Friday, February 15, 2019

How Government Caused the Opioid Epidemic

Jeffrey Miron, Greg Sollenberger, and Laura Nicolae are out with an important new paper, Overdosing on Regulation: How Government Caused the Opioid Epidemic.

From the introduction:
Opioid overdose deaths have risen dramatically in the United States over the past two decades. The standard explanation blames expanded prescribing and advertising of opioids beginning in the 1990s.

This “more prescribing, more deaths” explanation has spurred increased legal restrictions on opioid prescribing. Federal and state governments have enacted a variety of policies to curtail prescribing and doctor shopping, and the federal government has raided pain management facilities deemed to be overprescribing. Supporters believe these policies reduce the supply of prescription opioids and thereby decrease overdose deaths.

We find little support for this view. We instead suggest that the opioid epidemic has resulted from too many restrictions on prescribing, not too few. Rather than decreasing opioid overdose deaths, restrictions push users from prescription opioids toward diverted or illicit opioids, which increases the risk of overdose because consumers cannot easily assess drug potency or quality in underground markets. The implication of this “more restrictions, more deaths” explanation is that the United States should scale back restrictions on opioid prescribing, perhaps to the point of legalization. 
 The paper's conclusion:
The standard view of the opioid epidemic argues that increased prescribing caused the recent increase in opioid overdose deaths. Medical use of opioids, however, is not a major cause of opioid addiction or overdose. Instead, available evidence suggests that the array of recent state and federal restrictions on legal access to opioids likely contributed to increasing overdoses by pushing users to diverted or illicit sources. Over the past few years, the opioid epidemic has accelerated due to overdoses caused by heroin and synthetic drugs such as fentanyl, despite reduced prescribing. Further restrictions on prescribing are unlikely to decrease overdose deaths.
A simple first step in decreasing the risks associated with the consumption of opioids from diverted or illicit sources is to increase legal access. For example, the federal government could end or decrease the regulation of methadone, buprenorphine, and even morphine- or heroin-maintenance treatment for opioid dependence and remove rules that limit prescribing or increase the costs of opioid production. Federal and state governments could also end raids on pill mills. These reforms could increase access to opioid dependence treatment, prevent the undertreatment of pain, and reduce the harms associated with underground consumption.
The United States could consider making all opioids “more legal” by shifting opioids to less regulated schedules or even over-the-counter status. In the extreme case, opioids would be legally available for purchase without a prescription. While modest reforms to regulation can decrease the prevalence of underground opioid consumption, outright legalization would eliminate the underground market entirely. Individuals who choose to purchase and consume opioids would be able to do so in a safer setting, reducing the dangers of use. We suggest this would counteract the recent increase in opioid overdose deaths.
Beyond any implications for overdose deaths, restrictions on legal access to opioids should be assessed in light of all their costs and benefits. Even if increased opioid prescribing heightens the frequency of opioid dependence, prescribing also improves the quality of life of patients who suffer from severe or chronic pain. Decreased prescribing in recent years, for example, has apparently driven at least 23 patients to suicide.We have focused here on overdose deaths in particular, but we emphasize that a complete analysis of restrictions on prescribing almost certainly suggests that the harms of regulation outweigh the risk of increasing opioid dependence through greater legal access.
From inside the paper:
The claim that long-term opioid use or addiction generates more overdoses is not supported by the evidence: long-term opioid use has minimal life-threatening consequences under appropriate medical guidance. As long as “escalations in opioids are carefully titrated on the basis of appropriate control of symptoms … concerns that death will be hastened by opioids are unwarranted.” Patients receiving long-term stable doses of an opioid rarely suffer from respiratory depression because they quickly develop tolerance to the drug. Respiratory depression is more likely to occur as a result of consumption from the underground market, when doses are more likely to be taken without regard to the drug’s half-life or combined with other drugs.


  1. Whenever the government gets involved in something, it always gets worse. Everyone knows that except government bureaucrats.

    1. ...and the bulk of the population (unfortunately).

    2. Touché - also don't forget a huge amount of money is made by many parties from the war on drugs.

  2. Let's not discount our invasion of Afghanistan. Air America flies again.