Drug overdose death (DOD) has become a leading cause of injury-related death around the world. Hundreds of thousands of people lose their lives each year to drug overdose, and the numbers continue to mount. Three experts on drug policy reflect on the factors behind the increasing number of DODs, the responsibilities of the primary stakeholders in the prevention of DODs, and the best practices and policy approaches to respond to DODs.
What are the main reasons/factors behind the current prevalence of Drug Overdose deaths (DODs)?
Susan Bissett: The drug epidemic has changed over time. We are no longer dealing with prescription opioids (which have since been heavily regulated regarding prescription and dispensing) and heroin. Fentanyl is the driving factor changing the nature of America’s drug epidemic—with its inclusion in methamphetamine, recreational drugs, and counterfeit pills driving the increase in overdose deaths.
Methamphetamine (meth), which is cheaper on the street and more accessible to persons with chronic addiction has now become the drug of choice for many. An article published in August by the Journal of American Medical Association indicated that four out of five people who use drugs (particularly in rural areas across 10 states) reported using methamphetamines in the past 30 days. In addition, in most states, overdoses from meth have risen significantly in large part due to the inclusion of fentanyl in the manufacturing of meth.
Last month, Denver police found four persons dead inside an apartment. They had been recreationally using cocaine not knowing it had been cut with fentanyl and overdosed. The Denver police department described the deaths as criminal. Sadly, this is not a new story; recreational drugs often used at parties and in college dorms like cocaine and marijuana are now laced with fentanyl.
I tell my own children that recreational drugs are not what they once were. As someone who served as a college administrator for 25 years, I am not ignorant of the fact that much experimentation with illicit drugs happens on and around college campuses. We must talk to our children about recreational drugs—moving from a “just say no” to a “test before you take” conversation. And it’s not just recreational drugs like cocaine and marijuana. The fastest-growing misused prescription drugs on college campuses are stimulants like Adderall. In Spring 2022, two students at the Ohio State University died after apparent accidental fentanyl overdoses. The cause? Counterfeit Adderall pills containing fentanyl.
Counterfeit drug trafficking is one of the world’s fastest-growing criminal enterprises, according to the US Drug Enforcement Administration. Some estimate the global counterfeit market to be worth between $200 and $432 billion. China, Hong Kong, in particular, is the largest producer and distributor of these drugs. Incidentally, China is the number one supplier of fentanyl to the United States as well as the main supplier to Canada and Mexico. Cartels from Mexico then smuggle fentanyl into the United States, often mixing it with other illicit drugs.
Larissa J. Maier: Every drug-related overdose death is preventable. Synthetic opioids are responsible for most overdose deaths. Opioid overdoses can be reversed by administering oxygen or naloxone. The economic cost of opioid use disorder and fatal overdoses is more than $1 trillion each year in the United States. The main reason why people die from drug-related overdoses is that they use drugs alone. Most people know their preferred dose and can measure it accurately. However, emotional, or physical pain, drug tolerance, or curiosity may lead to the intake of higher doses than usual increasing the risk of an overdose. Solitary drug use is a direct consequence of the stigma toward and legal consequences of illegal drug use. If people are forced to hide their drug use from family, friends, employers, and the public more broadly, they are at greater risk of negative outcomes in the event of an overdose.
Another common reason for overdose deaths is the co-use of different psychoactive substances, not limited to the use of illegal drugs. For example, the co-use of alcohol or legally available prescription pills such as benzodiazepines can negatively impact the respiratory and cardiac functions of people who use opioids or stimulant drugs. Finally, unexpected adulterants or false declarations of the content or purity of psychoactive substances purchased from illegal drug markets can lead to undesired effects, overdose, or even death.
