In the shadow of the COVID-19 pandemic, the drug overdose crisis has reached new tragic heights. Between 1999 and 2019 nearly 841,000 people died from an overdose, and in 2021 we passed a grim milestone of people dying from drug overdose in a 1-year period. Each one of those deaths is someone's family member, friend, or neighbor. What makes these deaths all the more devastating is that no one should die from an overdose. We have years of evidence demonstrating which public health interventions keep people safe from overdose, we have medical interventions like naloxone to reverse the effects of an overdose, and we have effective, lifesaving treatment for opioid use disorder.
These deaths speak to the decades of failure in our policies, approaches, and treatment of and for people who use drugs.
While many factors are associated with the growing overdose numbers, one major driver is the ongoing poisoning of the illicit drug supply. Increasingly, the drug supply is contaminated with unregulated fentanyl, adding a dangerous level of unpredictability to drug use. Looking back at different waves of the current overdose crisis, we can see the lack of benefit -- and outright harm -- caused by an outsized focus on supply-side interventions. In response to the first wave of the current crisis, which began in the late 1990s and early 2000s and involved rising rates of prescription opioid related deaths, the focus has been on reducing prescribing. Since 2012, opioid prescribing rates and deaths involving prescription opioids . Yet, rather than seeing a positive impact on the overall overdose crisis, we have seen the opposite -- the death rate has increased. People who use opioids have been pushed into the unregulated, illicit drug market as access to prescription opioids diminished. Just like when you squeeze an inflated balloon on one side, the other side grows.
In addition to pushing people newly into the unregulated drug market, supply-side interventions create dangerous pressures on the drug market. This has been described as the "." This refers to lessons from alcohol prohibition where efforts to suppress the illicit alcohol supply created economic and logistical pressures favoring high alcohol content spirits, akin to what we are now seeing with pressure for more potent and compact substitutes with fentanyl analogs. In continuing the comparison with alcohol, where we now have a regulated supply, we still worry about alcohol use disorder and identify and treat it. However, you know the alcohol level of the product you're consuming, whether in a bar or restaurant or purchased from a store. Now imagine instead if you ordered a drink and couldn't tell if it was a 5% beer or an 80-proof liquor -- you would have no sense of how to regulate it and unintentional poisonings would occur regularly. This argues for the importance of treatment; harm reduction strategies like drug checking, overdose prevention sites, and safe supply; and demand reduction interventions, which address the structural determinants of health driving chaotic drug use.
Yet, rather than investing in effective and humane strategies to reduce mortality, we have spent a century criminalizing certain types of drug use and certain populations who use drugs. And we have doubled down on and funded ineffective and frankly harmful approaches, while not adequately supporting treatment and harm reduction interventions proven to reduce overdose death. We are now seeing the result of these years of failed policies and approaches.
The COVID-19 pandemic has only worsened things by increasing trauma, social isolation, loss of economic opportunity, boredom, despair, and political polarization. It has made it harder to access certain treatments and resources that keep people safe. COVID-19 has also been a stark reminder of the health harms of living in a racist society. The impact of racism, how it intersects with and drives drug policy, and the worsening racial disparities in the overdose crisis are crucial to note. In Massachusetts between 2019 and 2020, there was a in opioid-related overdose deaths among Black men, and in 2021 overdose death rates among American Indian individuals were three times higher than among non-Hispanic white individuals. Nationally, between 2019 and 2020 the in overdose death rates was among Black and American Indian individuals and the disparity for Black Americans was highest in areas with the greatest income inequality. These racial disparities are layered on top of the fact that many of these communities have already been devastated by the war on drugs, which has separated families through the child welfare system and sent people to prison instead of treatment. Acknowledging and repairing those harms is essential. Making people invisible is traumatizing; whitewashing the overdose crisis does just that to Black and Latino and Native communities -- sending the message that their lives don't matter
Another intersecting group who are sometimes forgotten or even pitted against those suffering from substance use disorder are people living with chronic pain. We have embarked down this supply-side strategy of cracking down on opioid prescriptions, criminal sanctions around selling and distributing drugs, and making it harder to access drugs. This has been completely ineffective and has not only harmed people who use drugs, but also people living with chronic pain for whom pain management has allowed them to function and are now being abandoned by their doctors.
So, if these strategies have failed, what are effective pathways forward? First, knowing and employing proven strategies to improve health and clinical outcomes for people with opioid use disorder is necessary. The evidence is clear that ensuring access to medications, namely the opioid agonists , are the treatments. These should be made available in every clinical and criminal legal setting and offered with, but not contingent on, participation in or supports like psychosocial interventions or recovery supports. Second, fully embracing and funding harm reduction strategies -- such as syringe service programs, safer smoking programs, overdose prevention sites, naloxone distribution, and more -- is crucial. Harm reduction focuses on minimizing the negative consequences of drug use while supporting the dignity and autonomy of people who use drugs. A frequent misperception is that making something safer means promoting it -- but does requiring seat belts promote reckless driving? These approaches should not be controversial. Lastly, we need to address people's structural barriers and basic needs. If you're unhoused, have no job, have been in and out of prison, have been harmed by racism, and have no hope, why would you stop using drugs?
Healthcare systems and clinicians can do so much to address the overdose crisis. Investing in and embracing this work is not only important but also tremendously rewarding. Substance use disorders are treatable, good prognosis conditions. Touchpoints with the medical setting offer teachable moments for engagement, support, and treatment. And there is immeasurable joy, professional satisfaction, and privilege in partnering with patients who use drugs and those with substance use disorder.
is medical director for Substance Use Disorder at Mass General Brigham and an associate professor of medicine at Harvard Medical School.