Last week, while in Atlanta covering a conference on drug policy reform hosted by the New York–based Drug Policy Alliance, there was one phrase I kept hearing over and over: “compassion fatigue.”
It’s a rational response to the overdose crisis, which grows darker and more unmanageable with each passing year; from 2015 to 2016, drug overdose deaths increased by more than 20 percent, according to preliminary data from the Centers for Disease Control and Prevention. People are tired of seeing rising death rates coming out of suffering communities. As a journalist who once struggled with his own heroin addiction, I count myself among the weary. Though I walked away from the conference feeling a renewed sense of camaraderie, I also left with a deeper understanding of an uncomfortable truth: The epidemic is changing too fast for any of our current policy solutions to stick.
In 2016, the majority of overdose deaths were not from prescription painkillers or even heroin. For the first time since the overdose crisis started, fentanyl — a potent synthetic opioid typically sold on the street as heroin — accounted for “nearly all the increases in drug overdose deaths from 2015 to 2016,” according to an article recently published in the Journal of the American Medical Association. Over the last three years, fentanyl-related deaths have spiked a jaw-dropping 540 percent. Still, the federal response from the CDC is by and large focused on reducing the supply of painkillers prescribed by doctors.
The good news is that prescription overdose deaths are finally plateauing. But “for every life we save from a prescription overdose,” Joel Bomgar, vice-chairman of Medicaid in the Mississippi House of Representatives, said during a town-hall-style meeting at the conference, “four more are dying from switching to heroin and fentanyl.” Bomgar’s analysis, based on CDC mortality data, hits a classic supply vs. demand dilemma. If you picture drug supply as a long balloon, tightly squeezing one end winds up inflating the other end. The air — or the demand for drugs — has to go somewhere.
During the town hall, where epidemiologists from the CDC had gathered to answer questions from public-health experts, many attendees focused on that very issue. “The CDC has been very resistant to recognize that reducing the supply of prescription opioids has contributed to people transitioning to heroin and fentanyl,” Leo Beletsky, a professor of law and health sciences at Northeastern University, told the CDC panelists. “It’s a puzzling stance to a lot of people observing the crisis and I encourage the CDC to reexamine that stance.”
But “if decreases in opioid prescribing were driving illicit drug use, we would expect to see heroin overdose increasing most where opioid prescribing was most reduced,” a CDC spokesperson told me in an email. “Instead, we see heroin overdoses increasing everywhere — in areas where opioid prescribing is decreasing and in areas where opioid prescribing is increasing.”
One thing everyone at the conference agreed on: Increasing access to addiction treatment is one of the most valuable strategies we have. As policy makers otherwise stay mired in wonky debate, though, efforts on the ground are trying to pick up the slack.
“The biggest failure in the publi- health aspects of the fentanyl crisis is that we’re treating it as a drug epidemic and not a poisoning epidemic,” said Dan Ciccarone, a physician at the University of California, San Francisco. Ciccarone is also leading a study called Heroin in Transition that looks at, among other things, changes in America’s heroin supply. “Imagine if this was a poisoning outbreak in infant formula and the only thing we did was test the dead bodies of the infants and tell the public: 13 dead bodies last week in San Francisco.”
One thing communities need, Ciccarone told me, is an advance-warning system that tells emergency responders and others in the community what’s in the local heroin supply. One study found that people were ten times more likely to reduce their dose, and 25 percent less likely to overdose, after discovering their powder tested positive for fentanyl. “Drug users are far more rational than we make them out to be,” Ciccarone said.
And across the country, other community-based solutions are in the works. From Seattle to Denver to New York, legislation for safe consumption sites — places where people administer their own drugs under medical supervision — are gaining political steam. The goal of these sites is simple: to keep people alive. “There are dozens of underground supervised injection facilities,” Ciccarone said. “We need to bring them above ground and give them funding.” And quickly, he believes, before the epidemic changes yet again, and a solution is even further from reach.