Is the opioid epidemic now the fentanyl epidemic?

Doctors, once swayed by opioid manufacturer marketing, aren’t overprescribing opioids anymore — that’s all in the past. Right?

Wrong.

Opioid prescriptions, appropriate or not, are still driving overdose death rates — and records.

Opioid overdoses remain so high that they have contributed to an alarming drop in life expectancy in the United States (to 78.6 years from 78.7) according to new data released by the Centers for Disease Control and Prevention. And last year, a record was set for drug overdose deaths: 70,237 up from 63,632 in 2016 -- previously the worst year on record. To put that into perspective, that’s more deaths in one year than the 58,000 Americans who died during the entire Vietnam War.

We know that opioid-related deaths are underreported, but let’s unpack the 2017 numbers we have:

Heroin contributed 15,482 deaths, a number similar to 2016. However, most heroin users did not begin opioid use with heroin; most started with prescription opioids. Some were prescribed opioids; others obtained them illicitly. But the fact is that opioids got into users’ hands via a prescription pad one way or another.

Fentanyl — and its hundreds of chemical cousins — contributed 28,466 deaths. Fifty times stronger than heroin, fentanyl is important as a surgical anesthetic, for treating cancer pain and for end-of-life care. Fentanyl is also a popular street drug, along with derivatives that may be 100 times more potent. Fentanyl drugs are easy to overdose on, and because they are used to cut heroin, result in many overdoses among people who thought they were using heroin, not fentanyl. (Cocaine, marijuana and other drugs may also be adulterated with fentanyl relatives.) Reducing access to prescription opioids could reduce future demand for street opioids.

So: Fentanyl drugs are involved in 41 percent of opioid overdose deaths, and heroin in 22 percent, but prescription opioids are close behind at 21 percent — and that number may be an undercount. Why? Because the deaths from prescription fentanyl and fentanyl relatives can’t be distinguished, so some fentanyl deaths may be due to prescribed fentanyl.

The prevailing media narrative is that street fentanyl drugs, not prescription opioids, are the problem, but OxyContin and other prescription opioids caused 14,495 overdose deaths in 2017 — a number that showed no improvement from 2016, when 14,487 deaths occurred.

Leveling off of prescription opioid deaths is not progress, it is unacceptable stagnation. What does it say about the state of regulatory, legislative and legal action in the United States that despite universal calls to stem the crisis, the prescription opioid death rate dropped not one iota from one most deadly year to the next?

Despite state and federal initiatives, prescribers are still overprescribing. Between 1999 and 2014, long-term prescription opioids drove the increase in prevalence of opioid use. Long-term opioid use is not protective against overdose risks and may have contributed to the fact that people ages 55-64 experienced the sharpest increase in overdose deaths over any other group from 2016 to 2017.

Payments by opioid manufacturers to physicians are significantly associated with opioid-related deaths, according to a recent county-by-county analysis. Considering that 8 percent of physicians take payments from opioid manufacturers, attention must be paid to removing industry influence from physicians and, increasingly, nurse practitioners and physician assistants.

The national media focus has shifted from prescription painkillers to illicit fentanyl shipped from abroad. Addressing street fentanyl is crucial, but opioid overprescribing right in our backyard continues to feed the opioid epidemic. Prescription opioids are still a major component of the epidemic and contribute both directly and indirectly to why overdose deaths remain unacceptably high. Doctors and other prescribers need to cut prescribing by far more than they have. Regulatory and legislative limits on opioid prescribing have the power to save lives. Continuation of a trend of tens of thousands of deaths annually is not a baseline we can stand for.

Sophie Krensky (sk1880@georgetown.edu) is project manager, Ben Goodwin (bgg12@georgetown.edu) is a research assistant, and Dr. Adriane Fugh-Berman (ajf29@georgetown.edu) is director of PharmedOut, a Georgetown University Medical Center research and education project that promotes rational prescribing, and a paid expert witness at the request of plaintiffs in litigation regarding pharmaceutical marketing practices including work on opioids.

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