A "Wobble" is not a Win:

Last week, The New York Times reported that the CDC found a ~3% decline in national overdose deaths between 2022 to 2023. A follow-up article asked, “Has fentanyl peaked?"

It hasn’t—and we’ve made this mistaken assumption before, with irrevocable consequences.

We warn against any interpretation that ‘the worst is over’ for our nation’s opioid crisis or that it will just “burn out” on its own as the article concludes. In fact, we must urgently deploy more resources, not fewer, if we wish to change its trajectory.

Here’s what we know:

US overdose deaths, regardless of substance, have been on a steady, exponential climb for the last fifty years. This phenomenon was first described in 2018 by Donald Burke and Hawre Jalal in Science and updated in 2022.¹ The NYT article points to a slight regression in a horrifying, persistent trendline that’s persisted since 1978, and posits the epidemic is “burning out.”

Sadly, what’s being celebrated as a downtrend is likely just what Burke and Jalal term a “wobble:” a temporary deviation from this exponential curve.^1,2

We’ve seen this inclination before: reporters, policy makers, and government officials are tempted to interpret each blip downwards as a signal of long-term success from policy interventions. But as history has shown, it’s dangerous to declare premature victory—especially for an unprecedented substance like fentanyl that is lethal, synthetic, compact, and cheap.

In 2017, STAT asked public health experts from 10 institutions to predict the trendline of future opioid fatalities.³ 7 out of 10 incorrectly forecasted a decline by 2023; the exponential prediction by epidemiologists Burke and Jalal was the most accurate and described the sharp rise in mortalities and $1.5 Trillion in opioid-related societal costs in 2020 alone.

We were gravely ill-prepared then, and the National Public Health Emergency declared in 2017 and still in effect is even worse today. Now is not the time to give up or rely on this epidemic going away by itself—what the phrase “burning out” implies.

Chronically unprepared, under-estimated, and under-resourced.

For years, HHS survey data defined the problem as 2 to 2.5 million Americans with opioid use disorder (OUD).⁴ The same national survey in 2023 reported 7 million people with OUD—corroborating ample evidence that we systematically undercount people with SUD by 4-6 times.⁵ The CDC now estimates 16 million people have OUD, eight times more than what was represented in 2017.⁶

In short, we myopically underestimated the massive scale of this problem in 2017 and how much worse it would get — and we are paying the price. While we still lack understanding of the true incidence of OUD, epidemiological data indicate we are vastly under-resourced to address even the lowest estimates.

To ignore the iceberg we’ve hit will only mean more suffering and loss. We’ve recorded more than 100,000 overdose deaths annually for three years in a row. In addition, adolescents and young adults face increasing risks and are dying at younger ages each year — not what one would expect in an epidemic that is “burning out.”⁷

We must listen to the experts, including those with lived and living experience, who have had a pulse on the problem all along that informs their pragmatic ideas for fixing it.

What must we do?

1. Expand access to evidence-based treatment. This means not only removing policy barriers to make methadone and buprenorphine readily accessible, but also funding care that works: urging insurance companies to cover the true costs of quality treatment with methadone and buprenorphine, including peer support and social services. To achieve a 40% reduction in overdose deaths requires increasing buprenorphine prescribing by 2 to 5 times, depending on location.^8,9 Incremental policy changes in recent years have not led to meaningfully increased prescribing.^10-20
2. Support harm reduction and prevention. The illicit drug supply is increasingly lethal. Affordable, accessible Naloxone to reverse overdose, drug testing (fentanyl test strips), safe syringe programs, and safe consumption sites can help curb deaths.²¹ The danger of fentanyl use and addiction is globally unprecedented, and interventions must weigh the relative risk of fatal harm.
3. Incentivize outcomes and support providers: Let funding flow to programs that are working, and support the scarce workforce of addiction practitioners who are willing and able to treat this marginalized population with increased reimbursement and reduced administrative burden. Ensure opioid settlement funds are allocated to high-quality addiction treatment programs. There is a dearth of specialists, and 2 in 5 addiction medicine fellowship spots are unfilled. We must develop the next generation of addiction medicine physicians while expanding the workforce with Advanced Practice Practitioners. Peer Recovery Specialists and other highly valuable providers.^22-26‍
4. Educate, don’t fear-monger. The public — especially youth — need fact-based education about drugs to make pragmatic choices and stay safe. “Just say no” misleads and erodes trust. Efforts to control supply (e.g., border control and policing) must not distract from the distinct and persistent public health challenge of scaling and sustaining respectful, low-threshold treatment to the millions of Americans harmed by their opioid use. The NYT article says the waves of the opioid crisis—, prescribed opioids, heroin, and fentanyl—have “felt like one” epidemic. They are indeed interrelated, such that the supply of licit prescribed opioids has only directly fueled potent versions to crop up: we cannot ignore the underlying problem of an unsafe illicit supply that is only becoming more dangerous.²⁷

When fighting a war that’s worse than we can comprehend with fewer tools than we need, declaring victory is the wrong call.

If our approach is to anticipate the epidemic will "burn out” this means many, many more loved ones will die from overdose (or experience the infections, trauma, wounds, anoxic brain injury, and other harms of use). It means we are complacent about adding to the hundreds of thousands of American children left without a parent. And that we will continue losing an unfathomable number of lives to a preventable problem.

This is the default solution implied by articles claiming the epidemic will passively dissipate of its own accord.

Finally, in response to the article’s contention, made in passing, that the “drug users most likely to die have already done so,” we feel moved to apologize on their behalf.

This is callous, inaccurate, and a slap in the face to millions of us who are grieving inconceivable loss, who are worried about whether a loved one will safely return home, or who are wondering how to explain the DEA’s “one pill can kill” campaign to our child as they venture out on their own in the world. You are not forgotten, you drive our work, and we won’t stop until lasting change is realized.

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Sources

1. Burke DS, Jalal H. The Historical Arc of US Overdose Deaths. Presented at: {HMS: Global Health and Social Medicine}; June 2, 2023. Accessed April 24, 2024. https://www.youtube.com/watch?v=KofRY34ixbM&ab_channel=HMS%3AGlobalHealthandSocialMedicine
2. Cited in the presentation above; via Ray Kurzweil in his "comments on the 'exponential growth' of computational power. Computer World, Nov 13, 2007" as it relates to Moore's Law
3. Blau M. STAT forecast: Opioids could kill nearly 500,000 Americans in the next decade. STAT. Published June 27, 2017. Accessed May 21, 2024. https://www.statnews.com/2017/06/27/opioid-deaths-forecast/
4. National Survey on Drug Use and Health (NSDUH) 2017
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