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A police photo from East Liverpool, Ohio, showing a young child sitting behind his grandmother, left, and her boyfriend, both of whom are unconscious from drug overdoses, September 7, 2016. (East Liverpool, Ohio Police Department)

The Opioid Crisis

David W. Murray, Brian Blake & John P. Walters

An investigative article in the Sunday, October 23, Washington Post detailed the Obama Justice Department’s actions to hamper the Drug Enforcement Administration’s aggressive efforts to stop the deadly diversion of pain medications. The article draws on testimony from multiple sources indicating that political and lobbying pressure sought to inhibit effective enforcement operations to shut down deadly “pill mills” and distribution networks. Dedicated, senior enforcement personnel—whom we have worked with—were pushed aside and into retirement. All this at a time when diverted opioid medications were known to be a key cause of overdose deaths. This scandal is only part of the story of the Obama opioid epidemic—and it is not the worst of it.

In 2014, the most recent year for which we have measurements, 47,055 Americans died from drug-induced deaths, with almost 29,000 dying from opioids, whether heroin, illicit synthetics, diverted or misused prescriptions, or some combination of these. The daily reports of overdoses have reached such a magnitude—including an eight-year, 400 percent increase in heroin deaths—that the human toll in communities across our nation is impossible to ignore.

The tales and images of the crisis in afflicted communities across America are bursting through the media clutter. A few have reached national prominence, such as the 7-year-old girl who told her bus driver on the way home from school that she hadn’t been able to wake her parents—who had died in a double overdose—for the previous two days; or the photo of two unconscious grandparents in the front of a car, with a helpless, crying child strapped into his car seat behind them; or the tragic video of a mother passed out in the aisle of a Family Dollar store in Massachusetts, with her traumatized toddler in footie pajamas trying to wake her up.

Aside from these dramatic stories and images amplified nationally by social media, the public policy and public health messages regarding opioid abuse have conspicuously not been either urgent, imperative, or forthcoming. In countering the opioid crisis, the public health apparatus has neglected the full set of effective epidemiological tools and has failed to mobilize an effective response.

Drug Deaths as a Public Health Emergency

The 47,055 drug-induced deaths in 2014 were the leading cause of accidental death in America, surpassing both motor vehicle accidents (33,636) and firearm deaths (33,599, of which 10,945 were homicides).

The Centers for Disease Control deaths and mortality report for that year shows 2,626,418 total mortalities in the United States, with heart disease and cancer, both at approximately 600,000, lead-ing the way. Within this tabulation, drug-induced deaths would stand ninth amongst “leading causes,” just below influenza/pneumonia (55,227) and kidney disease (48,146), and just above suicide (42,773).

While all opioid overdose deaths for 2014 totaled nearly 29,000, heroin deaths contributed at least 10,500 to that total, almost exactly the same as the toll from gun murders. And while the number of drug overdoses is increasing, overdose deaths caused by diverted prescription opioids—the illegal activity the Post‘s investigative piece highlights—have been overtaken in raw numbers by deaths from heroin and illicit synthetic opioids like fentanyl. All signs indicate that it is the supply of these illicit opioids that has accelerated most steeply since 2010 and that has driven deaths sharply higher in the months since the last reported mortality data from 2014.

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Our concern should be heightened by the fact that there are no real-time national mortality data. We are still viewing the crisis as it looked almost two years ago, with only partial information since then from a few states, law enforcement reports, and frightening local news stories. These suggest America faces an emerging set of hyper-potent synthetic opioids from illicit, rogue chemists that are dramatically increasing addiction and death.

Between 2013 and 2014, the CDC reports that deaths attributed to prescription opioid misuse rose 9 percent, while heroin deaths rose 26 percent, and deaths from the emerging threat of synthetic opioids such as fentanyl shot up 80 percent. The CDC will not have 2015 drug mortality data available until December of this year, but regional reports in the Northeast are already coming in, showing that these trends have accelerated since the 2014 reports. If these preliminary reports are any indication, the national measurements for 2015 and 2016 are all but certain to eclipse the nearly 50,000 deaths recorded in 2014.

The surge in illicit synthetic opioids driving these deaths is being fed by suppliers primarily in Mexico and China. The deadly poisons are produced in illicit labs in those countries and then smuggled or shipped in small but extremely potent quantities through the postal service and via other established smuggling routes. The threat to users, to first responders, and to communities across America is unprecedented. The numbers bear it out:

In Maryland, comparing the first six months of 2015 to the same period in 2016, prescription opioid overdose deaths increased 10 percent, heroin deaths climbed 68 percent, and deaths from fentanyl shot up a remarkable 268 percent.

