Journalists have largely presented the overdose crisis as a story of three interconnected and perhaps inevitable waves. First, drug companies, led by Purdue Pharma, maker of the notorious OxyContin, convinced gullible doctors to prescribe unneeded opioids. This led to hundreds of thousands of new addictions in the 1990s and 2000s. Observational research suggested that opioid prescribing was linked with increased disability and decreased productivity.
And overdose deaths began to rise.
The second wave in this narrative begins around 2011, when states cracked down on “pain clinics” that were really pill mills, offering doses for dollars. Prescriptions became scarce, prices rose and people who were addicted began to turn to heroin, which was cheaper and now had a big enough pool of customers to attract cartels to places that they’d never served before. Again, overdose deaths increased.
Finally, the third wave was initiated by dealers about four years later. Seeing a chance to make even more money, they began to cut heroin with illicitly manufactured fentanyl and various other synthetic opioids, which are both cheaper to make and more potent. Once again, addiction worsened. Nearly 100,000 people are thought to have died from overdose in 2020, the deadliest toll from overdose in American history.
This is the story being told in ongoing litigation against Purdue and other manufacturers and distributors of opioids. It’s being told now in West Virginia in a case against the three major distributors to pharmacies—a case seen as a landmark for thousands of similar cases.
But while the media has focused on the harm done by Big Pharma, it has largely ignored the greater damage done by policies intended to solve the problem.
Advocates led mainly by a group called Physicians for Responsible Opioid Prescribing made the case to policy makers and politicians that since overprescribing caused the epidemic, reducing medical use would solve the problem. And they did succeed in significantly shrinking the medical supply: since 2011, opioid prescribing has been cut by more than 60 percent.
Unfortunately, however, as medical use declined, the total number of overdose deaths more than doubled between 2011 and 2020. Indeed, even before the pandemic, more overdose deaths had occurred since prescribing began to fall than took place while medical opioid use was soaring.
The fact that cutting the medical supply could potentially make matters worse didn’t seem to factor in to the calculations of those who supported this approach. But this outcome was, in fact, completely predictable— so much so that the phenomenon has an academic name, “the iron law of prohibition.”
Coined by activist Richard Cowan in 1986, the phrase refers to the effects of reducing drug supplies while not acting significantly to manage demand. Almost always, it results in the rise of a more harmful drug because of a simple physical fact: hiding smaller things is easier than hiding bigger ones. So, because illegal drugs need to be concealed, prohibition favors more potent and therefore more potentially deadly substances.
This was seen even during alcohol prohibition, when hard liquor was preferred for sale over lower-alcohol wine and beer. Whisky is roughly eight times more potent than beer—so, it’s much easier to stash. Hence, we refer to alcohol smugglers as bootleggers, because they could hide flasks in their boots—not, say, “barrel hiders.”
During today’s overdose crisis, the iron law meant that when people with addiction lost access to pharmaceuticals like oxycodone (the active drug in OxyContin), they created a massive demand for street opioids. Historically, the most common of these has been heroin, but aided by the internet, dealers soon found a cheaper and more potent substitute: fentanyl and similar synthetics, which can be hundreds to thousands of times stronger.
It’s not clear what the thinking was here: did policy makers believe that simply taking away drugs cures addiction? Or pain? Regardless, drug dealers were far more nimble than the government, often trolling for customers outside the offices of shuttered pill mills.
There’s also another reason that this supply-side policy was predictably dangerous.
That is, legitimate pharmaceuticals are required to be of a standard dosage and purity, which means that people know how much they are taking and whether it’s more or less than usual. Street drugs, by contrast, are unregulated. It’s difficult to be sure what’s in that mystery pill or powder, let alone what the appropriate dose should be.
Though advocates of cutting the medical supply argued that prescription opioids are just “heroin pills,” and should be seen as similarly risky, this misses a critical distinction. If pharmaceutical and street versions of drugs are in fact equally safe, there’d be no need for regulators like the FDA. Sure, people can misuse both, but with pharmaceuticals, at least they have the option of dosing more safely. This fact makes using street drugs more deadly.
Moreover, it’s not like policy makers couldn’t have acted on the demand side. We have two medications— buprenorphine (brand name: Suboxone) and methadone— that are proven to cut the overdose death rate by 50 percent or more. We could have immediately made them available to patients with addiction when shutting down rogue doctors.
And this would have been a far easier task than trying to track down and treat people who use illegal drugs after their suppliers were taken down. Unlike street dealers, doctors must have a list of the real names of the patients to whom they prescribe: pharmacies require government ID like a driver’s license in order to dispense controlled substances.
If the goal of reducing prescribing were actually to help addicted people and improve pain care, these patients could have been contacted and given immediate access to appropriate treatment for their medical conditions when they lost their doctors. This would have left far fewer customers for dealers.
Instead, however, supply was simply cut and, in some cases, thousands of people were left to suffer withdrawal at the same time. As the crackdown progressed, even doctors who see their patients as benefitting from opioids began either to reduce doses or stop prescribing entirely for fear of being targeted by police and medical boards. Now, half of all general practitioners will not even accept new patients who have lost their doctors and want to continue opioid treatment.
Health departments can see the problem coming when pain clinics shut down. These days, some even issue alerts about a likely rise in overdose calls. But if the goal here is to save lives, why are these patients left at risk without even being offered help first? (The only published example I’ve found of law enforcement trying to aid patients in this situation was during a huge 2019 raid; why is this a rarity, rather than the rule?).
Further, none of this addresses the increased disability and suicidal thoughts that can occur when pain patients are deprived of the only treatment that they have found to bring relief. Though opioids were certainly overused, some intractable pain patients do benefit, and only lip service has been given to helping them. The result is that hundreds of thousands of people have simply had their opioid medications reduced or eliminated, regardless of whether this improved or destroyed their lives.
And research suggests that these cuts often haven’t helped people with pain. One study of millions of medical records, which compared the timing of state opioid regulations and reductions and could therefore suggest causality, found that opioid reductions actually led directly to increased disability, decreased productivity, rising medical costs and more pain. Another study found that among veterans who had their opioids stopped involuntarily, 9 percent became suicidal and 2 percent actually tried to take their own lives. Even worse, other research shows that rather than minimizing overdose risk, cutting access to medical opioids nearly triples the odds of overdose death among people in pain.
Journalists continue to echo the three-wave story that places the blame overwhelmingly on pharma. But the second two phases didn’t just happen: they were driven by policy choices.
And few have called for accountability for those who initiated the medical supply crackdown that drove the rise of fentanyl.
So, where is the reckoning for policy makers, from the DEA to the CDC to Congress and state legislatures, who closed pill mills and wrote laws, guidelines and regulations to decrease prescribing, while making no significant effort to immediately treat any of the abandoned patients, whether they were addicted or in pain or both?
Why are we still spending hundreds of millions of dollars on policing and cutting the medical supply, while more than 80 percent of people with opioid use disorder still don’t have access to effective treatment and while the vast majority of overdose deaths are now caused by street fentanyl and its chemical cousins, not prescriptions? Why do we ignore the fact that most opioid addictions start when people take drugs that are not prescribed to them?
Of course, there are potential negative effects from many kinds of policies, and lawsuits really aren’t the best way to hold policy makers accountable. Moreover, unlike in Purdue Pharma’s case, many of these efforts were made in good faith.
But if we actually want to use the money obtained by suing drug makers effectively, we can’t ignore the fact that the supply-side “cure” that we’ve enacted so far has actually worsened the disease. It’s understandable to want to punish drug makers for the genuine harm they have caused. To do better, however, we need to base policy on evidence, not emotion.
This is an opinion and analysis article.