High Wire is Maia Szalavitz's reported opinion column on drugs and drug policy.
Overdose deaths fell by around five percent between 2017 and 2018, the first time mortality has dropped since 1990, according to preliminary statistics released last week by the Centers for Disease Control and Prevention. It’s important to note as well that the decline in deaths hasn’t been uniform: Eighteen states even had increases, some of them in the double digits, according to the CDC—notably five of those that did not expand Medicaid.
But no one knows yet if this represents a real change in an apparently relentless rise in deaths—or just statistical noise. The death toll from 2018—estimated at 68,557—is still more than seven times higher than it was in 1980.
Annual overdose deaths still outnumber those from car accidents, gunshot wounds, and AIDS at their peaks—as well as those from AIDS. Indeed, people who have experienced addiction or work in the field have been hit hard by both the HIV epidemic and the overdose crisis.
And now, just as back in the mid-90s when AIDS finally began to come under control in the U.S., many are traumatized and highly suspicious of hope. We know that politically, when turning points in crises can be identified, both attention and money are drawn away from the issue—and that such a lapse can stall or even reverse progress.
“The small decline is welcome. However, the death rate is still unacceptably high,” said Dan Ciccarone, a professor of medicine at the University of California San Francisco and the director of the “Heroin in Transition” project, which is investigating changes in the heroin supply and the experiences of people who take heroin during the opioid crisis.
Ciccarone and other experts attribute the decline to several critical factors. For one, there’s the increased availability of the overdose antidote, naloxone—it’s clear from news accounts that this medication is being used hundreds or perhaps thousands of times a day to bring people back from the brink of death. Second, access to medication treatments that are proven to cut the death rate by 50 percent or more has risen significantly.
Third, the supply of prescription opioids has been cut by more than a third in recent years—although whether this has any positive effect on people who are already addicted and are at the highest risk of dying is contentious. Studies show that simply ending prescriptions or changing their formulation to make them harder to misuse can just drive people who are addicted to street drugs, which increases their death risk. (And for pain patients, stopping helpful medication can lead to disability and even suicide.)
Finally, there’s the fact that in all epidemics, at a certain point, all of the most susceptible people have already been affected and they die at a higher rate than they are replaced. In drug epidemics, potential new users are often scared off by the fates of their friends, siblings, and parents—and they tend to gravitate toward different drugs.
The traumatic impact of the overdose catastrophe on people with addiction and those working to try to reduce the harm associated with it is hard to overstate. Just as with AIDS, people are losing large portions of their social networks. Over the last few years in covering the crisis, I’ve spoken to dozens of people who have each lost dozens of friends and acquaintances. In fact, as I was writing the last column, one of my interviewees had to reschedule because yet another close friend had died of an overdose.
And, similarly to the HIV epidemic, so many of these deaths are occurring because of the criminalization of drug use and the stigma against people who take drugs that is exacerbated by it.
In New York in the 90s, criminalization of clean needles literally killed tens of thousands of people who injected drugs—as we fought to legalize access, many completely preventable new HIV infections occurred. It wasn’t only people who injected drugs who were affected, either: At the height of the epidemic, which was centered in New York City, three-quarters of infections in heterosexual people resulted from HIV originally spread through unsterile syringes, and then passed on sexually. And 75 percent of HIV in newborns occurred because one or both of their parents had been infected via needle sharing.
A similar tragedy is occurring now across the U.S. with overdoses. We know how to prevent a large portion of these deaths: medication treatment can cut the death rate in half and yet we still insist on making people jump through hoops to get it, rather than simply providing it to all in need. Naloxone works to reverse overdose—but it still isn’t available everywhere it is needed.
And locking up people with opioid addiction is basically the opposite of treatment—less than 1 percent of jails and prisons offer access to proven medications. This means that during the first days or weeks after being freed, addicted people have a risk of overdose that is at least tripled compared to before they entered. That’s not to mention the fact that most overdoses now result from a drug supply that is basically poisoned by fentanyl and its derivatives, another result of the black market.
It’s great news that overdose rates, at the very least, are no longer rising exponentially. But as the New York Times pointed out earlier last week, much of the funding for measures like naloxone and treatment medications that have helped stem the tide will run out next year. And if Obamacare is declared unconstitutional under an active, White House-supported lawsuit, the money that expanded treatment via Medicaid and by requiring insurers to cover addiction will vanish as well.
We can’t let welcome news be used to justify cutting back efforts that are beginning to show signs of success. We have to support each other despite the trauma; we need to be sure we care for the caregivers. We fought cruel and indifferent politicians through the AIDS years. We can’t give up now.
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