potency and at ever-lower prices.27


Understanding the opioid problem more accurately remains an essential first step for developing an improved drug policy.


Tracking System (FROST) reports the state- wide systematic, extensive toxicological testing done on all drug overdose cases. About 95% of the opioid overdose deaths involve other drugs, with an average of 2–4 and a maximum of 11 in addition to the opioids.24


A well-known example of


polysubstance use at death is the tragic death of actor Phillip Seymour Hoffman in 2014; his body contained not only heroin but also cocaine, a benzodiazepine and amphetamine.25 A final misconception of the opioid


overdose epidemic is that legal prescription opioids continue to be the cause of the overdose death epidemic. It is important to note that a significant number of drug overdose deaths in 2016 did not involve opioids. While legal—and oſten diverted—prescription opioids are a central part of the overdose epidemic, by no means do they account for all of the illegally available opioids in this country. Although prescription opioids contribute to a significant number of overdose deaths, the numbers have declined in 2016, while heroin and fentanyl-related deaths have risen steeply.26


Te proliferation of illegally


manufactured and sold opioids in the US is driven by the rapidly improving capability of illegal global drug supply networks to conveniently deliver opioids and other drugs to users at ever-higher


12 datia focus


Te


world’s illegal opioid supply is shiſting from agriculturally-produced heroin to synthetic opioids starting but not ending with fentanyl, which are also commonly more easily able to slip most detection strategies. Te market forces for distribution of synthetic opioids such as fentanyl are clear: laboratory synthesis can be undetected, whereas poppy fields are readily identified and destroyed. High-potency opioids can be synthesized, shipped and distributed in small volumes, such as business envelopes. Tese factors raise profits and reduce risks for illegal drug distribution. Te customers for illegal opioids are not only patients prescribed opioids for pain but also the very large number of Americans who currently use a wide range of illegal drugs. Te most vulnerable population is made up of individuals who initiated use of alcohol, marijuana and other drugs in adolescence, thus priming their brains for subsequent addictive chemical stimulation later in life.


Finding Solutions to the Opioid Epidemic Starts with a New Narrative Te older opioid epidemic narrative unnecessarily scares legitimate medical patients and discourages the non-abusive use of opioids in pain treatment because it ignores the crucial differences between appropriate medical use of opioids and addictive use of these same medicines. Te older narrative also downplays the role of purely illegal opioids which has the potential to vastly increase the availability of opioids and other drugs of abuse in the US and around the world. An expanded formulation of the causes


of today’s opioid epidemic narrative to beter inform future policy: • identifies the distinctive patern of drug use associated with opioid addiction;


• roots opioid addiction in polydrug use; • identifies individuals who began substance use in adolescence as the


population most vulnerable to opioid addiction; and,


• recognizes the efficiency and growth of the global illegal supply system which is rapidly shiſting to synthetics produced in mobile laboratories around the world. It is possible to turn back the epidemic


of opioid overdose death and addiction, but it is necessary to broaden the target beyond pain management, to increase vigilance in the distribution of prescription opioids, prescribing to the at-risk population, to clarify the prevention message to adolescents, their parents and the general public regarding the dangers of early drug use, and to reduce global illegal drug supply. Te nation—and the world—must become far more effective in the areas of treatment, prevention and law enforcement.28


Understanding the


opioid problem more accurately remains an essential first step for developing an improved drug policy. Tere is encouraging work being done


to develop beter ways to prevent and treat opioid and other addiction. Te recent CDC guideline for prescribing opioids for chronic pain serves as a landmark for health care.29


Health care and in


particular, medical practice, are making simultaneous and significant improvements in the understanding, prevention and management of addiction and in the treatment of pain. One of the most vital elements of an


improved national effort to turn back the overdose epidemic is to revitalize the law enforcement role in a comprehensive public health strategy. It is essential that renewed and intensified efforts be made on a global basis to reduce the illegal supply of opioids, including the increasingly widely sold synthetics such as fentanyl. Opioid addiction and nonmedical drug use generally are not only American problems; they are a threat to all countries. Te global drug supply, including prominently the supply of


winter 2018


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