The raw statistics of the opioid crisis in the United States are startling.
According to the National Survey on Drug Use and Health, almost one million Americans used heroin in 2016, a number that rose steadily in the years since 2007. Almost 200 million prescriptions for opioid painkillers were dispensed in 2017. Almost assuredly, these numbers are even higher today.
Worse yet, the synthetic opioid fentanyl has flooded the American illicit drug market. Fentanyl, which is up to 100-times more powerful than morphine, often originates from production labs in China and Mexico and is then smuggled into the United States. Once here, it becomes an inexpensive street drug as well as an additive that boosts the potency of other drugs like cocaine, methamphetamine, or heroin. It also makes those drugs much more dangerous, since drug end users might be unaware of its addition and strength, and therefore ingest too much of the adulterated drug.
Combined, the steady rise of drug use in the United States and the availability of cheap synthetic fentanyl has led to an epidemic of overdose deaths throughout the country. In 2020, amidst the COVID-19 pandemic, more than 93,000 Americans overdosed and died. In terms of drug related deaths, it was the worst year in our country’s history. A question I cannot get passed is this: how many of those 93,000 souls knew all their treatment options?
Throughout the United States in 2020, the percentage of overdose deaths soared, especially amongst vulnerable communities. According to researchers at the University of California at Los Angeles, the overall increase in overdose deaths in the country was 42-percent in 2020.
Percentages were even higher in black communities. In Philadelphia, African Americans saw an increase in overdose deaths of 50-percent. In Massachusetts, health officials estimated that black men experienced an almost 70-percent increase in overdose deaths.
In my home city of St. Louis, Missouri, the numbers are depressingly similar due to illicit drugs and a “tsunami of fentanyl.” During the first six months of 2020, overdose deaths increased 64-percent in the city’s black community compared to the same half-year period in 2019, while there was a 40-percent increase among white St. Louisans.
These statistics mirror the rise of fentanyl in the St Louis market. Since 2019, the Drug Enforcement Administration (DEA) has seized 231 kilograms of fentanyl in the St. Louis area, a vast increase compared to the 35 kilograms confiscated in 2018. According to the DEA, one single kilogram of fentanyl can contain up to 500,000 lethal doses.
These “horrifying” statistics, according to a recent Scientific American op-ed, “are shouting for change.” According to that article, written by Dr. Nora D. Volkow, the director of the National Institute on Drug Abuse at the National Institutes of Health, “it is no longer a question of ‘doing more’ to combat our nation’s drug problems. What we as a society are doing—putting people with drug addiction behind bars, underinvesting in prevention and compassionate medical care—is not working. Even as we work to create better scientific solutions to this crisis, it is beyond frustrating—it is tragic—to see the effective prevention and treatment tools we already have just not being used.”
I could not agree more. As Volkow points out, “the science of the matter is unequivocal: Addiction is a chronic and treatable medical condition, not a weakness of will or character or a form of social deviance” and that “the benefits of providing effective substance use disorder treatments—especially medication for opioid use disorder—are well-known.”
Well-known in the addiction treatment community, perhaps, but not as well understood among addicts themselves. Only 18-percent of opioid addicts receive medication-based treatment for their disease. The calculus is straightforward. If we can increase the percentage of Americans receiving medication-based treatment for their opioid addiction, we can decrease the number of people dying from drug overdose in the United States. There is a medical solution to this issue, and it is our moral obligation to make people better aware of their treatment options.
Not everyone agrees, however. In recent years, the philosophy of harm reduction has dominated the public sphere with regard to the opioid crisis in the United States and many harm reduction advocates choose to willfully ignore the efficacy of medical treatment for drug addiction. They are especially hostile to the opioid antagonist naltrexone, which blocks the effects of opioids in the human nervous system.
I think that is because so many harm reductionists accept heroin use and opioid addiction as a part of modern life in America. One such harm reduction proponent is the journalist, Maia Szalavitz. “Rather than seeking an unattainable ‘drug-free world,’” Szalavitz recently wrote in the New York Times, “harm reductionists focus on reducing drug-related damage. People always have and always will take drugs, they argue. A better approach is to target harm, not highs.” In this interpretation, drug use is an incurable disease that has bested the medical community.
