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A Dose Of Reality: Underscoring The Fatal Consequences Of The Opioid Epidemic

05.29.24 | 18 min read | Text by Michelle Rippy

The opioid epidemic is a public health and safety emergency that is killing thousands and destroying the quality of life for hundreds of thousands of Americans and those who care about them. Fentanyl and other opioids affect all age ranges, ethnicities, and communities, including our most vulnerable population, children. Producing fentanyl is increasingly cheap, costing pennies for a fatal dose, with the opioid intentionally or unintentionally mixed with common illicit street drugs and pressed into counterfeit pills. Fentanyl is odorless and tasteless, making it nearly untraceable when mixed with other drugs. Extremely small doses of fentanyl, roughly equivalent to a few grains of salt, can be fatal, while carfentanil, a large animal tranquilizer, is 100 times more potent than fentanyl and fatal at an even smaller amount.

The Biden-Harris Administration should do even more to fund opioid-related prevention, treatment, eradication, and interdiction efforts to save lives in the United States. The 2022 Executive Order to Address the Opioid Epidemic and Support Recovery awarded $1.5 billion to states and territories to expand treatment access, enhance services in rural communities, and fund law enforcement efforts. In his 2023 State of the Union address, President Biden highlighted reducing opioid overdoses as part of his bipartisan Unity Agenda, pledging to disrupt trafficking and sales of fentanyl and focus on prevention and harm reduction. Despite extensive funding, opioid-related overdoses have not significantly decreased, showing that a different strategy is needed to save lives. 

Opioid-related deaths have been estimated cost the U.S. nearly $4 trillion over the past seven years—not including the human aspect of the deaths. The cost of fatal overdoses was determined to be $550 billion in 2017. The cost of the opioid epidemic in 2020 alone was an estimated $1.5 trillion, up 37% from 2017. About two-thirds of the cost was due to the value of lives lost and opioid use disorder, with $35 billion spent on healthcare and opioid-related treatments and about $15 billion spent on criminal justice involvement. In 2017, per capita costs of opioid use disorder and opioid toxicity-related deaths were as high as $7247, with the cost per case of opioid use disorder over $221,000. With inflation in November 2023 at $1.26 compared to $1 in 2017, not including increases in healthcare costs and the significant increase in drug toxicity-related deaths, the total rate of $693 billion is likely significantly understated for fatal overdoses in 2023. Even with extensive funding, opioid-related deaths continue to rise.

With fatal opioid-related deaths being underreported, the Centers for Disease Control and Prevention (CDC) must take a primary role in real-time surveillance of opioid-related fatal and non-fatal overdoses by funding expanded toxicology testing, training first responder and medicolegal professionals, and ensuring compliance with data submission. The Department of Justice (DOJ) should support enforcement efforts to reduce drug toxicity-related morbidity and mortality, with the Department of Homeland Security (DHS) and the Department of the Treasury (TREAS) assisting with enforcement and sanctions, to prevent future overdoses. Key recommendations for reducing opioid-related morbidity and mortality include:

• Funding research to determine the efficacy of current efforts in opioid misuse reduction and prevention.
• Modernizing data systems and surveillance to provide real-time information.
• Increasing overdose awareness, prevention education, and availability of naloxone.
• Improve training of first responders and medicolegal death investigators.
• Funding rapid and thorough toxicology testing in emergency departments and coroner/medical examiner agencies.
• Enhancing prevention and enforcement efforts.

Challenge and Opportunity

Opioids are a class of drugs, including pain relievers that can be illegally prescribed and the illicit drug heroin. There are three defined waves of the opioid crisis, starting in the early 1990s as physicians increasingly prescribed opioids for pain control. The uptick in prescriptions stemmed from pharmaceutical companies promising physicians that these medications had low addiction rates and medical professionals adding pain levels being added to objective vital signs for treatment. From 1999 to 2010, prescription opioid sales quadrupled—and opioid-related deaths doubled. During this time frame when the relationship between drug abuse and misuse was linked to opioids, a significant push was made to limit physicians from prescribing opioids. This contributed to the second wave of the epidemic, when heroin abuse increased as former opioid patients sought relief. Heroin-related deaths increased 286% from 2002 to 2013, with about 80% of heroin users acknowledging that they misused prescription opioids before using heroin.  The third wave of the opioid crisis came in 2013 with an increase in illegally manufactured fentanyl, a synthetic opioid used to treat severe pain that is up to 100 times stronger than morphine, and carfentanil, which is 100 times more potent than fentanyl. 

