The Opioid Overdose Epidemic

Many of society’s problems are truly difficult to solve. The opioid overdose epidemic does not have to be one of them. I am sick and tired of hearing people refer to it as an intractable problem. Don’t get me wrong, it is a huge problem. Here’s the secret though… there are a few relatively simple steps we can take to fix it. The thing that is most frustrating to me is that nearly all of the “solutions” that people in government are proposing and implementing are making the problem worse. I’m going to propose new set of solutions and try to explain why they’re needed and why they can help reduce the severity of this crisis.

Step One: Distribute the cure. You hear stories from time to time about a lost hiker dying of dehydration with a full canteen. The opioid overdose crisis is kind of like that but on a national scale. You may or may not be familiar with a drug called Naloxone. It is literally a cure for opioid overdose. If someone is overdosing, you can administer naloxone and prevent them from dying. It is extremely effective, it has very few side effects, and it has no potential for abuse. It can be administered by injection or by super easy and convenient nasal spray. There is no good reason for people to be needlessly dying by the tens of thousands every year when we have access to a magic bullet that could prevent it.

The good news is that naloxone is now available over the counter in 46 states. The bad news is that while that previous statement is technically true, it is not true in practice. Last year, I decided to put this to the test. I walked over to my local Walgreens, went to the pharmacy, and asked the pharmacist if I could buy some Naloxone. He told me that they didn’t carry it at that pharmacy and that I’d have to go to a Walgreens in San Francisco to buy it. I walked home instead and decided to do some research before my next outing. After about an hour and a half of online searches and phone calls, I determined that out of the dozens of large retail pharmacies in the Bay Area, there were only a tiny handful that actually carried the lifesaving drug. Fortunately for me, one of those pharmacies was a CVS that was only a few miles from my house.

I hopped in my car a couple days later and drove over. This time, when I asked the pharmacist for Naloxone, he asked for my prescription. I kindly explained to him that Naloxone was available over the counter without a prescription in California. He went over to his computer looked up the drug in their system and then came back and told me again that I would need a prescription to purchase it. At this point I stepped aside to allow another customer to speak to the pharmacist. I pulled out my phone and found a press release on the CVS website from more than a year earlier that said that CVS was now going to sell Naloxone over the counter in a bunch of states, including California. When I finally got back to the front of the line, I showed the pharmacist the press release (on his own company’s website) and after reading through it he went into the back to make a phone call. He returned a few minutes later and told me that he had been wrong and I could, in fact, purchase Naloxone without a prescription. He then proceeded to tell me that they didn’t have it in stock and that he’d have to order it. He took my phone number and promised to call me when it was arrived.

The following week, he called to inform me that they had received the Naloxone and I could come pick it up. I drove back to CVS, went in, and the pharmacist checked my ID and went to the back to get the Naloxone. When it was time to pay for the drug, I was surprised to find out that the two dose package cost nearly $200. It had not occurred to me that it might be that expensive. It wasn’t covered by my insurance because it wasn’t prescribed by a doctor. I reluctantly paid for the Naloxone and went home.

When I got home, I took the box of Naloxone out of the CVS bag to take a closer look at this lifesaving substance that I had just spent so much time, energy, and money to acquire. To my disappointment, I noticed that there was a rather serious problem. The expiration date on the box was exactly one week from that day’s date. This was a drug that I hoped never to have to administer and since I had no immediate plans to take any opioids myself and no immediate plans to be around anyone taking opioids, the fact that the Naloxone was going to expire before I would even have a chance to find myself in a situation where I might need it, was a deal breaker. I called the pharmacy where I had just made the purchase to complain about the fast-approaching expiration date. The pharmacist said that he didn’t realize that it expired so soon and that I could come in to exchange it for a new one. There was a caveat though: they didn’t have any more in stock so I would have to wait for them to order more. “Are you fucking serious?!” I thought to myself when I got off the phone.

