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Performative Bafflement's avatar

On opiate deaths, I've done some research and have a little bit of flavor I can add to the picture. I'll probably do a post on this eventually.

Everyone remembers the "opiate crisis," right? Doctors being told oxies were non-addictive, passing them out like candy, etc. This was actually mostly fine. Overdose deaths at this point were ~20k a year, and those overdoses were mostly heroin rather than oxies. Having legal opiates of known strength may have led to addiction, but it led to many fewer deaths.

Then around 2014 / 2015, we started cracking down on doctors in the US, and told them to prescribe 10x fewer legal and safe opiates or lose their license. Then you see a significant 1.5x peak in heroin interdiction around 2015 (lower left), as the demand from people suddenly cut off from legal opiates transitions to heroin:

https://imgur.com/a/JhIhAZu

And then since demand is still there and there's less supply, and because fentanyl is vastly denser and more smuggleable and less interdicted than heroin, fentanyl takes off in 2015. You see a jump in the total overdose deaths graph then, but you *really* see it when you cut overdose deaths by substance, in which case fentanyl is on an exponential takeoff starting in 2015:

https://imgur.com/a/ykdRmA2

Opiate deaths, now at ~100k a year, have 5x-d thanks to our solution to the "opiate crisis." It's the single biggest cause of death for people under 40, above car accidents.

The primary reason overdoses happen is that the difference between 3mg of fentanyl and 5mg of fentanyl is the difference between "feeling good" and "overdose."

When fentanyl contaminates other drugs like cocaine and mdma, or when fentanyl is pressed into pills, there can be a "chocolate chip cookie" effect, where it's not evenly mixed, and a local surplus forms a "chocolate chip" of fentanyl in the other drug / pill. Oops, that chip was 5mg instead of 3mg and you're dead now.

The reason fentanyl kills people is because it's added in imprecise amounts with slapdash mixing to either masquerade as heroin or opiate pills, or to add more addictiveness and oomph to other drugs, and the imprecision and slapdashery is killing people because of the 3mg / 5 mg thing.

In my own opinion, the only thing that might save these incremental ~80k lives a year is being willing to pass out legal opiates of known strength and purity again. Wholesale legal opiates are dirt cheap in reality - even very heavy addicts can be high out of their mind on ~$5 a day.

Addicts don't even LIKE fentanyl more, for the most part, it's purely driven on the supply side by concentration and smuggleability:

Heroin is preferred by between 1.7-6.7x, with older folk preferring it more:

*Ferguson et al, Investigating opioid preference to inform safe supply services: A cross sectional study (2022)

And although giving people safe, legal opiates is a pipe dream in the US, they've done it in Canada with some decent preliminary results:

Safe supply reduced nonlethal OD's 5.5x, ER visits by 14 annually, and by 5 hospital admissions annually (and there were zero lethal OD's in the study period):

*Lew et al The impact of an integrated safer use space and safer supply program on non-fatal overdose among emergency shelter residents during a COVID-19 outbreak: a case study (2022)

*Gomes et al Clinical outcomes and health care costs among people entering a safer opioid supply program in Ontario (2022)

It's been hard to measure safe supply's impact on lethal OD's in the couple of years it's been around, because the base rate is still fairly low, but there should be enough data for papers to come out in early 2025 that have a read on it.

I have been talking to a health care worker in Canada who tells me that Safe Supply has been vastly expanded and it's been a bad thing, because now it's big enough that organized crime has gotten involved, and trades money or fentanyl for the safe supply homeless people's pharmaceutical opiates. If that's true, we'll have to see how it comes out in the data - obviously if they're still using illegal fentanyl rather than the safe ones, deaths probably won't drop much.

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Burning Down the Woodshed's avatar

"The true rates probably are declining now, owing to the impact of Ozempic and other semaglutides, a trend that should become increasingly visible as data from 2024 and 2025 are explored. Although I find some hope in this, I also have mixed feelings, because I suspect that for some people, what's needed most is a change in lifestyle rather than the drugs."

You "suspect" this? Seriously? You're a doctor! This is something elementary-school children, from a glance at themselves and their parents, KNOW. The ONLY long-term success is a coordinated assault on diet, consumption habits, and corporate drug-dealing in sugar and carbs. Ozempic isn't a solution; it's not even a Band-Aid. It's an illusory fix for the wealthy. It's *not* "hope"! Even if Musk got his way, and these drugs became cheap, the intravenous-drip dependency on these drugs for continued results is no different than crack to get high (skinny).

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