“Since 2014, state and local governments have filed thousands of lawsuits against pharmaceutical companies they blame for causing the “opioid crisis” by exaggerating the benefits and minimizing the risks of prescription pain medication. The theory underlying these cases is pretty straightforward: Drug manufacturers lied, and people died.
Two recent rulings—one by a California judge, the other by the Oklahoma Supreme Court—show how misleading this widely accepted narrative is. Both decisions recognize that undertreatment of pain is a real problem and that bona fide patients rarely become addicted to prescription opioids, let alone die as a result.”
“Between 2002 and 2019, according to the federal government’s survey data, the number of Americans who had a “substance use disorder” involving heroin roughly doubled. During that same period, according to the CDC’s data, the annual number of heroin-related deaths septupled, while the total number of opioid-related deaths quadrupled. The war on drugs helps account for that disparity, since it has made opioid use more dangerous”
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“Nowadays fentanyl is showing up in black-market pills sold as hydrocodone or oxycodone and even in stimulants such as cocaine and methamphetamine. Its proliferation is a response to the very supply control measures that were supposed to reduce drug-related deaths. To the extent that the government succeeds in exerting pressure on the supply of illegal intoxicants, it encourages traffickers to distribute more-potent drugs, which are easier to conceal and smuggle.
Since fentanyl is far more potent than heroin, a package weighing less than an ounce can replace one that weighs a couple of pounds. Synthesizing opioids is also a less vulnerable and much cheaper process than production that relies on poppy crops. Researchers at the RAND Corporation estimate that heroin is at least 100 times as expensive to produce as fentanyl, adjusting for potency.
Black-market drugs were already iffy because of prohibition; the prohibition-driven rise of fentanyl has made them even more of a crap shoot. And these are the substitutes nonmedical opioid users resorted to after drug warriors succeeded in driving down prescriptions of analgesics such as hydrocodone and oxycodone. That shift replaced legally produced, reliably dosed pharmaceuticals with illegal drugs of unknown provenance and composition. The result was predictable (and was in fact predicted): As opioid prescriptions fell, opioid-related deaths rose.”
“Although prescription pain medication is commonly blamed for the “opioid epidemic,” such drugs play a small and shrinking role in deaths involving this category of psychoactive substances.”
“Medications like methadone, as well as buprenorphine and naltrexone, are considered the gold standard of care for opioid addiction. Studies show that the medications reduce the mortality rate among those patients by half or more, and keep people in treatment better than non-medication approaches.
Yet rehab facilities in the US often treat medications with skepticism or even scorn, while embracing approaches with little if any peer-reviewed scientific evidence”
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“Medication isn’t the only effective way to treat opioid addiction. Other approaches, including cognitive behavioral therapy, motivational interviewing, and contingency management, also have evidence backing up their ability to treat addiction.
Still, for opioid addiction, medications “should be the first-line option,” Keith Humphreys, a drug policy expert at Stanford, told me. “Not forced, but every single person should be offered that in any decent program treating opioid addiction.””
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“despite their effectiveness, the available medications are often stigmatized with a common trope that they “replace one drug with another.” On its face, this is literally true: The medications do substitute, say, heroin or alcohol.
But the context matters. The issue with addiction is not just drug use. Most people use some kind of drug — caffeine, alcohol, or medications. Some people are even dependent on these drugs, whether someone needs coffee to get going in the morning or insulin to survive.
What makes addiction a medical disorder is not just drug use or even dependence, but continued, compulsive use despite negative consequences. So someone would be unable to stop using heroin even when it poses serious risks to his health, career, or family. It’s only then that drug use becomes a drug use disorder.
The medications alleviate those problems, turning a drug use disorder back into just drug use. That’s why they reduce all sorts of drug-related problems, including the risk of death.”
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““No other medication is prescribed in this way,” Sue, of the Harm Reduction Coalition, said.
Buprenorphine can be prescribed in a traditional health care setting, but it too faces unique restrictions. Doctors have to go through an eight-hour training course to get certification to prescribe it, and nurse practitioners and physician assistants have to go through a 24-hour training course. The restrictions are one reason that, according to the White House opioid commission’s 2017 report, 47 percent of US counties — and 72 percent of the most rural counties — had no physicians who could prescribe buprenorphine as of 2016.
Since methadone and buprenorphine are opioids themselves, the rules are meant to make it harder to get and illegally sell the medications for misuse. (Naltrexone, the non-opioid option, doesn’t face similar restrictions.) But the laws and regulations have also helped create an environment in which rehab facilities are more likely to try unproven methods than medication-based treatments with decades of scientific evidence.”