Are we making the opioid problem worse?

Opioid abuse is taking a tremendous toll on America, with 42,000 opioid-related deaths in 2016 and 343 in Alabama.  The problem involves both prescription opioid-based painkillers and illegal heroin and fentanyl.  Might our public policy response be worsening this terrible problem?

Economists have analyzed prohibition, both alcohol in the 1920s and illegal drugs more recently.  We evaluate prohibition, or any other government policy, by comparing the world with and without the policy in question.  This necessarily involves a state of the world which does not exist.  We will never see the toll opioids would have taken in 2018 if we had significantly different policies in place.  We must construct an alternative.

Rules govern the construction of alternatives to produce meaningful comparisons. One key is allowing only the policy to vary, not other factors, so differences can be attributed to alternative policy.  For example, prohibition does not automatically stop people from taking a substance.  Some potential users will be deterred because of illegality, but others won’t, as we saw with alcohol in the 1920s.

Economic analysis distinguishes harm from the substance itself and those due to prohibition.  Drug violence, for example, is almost entirely due to prohibition.  Dealers’ cash and drugs are vulnerable to theft, and these thefts will not be reported to the police.  Dealers will use violence to protect, steal or retrieve drugs and money. Walgreens and CVS do not have gun battles to control the OxyContin market.

Prescription painkillers provide a distinctive twist to the opioid crisis.  Introduction of opioid painkillers in the 1990s opened new options for millions of American pain sufferers.  Prescription drugs occupy a middle ground in prohibition, legal under government-approved conditions and illegal otherwise.

Perhaps the major controversy for policy and lawsuits brought by dozens of states and cities against drug companies is the addictiveness of opioid painkillers. Studies in leading medical journals show that perhaps one or two percent of patients using the drugs as prescribed become dependent.  Many of the Americans addicted to painkillers obtained them on the black market or through a bogus prescription.

In 2010, the Food and Drug Administration reformulated OxyContin to make the pills harder to crush and make into more potent opioids.  Other restrictions on prescribing followed, and pill mills have been shut down.  In Alabama, opioid prescriptions declined 17 percent between 2013 and 2015.  Yet the crisis has become much deadlier since 2010, with heroin- and fentanyl-related deaths increasing by factors of five and six respectively, with only a slight decline in prescription-related deaths. (Overdose victims often used more than one narcotic, so deaths are described only as related to a drug.)

Heroin, especially when laced with fentanyl, is far deadlier than prescription opioids.  It is tragic when people fall into substance abuse, which often happens after traumatic life events.  Rehab is often not effective until people decide to change their lives.  Unfortunately, public policy may only be able to limit the harm during a dark period in people’s lives, and ensure the availability of help when requested.  Forcing people to turn to heroin by restricting access to painkillers increases harm.

Restricting access to prescription opioids is costly.  Many people can no longer successfully manage their chronic pain, with tragic consequences.  In some documented cases, patients have committed suicide after being denied painkillers.  Any policy limiting access for people who do not “need” painkillers will deny some patients in pain needed help because pain is subjective; no doctor or nurse can know if it is tolerable.  And a strong argument exists that American adults should be able to decide how to treat their pain without the government’s approval.  Libertarian psychiatrist Thomas Szasz argued that free people have a right to drugs.

The concentration of the opioid deaths in regions with dwindling manufacturing and mining jobs suggests a significant economic element to the crisis. And this, to me, is the crisis’ most disturbing element.  America today boasts tremendous prosperity and opportunity.  Given the high overall quality of life today, why is the economy seemingly leading so many Americans to addiction?

Daniel Sutter is the Charles G. Koch Professor of Economics with the Manuel H. Johnson Center for Political Economy at Troy University.