Katharina Maier: (1) A toxic drug supply: Drug poisoning is one of the main reasons behind increasing drug overdose deaths. (2) Lack of accessible harm reduction and treatment options: Lack of accessible public health and life-saving harm reduction services are another driving factor. While we have seen an expansion of Safe Consumption Sites and other services, the availability of harm reduction interventions continues to be insufficient. Reduced linkage to care and access to critical services, which has been exacerbated during the COVID-19 pandemic, has been shown to have contributed to an increase in DODs. (3) Poverty and Marginalization: While anyone can be affected by drug overdose, research shows that marginalized people are at heightened risk of drug-related harm and vulnerabilities. Social marginalization, which restricts one’s access to critical health and social services, is a contributing factor to the current state of DODs.
Who are the primary stakeholders in the prevention of DODs and which institution(s) should lead these efforts?
Susan Bissett: While I am not an expert on drug trafficking or enforcement, there is no question that issues related to enforcement must be addressed. However, through my work, I focus on prevention, education, and harm reduction. We need more of all three.
We must educate our children early and frequently about the dangers of prescription and illicit drugs, and we must do so in a way that engages them in conversation and makes them feel safe. However, we must also educate adults. In many counties, for instance, in my home state of West Virginia, over 50% of our children are being raised by grandparents. We moved these children from seemingly unsafe environments into loving homes. However, grandparents are more likely to have prescription medications, more likely to have multiple prescriptions including opioids, and less likely to store them properly making them more accessible to children. We must work to change our behavior so that medications are stored properly and disposed of when no longer in use. We also need to make sure children understand that not everything with a prescription is medicine.
In addition to education, we can prevent overdose by encouraging people with a substance use disorder to test for fentanyl. In June 2022 fentanyl test strips became legal in the state of West Virginia and were removed from consideration as drug paraphernalia. Like many other organizations, the West Virginia Drug Intervention Institute has worked quickly to distribute these strips throughout our state focusing on universities, treatment centers, and harm reduction programs as distribution points in hopes of reaching groups more likely to use illicit, recreational drugs. To date, over 40,000 test strips have been distributed in 40 of West Virginia’s 55 counties.
Finally, increasing access to the life-saving overdose reversal drug, naloxone, is not enough—it needs to be at the ready and in immediate proximity to anywhere an overdose might occur. All indications from the US Food and Drug Administration suggest naloxone will go over the counter (OTC) in Spring 2023. However, naloxone is not Tylenol or even Plan B. You may have a headache, so you hop in your car, drive to the pharmacy, and purchase Tylenol. You can also drive to a pharmacy in the morning to purchase Plan B to prevent pregnancy. Naloxone is different. It must be in immediate proximity to reverse an overdose. You cannot walk into a pharmacy and purchase naloxone as you are overdosing OR as someone you love is overdosing; you must purchase it first as a preventative measure. Therefore, while OTC availability will indeed increase access at the point of sale, it will not necessarily put naloxone in proximity to where an overdose is occurring or is likely to occur. This is one reason; we have worked with ONEbox™ to distribute opioid response kits throughout West Virginia and the country.
This box is an on-demand, one-of-a-kind, technology-enabled opioid overdose rescue response kit intended to contain two doses of naloxone.
The box also contains instantaneous video instructions (in both English and Spanish) that are activated when ONEbox™ is opened. Using a bystander intervention model, this video talks the responder through the overdose emergency and administration of naloxone. A training mode is also available for use during a non-emergency. Furthermore, the box is purple to promote anti-stigma and we have been encouraging people across the state to find the purple box so that they are prepared for an overdose emergency.
Regardless of the OTC or prescription status of naloxone, more boxes like these are needed in all places where recreational drug use is likely to occur, putting naloxone in proximity for emergencies. Training on how to use this drug is also crucial for all of us since an overdose can happen to anyone, anytime, and anywhere.
Just last week, a police officer in Florida was performing a routine traffic stop, found illicit drugs, and overdosed on fentanyl due to exposure. News reports indicated it took three doses of naloxone to revive the officer. Had this life-saving medication not been in proximity, the officer would have likely died.
