Opioids and methamphetamine: a tale of two crises
The unchecked acceleration of
opioid-related deaths in the USA is, by many measures, the worst of
times. Prescriptions peaked in 2012 at more than 255 million (81·3 per
100 persons), then subsequently declined by about 15%. Yet the rate of
opioid-related deaths has continued to rise. In the grim ranking of
overdose deaths, illegally manufactured fentanyl and analogues have made
the most drastic gains, claiming over 20 100 Americans in 2016. Deaths
from natural and semisynthetic opioids, such as oxycodone and morphine,
remain exceedingly high (14 400). But while the opioid crisis has
exploded, the lull in the methamphetamine epidemic has quietly and
swiftly reversed course, now accounting for 11% of the total number of
overdose deaths.
The sheer number of
opioid-related deaths has dominated the national conversation. However,
that focus could distract from the larger issues of use and overdose
across classes of drugs. The methamphetamine and opioid crises were
previously considered distinct and affecting different populations. But
in states including Wisconsin and Oregon, new patterns suggest they are
beginning to overlap as increasing numbers of people use both drugs.
Methamphetamine and opioid use are destructive and associated with loss
of productivity, deleterious effects on families, and siphon substantial
resources for intervention and treatment. They are also multifactorial
epidemics urged on by underlying conflicts among health-care, law
enforcement, industry, and government policies. There are several strong
connections between the methamphetamine and opioid crises that have
only recently come under scrutiny—namely costs, control, and
consequences.
In
2005, at the peak of the methamphetamine epidemic, the economic burden
was placed as high as US$48·3 billion. In comparison, a February, 2018
analysis by the health research firm Altarum estimated the opioid crisis
in the USA has cost in excess of $1 trillion, with an estimated price
tag of $115 billion for 2017 alone. Individual and private sector costs
are enormous, but these are not trivial numbers in the scope of the
federal budget. The Trump administration's 2019 total proposed budget
for Health and Human Services is only $68·4 billion, although it is
reportedly seeking to expand opioid funding by $13 billion for
prevention and treatment. Many experts have suggested that it is too
little, too late. Although, the epidemic was declared a national
emergency in October, 2017, the President's Commission on opioids has
led to little more than calls for a border wall to impede suppliers and
has largely been derided for failing to meaningfully include drug policy
experts.
Previous control efforts
with methamphetamine have relevant policy implications for opioids. In
2012, over the protests of pharmaceutical companies, Congress authorised
the Drug Enforcement Agency to limit over-the-counter sales of
decongestants containing pseudoephedrine used to synthesise
methamphetamine. Availability was dampened for a few years, but cheap,
high-quality methamphetamine produced in Mexico has now flooded the
market. US Customs and Border Protection have reported a massive
increase in methamphetamine seizures and use nationally has risen to
about 4%. The shift in public health priorities to opioids has left the
methamphetamine market to flourish and primed for resurgence.
Access
to opioids is notably more varied, reaching users via prescription and
illicit routes. Fentanyl, for example, is produced for legal uses, but
weak manufacturing regulations in China have led to illicit exporting.
Ramping up US border control in the absence of other prevention and
treatment options is a myopic strategy that is unlikely to do much
beyond shifting the geolocation of suppliers. Pharmaceutical companies
must also be held accountable for the reprehensible and strategic part
that they have played in the crisis. In addition to actively promoting
misinformation to physicians, evidence, detailed in a February, 2018
Senate report, shows major financial inducements to advocacy groups to
promulgate “opioid-friendly messaging”. Most states have now introduced
legislation limiting opioid prescriptions, but well funded and powerful
lobbying efforts have left drug makers untouched.
As
local public health authorities, emergency rooms, and first responders
reel from the strain of the thousands of premature deaths caused by
opioids, the outlook might be more dire than anticipated as a second
methamphetamine wave begins. The co-use of methamphetamine and opioids
increases the probable uptick in injection drug use and transmission of
HIV, especially in the regions of the USA where public health resources
are severely taxed. Without considering the consequences of past efforts
and with limited bandwidth and funding pledged to provide intervention
and treatment, these crises will merge, and the winter of despair will
rage on.
Article Info
Publication History
Published: 24 February 2018
IDENTIFICATION
DOI: 10.1016/S0140-6736(18)30319-2Copyright
© 2018 Elsevier Ltd. All rights reserved.
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