Does the Drop in Opioid-Related Deaths Mean the Crackdown on Pain Pills Is Finally Working?

Since prescription restrictions pushed drug users toward deadlier substitutes, the decrease in fatalities is more plausibly attributed to harm reduction measures.


Opioid-related deaths in the United States, which had been rising steadily since 1999, fell slightly in 2018, from 47,600 to 46,802, according to the latest data from the U.S. Centers for Disease Control and Prevention. That 1.7 percent drop was mostly due to a decline in deaths involving pain pills, which decreased by 13 percent, from 14,495 to 12,552.

Does that mean the government's crackdown on prescription analgesics is finally having the desired effect? Probably not. The decline in opioid-related deaths is more plausibly attributed to harm reduction measures such as wider access to the overdose antidote naloxone and treatment programs involving methadone and buprenorphine. Ham-handed efforts to reduce the supply of pain pills, by contrast, have deprived bona fide patients of the medication they need while driving nonmedical users toward black-market substitutes, which are far more dangerous because their potency is highly variable and unpredictable.

That hazard has only been magnified by the increasing prevalence of illicit fentanyl, a cheaper and much more potent substitute for heroin. While heroin-related deaths fell by 3 percent in 2018, from 15,482 to 14,996, deaths involving "synthetic opioids other than methadone," the category that includes fentanyl and its analogs (some of which are even more potent), rose by 10 percent, from 28,466 to 31,335. That category of drugs was involved in 67 percent of opioid-related deaths in 2018, up from 60 percent in 2017.

The share of all drug-related deaths that involved opioids rose from 48 percent in 1999 to 69 percent in 2018. But while the share of opioid-related deaths involving prescription analgesics (excluding methadone) rose from 34 percent in 1999 to 52 percent in 2010, it has been declining since then. In 2018, pain pills were involved in 27 percent of opioid-related deaths, many of which also involved heroin or fentanyl.

Heroin's role in opioid-related deaths increased from 14 percent of cases in 2010 to 39 percent in 2015 but had fallen to 32 percent by 2018. Fentanyl's share, meanwhile, increased more than five-fold between 2013 and 2018. You can start to see why the upward trend in opioid-related deaths not only continued but accelerated after the total volume of opioid prescriptions began to decline in 2011, which coincided with the rising prominence of heroin and fentanyl.

The increase in opioid-related deaths during the last two decades is part of a broader long-term trend. The total number of drug-related deaths fell by 4 percent between 2017 and 2018, from 70,237 to 67,367, a change that helped reverse recent declines in life expectancy. But the 2018 total was still 11 times the number in 1980. The death rate was 20.7 per 100,000 people in 2018, compared to just 2.7 in 1980. And even as opioid-related deaths fell by about 2 percent in 2018, deaths involving cocaine and "psychostimulants" such as methamphetamine rose by 5 percent and 23 percent, respectively.

The upward trend in drug-related deaths goes back further than the 1980s. A 2019 report on "deaths of despair" from the Joint Economic Committee (JEC) notes that drug-related deaths were falling by the early 1900s, before Congress banned nonmedical use of opiates and cocaine in 1914. But "drug-related deaths have been rising at an accelerating rate since the late 1950s," notwithstanding the government's increasingly expansive and aggressive efforts to suppress the illegal drug trade.

"The increase has been especially sharp over the past 20 years," the JEC notes. And while "the proliferation of opioid deaths was initially a result of oversupply and abuse of legal prescription narcotics," the report says, "the crisis…shifted toward illegal drugs—first heroin and then more lethal synthetic opioids like fentanyl"—after "policy changes restricted the supply and form of prescribed opioids."

Humans have always been attracted to psychoactive substances, and that is unlikely to change anytime soon. While governments cannot stop people from using drugs, they can always make drug use more dangerous. Maybe it is time to consider a different approach.

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  1. Another possible explanation-- improving economic conditions.

    1. Or the widespread distribution of Narcan. At PA's annual Farm Show this month (which gets huge attendance), the state was handing them out for free. Plus we passed a law that allows anyone to buy it without a prescription. Cops and first responders all have it.