In 2022, nearly 110,000 people in the United States died from drug toxicity, with about 75% of the deaths involving opioids. In 2021, six times as many people died from drug overdoses as in 1999, with a 16% increase from 2020 to 2021 alone. While heroin-related deaths decreased by over 30% from 2020 to 2021, opioid-related deaths increased by 15%, with synthetic opioid-involved deaths like fentanyl increasing by over 22%. Over 700,000 people have died of opioid-related drug toxicity since 1999, and since 2021 45 people have died every day from a prescription opioid overdose. Opioid-related deaths have increased tenfold since 1999, with no signs of slowing down. The District of Columbia declared a public emergency in November 2023 to draw more attention to the opioid crisis.

In 2023, we are at the precipice of the fourth wave of the crisis, as synthetic opioids like fentanyl are combined with a stimulant, commonly methamphetamine. Speedballs have been common for decades, using stimulants to counterbalance the fatigue that occurs with opiates. The fatal combination of fentanyl and a stimulant was responsible for just 0.6% of overdose deaths in 2010 but 32.3% of opioid deaths in 2021, an over fifty-fold increase in 12 years. Fentanyl, originally used in end-of-life and cancer care, is commonly manufactured in Mexico with precursor chemicals from China. Fentanyl is also commonly added to pressed pills made to look like legitimate prescription medications. In the first nine months of 2023, the Drug Enforcement Agency (DEA) seized over 62 million counterfeit pills and nearly five tons of powdered fentanyl, which equates to over 287 million fatal doses. These staggering seizure numbers do not include local law enforcement efforts, with the New York City Police Department recovering 13 kilos of fentanyl in the Bronx, enough powder to kill 6.5 million people. 

The ease of creating and trafficking fentanyl and similar opioids has led to an epidemic in the United States. Currently, fentanyl can be made for pennies and sold for as little as 40 cents in Washington State. The ease of availability has led to deaths in our most vulnerable population—children. Between June and September 2023, there were three fatal overdoses of children five years and younger in Portland, OR. In a high-profile case in New York City, investigators found a kilogram of fentanyl powder in a day care facility after a 1-year-old died and three others became critically ill. 

The Biden Administration has responding to the crisis in part by placing sanctions against and indicting executives in Chinese companies for manufacturing and distributing precursor chemicals, which are commonly sold to Mexican drug cartels to create fentanyl. The drug is then trafficked into the United States for sale and use. There are also concerns about fentanyl being used as a weapon of mass destruction, similar to the anthrax concerns in the early 2000s.

The daily concerns of opioid overdoses have plagued public health and law enforcement professionals for years. In Seattle, WA, alone, there are 15 non-fatal overdoses daily, straining the emergency medical systems. There were nearly 5,000 non-fatal overdoses in the first seven months of 2023 in King County, WA, an increase of 70% compared to 2022. In a landmark decision, in March 2023 the Food and Drug Administration (FDA) approved naloxone, a drug to reverse the effects of opioid overdoses, as an over-the-counter nasal spray in an attempt to reduce overdose deaths. Naloxone nasal spray was initially approved for prescription use only in 2015 , significantly limiting access to first responders and available to high-risk patients when prescribed opioids. In New York, physicians have been required to prescribe naloxone to patients at risk of overdose since 2022. Although naloxone is now available without a prescription, access is still limited by price, with one dose costing as much as $65, and some people requiring more than one dose to reverse the overdose. Citing budget concerns, Governor Newsom vetoed California’s proposed AB 1060, which would have limited the cost of naloxone to $10 per dose. Fentanyl testing strips that can be used to test substances for the presence of fentanyl before use show promise in preventing unwanted fentanyl-adulterated overdoses. The Expanding Nationwide Access to Test Strips Act, which was introduced to the Senate in July 2023, would decriminalize the testing strips as an inexpensive way to reduce overdose while following evidence-based harm-reduction theories.

