The latest issue of Public Health Reports (the official journal of the Office of the Surgeon General and U.S. Public Health Service) presents a study by researchers at Boston University and the Massachusetts Department of Public Health which provides further evidence that the narrative driving present opioid overdose policy—that it results primarily from doctors prescribing opioids to patients in pain—is wrong. It results from non-medical drug users accessing drugs in the black market that results from prohibition. In the early part of this century the “drugs of choice” for non-medical users were diverted prescription pain pills. But users have long since moved on to cheaper, more available, and more dangerous drugs.

The researchers examined data on opioid-related overdose deaths in Massachusetts for the years 2013 through 2015, using records from the Massachusetts prescription drug monitoring program and postmortem toxicology reports to determine if the decedents had an active opioid prescription for the opioid(s) detected in the toxicology report on the date of death as well as the proportion of overdose deaths for which no prescribed opioid was detected in toxicology results.

The authors found:

Of 2916 decedents with complete toxicology reports, 1789 (61.4%) had heroin and 1322 (45.3%) had fentanyl detected in postmortem toxicology reports. Of the 491 (16.8%) decedents with ≥1 opioid prescription active on the date of death, prescribed opioids were commonly not detected in toxicology reports, specifically: buprenorphine (56 of 97; 57.7%), oxycodone (93 of 176; 52.8%), and methadone prescribed for opioid use disorder (36 of 112; 32.1%). Only 39 (1.3%) decedents had an active prescription for each opioid detected in toxicology reports on the date of death. (my emphasis added)

I have pointed readers to research by the University of Pittsburgh School of Public Health showing the overdose rate from the non-medical use of licit and illicit drugs has been on a steady exponential increase since at least the late 1970s, preceded the “prescription opioid overdose crisis” of the earlier part of this century, and continues apace. Different drugs have come in and out of predominance for non-medical use over the decades, but the trend line has remained remarkably consistent. The authors state:

Although there have been transient periods of minor acceleration or deceleration, the overall drug overdose mortality rate has regularly returned to the exponential growth curve. This historical pattern of predictable growth for at least 38 years suggests that the current opioid epidemic may be a more recent manifestation of an ongoing longer-term process.

And

These findings suggest that, to be successful, prevention efforts must extend beyond control of specific drugs to address deeper factors driving the epidemic.

Yet policy remains focused on reducing the amount of opioids prescribed to patients in pain, terrorizing doctors into under-prescribing or abruptly tapering medication for their patients in pain, and making many patients suffer and grow desperate.

The overdose crisis has always been, at bottom, a prohibition crisis. Until policymakers muster the courage to end prohibition, they should switch the focus away from doctors and patients and put greater efforts into harm reduction.