All opioid use is not an addiction; the dichotomy of opioids in the US by Dr. Susanne Fogger

March and April come in a rush; with trees blossoming and the early flowers heralding the return of warmth and color. Spring also feels bittersweet as the environment awakens a world where unnecessary lives are lost each day as the opioid epidemic continues with its quiet erosion of life. The numbers of lives lost in the past year is staggering—more than 100,000 Americans lost to drug overdoses in 2021. However, many of those who lost their lives were not addicted to opioids.

As we discuss the opioid crisis, it is important to understand the complexities of drug use and drug overdose. This is not a topic where sweeping conclusions can be made.

Recent headlines provide one example. In March, several cadets from West Point overdosed while on spring break, coming very close to losing their lives. The cause of the overdose was “cocaine” contaminated with fentanyl, a prescription drug with a high potential for addiction.

This is not the first instance of fentanyl-laced illicit drugs, either. This synthetic substance has been found contaminating multiple illicit drugs, so that no individual using any illicit substance is safe from a potentially deadly opioid overdose. I provide this example because it is also important to acknowledge that headlines about this overdose were met with surprise—these West Point students are not typically whom society thinks are the people to overdose, and many view overdose and death from overdose as a moral failing. But this judgment does not help improve the opioid crisis. It does not provide resources to prevent accidental overdose due to contamination, and it does not provide resources to individuals battling substance misuse.

In some circumstances, it can place barriers toward potentially lifesaving tools. In Alabama, for example, it has been illegal to purchase drug paraphernalia, which includes items that could analyze or test illegal drugs, such as test kits that can detect the presence of fentanyl. How many lives could be saved if the person could check to see if their cannabis was contaminated with fentanyl? These kits are a form of risk reduction, a public health concept that reduces the damage from substance use as an individual continues to use.

Some change is being made, however. Earlier this year, state senator Jim McClendon and state representative Allen Treadaway sponsored an exception to Alabama law which would make it legal to use and distribute test strips to detect the presence of fentanyl in other drugs. This passed the Alabama Senate in February and House in March. This law change can save multiple lives. At the time of this writing this blog, the bill has not been signed into law by the governor, but it shows a step toward identifying contamination in a substance and saving lives.

It is also important to consider the conversation around opioid prescriptions. There is an ongoing belief that most of the overdoses are caused by prescription opioids, however, as the number of prescriptions has dropped, the number of people dying from opioid use continues to rise. A decrease in prescriptions relates to the 2016 CDC Guideline for Prescribing Opioids for Chronic Pain, which cautioned against inappropriate use of opioids, recommending use of alternative treatments and adjunctive therapy to help manage chronic pain. Opioids are not recommended as first line for acute or chronic pain management.

While it is undisputed that acute use of opioids needs to be limited, policies developed in response these guidelines have had unintended consequences affecting those with chronic pain. Many patients with chronic pain have had limited ability to work or have had to quit work due to their ongoing pain. Their quality of life may be supported by their ongoing use of prescribed opioids, especially for individuals without insurance or who lack access to resources for supplemental therapies, such as swimming pools or massage therapists. For those living with chronic pain, ongoing therapy is needed for years, yet people are without the ability to receive additional therapy. As we consider policies, it is important to consider the role of opioids for those living with chronic pain, including providing relief and the freedom to continue working, to manage their households and care for others. This year, the CDC is updating their guidance on chronic pain; we can hope the new guideline will provide for improved care.

The opioid epidemic is an ongoing tragedy, and as we grapple with its many facets, a focus on risk reduction strategies can help save lives. Each of us can make a difference by recognizing opportunities for change.