During last night's Democratic presidential debate, billionaire hedge fund manager Tom Steyer claimed "72,000 people died of opioid overdoses last year" in the United States. That's not remotely true, and the fact that Steyer's blatant misrepresentation went unchallenged says a lot about the shaky empirical basis for political responses to the "opioid epidemic."
Although Steyer said "last year," final numbers for drug-related deaths in 2018 have not been released yet. According to a provisional count published by the U.S. Centers for Disease Control and Prevention (CDC), there were about 68,000 deaths involving illegal drug use in 2018. That's all drug-related deaths, not just "opioid overdoses."
In 2017, according to the CDC's numbers, there were 70,237 drug-related deaths. In about two-third of those cases (47,600), the decedents tested positive for opioids. And although the context of Steyer's statement was a discussion of legally produced pain medication, the records collected by the CDC indicate that three-quarters of opioid-related deaths in 2017 involved illicit drugs such as heroin and fentanyl. Just 30 percent of opioid-related deaths involved prescription analgesics such as hydrocodone and oxycodone, and about two-fifths of those cases also involved heroin or "synthetic opioids other than methadone," the category that includes black-market fentanyl and fentanyl analogs.
Adding more substances to the analysis shows that most records listing a prescription pain reliever also list other drugs: For example, 68 percent of deaths involving prescription opioids in 2017 also involved heroin, fentanyl, cocaine, barbiturates, benzodiazepines, or alcohol. In other words, less than 10 percent of opioid-related deaths involved pain medication by itself, and the actual percentage may be considerably lower, since coroners and medical examiners do not always test for fentanyl and do not always note additional drugs. In New York City, which has one of the country's most thorough systems for reporting drug-related deaths, 97 percent of them involve mixtures.
Although the vast majority of opioid-related deaths involve illegal drugs, last night's discussion focused on pain pills. Sen. Amy Klobuchar (D–Minn.) said companies that manufacture prescription analgesics should pick up the tab for treating opioid use disorder. Steyer said the problem is "drug companies buying the government and getting what they want." Entrepreneur Andrew Yang described opioid-related deaths as "a disease of capitalism run amok." Sen. Kamala Harris (D–Calif.) said she would send drug-company executives to prison because "they are nothing more than some high-level dope dealers." Former HUD Secretary Julian Castro agreed that pain pill manufacturers should face "criminal penalties."
Neither Harris nor Castro explained the legal basis for jailing pharmaceutical executives. Harris alluded to "false advertising," which is a central claim in the myriad lawsuits that cities and states have filed against opioid manufacturers. But that claim is part of efforts to recover civil damages for the harm that the companies allegedly caused by exaggerating the benefits and minimizing the risks of their products. To put people in prison, the government has to identify criminal statutes that they violated. Insofar as these companies produced and sold pain medication in compliance with federal laws and regulations, they committed no crimes, even if you agree than an oversupply of opioids fostered addiction through diversion to nonmedical use.
By contrast, every person who uses prescription analgesics prescribed for others or in a manner not authorized by their own doctors is clearly committing a crime. To their credit, Yang and former Rep. Beto O'Rourke (D–Texas) both said such people should not be treated as criminals. They favor decriminalizing possession of opioids, including heroin and fentanyl, for personal use. But they arrive at that conclusion only by denying the moral agency of people who use opioids for nonmedical purposes.
"We have to let the country know this is not a personal failing," Yang said. "This was a systemic government failing. And then we need to open up safe consumption and safe injection sites around the country, because they save lives."
While Yang's support for decriminalization and harm reduction is welcome, his insistence on portraying illegal drug users as helpless victims of pharmacological slavery promotes dangerous myths about addiction and pain treatment. Unlike pharmaceutical companies and black-market dealers, he suggests, drug users should not be held accountable for their actions, because they cannot help themselves: Opioids are so powerfully addictive that people who take them, even for legitimate medical purposes, are thereafter chemically compelled to continue taking them. O'Rourke reinforced that argument by citing a veteran who said he "bought heroin off the street because he was originally prescribed an opioid at the V.A."
Contrary to the impression left by that anecdote, opioid-related deaths typically do not involve patients who accidentally got hooked after they took medication prescribed for pain. Addiction rates among bona fide pain patients are low because the vast majority of people exposed to prescription analgesics do not find their psychoactive effects so appealing that they want to continue using them after their pain has subsided, let alone venture into the black market for substitutes once their prescriptions run out. But these drugs can be powerfully appealing to people in difficult social, economic, and personal circumstances, who generally have histories of substance abuse and take opioids that were not prescribed for them, usually in combination with other drugs.
That observation does not mean these people do not deserve sympathy or help, and it certainly does not mean they should face criminal penalties for conduct that violates no one's rights. But we can look for ways to reduce opioid-related deaths without implying that all opioid prescriptions are inherently suspect, an attitude that causes great harm to patients who need them to relieve acute or chronic pain.