The next week I got another call. They got another one in stock and I could go pick it up. Once again, I hopped in the car and drove down to the pharmacy. This time, everything went right and I finally had access to a medication that could literally save the life of someone who would otherwise die of an opioid overdose.

So yes, Naloxone is technically available over the counter but it took me nearly 3 weeks, nearly $200, and a ton of persistence to get it. I am well educated, well spoken, well versed in online research, have access to a computer and a phone and a car, have plenty of disposable income, can take a break from work to drive to the pharmacy, and I’m not intimidated by pharmacists who have their facts mixed up. Can you imagine how hard to get it would be for the people who are actually likely to need it?

I’ve purchased all sorts of drugs in my life. Legal drugs and illegal drugs. Over the counter drugs, prescription drugs, and street drugs. Naloxone is by far the most expensive and most difficult to acquire drug I have ever bought.

There are a couple of non-profit organizations that are giving away Naloxone in the community but they are woefully underfunded and underequipped. They are doing their best but they can’t even begin to address the scale of the need for their services.

Step Two: Stop making prescription opiates harder to get. This one might sound counterintuitive to some but hang tight and I’ll explain. Over the past few years, the government has taken several steps to try to restrict access to prescription opiates. They have made them harder to prescribe, restricted the amount that can be prescribed, increased the price, and artificially constricted the overall supply. While I agree that opiates are often overprescribed, these measures have unbelievably bad side-effects that serve to accelerate the overdose problem rather than reducing it.

Lack of access to regulated prescription opiates is a much bigger problem than the prescription opiates themselves. When someone is addicted to prescription opiates and you take away their ability to get them from a pharmacy or a hospital, they don’t stop using. Instead they start using opioids from other, less reputable, less safe sources. As the supply of authentic prescription opiates dwindles, the demand for counterfeit pills, heroin, and dangerous synthetic opioids grows.

The rate of overdose death from commonly prescribed opiates has stayed largely flat since 2010. In that same period the rate of heroin overdose deaths (which had been mostly flat prior to 2010) has quintupled. The rate of deaths from synthetic opioids like fentanyl and carfentanyl are experiencing an exponential growth curve and have gone from the least common cause of opioid deaths in 2013 to the most common in 2016. The reason for this is pretty straightforward, fentanyl and carfentanyl are extremely cheap to produce and easy to smuggle so they’re showing up in heroin and fake pills that are being sold to people who no longer have access to real medications. This is a problem of our own creation. When real prescription pain medications were readily available, there was virtually no market for counterfeit pills and the market for heroin was MUCH smaller. It’s remarkably easy to overdose if you are taking a fake pill with an unknown dose of an unknown substance.

Another side-effect of making prescription opiates harder to get is that it greatly increases the chance that people will mix them with other drugs. Drugs like alcohol, benzodiazepines, and some muscle relaxants multiply the effects of opiates. As the price of opiate pills increases and the availability decreases, people use these other potentiators to help get the pain relief or the high that they were looking for. This is very dangerous. It’s not very easy to accidentally overdose on drugs like oxycodone or hydrocodone by themselves. The same can’t be said if you mix those drugs with other central nervous system depressants like alcohol or Xanax.

By restricting the access to regulated prescription opiates, we are taking the serious but manageable problem of overprescribing and turning it into the much more deadly and completely unmanageable problem of unregulated drug overdoses on an epidemic scale.

In the interest of keeping the length of this post reasonable (and in recognition of my need to get some other things done today) I’m going to save my final two suggestions for a subsequent post but I hope that the thoughts that I’ve outlined above give you a new perspective about how we might be able to start to address this serious problem more effectively. I also have some thoughts about how we can address the separate but related issues around opioid dependence but I’ll save those for another time as well. Do you disagree with my suggestions above or have some additional thoughts to add? If so, let me know in the comments.

tl;dr: 1. Make naloxone available easily and cheaply. 2. Stop making the problem worse by creating a market for fake drugs. Stay tuned for 3. and 4.