Columnist Takes Aim at Policymakers for Reducing Opioid Prescriptions Without Increasing Pain and Addiction Services

Policymakers who pushed simply for reducing opioid prescriptions - without ensuring that patients receive adequate pain care and addiction treatment - are the new culprits in the opioid crisis, writes Maia Szalavitz in an opinion piece published in Scientific American.1

Her piece will no doubt raise objections over seemingly equating advocates for responsible opioid prescribing with, say, the Sackler family and drug cartels, but there is no disputing the fact that simply reducing the number of prescriptions was not enough.

"Nearly 100,000 people are thought to have died from overdose in 2020, the deadliest toll from overdose in American history," Szalavitz wrote.

In her piece, Szalavitz starts by describing three waves, starting with aggressive marketing strategies by Purdue Pharma and other opioid manufacturers that led to physicians prescribing more opioids, and leading to "hundreds of thousands of new addictions in the 1990s and 2000s."

The second wave began around 2011, when states cracked down on pill mills that called themselves pain clinics, but which had fueled the opioid crisis. As prescriptions became scarce, prices rose. People who were addicted "began to turn to heroin, which was cheaper and now had a big enough pool of customers to attract cartels to places that they'd never served before. Again, overdose deaths increased."

The third wave comes from dealers who now cut more potent fentanyl and other synthetic opioids into heroin, leading to more deaths.

Advocates led mainly by a group called Physicians for Responsible Opioid Prescribing made the case to policy makers and politicians that since overprescribing caused the epidemic, reducing medical use would solve the problem. And they did succeed in significantly shrinking the medical supply: since 2011, opioid prescribing has been cut by more than 60 percent.

Unfortunately, however, as medical use declined, the total number of overdose deaths more than doubled between 2011 and 2020. Indeed, even before the pandemic, more overdose deaths had occurred since prescribing began to decline than took place while medical opioid use was soaring.

"Advocates led mainly by ... Physicians for Responsible Opioid Prescribing made the case to policy makers and politicians that since overprescribing caused the epidemic, reducing medical use would solve the problem. And they did succeed in significantly shrinking the medical supply: since 2011, opioid prescribing has been cut by more than 60 percent.

"Unfortunately, however, as medical use declined, the total number of overdose deaths more than doubled between 2011 and 2020. Indeed, even before the pandemic, more overdose deaths had occurred since prescribing began to fall than took place while medical opioid use was soaring," Szalavitz wrote.

She wrote that no one should have been surprised that the sharp reduction in opioid prescribing let to more illicit use. This phenomenon, she wrote, has an academic name-the iron law of prohibition-coined by activist Richard Cowan in 1986.

"The phrase refers to the effects of reducing drug supplies while not acting significantly to manage demand. Almost always, it results in the rise of a more harmful drug because of a simple physical fact: hiding smaller things is easier than hiding bigger ones. So, because illegal drugs need to be concealed, prohibition favors more potent and therefore more potentially deadly substances," Szalavitz wrote.

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