BY RAYMOND BARGLOW

DRUG OVERDOSE IS NOW THE LEADING CAUSE OF death for Americans under the age of 50 and has lowered the average life expectancy in the United States.1 Over the next decade as many as half-a-million people in the United States will die from opioid substances that include heroin, pain-killers such as morphine and oxycodone, and synthetic agents such as fentanyl.2

Public policy to date has failed to counter this epidemic. Standing in the way of effective response are three mistaken approaches to the problem:

1. Misinterpreting correlation as causation.

2. Misunderstanding the physiology of addiction.

3. Overlooking the social psychology of addiction.

Mistake #1: Misinterpreting Correlation as Causation

Does epidemic opioid overuse result from too many prescriptions of medication for pain relief? In March of 2018 President Trump announced that his administration is “taking action to prevent addiction by addressing the problem of overprescribing…. We’re going to cut nationwide opioid prescriptions by one-third over the next three years.”3 The U.S. Centers for Disease Control and Prevention (CDC) also attribute the overuse of opioids and other addictive substances to prescription practices:

Drug overdose deaths in the United States more than tripled from 1999 to 2015. The current epidemic of drug overdoses began in the 1990s, driven by increasing deaths from prescription opioids that paralleled a dramatic increase in the prescribing of such drugs for chronic pain…. The problem with misuse of prescription drugs of various kinds is related to high levels of prescribing of such medications.4

This concern about excessive prescription is certainly legitimate. However, a close look at the historical data clarifies the causal role that prescription plays in the opioid epidemic.

The years of the steepest increase in overuse fatalities, 2012 to 2017, are also years in which prescription rates declined. This divergence between fatality and prescription rate trends is striking, even when we take into account that it might require several years for a lower prescription rate to result in significantly fewer overdose deaths. The sharp rise in recent years of opoid-induced deaths is in fact due to the consumption of drugs that are rarely used for medical pain management: As of 2015 the rate of overdose deaths due to illegally obtained heroin and synthetic opioids had gone up so much that they took more lives than did all of the other prescribed opioids combined.6 Synthetic opioids like fentanyl (a drug 50 times more potent than heroin) and carfentanil (5000 times more potent than heroin) are inexpensive to produce and easily shipped to customers through the mail. Moreover, heroin and other street drugs are often mixed with fentanyl and its derivatives, further raising fatal overdose rates.

Even during the years 1999-2012, when opioid prescriptions and overuse mortality rose in tandem, this correlation does not show that the first was a major cause of the second—the addiction rate among patients taking opioid medication for chronic pain is in fact quite low, less than 8 percent. 7 Over the past two decades, U.S. states have enacted a number of prescription-control laws, most targeting opioid drugs. However, this legislation has had a very limited impact on the rate of overdose fatalities.8 The correlation between prescription and overuse of opioids is no more causative than any number of treatment-illness relationships. Surgery, for example, typically makes a patient more susceptible to infection—a fact that supports more attention to sanitizing operating environments, but doesn’t justify a reduction in the number of surgeries.9 Similarly, taking birth control pills slightly raises a woman’s chances of contracting cervical or breast cancer,10 but this happens sufficiently rarely that it provides little reason to forego this method of contraception.