2021: Yet another record rear for overdose deaths

Meth and cocaine doses driving increased death

Harm Reduction Ohio estimates that Ohio’s overdose death count will reach 5,100 to 5,250 in 2021, a record and about a 3% increase over last year’s death toll.

Overdose death in Ohio is being driven today primarily by stimulant use, both cocaine and meth. Meth will be involved in more than 1,300 overdose deaths in 2021, up from fewer than 100 in 2015. Cocaine-related deaths will exceed 1,300 as well, up from 685 in 2015. About 80% of stimulant overdose deaths involve fentanyl.

The dramatic shift toward fentanyl-related stimulant deaths has fundamentally altered the demographics and geographic epicenter of overdose death in Ohio.

This article will explain Ohio’s overdose epidemic in detail and in a way you may not have heard before.  The overdose epidemic is a human-made tragedy of accidental deaths that is now more than a decade old and has had four distinct periods of which stimulant-related overdose deaths are the latest.

For this analysis, Harm Reduction Ohio used overdose deaths recorded through November 17 in the Ohio Department of Health mortality database, as well as Ohio-specific historical data on drug adulteration and prescription opioids. About two-thirds of overdose deaths for 2021 have been recorded in the state’s mortality database, making reliable, albeit imperfect, full-year projections possible.

The results are not pretty.

Ohio’s Overdose Epidemic: Bad to Worse

Ohio’s overdose epidemic shows no sign of slowing. Instead, death is expanding into new populations and new patterns of drug use.

In short overdose deaths are on track to increase about 3% in 2021 versus 2020, which itself was a record year for overdose deaths in Ohio.

Source: Harm Reduction Ohio analysis of Ohio Department of Health mortality data

In 2020, 5,017 Ohio residents died of accidental drug overdoses. The record level of overdose death was driven by record levels of fentanyl adulteration in Ohio’s drug supply, the result of pandemic-driven decreases in heroin and cocaine arriving Mexico, only to be replaced by more compact and potent fentanyl and fentanyl analogs.

If  overdose deaths continue at the pace reported through November 17, Ohio’s overdose death count would total 5,189 this year. To account for historical variation in weekly and monthly overdose deaths, Harm Reduction Ohio projects the full-year death toll of Ohio residents dying of accidental overdose deaths will range from 5,100 to 5,250 in 2021. By comparison, about 1,300 will die in vehicular accidents in Ohio this year.

The same overdose death toll is shown here as a rate per 100,000 Ohio residents. You can see that overdose death has increased nearly 400% since 2007, when the Ohio Department of Health’s data series begins.

This chart helps readers understand the level of overdose death that occurred during the peak of the prescription opioid era in the late 2000s.

What caused the overdose epidemic?

In retrospect, prescription opioid overdoses were a small problem compared to what followed when the state limited them. Overdose deaths increased by several hundred per year during the 15-year period of relaxed opioid prescribing that ran from roughly 1995 (when Oxycontin was introduced) to 2011 (when Ohio started imposing severe restrictions on access to prescription opioids).

Ohio started imposing strict limits on legal opioids in 2011. As those restrictions were implemented and expanded, overdose deaths in Ohio soared by many thousands. The correlation between expanded opioid prescribing and increased overdose death is clear but small compared to what followed. However, the relationship between restrictions of opioid prescriptions and increased overdose death  is clear and large.

The hard question that must be asked is also clear: Did a policy intended to reduce overdose death actually do the opposite?  In other words, did the government’s crack down on prescription opioids cause a decrease in overdose deaths or increase in overdose deaths?

This chart shows the relationship between the Ohio residents receiving prescription opioids and the number of Ohio residents dying from drug overdoses. The green line shows the decline in Ohio residents using legal opioids annually from 2010 through 2020. The red line shows overdose deaths of Ohio residents during that same time, from 2010 through 2020.

The results look the same even when you use slightly different variables, such as the amount of opioids prescribed (rather than patients receiving opioids) or opioid-related overdose deaths (rather than all overdose deaths).

Ask yourself honestly and objectively: What does the evidence show?

It is indisputable that overdose deaths did not decline as predicted in response to Ohio’s increasingly severe restrictions on prescription opioids. To the contrary, overdose deaths soared. The tighter the restrictions got and the less available legal opioids became, the more Ohioans died of accidental drug overdoses.

Why might restricting opioid prescriptions lead to a horrific increase in overdose death?

Hypothesis: When Ohioans were consuming prescription opioids, they knew the purity, potency and dosage. When Ohio pushed people into illegal markets, people began using opioids of unknown purity, potency and dosage.

Even if the total number of (frequent or infrequent) opioid consumers declined, as some evidence shows happened, the danger and deadliness of consuming opioids would have skyrocketed by eliminating consumer knowledge of purity, potency and dosage. Opioids, including fentanyl, are relatively safe drugs when taken as intended and in known amounts. However, opioids, especially fentanyl, can cause fatal respiratory depression (stopped breathing) when ingested in unexpected amounts.

