A Supply-Side Perspective on the Opioid Crisis

Published in: Journal of Policy Analysis and Management [Epub February 2018]. doi: 10.1002/pam.22049

Posted on RAND.org on March 01, 2018

by Rosalie Liccardo Pacula, David Powell

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Research Questions

  1. What supply-side factors contribute to the rise of the opioid crisis?
  2. How has the supply of opioids shifted during the course of the crisis?
  3. What public health challenges does the shifting supply dimension pose?

The opioid crisis is a complex, multifaceted, and dynamic problem requiring a comprehensive strategy for dealing not just with the stock of addicted users who are at risk of overdosing, but also considering the flow of new initiates and escalators in abuse. We had a limited understanding of the best approaches for tackling these issues when it was a prescription opioid problem; our understanding of effective levers in the current situation is even more limited. In the past two years, substantial attention and funding has been given to efforts to expand naloxone distribution and access to substance abuse treatment, two very important components of a comprehensive strategy. Prior to this, supply-side interventions dominated the policy landscape. Initial conflicting evidence of the effectiveness of supply-side interventions and the ongoing rise in overdoses despite widespread adoption of such policies, has led to pessimism about the potential of supply-side strategies. Criticisms about these approaches when dealing with black markets further abound. Ignoring the supply side of the equation at this stage, however, particularly the potential reactions and innovation of suppliers in these markets, would be a mistake and could further generate unintended consequences to well-meaning demand reduction strategies just as they did with well-meaning supply-side strategies. We explain below how ignoring the motivation and innovation of suppliers, both in the legal or illicit market, got us to this point in the opioid crisis, and how ignoring their continuing role could be even more devastating.

Key Findings

Supply Side Factors Contributed to the Rise of the Opioid Crisis

  • Opioids were promoted by manufacturers to medical professionals, medical and hospital boards, and patients, sometimes with misleading evidence of their addictiveness or effectiveness.
  • Declining drug prices lowered the cost of prescription opioids since 1999, which led to increased utilization.
  • Health care reimbursement rewards volume of services, creating an incentive for providers to overprescribe.

The Opioid Crisis Has Transformed from a Prescription Drug Problem to One Centered on Illicit Opioids

  • Starting in 2010, fatal overdoses from prescription opioids declined.
  • At the same time, fatal overdoses from illicit opioids—heroin, fentanyl, and carfentanyl—grew dramatically, more than quadrupling between 2010 and 2015.

What Are the Challenges Posed by the Shift from Prescription Drugs to Illicit Opioids?

  • New users of illicit street drugs tend to be unsophisticated and thus at elevated risk of overdosing.
  • Consumers of street drugs can be exposed to "cutting agents"—additives designed to stretch the supply of opioids—that can heighten the danger of using the drug.
  • Illicit opioids are more likely than prescriptions to be injected, creating the risk of exposure to costly and fatal infectious diseases, such as Hepatitis C and HIV.

Recommendations

For Policy:

  • Maintain efforts to limit supply in black markets.
  • Reduce the harms experienced by those currently dependent.
  • Address the affordability of high quality treatment, including medication-assisted therapies (MAT).

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