The other day, I saw this media clip, CDC: Opioid overdose deaths decline nationwide from PBS. It notes that according to provisional data, we have the lowest rate of national overdose related deaths in three years. It describes a 10.6% decline in overdose deaths from April 2023 to April 2024. The article frames naloxone as a major factor in this reduction and terms it medical treatment. As someone who has directly experienced these deaths in my community, I am relieved to see this news. However, we should be very cautious in celebrating for three reasons:
- An overall national decline in deaths is not representative of what is happening in all our communities. Some regions are not seeing them, and we have staggeringly high rates of overdose death in African American communities.
- Measuring our success with our addiction epidemic solely by considering overdose rates fails to capture the complexity of what we face and presents a multifaceted challenge from a single dimension that is misleading at best.
- History is illustrative of the fact that drug use patterns tend to shift generationally. While we may wish that younger generations see the devastation of addiction and avoid drugs, it seems that they see the devastation and choose different drugs as we move between broad patterns of opioid to stimulant drugs having dominance with the ever-present drug alcohol in the background.
We continue to improperly characterize what is occurring in America as an opioid epidemic, what we are experiencing is much broader than that. It is well past the time to properly account for how else the millions of Americans who die from other drugs or multiple drug use patterns perish, even as we celebrate the overall decline in one of these measures not experienced uniformly across all communities. We fail those we have lost by not accounting for all the causes and placing these losses where they would rank if we did, the number one cause of death in the United States. We need to properly frame what is occurring to formulate comprehensive solutions for what actually is unfolding. We do not do this.
Notable in the NPR piece above, it seems somewhat inappropriate to term naloxone as medical treatment. It is technically that in the same way a portable defibrillator is medical treatment for a person in cardiac arrest but when we think of medical treatment for a cardiac arrest, we would consider the use of a portable defibrillator as first aid and not the completed medical care. We should think in those terms in respect to naloxone, it is first aid. Even if doing so makes it more complicated and we must acknowledge that many people who overdose only get band aid care.
We tend to like simple solutions to complex problems, even as such solutions are partial and thereby flawed at best. Measuring our crisis by the yardstick of how many fewer people die in this one way is incomplete and almost grotesque when one fully considers the scope of our losses. This is something I attempted to do in a piece last year, Caring Enough to Count – How We Die from Drug Misuse and Addiction in America.
As I wrote about in respect to overdoses we fail to account for in Cerebral Hypoxia the Elephant in the Room. Every time a person overdoses, they risk irreversible brain damage as a result of a loss of critically necessary oxygen to the brain. This makes treatment and recovery more difficult. Two decades into the “opioid epidemic” how many people have overdose related hypoxic brain damage? We do not even know. According to a research study Collateral Damage: Neurological Correlates of Non-Fatal Overdose in the Era of Fentanyl-Xylazine, “non-fatal opioid OD is associated with significant post-OD morbidity, including pulmonary edema, pneumonia, seizures, cardiac arrhythmia, cognitive deficits, depression, and increased risk of subsequent fatal overdose. However, available data on the neurological effects of non-fatal OD in humans are limited.” How can we consider celebrating progress when we have failed to even quantify the extent of the damage? How could we have failed to even count this let alone seek to address it?
We also must account for drug use patterns shifting over time for the decrease in overdose mortality. Including how users far too often end up dying. One study found over a 25% mortality rate twenty years beyond initiation of use. Additionally, improved interdiction efforts may impact supply, and most likely the very visible carnage influences newer drug users to use other types of drugs instead of the ones they can see devastating the last generation of users.