Ohio’s prescription opioid regulations drove people who use drugs into increasingly dangerous illegal drug markets in which even the drug being consumed was uncertain (heroin or fentanyl or carfentanil?), as was purity, potency and dosage. In short order, the danger of consuming opioids increased by many multiples. The state of Ohio may have reduced the total number of people using opioids, but it increased the total number of people dying from opioid overdoses to a previously unimagined and catastrophic level.

Ohio did the opposite of what good public health policy does. It took hundreds of thousands of Ohioans away from legal drugs that carry some risk and pushed them into a illegal markets that carry enormous risk.

To be blunt: Ohio’s overdose epidemic was caused by our government’s gross miscalculation of the risk of a well-intended regulation. The policy was implemented with no consideration of how markets operate and interact in the real world, i.e.,  how consumers and sellers adjust to changes in rules and regulations, how supply and demand and price and quantity and incentives and disincentives work in the marketplace. 

At its core, our overdose epidemic is an economic phenomenon with public health consequences, not the other way around. We made a regulatory mistake that has killed tens of thousands by increasing the use of adulterated drugs. 

The state may have wanted to prevent overdose deaths, but it did the opposite because it failed to net the regulations’ potential positive effects (reduce Rx drug overdoses) against potential negative effects (increased non-Rx drug overdoes). The state didn’t just get the analysis wrong; it failed to do the analysis at all. I have found no record that those implementing this policy considered the potential negative effect, i.e., what might go slightly wrong, much less catastrophically wrong. Even today, with thousands of additional deaths that coincided with the policy change, you hear no public discussion from Ohio’s political and medical establishment about how a well-intended policy may have horrific unintended consequences..

The success of public health policies is not measured by what was hoped for or predicted. Health policies are judged by what actually happened. In Ohio, overdose deaths increased by thousands following the implementation of a policy meant to reduce overdose deaths by several hundred. Whether intended or not, as the policy was implemented and escalated, more people died from opioid overdoses.

Did the prescription opioid crackdown cause the overdose epidemic as we know it today? Correlation is not causation — except sometimes it is.

Overdose Epidemic: Starting with Rx drugs

Former Ohio Gov. John Kasich

The current overdose epidemic can be dated to the increase in opioid prescribing that followed FDA approval of the long-lasting opioid OxyContin in 1995. Prescriptions of OxyContin and other opioids increased nationwide and an increase in overdose deaths followed. The government and the news media identified this as a serious problem.

Ohio did not have a more serious problem than the rest of the country. As this chart from an Ohio University report shows, Ohio had average overdose deaths for the first decade and a half after the introduction of OxyContin.

Ohio’s sharp rise in overdose deaths coincided with then-Gov. John Kasich decision to launch one of the nation’s most aggressive efforts to limit opioid prescribing. With then-Attorney General Mike DeWine, Kasich implemented increasingly sharp restrictions on prescription opioids starting in 2011. (See Kasich’s crackdown timeline here.) To pain patients worried about losing access to their medicine, Kasich said : “Don’t worry. You’ll get what you need and you’ll get it in a more positive, more successful way.”

The moralistic belief that people, even when in pain, would stop using opioids or use them only as government thought best proved false. Instead, the regulatory attack on prescription opioids pushed Ohioans into more dangerous illegal opioid markets, where heroin was the predominant option.

The heroin era, the second period of Ohio’s overdose epidemic, drove overdose death to new heights and lasted from about 2012 through 2016.

The fentanyl on heroin era

Fentanyl is an easy-to-make synthetic opioid that was patented in 1959. As demand for illegal opioids increased in response to the crackdown on legal opioids, fentanyl entered the drug supply as an inexpensive supplement to heroin, fake Oxycodone pills and other opioids.

Fentanyl started arriving in significant volumes in 2014, mostly in the mail from China. The fentanyl-opioid era was the primary driver of overdose death from 2014 through 2018. Carfentanil, a powerful fentanyl analog, drove deaths to the peak in this period in second half of 2016 and the first half of 2017.

While fentanyl consumed by opioid users (primarily as a heroin substitute) continues today, the spread of fentanyl and its analogs into all drugs (except marijuana) began in earnest in 2016.

The fentanyl in stimulants era

Fentanyl spread first into cocaine, causing overdose deaths to increase, especially among Black Ohioans.

Cocaine-related overdose deaths (shown in the chart below) closely track the share of Ohio’s cocaine supply containing fentanyl or an analog (chart above).

Fentanyl spread later later into methamphetamine.

An increase in meth-related overdose deaths — 80% of which also involve fentanyl or a fentanyl analog — following the spread of fentanyl into Ohio’s meth supply.

Some of the fentanyl-meth overdose deaths are related to people consuming both fentanyl and meth at about the same time, sometimes using meth to relieve opioid withdrawal symptoms or to use opioids to cushion the end of a long period of meth use. No research exists to know what share of meth-fentanyl fatalities involve adulterated drugs and what share is from people who use combining the drugs intentionally.

