Overdose Inaction

By Tom Horvath, PhD

How can we explain the widespread expressed concern about US overdose deaths, coupled with our rather ineffective response to them? US overdose deaths may be the highest in the world. I will limit the following discussion to opiates, but alcohol, meth and multiple substance use are also of concern. I suggest that harsh and inaccurate beliefs about substance use and substance users have led many of the parts of our “system” for addressing substance problems into actions that increase overdose deaths rather than reduce them. In the remainder of this blog, I provide some details to support that idea.

Buprenorphine and methadone: The medications most helpful for opiates are buprenorphine and methadone.  As it stands much less than half of the US individuals who could benefit from these medications receive them. We could substantially reduce (but not eliminate) overdose deaths if these medications were fully available. Other changes are also needed. Naloxone needs to be widely available to reverse overdoses. Other harm reduction efforts would be essential and too numerous to list here.

The primary objection to these medications appears to be the belief that they are substitutions and not a genuine resolution. This objection is partly accurate in that these medications are also opiates. However, there is a very large difference between life on methadone or buprenorphine, and life on other (illegal) opiates. Legal opiate users are treated by us very differently, and the legal medications have somewhat different effects.

These objections have been the foundation for laws that are a primary source of our current problems. We need to make these medications much less difficult to obtain, as other nations have done. Those changes primarily involve medical providers and health care systems taking the need to provide these medications very seriously. If we had a genuine healthcare system, many of these issues could be addressed systemically.

We might also benefit from laws that required pharmacies to carry these medications, required prisons and jails to prescribe them, and required licensing and certification boards (for health care providers, pilots, drivers, etc.) to accept them (assuming other standards are maintained). Making these changes would involve changing laws, regulations, operating procedures, and beliefs.

Attempting to coerce physicians to prescribe these medications would be problematic, but even without a genuine health care system the multiple existing systems could be required to make them available. In 2023 the state of California required all credentialed substance use disorder facilities to provide or arrange for their clients to have access to these medications, and not to penalize a client for using them. I expect this change could be a substantial one. I also expect that many providers will not approve of it. Adherence to this law may be less than complete.

Naltrexone: The third medication for opiates has value only in a very restricted range of cases. Once on naltrexone, an opiate blocker, the patient cannot experience the opiate effect. Although that plan might sound sensible, naltrexone use has led to many overdose deaths. The patient does not stay on it forever and may feel deprived of opiates while on it. That sense of deprivation is exacerbated when they have been coerced onto the medication. Once they are off, it is not surprising that using opiates can become a priority. Unfortunately, the desire to have a great opiate experience can cloud someone’s judgment about what a safe dose might be. Doses from street drugs are hard to regulate to start with, and the user’s tolerance is lower from no recent use. If the opiate is also combined with other substances, as is common, it is not surprising that individuals discontinuing naltrexone are at very high risk of OD. This medication needs to be used cautiously and only in selected cases.

Narcotics Anonymous (NA): Although the government has the capacity to establish requirements for healthcare providers and systems, one of the most significant components of our response to overdose death, Narcotics Anonymous (NA), is mostly beyond the reach of regulation.

Based on its own documents, NA has wrestled with this issue. Is NA allowed to maintain whatever position it wants? Of course. However, if NA wishes to continue as a “total abstinence” approach, should it not be responsible for informing its participants that there are other approaches (and this is where to find them)?

Drug Replacement Therapy/Medication Assisted Treatment as It Related to Narcotics Anonymous, on NA’s website, raises the question: “What actions can we take to help make people receiving DRT/MAT medication’s feel more welcome in our meetings and more likely to stay long enough to understand NA’s message of recovery?” I interpret this question to mean that NA seeks to keep around individuals on DRT/MAT long enough to persuade them to stop using the medication. This question was raised after this document emphasized that “now that we are all on the same page that NA is a program of total abstinence, and will remain so, we can talk about ways to better carry our message to some of the people who need to hear it.”

NA continues to carry its message of total abstinence to anyone who is interested in hearing it. I have no objection. The message will resonate with some people. However, to repeat, should NA be responsible for informing people that there are other approaches also? I believe they should be. Because a substantial portion of the individuals who seek help for opiate problems consider attending NA, we need to emphasize the overall message that NA has an approach, but not the approach.

Fentanyl: As long as fentanyl is in the illegal drug supply (there is no indication it is going away), even first-time users are at risk of dying because they do not realize they are taking an overdose. It is not believable that we will eliminate fentanyl or persuade users to test their medications (that would require making test strips or other methods available). Legalizing all drugs, and manufacturing them according to FDA standards, so that users would know what they are purchasing, would address this issue. That type of change would go beyond what any nation has done and would entail other risks. This blog has focused on buprenorphine and methadone, but a comprehensive approach to overdose would include addressing fentanyl.

To summarize the beliefs that are the basis of our inaction:

In the first paragraph it states: “harsh and inaccurate beliefs about substance use and substance users have led many of the parts of our ‘system’ for addressing substance problems into actions that increase overdose deaths rather than reduce them.”

It is unlikely that many people will state these beliefs out loud. However, what must people in charge of our systems of care believe, to act as they do? It seems to me the underlying beliefs are something like the following:

1. Opiate users are less than fully human.
2. Opiate users should be punished (and therefore not allowed an opiate medication that makes stopping other opiates much easier). Instead, users should suffer.
3. Our system should emphasize “total abstinence.” Only through complete abstinence do these sub-human beings have any chance of becoming fully human (if ever). Making changes in the system to allow for opiate medication is not needed.
4. As sub-humans, opiate users are not a priority. We have more important people and issues to focus on. If some of them die before we get to making these changes, so what?

Because it appears that many non-opiate users share these beliefs, even though they do not state them out loud, collectively we may continue promising changes, but not actually delivering them.

If you or a loved one are curious about alternative methods of treatment for opiate use, our outpatient rehab services could be a good fit. Please don’t hesitate to reach out today – you don’t have to do this alone.