Illicit drugs are also one of the top threats to national security. Law enforcement agencies are dealing with a triple epidemic of gun violence, the opioid crisis, and critical staffing levels. Crime prevention is tied directly to increased police staffing, with lower staffing limiting crime control tactics, such as using interagency task forces, to focus on a specific crime problem. Police are at the forefront of the opioid crisis, expected to provide an emergency response to potential overdoses and ensure public safety while disrupting and investigating drug-related crimes. Phoenix Police Department seized over 500,000 fentanyl pills in June 2023 as part of Operation Summer Shield, showing law enforcement’s central role in fighting the opioid crisis. DHS created a comprehensive interdiction plan to reduce the national and international supply of opioids, working with the private sector to decrease drugs brought into the United States and increasing task forces to focus on drug traffickers. 

Prosecutors are starting to charge drug dealers and parents of children exposed to fentanyl in their residences in fatal overdose cases. In an unprecedented action, Attorney General Merrick Garland recently charged Mexican cartel members with trafficking fentanyl and indicting Chinese companies and their executives for creating and selling precursor chemicals. In November 2023, sanctions were placed against the Sinaloa cartel and four firms from Mexico suspected of drug trafficking to the United States, removing their ability to legally access the American banking system. Despite this work, criminal justice-related efforts alone are not reducing overdoses and deaths, showing a need for a multifaceted approach to save lives. 

While these numbers of opioid overdoses are appalling, they are likely underreported. Accurate reporting of fatal overdoses varies dramatically across the country, with the lack of training of medicolegal death investigators to recognize potential drug toxicity-related deaths, coupled with the shortage of forensic pathologists and the high costs of toxicology testing, leading to inaccurate cause of death information. The data ecosystem is changing, with agencies and their valuable data remaining disjointed and unable to communicate across systems. A new model could be found in the CDC’s Data Modernization Initiative, which tracked millions of COVID-19 cases across all states and districts, including data from emergency departments and medicolegal offices. This robust initiative to modernize data transfer and accessibility could be transformative for public health. The electronic case reporting system and strong surveillance systems that are now in place can be used for other public health outbreaks, although they have not been institutionalized for the opioid epidemic.

Toxicology testing can take upwards of 8–10 weeks to receive, then weeks more for interpretation and final reporting of the cause of death. The CDC’s State Unintentional Drug Overdose Reporting System receives data from 47 states from death certificates and coroner/medical examiner reports. Even with the CDC’s extensive efforts, the data-sharing is voluntary, and submission is rarely timely enough for tracking real-time outbreaks of overdoses and newly emerging drugs. The increase of novel psychoactive substances, including the addition of the animal tranquilizer xylazineto other drugs, is commonly not included in toxicology panels, leaving early fatal drug interactions undetected and slowing notification of emerging drugs regionally. The data from medicolegal reports is extremely valuable for interdisciplinary overdose fatality review teams at the regional level that bring together healthcare, social services, criminal justice, and medicolegal personnel to review deaths and determine potential intervention points. Overdose fatality review teams can use the data to inform prevention efforts, as has been successful with infant sleeping position recommendations formed through infant mortality review teams.

Plan of Action

Reducing opioid misuse and saving lives requires a multi-stage, multi-agency approach. This includes expanding real-time opioid surveillance efforts; funding for overdose awareness, prevention, and education; and improved training of first responders and medicolegal personnel on recognizing, responding to, and reporting overdoses. Nationwide, improved toxicology testing and reporting is essential for accurate reporting of overdose-involved drugs and determining the efficacy of efforts to combat the opioid epidemic.

Recommendation 1. Fund research to determine the efficacy of current efforts in opioid misuse reduction and prevention.

DOJ should provide grant funding for researchers to outline all known current efforts of opioid misuse reduction and prevention by law enforcement, public health, community programs, and other agencies. The efforts, including the use of suboxone and methadone, should be evaluated to determine if they follow evidence-based practices, how the programs are funded, and their known effect on the community. The findings should be shared widely and without paywalls with practitioners, researchers, and government agencies to hone their future work to known successful efforts and to be used as a foundation for future evidence-based, innovative program implementation.