We are seeing a lot of alcohol and other drug related deaths. As described in A Look at the Latest Alcohol Death Data and Change Over the Last Decade, “alcohol deaths increased steadily over the past decade with sharp rises during the pandemic years. Overall, the national alcohol death rate has risen 70% in the past decade, accounting for 51,191 deaths in 2022, up from 27,762 deaths in 2012.” As noted by the CDC, “the age-adjusted rate of drug overdose deaths involving psychostimulants with abuse potential, which includes drugs such as methamphetamine, amphetamine, and methylphenidate, increased from 0.2 in 2001 to 0.5 in 2005, remained stable through 2008, then increased from 0.4 in 2008 to 10.0 in 2021, with different rates of change over time. The rate in 2021 was 33% higher than the rate in 2020.” As noted, these long-term patterns tend to shift between opioids and stimulants. This is particularly relevant because despite these shifting trends, we tend to get caught flatfooted when these new drug use patterns change in ways that we should anticipate. They are relatively consistent over the long term. I don’t like the drug war analogy, but to the degree it fits, we continually prepare for the last war rather than anticipating these sadly predictable shifts and fail to prepare for emerging trends. We would be best served by examining our own history and recognizing that drug use patterns and their corresponding challenges change over time. To take the time to understand what has worked historically, where our service gaps are and how to shore them up in anticipation of unfolding needs.
We should celebrate the overall decrease in overdose deaths. Yet we should do so while acknowledging that we are seeing increases in other substance use related mortality. We should seek more comprehensive treatment and recovery support options. Strategies that include the right duration and intensity of care and support for everyone having a problem. When we fail to address underlying alcohol or other addictions for all persons with an OUD or other substance dependence, death is the far too often ignored reality. We die in car crashes, falls, liver failure, suicides, and a myriad of other ways. Substance use even causes bystander deaths. We can’t ignore it in hopes it goes away, another persistent strategy over the long term. We tend to ignore it until it is the elephant on the coffee table size problem and then act surprised to things that should not be a shock to us.
The first step in acknowledging a problem is to fully acknowledge it exists in all its dimensions, not just one. It is time we do. These losses matter. Let’s at least account for all these deaths in a visible way on a national dashboard, dignify what is happening and focus on comprehensive solutions beyond the one-dimensional measure of overdose deaths. All these lives matter a whole lot, not just those at risk for overdose. It is great that overdose related deaths are decreasing but celebrating that without acknowledging the rest of the elephant serves no one among us.
Sources
CDC. (2022, December 21). Drug Overdose Deaths in the United States, 2001–2021. Www.cdc.gov. https://www.cdc.gov/nchs/products/databriefs/db457.htm
CDC: Opioid overdose deaths decline nationwide. (2024, September 18). PBS.org. https://www.pbs.org/video/opioid-overdose-deaths-decline-nationwide-1726693694/
Ndugga, N., Hill, L., & Published, S. A. (2024, May 21). Key Data on Health and Health Care by Race and Ethnicity. KFF. https://www.kff.org/key-data-on-health-and-health-care-by-race-and-ethnicity/?entry=executive-summary-introduction
Saunders, H., & Published, R. R. (2024, May 23). A Look at the Latest Alcohol Death Data and Change Over the Last Decade. KFF. https://www.kff.org/mental-health/issue-brief/a-look-at-the-latest-alcohol-death-data-and-change-over-the-last-decade/
Stauffer W. (2023, September 23). Recoveryreview.blog; WordPress.com. Caring Enough to Count – How We Die from Drug Misuse and Addiction in America. https://recoveryreview.blog/2023/09/23/caring-enough-to-count-how-we-die-from-drug-misuse-and-addiction-in-america/
Stauffer, W. (2023, October 28). Cerebral Hypoxia & the “Opioid Epidemic” – An Elephant in the Room. Recoveryreview.blog; WordPress.com. https://recoveryreview.blog/2023/10/28/cerebral-hypoxia-the-opioid-epidemic-an-elephant-in-the-room/
Termorshuizen, F. (2005). Long-term Outcome of Chronic Drug Use: The Amsterdam Cohort Study among Drug Users. American Journal of Epidemiology, 161(3), 271–279. https://doi.org/10.1093/aje/kwi035
Todaro, D. R., Volkow, N. D., Langleben, D. D., Shi, Z., & Wiers, C. E. (2024). Collateral Damage: Neurological Correlates of Non-Fatal Overdose in the Era of Fentanyl-Xylazine. Neuroscience Insights, 19. https://doi.org/10.1177/26331055241247156
Warraich, H. (2022, August 15). Opioid addiction and overdoses are increasingly harming Black communities. Harvard Health. https://www.health.harvard.edu/blog/opioid-addiction-and-overdoses-are-increasingly-harming-black-communities-202208152800
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