We are in the midst of the greatest American health crisis of this young century, an opioid epidemic that has now led to an astounding 500,000 deaths in the past two decades. There has been substantial ink—appropriately—devoted to this issue, we think there are three areas that receive far less attention than they should. One relates to the silent, concurrent increase in other substance use that is happening, the second relates to who we believe is affected by opioids, and the third to our best hope of stemming this crisis.
First, there are two other drugs being misused in America at newly alarming rates that have paralleled the rise in opioids. These are cocaine and its stimulant cousins that are prescribed, such as Adderall and Ritalin.
The availability of cocaine has risen, and with it there has been a 60% rise in cocaine overdose deaths in the past five years. Like opioids, cocaine addiction is a chronic relapsing condition that requires repeated treatment interventions. But unlike the treatments for opioids, which are effective in reducing deaths, the treatments for cocaine have extremely modest effects. With fentanyl now getting mixed into cocaine batches, even occasional cocaine use has become notably lethal.
In parallel, with increases in prescriptions of attention-deficit hyperactivity disorder (ADHD) medications of more than 50% in the past decade, there is an accompanying increase in the non-medical use of prescription stimulants. Stimulants are now the second most common drug misused on college campuses after marijuana, with 15-35% of college students having tried them recreationally—to study longer, concentrate better, get high, or lose weight—with ill effects on mood and sleep and an increasing potential for addiction.
Our second side note relates to who is being affected by opioids. This opioid tsunami has given us countless news stories about the toll on White, middle class, suburban, and rural users. While there have indeed been dramatic increases in opioid deaths in these groups, Black American deaths due to opioids have doubled in the past fifteen years. In some states, Blacks are experiencing opioid-related deaths at higher rates than other racial or ethnic groups. We must remind ourselves this is not only a White epidemic. While nationally the rate of opioid medication treatment is higher among Blacks who seek care than among other groups, rates of treatment remain low overall.
Finally, because access to treatment remains fragile, we should keep in mind that Medicaid remains a key source of coverage for many people who use drugs. As we ratchet up a treatment system for opioid, cocaine, and stimulant misuse that has been woefully inadequate, threats to Medicaid’s structure and funding need ongoing public health attention or the consequences of drug use will continue to expand.
Warmly,
Michael Stein & Sandro Galea