Recommendation 2. Modernize data systems and surveillance to provide real-time information.

City, county, regional, and state first responder agencies work across different platforms, as do social service agencies, hospitals, private physicians, clinics, and medicolegal offices. A single fatal drug toxicity-related death has associated reports from a law enforcement officer, fire department personnel, emergency medical services, an emergency department, and a medicolegal agency. Additional reports and information are sought from hospitals and clinics, prior treating clinicians, and social service agencies. Even if all of these reports can be obtained, data received and reviewed is not real-time and not accessible across all of the systems. 

Medicolegal agencies are arguably the most underprepared for data and surveillance modernization. Only 43% of medicolegal agencies had a computerized case management system in 2018, which was an increase from 31% in 2004. Outside of county or state property, only 75% of medicolegal personnel had internet access from personal devices. The lack of computerized case management systems and limited access to the internet can greatly hinder case reporting and providing timely information to public health and other reporting agencies.

With the availability and use of naloxone by private persons, the Public Naloxone Administration Dashboard from the National EMS Information System (NEMSIS) should be supported and expanded to include community member administration of naloxone. The emergency medical services data can be aligned with the anonymous upload of when, where, and basic demographics for the recipient of naloxone, which can also be made accessible to emergency departments and medicolegal death investigation agencies. While the database likely will not be used for all naloxone administrations, it can provide hot spot information and notify social services of potential areas for intervention and assistance. The database should be tied to the first responder/hospital/medicolegal database to assist in robust surveillance of the opioid epidemic.

Recommendation 3. Increase overdose awareness, prevention education, and availability of naloxone.

Awareness of the likelihood of poisoning and potential death from the use of fentanyl or counterfeit pills is key in prevention. The DEA declared August 21 National Fentanyl Prevention and Awareness Day to increase knowledge of the dangers of fentanyl, with the Senate adopting a resolution to formally recognize the day in 2023. Many states have opioid and fentanyl prevention tactics on their public health websites, and the CDC has educational campaigns designed to reach young adults, though the education needs to be specifically sought out. Funding should be made available to community organizations and city/county governments to create public awareness campaigns about fentanyl and opioid usage, including billboards, television and streaming ads, and highly visible spaces like buses and grocery carts. 

ED allows evidence-based prevention programs in school settings to assist in reducing risk factors associated with drug use and misuse. The San Diego Board of Supervisors approved a proposal to add education focused on fentanyl awareness after 12 juveniles died of fentanyl toxicity in 2021. The district attorney supported the education and sought funding to sponsor drug and alcohol training on school campuses. Schools in Arlington, VA, note the rise in overdoses but recognize that preventative education, when present, is insufficient. ED should create prevention programs at grade-appropriate levels that can be adapted for use in classrooms nationwide.

With the legalization of over-the-counter naloxone, funding is needed to provide subsidized or free access to this life-saving medication. Powerful fentanyl analogs require higher doses of naloxone to reverse the toxicity, commonly requiring multiple naloxone administrations, which may not be available to an intervening community member. The State of Washington’s Department of Public Health offers free naloxone kits by mail and at certain pharmacies and community organizations, while Santa Clara University in California has a vending machine that distributes naloxone for free. While naloxone reverses the effects of opioids for a short period, once it wears off, there is a risk of a secondary overdose from the initial ingestion of the opioid, which is why seeking medical attention after an overdose is paramount to survival. Increasing access to naloxone in highly accessible locations—and via mail for more rural locations—can save lives. Naloxone access and basic training on signs of an opioid overdose may increase recognition of opioid misuse and empower the community to provide immediate, lifesaving action. 

However, there are concerns that naloxone may end up in a shortage. With its over-the-counter access, naloxone may still be unavailable for those who need it most due to cost (approximately $20 per dose) or access to pharmacies. There is a national push for increasing naloxone distribution, though there are concerns of precursor shortages that will limit or halt production of naloxone. Governmental support of naloxone manufacturing and distribution can assist with meeting demand and ensuring sustainability in the supply chain.

