Last year, we officially had close to 60,000 accidental overdose deaths and hundreds of thousands of accidental overdoses which were reversed with lifesaving medications such as naloxone. In short, that’s a lot of accidents, and the number of these accidents has been on the rise in recent years. Why exactly are so many people experiencing accidental overdose? Has the population of individuals with opioid use disorders suddenly become much more accident prone? Are illicit drug dealers actively trying to kill their consumers in large numbers to shrink the market for their product? We all know that the public health crisis is spiraling out of control, but we have incredible difficulty determining why. We all know that increases in heroin purity and the large-scale inclusion of fentanyl into illicit opioid supplies is pushing up the body count, but why exactly has the market demanded such potency in the first place?
The most logical explanation is that people with active substance use disorders need to get high. I use the word “need” because it more accurately describes the phenomenon of craving than words like “want” or “desire.” The problem we’re now facing is that we’ve made getting high on opioids harder, particularly for the most seriously afflicted individuals, and concurrently made access to appropriate level of care treatment for opioid use disorders less accessible. This isn’t a new mistake. It’s the same mistake repackaged and then doubled and tripled down on, that we always make with our Faustian bargains to address substance use disorder. In 1920, we tried to address an alcohol pandemic through prohibition and defunding all the alcohol treatment centers (alcohol and alcohol related illnesses still account for 100,000 deaths per year a century later). In the 60s and 70s, we brought methadone maintenance protocols to scale and similarly didn’t invest in the wraparound services needed to help people get better. In the 1980s, we pumped money into the industrial prison complex and scaled up mass incarceration rather than drug treatment of our citizens during the crack cocaine epidemic. In the 90s and 00s, we let the legal American opioid cartel’s “pain is the fifth vital sign” campaign go unchecked under the premise that the medical community would safeguard the population from concerns around addiction (that’s the gem that brought people access to massive amounts of pharmaceutical grade opioids by pointing to the frowny face on a subjective chart that looks like the emoji list on your cell phone).
This decade, we have a “new” solution with new unintended consequences. We’re again looking for a silver bullet solution to substance use disorder without providing the support services people need to get well at an appropriate scale. We’ve been very effectively using medication assisted treatment during detoxification protocols for decades, so we got the bright idea to extend five days into five weeks, which became five months, which in turn jumped up to five years, which is now in the process of becoming lifetime maintenance without the need for clinical support services. Leaving aside the fact that if maintenance was the solution in and of itself, we would have solved all our problems half a century ago when we brought methadone to scale. We have another bigger problem on our hands. The current maintenance medications are opioid antagonists which block the opioid receptors and, in theory, prevent the individual using opioids from getting high. This sounds good in principle and has even looked promising in controlled trials that measure success based on med compliance. Unfortunately, this approach completely and utterly fails to account for the fact that A) many individuals with substance use disorders oftentimes don’t want to stop getting high until they are presented with better alternatives, B) virtually everyone in an active opioid use disorder is aware that the barrier can be broken simply by taking more and stronger substances and most importantly, C) the streets do not even remotely constitute a controlled environment.
Which brings us to our current mishandling of a national health pandemic. The best and most effective treatment is always going to involve getting people off the street and into the care they desperately need. Irrespective of what your opinion is on this subject, the fact that people in early recovery engagement from opioid use disorders don’t die while in inpatient treatment and frequently do when this level of care is not provided is irrefutable. While this is a very controversial topic, this article is not intended to be an anti-MAT article. I’m very much in favor of the appropriate utilization of MAT (specifically Vivitrol protocols being initiated while individuals are undergoing acute care for an opioid use disorder). Rather, this is an argument for the “A” and the “T” in MAT. If we just give people the “M” and limit access to treatment (particularly appropriate level of care treatment, as the overwhelming majority of people only seek help when symptoms are so severe that acute care is medically necessitated), we’re going to continue to see the death toll rise as desperate people take riskier actions to break the barriers established by the “M.”
We already live in a world where virtually every heroin dealer also trades and sells black market maintenance medications (specifically the ones that are both an opioid and an opioid antagonist in the same pill). We already live in a world where an increasingly large portion of the population with opioid use disorders take both maintenance medications and increasingly potent fentanyl laced heroin to get around the opioid barriers those maintenance medications establish. We already live in a world where 60,000 people “accidentally” dying each year is now considered normal.
You don’t have to take my word for it though. Go ask any first responder. Any nurse at a detox receiving facility or ER. Any therapist working with this population. Any family member who’s had to revive a loved one or had to bury one. Any human being struggling with or in recovery from an opioid use disorder. The majority will tell you that countless people with opioid use disorders are taking prescription or black market maintenance medication to avoid being sick and consequently having to take increasingly potent doses to break the barrier and get high. To make matters worse, even individuals not involved in this deadly trap are at increased risk for accidental overdose, as the general heroin supply has become much more potent to accommodate demand from those who are.
Lastly, if you’re still unconvinced by all of our collective experiences and your own common sense, there’s one other group you can talk to that simply can’t do anything other than give you a completely unbiased answer on this question. You can go ask our dead. You’ll find they didn’t die while in acute care treatment, but rather while they were either not receiving the appropriate level of care or even care at all. Ask what percentage of them tested positive for fentanyl? Most importantly though, ask what percentage of them tested positive for or were recently prescribed the maintenance medications that promised to save their lives, in lieu of treatment, before their “accidental” death?