Larissa J. Maier: People who use drugs are the key stakeholders that help prevent the majority of overdose deaths. They are experts in drug use and overdose prevention and should always be invited to discuss solutions that affect them. For example, a city may design, build, and open a supervised consumption space with the best intentions but may fail to consider important details that decide whether people who use drugs feel safe and comfortable accessing the space. Also, a single space may not be sufficient for a diverse local community of people who use drugs. Having members from different local groups at the table will help prevent misplanning and facilitate the needs assessment. Importantly, this is a process that should be guided by experts in harm reduction and institutions focusing on public health and social welfare.
Law enforcement will also have a seat at the table to collaborate with local services with expertise in treating overdoses and to ensure that people who access services will not be arrested, charged, or prosecuted for the use, possession, and sharing of drugs. This will ideally protect small-scale drug distribution in service institutions and attempt to reduce violence in street drug markets so long as there is no legal access to currently illegal drugs.
Related to this, big cities with a high prevalence of open-air drug dealing may also discuss establishing safe dealing zones to reduce violence and increase the quality of products sold on illegal markets. People will continue to use psychoactive substances for the foreseeable future. Thus, it is more practical to make drug use safer than to deny it. In addition, access to naturally occurring substances that alter consciousness may reduce the use of and addiction to more harmful synthetic products. Re-establishing a connection with nature through creative community spaces with activities centering around music, culture, and art is promising. Finally, local initiatives to reduce stigma toward people who use drugs will help to prevent drug-related overdose deaths.
Katharina Maier: There are many stakeholders in the prevention of DODs. Public health and harm reduction organizations/services (e.g., Safe Consumption Sites) are key actors, especially community-based organizations which provide services and support to individuals and communities. Overdose prevention further requires government action, and all levels of government must play a role in working to prevent drug overdoses. Key stakeholders also include the medical profession (doctors, clinicians, mental health supports) which is the key to improving linkage to care, as well as social service agencies and community partners. Indeed, it is important that actors across a range of services (including criminal justice personnel) are trained in drug overdose prevention. Critically, people with lived experience must be active participants in any policy and programs in the prevention of DODs. The prevention of DODs demands a multi-stakeholder response. There is no single institution to lead these efforts — stakeholders must engage in dialogue and work together in order to effectively prevent DODs.
What is known as the best practice(s) and policy approach to responding to DODs?
Susan Bissett: Again, I will leave the comments about new approaches to preventing drugs like fentanyl from crossing our borders to persons who are better equipped to respond to drug trafficking and enforcement. Clearly, there are changes that must be made if we are to stop the distribution of fentanyl throughout North America. This likely involves topics politicians do not always want to discuss including increased tariffs and sanctions.
In the meantime, those of us entrenched in urban and rural communities across the country are taking a boots-on-the-ground approach with education, prevention, and harm reduction. These efforts must include a coordinated effort between public and private sectors, government and communities, public health entities, and municipalities. These are the efforts that, in my opinion, should be funded and supported by state opioid response budgets, settlement funds, and abatement efforts. State legislatures need to look at these efforts when developing policy so that our state statutes support increased harm reduction and prevention efforts (like how WV deregulated fentanyl test strips).
This is a changing epidemic. Our children and we are being poisoned. A response focused on education, prevention, and harm reduction is necessary and crucial if we are to combat this crisis at the ground level. While many still argue that this opioid epidemic is due to personal choice or moral failings. Those arguments will not endure any longer. We all have a responsibility to our children, our families, and our communities to stop the poisoning of our country.
Larissa J. Maier: From a policy perspective, the most important and long-overdue step to prevent drug-related overdose deaths is the decriminalization of the use, possession, and sharing of currently illegal psychoactive substances. People are more likely to seek help for themselves and others if they do not risk legal consequences for their actions. Good Samaritan drug overdose laws as introduced by some US states are well-intended but not sufficient. From a harm reduction perspective, supervised drug consumption spaces are the best approach to preventing drug-related overdose deaths. Most people who use illegal drugs do so recreationally with a low or no risk of overdose. For them, every bar, nightclub, and private home is a supervised space to consume legal and illegal drugs. People with potentially harmful drug use patterns including addiction are at the highest risk for overdose but have no access to supervised consumption in most places. This needs to change.