Recommendation 4. Improve training of first responders and medicolegal death investigators.

Most first responders receive training on recognizing signs and symptoms of a potential overdose, and emergency medical and firefighting personnel generally receive additional training for providing medical treatment for those who are under the influence. To avoid exposure to fentanyl, potentially causing a deadly situation for the first responder, additional training is needed about what to do during exposure and how to safely provide naloxone or other medical care. DEA’s safety guide for fentanyl specifically outlines a history of inconsistent and misinformation about fentanyl exposure and treatment. Creating an evidence-based training program that can be distributed virtually and allow first responders to earn continuing education credit can decrease exposure incidents and increase care and responsiveness for those who have overdosed.

While the focus is rightfully placed on first responders as the frontline of the opioid epidemic, medicolegal death investigators also serve a vital function at the intersection of public health and criminal justice. As the professionals who respond to scenes to investigate the circumstances (including cause and manner) surrounding death, medicolegal death investigators must be able to recognize signs of drug toxicity. Training is needed to provide foundational knowledge on deciphering evidence of potential overdose-related deaths, photographing scenes and evidence to share with forensic pathologists, and memorializing the findings to provide an accurate manner of death. Causes of death, as determined by forensic pathologists, need appropriate postmortem examinations and toxicology testing for accuracy, incorporated with standardized wording for death certificates to reflect the drugs contributing to the death. Statistics on drug-related deaths collected by the CDC and public health departments nationwide rely on accurate death certificates to determine trends.

The CDC created the Collaborating Office for Medical Examiners and Coroners (COMEC) in 2022 to provide public health support for medicolegal death investigation professionals. COMEC coordinates health surveillance efforts in the medicolegal community and champions quality investigations and accurate certification of death. The CDC offers free virtual, asynchronous training for investigating and certifying drug toxicity deaths, though the program is not well known or advertised, and there is no ability to ask questions of professionals to aid in understanding the content. Funding is needed to provide no-cost, live instruction, preferably in person, to medicolegal offices, as well as continuing education hours and thorough training on investigating potential drug toxicity-related deaths and accurately certifying death certificates.

Cumulatively, the roughly 2,000 medicolegal death investigation agencies nationwide investigated more than 600,000 deaths in 2018, running on an average budget of $470,000 per agency. Of these agencies, less than 45% had a computerized case management system, which can significantly delay data sharing with public health and allied agencies and reduce reporting accuracy, and only 75% had access to the internet outside of their personally owned devices. Funding is needed to modernize and extend the infrastructure for medicolegal agencies to allow basic functions such as computerized case management systems and internet access, similar to grant funding from the National Network of Public Health Institutes.

Recommendation 5. Fund rapid and thorough toxicology testing in emergency departments and coroner/medical examiner agencies.

Rapid, accurate toxicology testing in an emergency department setting can be the difference between life and death treatment for a patient. Urine toxicology testing is fast, economical, and can be done at the bedside, though it cannot quantify the amount of drug and is not inclusive for emerging drugs. Funding for enhanced accurate toxicology testing in hospitals with emergency departments, including for novel psychoactive substances and opioid analogs, is necessary to provide critical information to attending physicians in a timely manner to allow reversal agents or other vital medical care to be performed.

With the limited resources medicolegal death investigation agencies have nationally and the average cost of $3000 per autopsy performed, administrators need to triage which deaths receive toxicology testing and how in-depth the testing will be. Advanced panels, including ever-changing novel psychoactive substances, are costly and can result in inaccurate cause of death reporting if not performed routinely. Funding should be provided to medicolegal death investigating agencies to subsidize toxicology testing costs to provide the most accurate drugs involved in the death. Accurate cause of death reporting will allow for timely public health surveillance to determine trends and surges of specific drugs. Precise cause of death information and detailed death investigations can significantly contribute to regional multidisciplinary overdose fatality review task forces that can identify potential intervention points to strengthen services and create evidence to build future life-saving action plans.

Recommendation 6. Enhance prevention and enforcement efforts.