      1. Naloxone has certainly helped, but not as much as you might think. It's a lot like a code blue in the hospital/ER. Most of the ones you save are prone to needing it again, sooner rather than later, and if that keeps up eventually it doesn't solve the problem, either because help arrives too late, or the problem is simply to severe to overcome.

        People are also more aware of the dangers of fake/copycat drugs, but mostly it's been greater awareness of the fact that even the 'real medicine' can and will kill you. You might be amazed to learn just how many people have the attitude that 'if it's government approved/commercial product it must be safe' applies to their own methods of using it. I really suspect that we've reached an inflection point where enough people have been personally touched by someone dying that it's just a matter of enough people exercising enough added caution to make a difference. More people today know that casually popping a methadone or MS Contin or two is simply dangerous, as compared to ten or fifteen years ago.

        This has been something of a historical pattern. Each time the changes are precipitated by a growing awareness of the human costs of whatever it is we are doing to ourselves, leading to some sort of backlash or intervention. One of the last great episode marking the end of patent medicines and the start of accurate product labeling (whereby people could not deny that they were indeed consuming opium/opiates.).

        Inevitably we then go through a period where people think that those external actions and restrictions have somehow rendered the fundamental nature of the substances safer and less harmful. This then leads to a return to less cautious behaviors or even flat out indifference to the risk, and deaths start to rise again.

        Lather, rinse, repeat.

  2. >>While governments cannot stop people from using drugs, they can always make drug use more dangerous.

    thanks Mom.

    >>"drug-related deaths have been rising at an accelerating rate since the late 1950s,"

    haven't births also?

    1. Government doesn't make the drugs inherently more dangerous. Government creates an illusion of safety.

      1. Government makes the drugs more dangerous by limiting the need for the sellers to provide high quality products since there is no legal recourse from the customers.

  3. Did the drop in Jewish insults of Nazis by 1945 mean the gas chambers were finally working?

    Did the die-off in starving kulaks mean the farm communization was finally working?

    Did the reduction in thought crimes mean Mao's re-education camps were finally working?

    1. Given the purposes of those regimes, the answer is YES.

  4. ObamaCare expanding Medicaid was a big factor in the increasing abuse of opioids, since the overwhelming majority of drug addicts get their drugs either through a prescription or through someone with a prescription--and the people who are most likely to become addicts are those with the lowest income. That increase in the Medicaid pool has likely played itself out. Expand Medicaid again, and the rate of opioid abuse will no doubt start rising again.

    Meanwhile, the greatest incentive to stop abusing probably has to do with more job opportunities and higher pay for people in the lower tax brackets. It may be that opioid addicts are deciding not to abuse so that they can take advantage of the job opportunities, but it's more likely that the demographic who would have become opioid addicts in the past are deciding to abstain because they have job opportunities and pay raises like no one in their income bracket has experienced for 50 years.

    If that's the relationship, strong economy for unskilled workers, that shouldn't be surprising. You see the same kind of relationship in the developing world between the birth rate and 1) a declining infant mortality rate and 2) education and increased employment opportunities for women. Cross culturally and throughout history, as women are given more opportunities to contribute to family income by working outside the home, the fewer children they have. This holds true across deeply Catholic countries, where and when birth control is taboo, and even heavily paternalistic countries like in the Middle East. The positive effects of being able to contribute to family prosperity outweighs the other factors.

    Why would opioid abstinence behave differently?

    Like having more children, taking opioids is a relatively more attractive option when you have nothing better to do.

      1. LOL

        I doubt it. Maybe a small amount of deaths are prevented, but that's never going to help the overall number of users, or probably even people that OD. They will just notice they OD earlier and possibly save them from dying that time.

