The opioid crisis and the border Wall

The states hardest hit by the opioid crisis are a long way from the Mexican border. Trump’s Wall remains a solution in search of a problem.

One of the sillier talking points in the Wall debate is that we need a physical barrier to keep opioids from coming into the country from Mexico.  Various commenters have pointed out that: (1) The fentanyls, which are the fastest-growing segment of opioid use and overdose deaths, mostly come directly from China; and (2) What does come across the U.S./Mexico border comes through overwhelmingly by common carrier at ports of entry; it isn’t backpacked through the desert by immigrants.

A point I haven’t seen made, and didn’t know about until Kevin Drum posted this graph based on data from the CDC’s Morbidity and Mortality Weekly Report, is that the crisis isn’t concentrated anywhere near Mexico. All of the hardest-hit states in terms of opioid mortality rates are east of the Mississippi and north of the Tennessee, about as far as they could be from the Rio Grande. Of the four states that actually border Mexico, New Mexico and Arizona are in the middle of the pack, while California and Texas rank 45th and 47th.

So Trump’s Wall remains a solution in search of a problem.

Hoffman and the Hype about “Killer Heroin”

Phillip-Seymour-HoffmanWithin hours of the death of Philip Seymour Hoffman, rumors spread that this magnificent actor had been taken from us by “killer heroin”. The threat of a batch of impurity-laced, unusually potent heroin is a staple of opioid overdose news coverage and popular debate. But it’s usually hype.

Hoffman’s tragic overdose was absolutely the norm: He died from a combination of drugs, not from impure or unusually strong heroin. The benzodiazepines may have been particularly lethal in that they, like alcohol, seem able to lower acute tolerance for opioids, thereby turning a user’s standard dose into an “overdose”.

Two people who will be totally unsurprised by Hoffman’s toxicological test results are addiction researchers Shane Darke and Michael Farrell:

If there’s one thing we can quite clearly say about heroin deaths, it’s that impurities are rarely, if ever, found or are relevant to the death. Those that are found are typically innocuous substances, such as sucrose.

Data on overdose deaths from legally-manufactured prescription opioids are the other reason to doubt the killer heroin hype that so regularly grips the media. Prescription painkllers are consistently pure and of knowable dose, yet they kill 5 times as many Americans a year as does heroin.

Opioid Addiction is Everywhere

Many middle-class parents were appropriately rattled by Ben Cimons’ powerful account in Washington Post of being a “nice suburban kid” who became addicted to opiods and ultimately almost died of a heroin overdose. The desire of people from “good families” to believe that drug problems are confined to low-income urban communities is understandable, but also false — indeed perniciously so.

Ben and I, along with Wall Street Journal reporter Zusha Elinson and Stanford visiting fellow Markos Kounalakis were on Warren Olney’s To the Point radio program last week to discuss how heroin is making a comeback. Among the key themes of the discussion was that the origins of the recent rise of heroin can be traced directly to the recent and continuing extensive availability of prescription opioids.

p.s. I had a brain freeze when Warren asked me for the common trade names of hydrocodone-containing pain medications; I said Lortab but forgot to mention Vicodin.

What to do about heroin

Heroin overdoses are the tip of the prescription-opiate iceberg.

In the wake of Philip Seymour Hoffman’s overdose death, Bloomberg sought an op-ed from Lowry Heussler and me, and one from Sally Satel. Short version of both pieces: the heroin problem is the tip of the prescription-opiate iceberg, and that’s where to focus. There’s stuff worth doing – SBIRT to catch developing opiate problems early, overcoming the prejudice against substitution therapy, making naloxone spray available – but no solution around the corner.

Footnote Oddly, there was no similar request for anyone’s wisdom in the wake of the 22 overdose deaths among ordinary folks in Pittsburgh.

Quote of the Day

The Nixon tapes reveal the President endorsing methadone maintenance for heroin addicted patients

Moving someone from heroin to methadone — that’s a wonderful move.

–President Nixon, in an oval office conversation with Mayor Daley during which he tried to persuade Daley to expand methadone maintenance for heroin addicted people in Chicago