After Brief Decline, ‘Exponential Trajectory’ of U.S. Overdose Crisis Resumes
/By Pat Anson, PNN Editor
A brief decline in fatal overdoses in 2018 was just a blip in the trajectory of a 40-year pattern of rising drug deaths in the United States, according to a new study published in the journal Addiction.
Researchers at the University of Pittsburgh Graduate School of Public Health analyzed over a million overdose deaths in the U.S. between 1979 and 2019 – and developed a startling chart that shows an exponential curve in overdoses that continues to rise virtually unchecked. The number of deaths has doubled every 10.7 years.
"The U.S. has not bent the curve on the drug overdose epidemic," said lead author Hawre Jalal, MD, an assistant professor of health policy and management at Pitt Public Health. "We are concerned that policymakers may have interpreted the one-year downturn in 2018 as evidence for an especially effective national response or the start of a long-term trend. Unfortunately, that isn't supported by the data."
PITT PUBLIC HEALTH
Overdose deaths fell about 4% in 2018, which public health officials attributed to a decline in deaths involving prescription opioids and heroin. However, overdoses began rising again in 2019 and preliminary data for 2020 suggests the upward trajectory has resumed.
Jalal and co-author Donald Burke, MD, say the 2018 decline in overdoses was largely caused by a reduced supply of carfentanil, an illicit drug and potent analogue of fentanyl that is 10,000 times more powerful than morphine.
China added carfentanil to its list of controlled substances in 2017 and began shutting down illicit drug factories that produced it. The U.S. supply of carfentanil soon began to dry up and law enforcement seizures of the drug fell dramatically in five states -- Ohio, Florida, Pennsylvania, Kentucky and Michigan. It was the “sudden rise and then fall of carfentanil availability” that led to the drop in overdoses, researchers found.
"We all celebrated when the overdose death rate dropped, but it was premature," said Burke, former dean of Pitt Public Health and a professor in the Department of Epidemiology. "When policymakers believe a problem is solved, history has shown that funding is reprioritized to other efforts. The drug overdose epidemic is not solved. It continues to track along an ever-rising curve, with deaths doubling nearly every decade. We must address the root causes of this epidemic."
Jalal calls the U.S. overdose crisis an “entangled epidemic” that’s been fueled by multiple drugs, including prescription opioids, but is now largely caused by illicit fentanyl.
“There is a force that keeps overdose deaths on an exponential trajectory. This is in spite of policies that have been trying to bend the curve,” Jalal told PNN. “The main problem is that we don’t know why it keeps tracking an exponential trajectory. I think we should do everything we can to bend the curve, but the policies that we’ve used so far have been more targeted toward drugs that can be modified easily. We can target prescription opioids and we can increase the use of naloxone and methadone, but I think we also have to invest in understanding what’s driving people to use drugs. That’s a major problem that we still don’t have an answer for.”
Jalal says lack of economic opportunity and social isolation — so-called “deaths of despair” — may be partly responsible for the overdose crisis, but more research is needed into the underlying causes. As for possible solutions, he’s as stumped as anyone.
“I wish I knew. I truly wish,” Jalal said. “I think we have to pay attention to what’s driving this whole epidemic. Without understanding it, we are basically targeting our policies toward whatever we think might work or think we have control over. We’re not targeting why people use drugs or what’s causing people to die from drugs.”
A recent study by the CDC found that nearly 85% of overdose deaths in the first six months of 2019 involved illicit fentanyl, often taken in combination with other drugs. About 20% of overdoses were linked to prescription opioids.
The CDC study did not determine whether the opioid medication was obtained legally, or if it was diverted, stolen or bought on the street. Previous research in Massachusetts and British Columbia found that only about 2% of fatal overdoses involved a legitimate prescription for opioids.