DOJ should fund municipal and state law enforcement grants to use evidence-based practices to prevent and enforce drug-related crimes. Grant applications should include a review of the National Institute of Justice’s CrimeSolutions.gov practices in determining potential effectiveness or using foundational knowledge to build innovative, region-specific efforts. The funding should be through competitive grants, requiring an analysis of local trends and efforts and a detailed evaluation and research dissemination plan. Competitive grant funding should also be available for community groups and programs focusing on prevention and access to naloxone.

An often overlooked area of prevention is for justice-involved individuals who enter jail or prison with substance use disorders. Approximately 65% of prisoners in the United States have a substance abuse order, and an additional 20% of prisoners were under the influence of drugs or alcohol when they committed their crime. About 15% of the incarcerated population was formally diagnosed with an opioid use disorder. Medications are available to assist with opioid use disorder treatments that can reduce relapses and post-incarceration toxicity-related deaths, though less than 15% of correctional systems offer medication-assisted opioid use treatments. Extensive case management coupled with trained professionals to prescribe medication-assisted treatment can help reduce opioid-related relapses and overdoses when justice-involved individuals are released to their communities, with the potential to reduce recidivism if treatment is maintained.

DEA should lead local and state law enforcement training on recognizing drug trends, creating regional taskforces for data-sharing and enforcement focus, and organizing drug takeback days. Removing unused prescription medications from homes can reduce overdoses and remove access to unauthorized users, including children and adolescents. Funding to increase collection sites, assist in the expensive process of properly destroying drugs, and advertising takeback days and locations can reduce the amount of available prescription medications that can result in an overdose. 

DHS, TREAS, and DOS should expand their current efforts in international trafficking investigations, create additional sanctions against businesses and individuals illegally selling precursor chemicals, and collaborate with countries to universally reduce drug production.

Budget Proposal

A budget of $800 million is proposed to evaluate the current efficacy of drug prevention and enforcement efforts, fund prevention and enforcement efforts, improve training for first responders and medicolegal death investigators, increase rapid and accurate toxicology testing in emergency and medicolegal settings, and enhance collaboration between law enforcement agencies. The foundational research on the efficacy of current enforcement, preventative efforts, and surveillance should receive $25 million, with findings transparently available and shared with practitioners, lawmakers, and community members to hone current practices.

DOJ should receive $375 million to fund grants; collaborative enforcement efforts between local, state, and federal agencies; preventative strategies and programs; training for first responders; and safe drug disposal programs.

CDC should receive $250 million to fund the training of medicolegal death investigators to recognize and appropriately document potential drug toxicity-related deaths, modernize data and reporting systems to assist with accurate surveillance, and provide improved toxicology testing options to emergency departments and medicolegal offices to assist with appropriate diagnoses. Funding should also be used to enhance current data collection efforts with the Overdose to Action program³⁴ by encouraging timely submissions, simplifying the submission process, and helping create or support overdose fatality review teams to determine potential intervention points.

ED should receive $75 million to develop curricula for K-12 and colleges to raise awareness of the dangers of opioids and prevent usage. The curriculum should be made publicly available for access by parents, community groups, and other organizations to increase its usage and reach as many people as possible.

BOP should receive $25 million to provide opioid use disorder medication-assisted treatments by trained clinicians and extensive case management to assist in reducing post-incarceration relapse and drug toxicity-related deaths. The policies, procedures, and steps to create medication-assisted programming should be shared with state corrections departments and county jails to build into their programming to expand use in carceral settings and assist in reducing drug toxicity-related deaths at all incarceration levels.

DOS, DHS, and TREAS should jointly receive $50 million to strengthen their current international investigations and collaborations to stop drug trafficking, the manufacture and sales of precursors, and combating organized crime’s association with the illegal drug markets.

Conclusion

Opioid-related overdoses and deaths continue to needlessly and negatively affect society, with parents burying children, sometimes infants, in an unnatural order. With the low cost of fentanyl production and the high return on investment, fentanyl is commonly added to illicit drugs and counterfeit, real-looking prescription pills. Opioid addiction and fatal overdoses affect all genders, races, ethnicities, and socioeconomic statuses, with no end to this deadly path in sight. Combining public health surveillance with enforcement actions, preventative education, and innovative programming is the most promising framework for saving lives nationally.