Dr. Carl Hart, a professor of psychiatry at Columbia University, goes a step further. For Hart, the term harm reduction is too preoccupied with negative consequences of drug use and marginalizes those who choose willingly to partake in narcotics for enjoyment. Instead, Hart proposes the title “health and happiness” for his encompassing philosophy and as a replacement for harm reduction.
In his book, Drug Use for Grown-Ups (2021), Hart contends that “the phrase health and happiness reminded me of the noble ideals laid out in our Declaration of Independence. The signers unequivocally declared that it is our unalienable right to pursue life, liberty and happiness. The bottom line is this: Millions of Americans, including me, have discovered that certain drugs facilitate our ability to achieve this goal, even if only temporarily.” I think it is unlikely Thomas Jefferson, a man who enjoyed a glass of wine but refused to “use ardent spirits in any form,” foresaw his words being used to justify heroin use in the United States.
Hart proposes a radical solution to the overdose crisis: the legalization of all drugs, including opioids like heroin. According to Hart, “legal drug regulation would markedly reduce drug-related deaths caused by accidental overdoses. A large proportion of these deaths are caused by adulterated substances purchased on the illicit market. A regulated market, with uniform quality standards, would virtually put an end to contaminated drug consumption and greatly reduce fatal accidental drug overdoses.”
This is counterintuitive and unhelpful. No one proposes the curing of alcoholism and alcohol related deaths through the widespread distribution of safely distilled spirits nor the treatment of obesity, high cholesterol and heart disease through easier access to fast food restaurants and buffet lines.
Alcoholism, obesity and opioid addiction are all serious medical issues, and they require equally serious medical solutions. Both Szalavitz and Hart ignore the efficacy of treatments like naltrexone, which can safely help many addicts end their use of opioids such as heroin. Naltrexone does not fit their personal philosophies of freedom of choice for drug use and they virtually ignore medical based treatments in their writings. In a medical sense at least, the hostility towards naltrexone in the harm reduction community is an immoral act.
According to the American Medical Association (AMA), a “patient’s right of self-decision can be effectively exercised only if the patient possesses enough information to enable an informed choice. The patient should make his or her own determination about treatment.” This requires patients—including those seeking treatment for drug addiction—to know all their options. Failure to disclose medical treatment options is immoral. “The physician has an ethical obligation to help the patient make choices from among the therapeutic alternatives consistent with good medical practice. Informed consent is a basic policy in both ethics and law that physicians must honor.”
Harm reduction has an important place in the ongoing opioid crisis in the United States, but it cannot and must not be the only option presented in public debates. Naloxone is the medication of choice for harm reduction advocates—the “superhero” of overdose reversal. If administered quickly, naloxone can safely end a patient’s overdose. Naloxone is an opioid antagonist that works by replacing narcotic molecules on opioid receptor sites in the human nervous system. According to Hart, “the opioid overdose antidote naloxone should be made more affordable and readily available not just to first responders but also to opioid users and to their family and friends.” Hart, therefore, is a proponent of widespread distribution of naloxone but an ignorer of the benefits of naltrexone treatment as an option for ending addiction.
This is ironic since naloxone and naltrexone are essentially the same drug, pharmacologically speaking. Both are opioid antagonists that block opioid molecules from attaching to opioid receptors and therefore render drugs like heroin ineffective. If a heroin user takes either drug, they will not feel euphoria—they will not get nor remain high. The difference is that naloxone is a short acting form of this drug designed to instantly reverse overdose while naltrexone is a longer acting drug designed to prevent those in treatment from getting high in the event of relapse.
Naloxone is favored over naltrexone in harm reduction circles because it keeps people alive but does not prevent the continued future use of opioids like heroin. From my standpoint—from the medical point of view—the continued ignoring of naltrexone in the public sphere as a viable option for opioid abuse is an immoral act. Patients must know their options and be encouraged to make healthy, informed decisions about their futures.
Percy Menzies, M. Pharm. is the president and founder of the Assisted Recovery Centers of America (ARCA), an integrated medical clinic based in St Louis. He can be reached at: pmenzies@arcamidwest.com