use of naloxone, an easy-to-administer overdose reversing nasal spray. Encourage drug users or their relatives to receive training on how to use naloxone and carry nasal sprays.
Those who advocate safer drug supply and decriminalization point to success abroad. Heroin adjuvant therapy has been shown to be effective in keeping people away from the unpredictable drug market, thereby reducing the risk of drug overdose. The use of heroin adjuvant therapy in Germany has improved the physical and mental health of patients, while greatly reducing the use of illegal drugs. In the early 2000s, Portugal legalized all drugs in response to the highest rate of fatal overdose in Western Europe. With the transfer of funds from bans to education and treatment, Portugal’s overall drug use has declined, and it is now one of the countries with the lowest fatality rate in Western Europe.
Americans are the world’s largest consumers of drugs and have consistently been among the countries with the highest rates of opioid and cocaine dependence in the world. In my own research, I found that people often describe drug use as a struggle between sobriety and death. But the heartbreaking surge in accidental, fatal overdose deaths tells a more complicated story. Ignoring the evidence will definitely cost more lives.
If you or someone you care about has substance abuse disorder and needs help, you can call SAMHSA’s national helpline: 1-800-662-HELP (4357). You can get immediate emotional support from the National Suicide Prevention Hotline 800-273-8255.
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