For all the public discussion about the opioid crisis in the last several years, we should have made a far greater impact in American lives. But approaches to this epidemic are likely to lead to more deaths because of a cultural legacy of oversimplified and incomplete thinking about drugs and users. What we assume about drug users may be our biggest obstacle to helping them.
A cultural legacy of oversimplified and incomplete thinking about drugs and users—and the systems this thinking has created—prevents us from truly helping the drug users who need it. The stories we have told ourselves about drug users for over a century are incomplete, biased, and sometimes flat out wrong. It is time we change that. We should start by dispelling long-held drug myths that frame misinformed thinking about opiate-related deaths in the US.
Many Americans’ lives are touched directly by addiction. That connection to the most extreme outcomes of drug use often shapes our response to drug-related issues. We tend to extrapolate that expected outcome to all drug users. It is critical to recognize that the vast majority of any drug users, including opioid users, are not addicts. Decoupling our expectation of drug use and addiction allows us to think about other factors.
What factors have created the “opioid epidemic,” and what kinds of healthcare and policies would end it? While addiction is a serious and complicated public health issue, it is not the sole factor at the center of the rise in opiate-related deaths. Other factors include: pain management, over-prescription of opiates, drug substitution, poly drug use interactions, and use for pleasure.
Over the last few years, we have come to realize that heroin is often not heroin. Even before this crisis, heroin was, at best, 30% pure. Other adulterants, including, synthetic opioids like fentanyl and carfentanil, have become passed off as heroin or made into counterfeit OxyContin pills because they are inexpensive and available or simple to synthesize. Because these drugs are hundreds of times stronger than heroin or morphine, the high is much greater. Users do not know that they’ve been handed a substance that so greatly exceeds the strength and dosage with which they are familiar.
According to the Center for Disease Control, the near quadrupling of prescription opiates sold in the US from 1999-2015, tracks exactly with the total opiate overdoses from both prescription and heroin. During this time, there was not a change in the amount of pain reported by Americans. With access to drugs under scrutiny, many users managing pain have moved to heroin or other opiates bought in the black market.
While we have started to collect data about the various kinds of opiates involved in deaths, we have not sought a full understanding of other factors, such as the potential interactions of poly drug use in these deaths. Two widely used prescription drug classes, benzodiazepines and opiates, are potentially lethal when taken together. Users who take drugs like Xanax or Klonipin for anxiety or mood disorders with Vicodin, Hydrocodone, or other prescription opiates, methadone, heroin, or alcohol for pain management can suffer lethal respiratory depression. Although the FDA now requires “black box” warnings about the combination of these drugs, we have much more work to do in terms of communication the potential harms to users.
The key element missing from public drug discussions is why people take drugs and who uses them. Aside from pain management, the other reason people use opiates is for pleasure. This is a hard pill to swallow in a country that has gone with “just say no” instead of dealing with the very human desire to alter consciousness and even intoxication. In many ways, we are fearful of examining why people use “drugs,” even as we know we probably need to.
According to both domestic and international drug researchers, only a small percentage of users of any psychoactive drug, including heroin and other opiates are addicted. If most users of heroin or street Oxy are not using compulsively, they are using for other reasons—among them, pleasure. This is something we have to discuss as we create policies and seek funding to help prevent overdoses. If we don’t, we will replicate the kinds of drug war era policy and practices that have gotten us here.