    1. I hadn't thought of this angle. It certainly sounds like it has merit. Giving more people free drugs would logically correlate with more drug abuse.
      I only partially buy into the argument about noxalone. It seems unlikely to me that addicts would be responsible enough to keep a OD counter handy. Sure, the argument can be made that loved ones nearby are taking that responsibility, but I think such addictions partially arise from a lack of such care and support.
      My take remains the same. Reduce exposure to an addictive substance and you will reduce addiction to that substance. Why don't I smoke? Because I never exposed myself to nicotine enough to acquire the addiction. Of course pain management practices and poverty play a role. However, if there is more of the substance available with high potency then there will also be a higher possibility of use, abuse, and complications

  5. Yes, they all died. The government saved them from addiction by murdering them.

  6. It can’t go on forever, you run out of addicts sooner or later as they die off.

    1. A huge proportion of the people dying are not what you call "addicts," they are irregular users. Habitual users are less likely to OD.

      Feynman is proven right incessantly. We do not live in a scientific age.

      1. +1 cargo cult
        +1 what do you care what other people think

  7. I'd imagine it's a combo of the economy being better, so fewer people turning to becoming totally useless drug addicts, and perhaps a lot of the most unstable ones literally just dying off.

    In theory if the rate of new extreme addict creation is lower than the number dying, the rate of death will decline. There's less reason to become a druggie for the moment vs when a lot of these people probably got hooked during the Great Recession, so it may just be winding down with a lot of the addict boom dying off finally?

  8. Death rates. Seems that is what is simple and easy to report.

    Mortality and morbidity are not the same thing.

    1. Please enlighten us with further information.

      1. Morbidity refers to the consequences other than death.

        And that is a valid concern. Even if less people are dying that doesn't tell the whole story - if you still have a bunch of people suffering due to drug misuse/abuse how much have you accomplished?

        Consider that almost nobody dies from direct tobacco consumption. It is consequences like COPD, heart disease, and cancer that create years, or even decades of suffering and diminished health even before they kill.

        1. I understand morbidity, but no statistics are presented to indicate its prevalence is declining or increasing.

          1. Correct because statistics do not report that. Media articles underreport morbidity and focus on deaths. So reading these articles it needs to be taken into account.

            Vaping lung disease which is a real thing is one example. Many of those patients who survive will have serious long term lung damage and disability. Same happens with war or other trauma. We overlook the long term consequences and report deaths.

            So it is difficult to really assess because we do not have the whole picture. Opioid addiction is an example because many people can be affected in a given case.

            Most of us here agree that the law enforcement approach is a total failure. Decriminalize and focus on an evidence based approach.

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  11. I have been watching the 'War On Drugs, in various incarnations, since I first got interested in Politics in the mid' 1970's. In that time the general rule has been that if there is a falling off in the use of one drug, there will soon be a rise reported in the use of something else. Cocaine gives way to Ecstasy to Heroin, and so on and on. There was period of about a decade in the 1990's to early 2000's when I checked the DEA's numbers every year, and they were generally very similar; about 16 million 'regular' users of illegal drugs (regular being defined as once a month or more), of which 10-11 million were basically pot smokers. At the time that left 5-6 million users of 'hard drugs' out of a 270-280 million population, or around 2%.

    2% isn't an epidemic. 2% is a hiccup.

    1. No, 2% is significant. Remember that for every one of the 2% there are many others who are affected: single mothers, abandoned or orphaned children, grandparents saddled with childcare, unhealthy living conditions, poverty, squalor, etc. Making drugs legal would allow the addicts to ask for assistance without the fear of legal problems, not to mention drastically reducing the number of overdose deaths, and other side effects.

  12. What a dumb and misleading headline to put on a good article. Doesn’t Reason know that most people ONLY read the headlines? You have just confirmed for a bunch of people that the war on doctors and pain patients is working and that the OD epidemic is due to legitimately prescribed, pharmaceutical pain pills...when statistics show 80 percent or more are due to FAKE illegal market pills containing Fentanyl and analogues and/or mixing of heroin, pain pills ( legit or fake) with additional central nervous system depressants such as alcohol, benzodiazepines, certain psych meds etc...I expect misleading headline from Breitbart, Fox and other trash media NOT from Reason

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