[OP-ED] Not One But Many: Opioid Crisis Misunderstood

I’d like to nominate the opioid overdose crisis as the most misunderstood public health issue of 2020.

While it has been labeled as a monolithic drug problem, it is really one of polysubstance misuse.

In my role as principal investigator of the Illinois Statewide Unintentional Drug Overdose Reporting System, I review approximately 2,400 drug overdose deaths annually.  Nationally in 2018, there were 67,367 drug overdose deaths; 69.5 percent involved opioids.

While about 90 percent of drug overdose deaths in Illinois involve opioids, they also involve a wide variety of other substances. On average a person who dies from an opioid overdose tests positive for eight other substances.

The mix of substances is wide and includes stimulants such as cocaine and methamphetamines, alcohol, and benzodiazepines.  Used together, these create a deadly cocktail; only one component is opioid-related.  

In a recent review of overdose cases, there was a subset who died of opioid overdose were not knowingly using opioids.  Unknown to the user, the substances they were using (usually a form of cocaine) contained fentanyl, a powerful synthetic opioid many times more powerful than heroin.  

This happens when drugs are mixed with cheap and plentiful substitutes such as fentanyl. This is just one-way polysubstance use contributes to overdose deaths.  Ample evidence indicates that many of substance users mix substances knowingly mixing substances and by doing so increase the likelihood of harm. 

These incident accounts are not unusual. One report stated that a woman and a friend met up at the place where the fatal overdose occurred. They both smoked crack. Soon after smoking crack, the woman began snorting heroin. About 5:30 am the friend went out. Upon returning an hour later the friend found the decedent unresponsive. 

In another case, a man and his friend went out drinking alcohol. He returned home at about 2 am.  Later that day he was found unresponsive in bed and pronounced dead at the scene.  He tested positive for alcohol, caffeine, cotinine, hydrocodone, dicyclomine, buprenorphine, creatine, potassium, and opiates.

Polysubstance use is common among drug users.

It isn’t unusual to misunderstand a public health problem because of the way it is framed. The earliest understanding of AIDS/HIV was that it was considered a “gay man’s disease.” This limited the researcher, medical professional, and the public’s ability to understand who was at risk and how to communicate and prevent its spread.

Later, the frame was readjusted to better represent the risk; HIV is spread by blood products, unprotected sex, or by mother to baby via pregnancy, labor, or nursing.

Similarly understanding the overdose crisis gripping the U.S. today, with about 47,000 opioid-involved deaths annually, as solely opioid-based, frames the problem in a way that does not enable effective response.  

Rather, it is crucial to understand opioid use as intersecting with the use of multiple substances in ways that contribute to overdose deaths, addiction, and misuse.  

The combination of alcohol and opioids is important to address as it is one of the most common substance misuse cocktails that increases the risk of overdose and death.  This is especially alarming in older adults who have increased exposure to opioids due to health issues related to aging, such as arthritis, back pain, and lung disease, and a group for whom alcohol misuse is the most prevalent substance misuse issue.  

In addition, deadly combinations of opioids and benzodiazepines are seen in drug overdoses in all age groups.  

The added harm of multiple substance use can show itself in several ways.  It can impair judgment that may result in overuse.  The interaction of drugs can accelerate and magnify negative physiologic impact including suppression of respiration that leads to overdose.  

To be sure, some may argue that opioids are the common thread across these overdose deaths and that is why this focus is on opioids. 

However, the prevalence of polysubstance use and the negative effect of drug interactions which increases overdose risk cannot be ignored if we are going to save lives.  

To address this, it is critical to redefine messaging about the nation’s overdose crisis. When the conversation broadens beyond opioids, the possibility increases for the understanding of the dynamics of these unintentional and tragic deaths. 

This can open doors to collaboration and insight into how to prevent the entrenched and growing drug overdose problem in the U.S. Simply put, this will save lives.  

Maryann Mason, Ph.D. is Associate Professor of Emergency Medicine at Northwestern University’s Feinberg School of Medicine and Principal Investigator of the Statewide Unintentional Drug Overdose System and a Public Voices fellow through The OpEd Project.

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