Will Criminalizing Opioid Abuse Stop the Problem? Public Health Watch Report

On August 10, 2017, President Donald Trump declared a national state of emergency in response to rising rates of opioid abuse, misuse, and addiction across the country.

The move, which had been recommended by his own Opioid Commission in late July, is largely a symbolic one, in that it’s unlikely that those working—and suffering—at the frontlines of what has arguably become an epidemic of drug addiction will see any immediate impact. However, it does draw attention to the issue—at a time when increased focus is vital, given reports suggesting that there are as many as 100 opioid overdose-related deaths per day in the United States, and—as outlined in a study published on August 11, 2017 in the Annals of the American Thoracic Society—a 34% increase in US ICU admissions related to opioid overdoses since 2009.

Of course, as infectious disease and public health specialists know, overdoses are not the only source of morbidity and mortality associated with opioid use. As Contagion^® reported last year, HIV and hepatitis C virus (HCV) case clusters in several Midwestern states have been linked with “recreational” injection opioid use (including heroin and prescription narcotics), with both diseases spreading, primarily, as a result of use of shared and/or used needles. According to a World Health Organization report, the United States is the only country in the world where incidence of HCV is increasing—a fact that has been attributed primarily to injection opioid abuse.

In fact, in July 2017, the US Food and Drug Administration (FDA) requested that the opioid Opana ER be pulled from the market over concerns regarding “injection abuse” of the drug being linked with “a serious outbreak of HIV and HCV.” Its manufacturer, Endo, agreed to the FDA request following reports last year that users had discovered a way to overcome the attributes of a reformulation of the drug designed to prevent misuse.

Unfortunately, there is some disagreement as to what, exactly, the proper public health response is, and should be, to the opioid crisis. One such prevention initiative was introduced a week before President Trump’s state of emergency announcement when US Attorney General Jeff Sessions revealed that the Department of Justice had formed a new investigation unit targeting pharmacies and doctors who provide opioid users with access to illegal prescriptions for drugs. The disagreement comes in because there is evidence to suggest that such criminal justice-related initiatives may not solve the problem.

Indeed, an analysis performed by the National Bureau of Economic Research (NBER) suggests that the issue may be one of competence, as opposed to criminality. The NBER assessment found that physicians educated at lower-ranking medical schools in the United States are roughly 30% more likely than their colleagues who are educated at the country’s top schools to improperly (though not necessarily illegally) write prescriptions for patients for opioids. Because American physicians wrote more than 2 billion prescriptions for opioids between 2006 and 2014 alone, these numbers are not insignificant.

Furthermore, as Contagion^® reported in June, a systemic review of 106 studies conducted by researchers at Johns Hopkins Bloomberg School of Public Health and the University of British Columbia found that criminalizing drug use had adverse effects on health outcomes in those with HIV related to injection drug use. The authors concluded that the joint stigmas surrounding HIV and illegal injection drug use, coupled with their fear of incarceration for drug-related offenses, prevented many of these patients from seeking, and thus receiving, proper treatment.

Conversely, as Amanda Binkley, PharmD, AAHIVP, Clinical Pharmacy Specialist-Infectious Diseases at the University of Pennsylvania Health System, wrote in an analysis for Contagion^®’s August 2017 print issue, multiple studies have indicated that behavioral interventions; substance abuse treatment, including opiate-replacement therapy; needle exchange programs; and the creation of affordable and accessible treatment programs have been successful of reducing HCV transmission among people who inject drugs.

And, so, while it is positive that the president and his administration are speaking to the issue of opioid addiction in the United States, it remains to be seen what actions will result from their words. Declaring a state of emergency will free up federal disaster funds to implement new programs to respond to the crisis and allow for the waiving of certain rules and regulations to enable agencies to respond quicker.

But, will that response be care-focused or crime-focused? As with most government regulations, we will need to wait and see.

Brian P. Dunleavy is a medical writer and editor based in New York. His work has appeared in numerous healthcare-related publications. He is the former editor of Infectious Disease Special Edition.