Donald Trump says that an epidemic of opioid addiction in the US is a "national emergency". How bad is the problem and what should be done? Simon Wilson reports.
What are opioids?
A class of highly addictive drugs that includes powerful painkillers (which are legal if prescribed by a doctor) and heroin (which is not). Morphine and heroin are both derived from opium, as are strong prescription painkillers such as Vicodin, Percocet and oxycodone.
In addition, there are synthetic or semi-synthetic opioids, the most important of which are methadone and fentanyl a drug 50 to 100 times more potent than morphine which is used (legally) as a surgical anaesthetic and (illegally) as a powerful recreational narcotic.
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How big is the problem?
More than a third of Americans (97 million people) took opioid prescriptions in 2015. Of these, 12 million acquired prescription drugs illicitly and least 2.6 million of them are addicted to them. However, while the crisis has its roots in the over-prescription of opioid painkillers from the 1990s onwards, deaths from prescription opioids have levelled off since 2011.
Meanwhile, deaths from heroin and fentanyl are rising fast. Indeed, in some states, where the opioid crisis is at its worst Rhode Island, Pennsylvania and Massachusetts fentanyl alone is now involved in more than half of all overdose deaths. Official statistics show that about three-quarters of US heroin users first became addicted via prescribed opioids.
How many users are dying?
Last year an estimated 60,000 Americans died of overdoses with around half of these being overdoses of prescribed painkillers. That makes the opioid epidemic the deadliest drugs crisis in US history. It's more than the total killed by gun homicides and car crashes combined; more than the HIV-Aids crisis at its peak; and more than the total US death toll in the Vietnam war. Opioids are now the leading cause of death of Americans aged under 50.
In general, the dead are disproportionately white, male, and poor, though there is a wealth of evidence that the epidemic is increasingly affecting all sections of society. The epidemic is one reason why US life expectancy declined in 2015 for the first time since 1993, and has been cited as a cause of the US labour market's millions of "missing men" the growing proportion of men aged 25-54 who are neither working nor looking for jobs.
What caused the crisis?
Several academics have posited that the opioid crisis is part of a wider long-running story of stagnating real wages, unemployment and white working-class "deaths of despair". The statistical evidence on this is mixed and disputed. What is not in dispute is the role of the pharmaceutical industry in enabling the crisis by aggressively marketing opioid painkillers.
In the words of the presidential commission report published last week, "we have an enormous problem that is often not beginning on street corners; it is starting in doctors' offices and hospitals in every state in our nation this crisis began in our nation's healthcare system". At the same time, the price of heroin has fallen dramatically due to oversupply.
And then from 2014 fentanyl started to become widely available a particular danger as it is so potent, so profitable for traffickers, and so easy to mix in with other drugs.
How can it be tackled?
President Trump last week declared the epidemic a "national emergency", though hasn't yet taken the official steps needed to give that declaration legal effect. Chris Christie, the Republican governor of New Jersey who put together the interim report on the epidemic that prompted Trump to make his declaration, has urged the president to treat it as a "public health crisis rather than a war" on drugs, says Edward Luce in the Financial Times. This would involve some big changes, such as using medical substitutes to treat addicts, which is currently not allowed under the strict abstinence regime imposed on users.
The report even calls for Naloxone, a key opioid overdose antidote, to be issued under federal mandate to all law-enforcement officers. It would also mean lifting restrictions on Medicaid funding of drug treatment centres something that looks far from certain given that Medicaid funding faces dramatic cuts if the Trump administration ever succeeds in abolishing Obamacare.
What will Trump do?
Ominously, his hardline conservative attorney-general Jeff Sessions has been reviving the "just say no" approach championed by Ronald (and Nancy) Reagan in the 1980s. That has experts worried, given that the Reagans' "war on drugs" approach had no more success than did the prohibition of alcohol in the 1920s and 1930s.
However, Trump is "limited in the degree to which he can criminalise the problem", argues Luce, given its scale and the politics involved: the US counties with the highest drugs mortality rates were far likelier to vote for Trump than Hillary Clinton. It would be "political suicide" to make large numbers of Trump voters criminals.
How much is this costing?
A study in the journal Medical Care puts the economic cost of opioid overdose, abuse and dependence at $78.5bn a year. Healthcare accounts for about a third of that, while expenses due to lost productivity in non-fatal cases add another $20bn. For US pharmaceutical companies, the financial pain could just be beginning.
Back in 2007, Purdue, the maker of OxyContin, admitted misleading the public about the risk of addiction, and paid $600m in damages. It, and several other companies, now face a slew of upcoming cases. This week South Carolina became the sixth state to sue opioid makers, alleging they have created a public-health crisis.
The suit was filed by Joe Rice, a lawyer who helped negotiate a $246bn settlement with the tobacco industry in 1998 and something similar can be expected this time, according to Bloomberg. "Big Pharma is having a Big Tobacco moment," it suggests.
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