The opioid epidemic in America could get worse


The latest news on the opioid epidemic in America looks positive: based on preliminary data, the number of drug overdose deaths may have decreased in 2018 – for the first time since the beginning of the crisis in the 1990s .

But a new comprehensive report from RAND, led by researcher Bryce Pardo, says the opioid crisis could still worsen, possibly resulting in thousands of deaths each year if the fentanyl market becomes more widespread.

The report documents the rise of fentanyl to synthetic opioids and its analogues, which are increasingly mixed with heroin and opioid analgesics, or even replaced outright, in the illicit drug market. This trend to fentanyl is known as the third wave of the opioid crisis, after the first wave of prescribed opioids and the second wave of heroin.

The trend has led to a sharp increase in the number of overdose deaths, as fentanyl and its analogues are much more potent than other illicit opioids and are less known than heroin, making it difficult for people use opioids to properly calculate their consumption. safe dose. RAND report reveals that fentanyl introduction does not increase the number of people who use opioids – the increase in recent decades is still linked to the proliferation of analgesics – it is increasing the number of overdose deaths .

However, while fentanyl and its counterparts have already led to an increase in overdose deaths, this phenomenon has mainly occurred in the eastern United States, and particularly in the north-east and west-central regions. in large part because of the differences between drug trafficking networks and the type of heroin that fentanyl originally were related to. And that means, in a terrifying possibility, that fentanyl still has a lot of room to grow.

"One of the most important – and depressing – ideas of this analysis is that, irrespective of the current state of the synthetic opioid problem, it is likely that it will worsen before that it does not improve, "says the report. It continues:

In 2017, ten states accounted for one-third of all reports of synthetic opioid overdoses, although they account for just over one-tenth of the country's population. Conversely, nearly three out of ten states report synthetic opioid overdose death rates equivalent to a quarter of the national average of nine out of 100,000. The calculation is simple and painful: if the rest the country had a synthetic opioid death rate equivalent to half that of New England in 2017, it is estimated to be approximately 38,000 fatal overdoses involving synthetic opioids.

If this estimate were true, Pardo said, this translates into nearly 10,000 additional synthetic drug overdose deaths compared to 2017, about a third more than the 28,000 overdose deaths in Canada. Synthetic opioids (to the exclusion of methadone) that actually occurred that year.

Why fentanyl could go to the west

Fentanyl may remain a predominantly Neo-Anglo-Saxon and Midwestern phenomenon for the same reasons that it has not yet spread to the west. On the one hand, the most prevalent type of heroin in the east of Mississippi is simply a lot easier to mix with fentanyl than the type of heroin in the West. . This dynamic, as well as the networks of drug traffickers who have maintained it, could spare the West a much more serious crisis of fentanyl.

Yet fentanyl could spread. Fentanyl has become the opioid of choice in the eastern United States, according to the RAND report, not because opioid consumers wanted it. Instead, the


wanted it because fentanyl is much more powerful and cheaper – and therefore more lucrative – than heroin.

These economic realities apply just as much to the western heroin markets as to the eastern heroin markets; therefore, it may be a matter of time before the illicit drug trafficking networks make this change. According to RAND, fentanyl can then spread rapidly and there is no example of a market that returns to heroin once fentanyl takes over. (Estonia, in Europe, has maintained a market for fentanyl for 20 years.)

But according to the same data, overdose deaths related to synthetic opioids, such as fentanyl, would have increased from more than 29,000 in 2017 to nearly 32,000 in 2018. The RAND report indicates that one of the ways of Increase the number of deaths by fentanyl could continue: other parts of the country.

There are solutions to fentanyl, but innovation is needed

The RAND report is bleak about the prospects for using fentanyl, but he argues that some steps might be helpful.

More investment and access to drug treatment could save lives. In particular, studies show that drugs such as methadone and buprenorphine reduce the death rate of patients with opioid dependence by half or more. But in the United States, only one in 10 addicts receive specialized treatment and the majority of treatment providers do not offer drugs.

Efforts to better detect fentanyl at the border could also save lives, particularly in terms of mail and shipping routes, particularly from China and Latin America, through which most fentanyl would pass. Harm reduction efforts, such as greater access to the antidote to opioid overdose, naloxone and more needle exchanges, could also be helpful.

The RAND report states, however, that fentanyl is a new type of drug problem that requires new ways of thinking. Some ideas suggested by RAND are trying to adapt to the Internet era of drug markets, such as a proposal to create fake drug-selling websites to attract potential buyers to the growing number of sales transactions drug on the web.

The report also highlights some much more controversial ideas in the United States. One is a prescription heroin program that prescribes heroin to opioid-resistant patients and uses it in a physician-supervised setting. Another idea is for supervised consumption sites, safe spaces where people can use drugs with medical monitoring. A report from RAND last year found strong evidence that prescription heroin programs can save lives and reduce all kinds of drug-related problems, as well as positive, albeit weaker, evidence of drug abuse. supervised consumption.

Recognizing that it will not be possible to stop some people from using drugs, these ideas may seem strange, even dangerous, especially after decades of a "just say no" approach. But if the evidence shows that these new approaches save lives (which is the case), and there is a risk that fentanyl will spread and wreak havoc in the United States (what remains possible ), so maybe it's time to think differently about drugs and drug policy.

The RAND report makes it clear that fentanyl remains true to the status quo: "Limiting responses to minor adjustments to existing approaches in the United States may put many people at risk of premature death."

administrators and teachers, not students. The company then informed the agency in October that it had dropped the idea, Zeller said.

"We told the FDA that we had planned to discuss with administrators and teachers and that before the meeting, we had met with students to educate young people about the dangers of nicotine addiction," he said. David, spokesman for Juul. David said the program was "clearly misinterpreted" and aimed to warn young people about the danger of nicotine use.

No more worries

The vape has not only been associated with convulsions, but has recently been involved in an epidemic of mysterious lung disease. The Centers for Disease Control and Prevention announced Friday that they were investigating 193 possible cases of serious lung disease related to the use of electronic cigarettes in 22 states. An adult man in Illinois is dead.

Some states stated that patients with pulmonary problems largely reported using vaping products containing THC, the psychoactive substance of marijuana. The federal authorities have not made such a clear distinction, despite requests for clarification from the vaping advocates.

"You need to know more," said Zeller.

Robert Redfield, director of the Centers for Disease Control and Prevention, tweeted on Friday that there are "serious risks associated with electronic cigarette products".

Former FDA Commissioner Gottlieb, who left the agency in April, said concerns about a risk of seizure related to e-cigarettes were partly focused on whether products with Nicotine base in high doses were involved. Depending on the strength, the amount of nicotine in a Juul capsule is roughly equivalent to a pack of cigarettes.

"You can draw your own conclusions, but Juul is a high-dose nicotine product," Gottlieb said in an interview. "This does not just imply that Juul is involved. This could be other products, it could be illegal products. "

(Updates Altria shares in the fifth paragraph.)

– With the help of Ellen Huet.

To contact the reporters on this story: Anna Edney in Washington at [email protected], William Turton in New York at [email protected]

To contact the editors responsible for this story: Drew Armstrong at [email protected], Kevin Miller

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