As released in August 2016, opioid overdose deaths in Massachusetts have risen 200 percent since 2010 and in the single year 2014-2015 shot up 23 percent, to their highest rate ever.

New Hampshire reports an increase of 157 percent in overall drug deaths between 2013 and a projected 2016 total, with the vast majority being caused by heroin, fentanyl, or a combination of the two drugs.

New York City notes the fifth consecutive year of overall death rate increases, up 66 percent from 2010 to 2015, while heroin death rates rose 158 percent over that time.

When national data for 2015 and 2016 finally become visible, we may confront a death toll that seems unimaginable to us now. This increase will occur even as countless lives have been narrowly saved by a huge deployment of antidote drugs like naloxone, one of the few major initiatives from federal officials. But these life-saving drugs are often used time and again on the same opioid abusers, who never get the long-term treatment they need to break the cycle of addiction. Their Russian roulette lifestyle of continued drug use often, tragically, catches up with them.

More High-Potency Opioids, More Deaths

The CDC operates, in addition to their Morbidity and Mortality Weekly Reports, several alert systems for topics ranging from the threat of food-borne risks to travel advisories, including a system known as the Health Alert Network (HAN) that sends alerts to public health communities. Through such systems we can learn about everything from the threat of salmonella from small turtles on up to the ramifications of the Zika virus.

There is a useful lesson in the Zika alerts. The actual U.S. death toll from Zika thankfully remains minimal. But common to the public health responses are efforts that go beyond simple warnings to communities. Authorities also move to control mosquito populations (spraying them) and to eliminate the environmental conditions that foster them (standing water, for instance). They further warn the public to change their behavior in response to the crisis (encouraging the use of mosquito repellent).

What we see, viewed epidemiologically, are efforts to control the sources of the disease and the conditions that contribute to its spread; that is, public health experts seek to limit the pathogens of disease as well as the vectors by which the disease spreads.

Through this lens, our failures to meet the opioid crisis can be seen in sharper perspective. We are not taking seriously the realization that opioid abuse is a public health threat that calls for similar sorts of epidemiological actions. We need urgent alerts and, beyond those, directed responses to constrain or eliminate the sources and supplies of the deadly drugs, as well as efforts at interrupting the vectors of transmission—namely, traffickers and other users.

To its credit, the CDC has issued a recent “health update” regarding fentanyl-laced counterfeit pills, a significant contributor to fentanyl-related fatalities. The counterfeit pills are especially cruel and lethal. They are sold as labeled versions of diverted prescription pills, such as Oxycontin or Xanax, but contain unmarked and unknown quantities of fentanyl and chemical analogues, inexpertly cut and mixed. This fact is crucial, as fentanyl doses are measured in millionths of a gram, and as little as 2 milligrams can be lethal. A single kilogram of pure fentanyl contains a potential 500,000 lethal doses; a fraction of a grain too much can be fatal.

The Russian roulette analogy is apt. While one pill may provide an opioid high, because the badly mixed doses of fentanyl are measured in such minute quantities, the next pill may contain a lethal overdose. Increasingly, the deaths transpire despite the administration of a naloxone antidote, which too often is insufficient to counteract fentanyl potency.

The CDC’s alert goes on to mention further “extremely toxic” analogues such as carfentanil, implicated in several recent tragic overdose outbreaks when mixed with injected heroin. Meanwhile, the Drug Enforcement Administration (DEA) issued a nationwide report in July indicating that “hundreds of thousands of counterfeit pills, many containing deadly amounts of fentanyl .  .  . have made their way into the U.S. drug market.” In fact, in 2014 and 2015, the number of drug submissions going to DEA forensics labs from illicit manufacture increased from 4,642 to 14,051. Meanwhile the amount of fentanyl seized has doubled in the past two years. Between October 2014 and September 2015, 168 kilos were seized; through June 2016, the seized amount has risen to 364 kilograms.

The DEA calls this drug threat “unprecedented,” and the DEA administrator has termed carfentanil “crazy dangerous.”

What responses, then, does the CDC alert call for? Simply put, they are inadequate. They recommend that we “improve detection” and “prioritize and expedite” laboratory testing, while tracking demographic trends and risk factors among decedents.

When it comes to law enforcement, the recommendations also fall short; specific instructions are to “use extreme caution” when handling suspected fentanyl and to “carry a supply of naloxone“—officers are even told to have “multiple dosages of naloxone” because of the potency of fentanyl.

