I recently spent a week at the outer Cape and saw large schools of seals close to the beach. When I mention this, the invariable response is “sharks.” Where there are seals, there will be sharks. It’s the nature of predators and prey. Which brings me to our worsening opioid-overdose epidemic, why it’s getting worse, and why it will deteriorate further if we don’t change our approach. The sharks are here. They want your children.
Let’s start with the first six months of 2017 overdose data from Connecticut’s chief medical examiner, Dr. James Gill (See below). With 539 deaths between January and June, we’re on track to hit 1,078 fatalities— a nearly threefold increase since 2012. That doesn’t include the thousands of overdose reversals now being performed by emergency medical services, friends, family, and people who happen to be on hand with a couple of doses of Naloxone in their briefcase or purse.
But check out the line where fentanyl, a group of highly potent and potentially lethal synthetic opioids, shows up in fatal toxicology reports. In 2012 it was present in 14 cases, less than 4 percent. In the first half of 2017, fentanyl factored into 322 deaths —nearly 60 percent.
There has been positive news. We’re getting more and more Naloxone, which reverses overdoses, into the hands of those most likely to use it. But drug cartels and local dealers smell money, and they have countered every gain made by politicians, law enforcement, state agencies, peer, medical, and community groups.
The economics of packaging and selling fentanyl are irresistible when the investment of a few thousand dollars can yield five to ten million dollars of product. This is well documented, and has fueled the surge in deaths.
There is more than one breed of shark in the water. The current crisis started when the pharmaceutical companies began to push products while they downplayed the risks of addiction. Doctors got on board, and legally prescribed pain pills became the gateway for 70 percent of the people who become addicted to opioids today. Most people start with pills obtained from friends or family. Addiction begins in the medicine cabinet.
The good news is that doctors are finally prescribing fewer narcotics. With new legislation and on-line resources, any prescriber can—and must—check their patient’s pharmaceutical history before they write a prescription for an opioid. Those most prone to addiction often have red flags —multiple doctors, multiple medications, multiple pharmacies, habitually refilling prescriptions a week before they should, frequent emergency room visits, etc.
What I’ve come to realize is that those things that can be legislated can be influenced. That’s where we’ve made an impact on the numbers of prescription pain medications dispensed by doctors. But the fentanyl-and-heroin drug trades, other than what law enforcement can catch, are resistant to public health and political maneuvers. And the presence of fentanyl in the body fluids of overdose victims has skyrocketed, as it has in drugs confiscated in busts.
Where this crisis is fueled by economics, it’s possible to predict where it’s headed next. Smart drug businessmen and women are sniffing the waters for their next targets—and it’s kids. Samples of fentanyl-laced marijuana have recently been reported in multiple states. As the first drug other than alcohol that most kids will try, the implications are clear. And fentanyl analogs are being packaged in pills with cute emojis pressed in.
While the average ages on the Connecticut overdose database are in the 20s to 40s, there are a growing number of teenagers. The youngest was a 14-year-old girl.
What do we do? We start with prevention. If we can stop a person from using any drugs or alcohol before the age of 18 —or even better, 21—they will have a minimal chance of ever developing an addiction. The not-fully formed brain is easily influenced and hijacked by drugs.
But prevention has never and will never be enough. People have always sought ways to get high, and when government tries to stop that, it locks up a lot of people and creates a criminal underworld.
The answers are not simple. There are roles to be played by law enforcement, legislators, educators, the medical profession, by friends, family, and the by the individuals themselves who are addicted to opioids and don’t want to die as a result. Here are some thoughts on interventions that could help.
To counter the rise of the criminal economy, perhaps we should legalize marijuana, even for recreational use. Goodness knows our state economy would benefit. More importantly it would put a damper on what is likely coming next in the fentanyl tragedy.
We might look at culpability around these overdoses. If someone knowingly sells fentanyl-laced product and someone dies, it’s murder.
We should continue to expand access to treatment and encourage new programs that show results, such as offering treatment immediately when an overdose victim is revived in the emergency room.
We must continue to expand access to Naloxone, and in the midst of a crisis, normalize it. It’s just something to have in your briefcase. If you’re a parent, it’s something to keep in the medicine cabinet. You can get it at most pharmacies and you won’t need a prescription.
There’s a lot being done, but there’s a lot that needs to be done and new strategies that we must seek out.
I hope the next round of data will show an improvement, but I’m skeptical. There’s too much blood in the water, and it’s the blood of our children.
Charles Atkins, M.D., is a psychiatrist, author, and the chief medical officer for Community Mental Health Affiliates (CMHA) a multi-site behavioral health and substance abuse agency in New Britain, Torrington, and Waterbury. He is a member of the volunteer faculty at the Yale School of Medicine.