What is clear is that Ohio’s overdose epidemic is in a fourth stage, an era of stimulant-related overdose death. Although the change started in earnest in 2016, the role of stimulants in driving became dominant in 2018 and continues today.

Bad regulation of drug markets

The most important thing to understand about Ohio’s overdose epidemic — as well as the national overdose problem — is that, at its core, it is an economic phenomenon. It has public health, legal and other consequences, but the cause of our overdose death catastrophe is bad regulation of the large consumer market for drugs.

Prohibition causes drug adulteration, which causes death. Prohibition of nearly all consumer drugs causes widespread death. The primary drugs used today are the same drugs that have been the primary drugs of choice for thousands of years — fermented grains (alcohol) and products from the cannabis plant, the coca bush and the opium poppy and coca plant. .

The belief that outlawing widely used consumer products will prevent their use is folly. But it does distort the marketplace. Safety, dosage, purity and other forms of knowledge are denied to consumers (and sellers). Bulky traditional drugs get replaced with compact, potent substances that are easier-to-hide from law enforcements. The deadly effects are all natural, inevitable, unavoidable market responses to banning drugs.

Our overdose epidemic is not a “side effect” of a drug war poorly executed and insufficiently extreme. The more the drug war expands, the more people die. We’ve seen that for a century when drug prohibition started as a well-meaning progressive effort to ban patent medicines and especially since 1970 when the “war on drugs” became a thing and we began our way to imprisoning a half million people, mostly people of color, in the name of drug safety, and most especially in the last decade when opioid regulation went awry in a particularly dangerous market. Mistakes in regulating marijuana costs people their freedom and ability to live happy, healthy lives. Mistakes in regulating opioids has caused mass death.

Imagine if food was regulated to permit only five “healthy” foods to be legally bought, sold and consumed. An enormous black market would develop to supply consumers other foods that people desired for reasons of taste, health, religion, texture and experience. Worry whether a food was truly organic would be the least of your worries. Your illegal Pop Tart could contain anything, from dangerous bacteria to peanuts.

The drug war is the cause of our overdose death epidemic. We cannot significantly reduce overdose death without allow more legal access to more consumer goods. Legalizing marijuana may be the most important practical step that can be taken to reduce overdose death. It is an extraordinarily safe drug and, by far, the most popular drug other than alcohol or caffeine. People have different drug preferences, just as they do for food, sex, reading, sports, movies, podcasts and everything else.

More choices would allow safer options when drugs are used recreationally or medicinally or in a combination of those two needs.

Regardless of what we hoped the drug war has accomplished, we must be honest about what has happened: tens of millions of people have been labeled as felons, 500,000 are behind bars as you read this and today 100,000+ people are dying annually from accidental drug overdoses.

Is this what people predicted would happen? It is not. Did former Gov. Kasich want his policy to unnecessarily kill thousands of Ohioans. He did not. But it is what did happen. And it is what is happening today when one dozen Ohio residents will die from accidental drug overdoses, followed by another dozen who will die tomorrow.

Ohio will lose 5,000 wonderful human beings this year not because of drug addiction or drug use or evil people in China or Mexico. Ohio residents use drugs at levels a little below the national average. But we die at some of the highest rates in the county. Ohio’s overdose death rate matched its drug use levels before we became a national leaders in restriction access to legal opioids…only to become a national leader in overdose deaths…and fentanyl and fentanyl analogs…and so on.

The ironic thing about banning drugs is that it deregulates drug markets. I can text a seller on my phone right now and get heroin or cocaine or fentanyl delivered to me untaxed at a price cheaper than it was a year ago and less than one-tenth the inflation-adjust cost of 25 years ago. I can’t do that for alcohol or tobacco. Both booze and cigarettes are legal, taxed, regulated and more expensive than ever. Any adult can get them legally but they’re less convenient to obtain and can be used in more limited circumstances.

How is it that use of the legal drugs of alcohol and tobacco has fallen? As every economist knows, incentives matter. We’ve made them more expensive and harder to get.

Illegal drugs, the ones killing so many people, are unregulated, except for the blunt labor market penalty that a (poor person, usually of color) is removed every now and then from the marketplace, a change that has no effect on supply or demand any more than a potato chip truck crashing on the highway makes it hard to get potato chips.

The drug war and overdose death go together like gravity and objects falling to earth. They are the same phenomenon. Drug prohibition kills. Always has. Always will. Is doing so right now.

That wasn’t the goal when our government started this effort, but it has been the result. And the more the government has escalated the drug war, the more citizens have paid with their lives. The time is now for citizens to admit we made a mistake. Elected officials are followers, not leaders. Taxing and regulating opioids, coca products and other consumer drugs — not just marijuana — is the only way to end the overdose epidemic and live in peace with drugs and people who use the.


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