Ideally, establishing new spaces for supervised consumption would follow a participatory approach, involving people who use drugs throughout the planning and implementation process. While such spaces are perfectly suited to build community and refer people who use drugs to other social, harm reduction, and treatment services, the intention to change substance use behavior should never be a criterion to access such spaces. Harm reduction only works if we meet people where they are. The first supervised consumption space opened in Bern, Switzerland in 1986. The implementation process in the US is slow. An unsanctioned site reversed 33 overdoses over five years and two newly established sites in New York reversed 690 overdoses. By now, more than 200 legal supervised consumption spaces operate worldwide with not a single overdose death occurring in such spaces.
Similarly, to address adulterants and the unknown purity of substances purchased from illegal markets, some cities or community projects offer drug-checking services at no cost so people can make more informed decisions on whether and how to use psychoactive substances. Analytical technologies that can reliably identify both the content and purity of drug samples are recommended. If the drug supply is strongly contaminated in a certain area, another strategy to prevent overdose deaths is the safe supply of drugs for people who are addicted and to avoid withdrawal symptoms who would otherwise use drugs that can potentially be lethal. This strategy could also address the co-use of different psychoactive substances if people use multiple substances to cope with the poor quality of their drug of choice in illegal markets.
If none of the above-mentioned solutions can be immediately implemented, start with low-threshold community spaces that welcome people who use drugs and offer information about existing local support services. Street outreach and syringe access services are uniquely positioned to raise awareness about how to treat overdoses in the community. Each harm reduction strategy is just a piece of the puzzle, and they are most successful when implemented as a package.
Katharina Maier: The factors behind DODs inform us much about the best practices and policy approaches needed to prevent DODs. There are many practices that would serve overdose prevention purposes. Three key responses include (1) Safe Supply: A safer drug supply is essential to preventing drug overdoses and helps ensure drug use is treated as a public health, not a criminal justice issue. (2) A Comprehensive Public Health Response: It is critical that people have access to harm reduction services (e.g., Safe Consumption Sites) as well as stigma-free and affordable treatment options. Such services need to be available across communities (both urban and rural) and respond to the specific circumstances and conditions of various places. Peer support is also an important aspect of drug overdose prevention, as is individualized, stigma-free support.
(3) A Welfare Response: In addition to enhanced public health/harm reduction services, providing comprehensive access to care and services is vital. This means ensuring people have access to safe and stable housing, food, employment opportunities, health care including mental health services, and social support systems that provide people with community, belonging, and a sense of security. Critically, these responses are interrelated and belong to a multi-stakeholder approach to the prevention of DODs.
Experts:
Susan Bissett, Ph.D. is president of the West Virginia Drug Intervention Institute. Dr. Bissett grew up in Detroit in the 70s and 80s during a very different epidemic and has been a 25-year resident of West Virginia, the epicenter of the opioid epidemic.
Larissa J. Maier, Ph.D. is a visionary psychologist and international drug policy expert from Switzerland who is passionate about health, equality, and human rights. She is a member of the core research team at the Global Drug Survey (@GlobalDrugSurvy). She is currently traveling in South America to learn more about indigenous culture, plant medicine, and community healing.
Katharina Maier, Ph.D. is an Assistant Professor in Criminal Justice at the University of Winnipeg.
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Orion Policy Institute (OPI) is an independent, non-profit, tax-exempt think tank focusing on a broad range of issues at the local, national, and global levels. OPI does not take institutional policy positions. Accordingly, all views, positions, and conclusions represented herein should be understood to be solely those of the author(s) and do not necessarily reflect the views of OPI.
