Government actions to curb the opioid epidemic

To the Editor:

In their Viewpoint, Drs Kolodny and Frieden advanced 10 priorities for addressing the opioid crisis in the United States.¹ Although some of the proposed steps, such as expanding access to opioid agonist treatment and naloxone, rest on solid evidentiary ground, other suggestions risk doing more harm than good. First, Kolodny and Frieden proposed using prescription drug monitoring programs (PDMPs) to identify incident trends in opioid addiction by tracking newly filled prescriptions for a 30-day or longer supply as a marker of addiction. This approach is prone to type I error and renders the substantial (and growing) proportion of opioid-addicted individuals who access opioids outside of prescription channels completely hidden.^2,3 While better surveillance for opioid addiction is imperative, PDMPs are especially poorly suited for this purpose.

Second, the way the authors suggested expanding the scope of PDMPs raises privacy concerns. For example, they argued for the curtailment of 42 CFR Part 2 (Confidentiality of Substance Use Disorder Patient Records), a federal law protecting substance use disorder treatment-related data. Curtailment would facilitate the integration of substance use disorder treatment data into PDMPs, which, as a result of recent federal court decisions, would expose private information to warrantless DEA searches.⁴ Such access could discourage substance users from seeking help and health care, especially the most vulnerable patients. Instead, federal law should be reformed to better protect PDMP data from unfettered law enforcement access at state and federal levels.

Third, the authors claimed that more intensive interdiction would reduce black market opioid consumption by raising prices. To our knowledge, peer-reviewed evidence does not support this claim for opioids; in fact, the authors’ citations focus on dated tobacco control data of limited relevance.¹ In actuality, interdiction and law enforcement pressure can backfire by nudging black market supply chains towards ever-more-potent substances, reducing prices and increasing user risk.³ The recent increase in fentanyl-involved overdoses in the United States is an illustration of this trend.

Kolodny and Frieden’s focus on tracking prescriptions and implementing supply-reduction measures is puzzling, given that the crisis’ current trajectory is primarily fueled by black market drugs, rather than prescription medications. This narrow emphasis crowds out the discussion of more urgent opportunities to mitigate opioid-related harms, including improving care coordination and system integration to address users’ complex physical and mental health needs; expanding evidence-based harm reduction options to include prescription heroin and safe consumption spaces; and focusing on addressing the structural determinants of the opioid crisis.⁵