These are reasonable steps, yet nowhere in these various alerts is there a call for urgently stopping the supply of the illicit heroin or fentanyl analogues, or for taking down the trafficking networks that are killing people with extreme indifference—by the tens of thousands. Moreover, there has been no urgent national warning to drug users and their families and friends that the illegal opioid supply has become highly lethal, that it is now critically important to get treatment and help loved ones to stop using these deadly substances.

With no other deadly disease—whether it be exotic pathogens like Ebola or Zika or a common killer like influenza—does the CDC, while warning the public, fail to also stress strategies to limit the transmission of the disease. Yet in the federal response to the opioid crisis, where the drugs themselves are the pathogens and the drug markets the vectors of transmission, this proven approach is lacking. The public and government officials are given advice on how to treat those who have succumbed to the disease, but no direction on how to curtail the outbreak and prevent its spread to future victims. The current response is not just weak, it is a path of deadly failure.

The CDC leadership could at least pass along the guidance from their own physicians, such as those reviewing the trajectory of opioid overdose deaths between 2000 and 2014: “There is a need,” as they seemed to signal their own leadership, “to reduce the supply of illicit opioids, particularly heroin and illicit fentanyl.”

A serious public health strategy would take appropriate lessons from efforts to control infectious diseases—the steps are to alert, test, track, and reduce the supply and the transmission-vectors of the lethal outbreak.

To address what needs to be done, however, would require the Obama administration to recognize that their policies are failing to curtail the escalating crisis. They would, as well, have to reassess their own political priorities on international relations, the border, and the necessity of drug enforcement.

Drug Politics and the Impact of Stigma

A contributing factor in the opioid death toll is often deemed to be the “stigma” associated with illicit drug use. That is, if society did not make addicts feel so ashamed of their habit, they would be more open to seeking help for their deadly affliction, possibly saving their lives. There is clearly some truth to this, as drug addiction usually occurs in secret, hidden foremost from the loved ones who would be most eager to get the user the help he or she needs.

Yet there is another type of “stigma” afflicting drug users—that their crisis is somehow undeserving of the full resources necessary for their rescue. Drug overdose deaths represent, after all, a preventable loss of life. But rather than urgent interventions to stop the spread of the drugs that are increasingly poisoning the populace, Americans confronted with the opioid crisis have become conditioned to passively submit to what is happening.

Despite the dystopian images on social media, we risk settling into a kind of national numbness to the sight of dead adults and neglected children. Indifference risks becoming the norm, while the administration appears paralyzed by their own self-induced fear of changing policies.

When Hurricane Matthew recently headed up our eastern coastline, the televised alerts and messages to endangered residents were stark and imperative. “Get out!” declared more than one governor, with Florida’s Rick Scott bluntly warning that “this storm will kill you.” As we face an unprecedented drug threat, killing tens of thousands, where are the similarly blunt public health warnings?

Where are the surgeon general and secretary of health and human services, for instance? You might expect to see them regularly on television dramatically urging illicit drug users to get into treatment, but no. Where is the White House? The full power of the bully pulpit could be deployed to tell Americans that these drugs “will kill you” and your loved ones unless they get help, but no. Where are the frequent, urgent appeals to families and neighbors and workplace or community members to intercede and get addicts the help they desperately need with their lives at risk?

And even more striking, where is the urgent directive to law enforcement, criminal justice, and public safety institutions of all forms, to interrupt and take down the criminal traffickers and those who smuggle drugs across the borders or even ship the drugs or their chemical precursors from China, unchecked through the Postal Service?

Instead, we witness the vivid contradiction of a White House that touts its policy of releasing convicted drug traffickers through pardons, commutations, and clemency at the very moment that an overdose plague is rampaging, returning experienced traffickers and dealers to communities already on the brink.

Indeed, drug policy appears to be gripped by a state of deadly denial at the highest levels, lest we recognize that we may have to use the resources of criminal justice and national security to dig out of this crisis.

The death toll will continue to rise until we acknowledge that more dollars poured into an ineffective and broken treatment system cannot change the fundamental dynamic of more and more deaths. When 95 percent of those in need of drug treatment are not seeking it, and when the available billions in public treatment dollars are spent haphazardly across states without provisions for targeting actual and acute need, drug policies will at best continue to address only the consequences of the disease, with antidote revivals and drug-substitution treatment that only serve to defer or cope with, but do not resolve, the continuing crisis.

In March, the president spoke about the crisis as if he were a distant observer, calling the overdose deaths “heartbreaking” and adding: “I think the public doesn’t fully appreciate yet the scope of the problem.”

But if any one person has the power to change that reality, it is President Obama himself, by bringing the full weight and power of the executive branch to bear, even in his final months in office.

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