The opioids crisis is affecting communities across the nation. The disease of opioid use disorder does not discriminate. As the Assistant Secretary for Mental Health and Substance Use, I believe strongly that we must do all we can to stem the tide of this crisis; however, I believe we must take measured, well-thought-out and responsible steps to do this.
The temptation to develop seemingly quick solutions is understandable but I urge the nation to proceed instead with caution.
One of the steps that have been entertained by some states and communities is the use of fentanyl test strips. Fentanyl is a synthetic opioid analgesic that is similar to morphine but is 50 to 100 times more potent. According to the U.S. Centers for Disease Control and Prevention, deaths due to synthetic opioids (other than methadone) and primarily driven by illicit fentanyl doubled between 2015 and 2016. Similarly, provisional data from 2017 appear to show that 29,000 of the 49,000 opioid-related deaths involved fentanyl.
These statistics are indeed alarming and the desire to quickly halt these increases in deaths seems reasonable; however, is encouraging people who use drugs to test them first for “safety” the answer? Can’t the nation do better?
As a physician who has spent most of my career treating opioid use disorder, I find a fundamental problem in the justification for using such strips. The purpose of the test strip is for an individual who is about to use a drug to first test the drug to detect fentanyl’s presence. If fentanyl is detected, the idea is, either the individual will not use or will change the way he or she uses (e.g., will use the more potent drug at a slower rate to try to avoid overdose). On the surface, given the trends in deaths, this seems like a valid step to take.
However there’s one significant problem.
The entire approach is based on the premise that a drug user poised to use a drug is making rational choices, is weighing pros and cons, and is thinking completely logically about his or her drug use. Based on my clinical experience, I know this could not be further from the truth.
People who are addicted to opioids are not making a rational choice to continue their drug use. Addicted individuals whose bodies demand that they find their next opioid to stave off withdrawal symptoms are not in positions to weigh all options and to choose to not use the only opioid at their disposal.
Although I know that there are self-reported data that may suggest otherwise, at the moment before they’re about to use— again, based on my clinical experience—it is hard to imagine that drug users will not use the substance despite its apparent danger.
Consider for a moment that an injection drug user already knows that their actions are not safe but will inject anyway: There is a chemical and not necessarily logical need for them to use. It is not inconceivable to think that people who are severely addicted will actually use the test strips to seek fentanyl, which might be able to give them the high that their current opioid no longer gives them—and which will place them at risk for overdose and death.
Even if we accept the premise that an individual is making a rational choice, we must consider these types of unintended consequences. Similarly, we cannot guarantee that the strips will always have 100 percent accuracy. We can’t afford to create a false sense of security.
Again, I understand the need to do all we can to combat this crisis. But, is it our goal simply to stop people from dying so they can continue a life of “safe” heroin use? Or should our goal be different?
I believe we owe it to Americans struggling with these problems to change the goal for them, their families, their communities, and our nation: Our goal should not solely be to end deaths; it should also be to facilitate the opportunity to recover to safe, healthy and productive lives.
We cannot lose sight of the fact that our goal always must be to get people the help they need. There is known, life-saving, evidence-based, medication-assisted treatment available to individuals who have these conditions. Let’s not write off their access to that; let’s not determine in advance that they won’t seek help, and let’s not rationalize putting tools in place to help them continue their lifestyle more “safely.”
About “safely”—I would also argue that this is a false rationale. Heroin and illicit drug use are not safe but rather are associated with risks for other deadly medical illnesses, mental illness, suicidality, victimization and criminal activity that cut short a person’s life and—without treatment and recovery services—have a great risk of ultimately leading to death.
Let’s work together to build upon the successes seen in our most recent National Survey on Drug Use and Health. In 2017, first-time heroin use was less than half of what it was in 2016, and more Americans are getting the treatment they need.
These data are just the beginning; I believe that we will address this epidemic. Under the leadership of President Donald J. Trump and Congress, SAMHSA has released more than $2 billion in funding to address the opioid crisis across our nation—and more resources are coming. We want those funds to be used to enhance prevention strategies; to ensure that people gain access to medication-assisted treatment and psychosocial therapies, and to provide needed community recovery supports. SAMHSA has made available local teams of experts in each state to provide the training and technical assistance needed to ensure that individuals across our country get the help they need. We need to continue efforts that will increase access to saving lives rather than just stopping deaths and creating the false sense of accomplishment this causes.