Introduction
The topic of drug and drug policy can be traced back to the colonial era when the government had taken responsibility for regulating the consumption of drugs, both legal and illicit. In the United States, the fight against illegal drugs has already been described as a failure considering that substance abuse involving hard drugs is a problem that has not yet been solved (Coyne and Hall). Similarly, the country does not appear to be successful in regulating legal drugs whose abuse is not different from that of illegal drugs. The government has largely adopted a probationary approach to illicit drugs. However, prescription drugs cannot be dealt with in the same manner. Such an observation makes it interesting to examine the efficacy of drug policies.
Currently, the United States is experiencing what has been termed as ‘the opioid crisis’ meaning a surge in the abuse of opioids prescribed for pain relief. According to Rummans et al., the current crisis has been developing over the past three decades where the efforts to improve pain and suffering resulted in more opioid prescription, which subsequently led to abuse and death (344). Prescription drug abuse is the consumption of medication drugs for intoxication purposes or for uses other than those they were prescribed for (GAO). GAO estimates that the United States government spent over $36 billion in 2019 on drug misuse, undertaking efforts such as prevention, treatment and law enforcement activities. However, the real effects of prescription drug abuse can be understood by concentrating on individual states.
This research seeks to examine opioid drug abuse in Ohio. The drug in question is fentanyl, a prescription drug categorised as a painkiller. This drug has also been known to be consumed in contexts other than prescription and has been associated with hard drugs such as heroin. The case of Ohio may not be unique in any way as the state faces the same policy problems as all states in the regulation of drugs. The research will briefly describe the drug policy both at the national and state level. Secondly, fentanyl abuse in Ohio will be discussed in detail outlining all the dangers of the drug and the incidence of drug abuse in the state. State (and national) regulation and implications for drug policy will also be examined.
Background to Drug Policy
The drug policy in the United States has evolved with time but the ultimate objective has always been to prohibit illicit drugs. The intended outcomes of the policy include eliminating the availability of drugs to prevent their consumption. A closer look at the National Drug Control Strategy of the country will reveal that many of the drug policies target illegal drugs such as marijuana (now legalised), heroin, cocaine and other hard drugs. However, the National Drug Control Strategy includes prescription drugs where the national policy seeks to achieve safe prescription practices. Opioids are targeted by this policy which is founded on the CDC Guideline for Prescribing Opioids for Chronic Pain. This guideline was published in 2016 and focuses on three basic areas: determination of when initiation or continuation of opioids should be done, selection, dosage, duration, discontinuation and follow-up of opioids, and an assessment of the harms and risks involved in the use of opioids (Office of National Drug Control Policy, “National Drug Control Strategy (January 2019”). Such practices are nation-wide efforts to mitigate prescription drug abuse in the United States.
The drug policy in the United States regarding prescription drugs seeks to reduce the risk of addiction among those patients taking opioids and other controlled medications. The safe prescription policy is critical for patients requiring high opioid dosages where care needs to be taken to avoid overdoses. The most important aspect of this policy, in the context of this paper, is that it also seeks to prevent the usage of the opioids for non-medical purposes (Office of National Drug Control Policy, “National Drug Control Strategy”). The addictive nature of opioids is a worrying problem with many pharmaceuticals in the country being subjected to investigations for manufacturing highly addictive painkillers (Noguchi). As a policy issue, addictive prescription drugs become a major challenge as their consumption after the discontinuation of treatment may become hard for patients. They could carry on with the consumption of the drugs or attempt to replace them with illicit drugs with the same effects.
In the case of Ohio State, the opioid policy pursues similar objectives as the national policy. Ohio has attempted to implement a comprehensive approach to fighting deaths from prescription drug overdoses and abuse. The problem has become an epidemic and its ever-changing nature means that the state has to keep adjusting both policies and strategies (Penm et al. 148). Law enforcement has had to be stepped up and penalties for trafficking drugs such as fentanyl increased. Access to addiction treatment has also been improved in addition to increased awareness and availability of drugs that reverse opiate overdoses. The question that remains after all these efforts is whether the policy and strategies have succeeded in addressing the public health issue.
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Fentanyl is a crisis in Ohio and, as will be examined in the following sections, requires a new policy approach. The main challenge and barriers to policy implementation should help explain why Ohio and other states find it hard to fight prescription drug abuse. The policies are, however, not critiqued as the focus is on the extent of the problem and the policy implications. Such an approach is adopted because the federal and state policies, no matter how good, have historically failed to achieve the ultimate goal of fighting substance abuse.
Fentanyl Crisis in Ohio
The state of Ohio is perhaps one of the best examples of the opioid problem in the United States. The deaths caused by opioid overdoses have reached epidemic proportions not only in Ohio but also across all the states. In 2013, for example, about 38851 deaths were recorded, which could only be the tip of an iceberg. In other words, these figures are estimated to account for between 3.1% and 4.2% of the total overdose cases (Winstanley et al. 42). Even though the fatality percentages are comparatively low, it should be noted that even the non-fatal overdose cases have devastating consequences for the community in addition to the huge burden on the country’s healthcare problem. In Ohio, the deaths from opioid overdoses have been on the rise since 1999. In 2013, Ohio recorded about 2110 fatalities from unintentional drug overdoses. Of these deaths, over 73% are either prescription drugs (opioids) or heroin. The prescription drugs are responsible for the vast majority of fatalities apart from 2012 when heroin fatalities surpassed those of opioids (Winstanley et al. 43). Such figures are evidence of the need to examine Ohio’s drug policy.
Comparing with other states, Ohio has the fifth-highest rate of deaths resulting from drug overdoses. According to Penm et al., Ohio records 24.6 deaths per 100000 overdose cases with unintentional overdose being the leading cause (148). In a primary research conducted by Hall et al., an exploration of deaths related to specific drugs revealed that fentanyl was the most recurrently mentioned opioid in the 2016 survey in Ohio (158). To fully appreciate the fentanyl problem in Ohio, a more general view covering the entire nation depicts the drug as a critical public health issue. In a 2016 survey by the CDC indicated Ohio recorded 400 deaths involving only one fentanyl analogue called carfentanil between July and December. The state of Florida recorded less than 500 deaths in the same period. Additionally, of the 11045 opioid overdose deaths between July 2016 and June 2017, about 2275 (20.6%) tested positive for at least one analogue of fentanyl while 1236 (11.2%) tested positive for carfentanil (O’Donnell et al. 767). The survey identified over 14 analogues, with 95% discovered by medical examiners and coroners. Such an observation is evidence that fentanyl could be present in any drug.
As such, it is important to understand why fentanyl causes more deaths than most opioid. Two arguments can be presented: that fentanyl is more dangerous than other drugs, or that fentanyl is more consumed in Ohio (among other states) than other opioids and hence the higher fatality rates. However, the uses of the drug outside prescription can offer an alternative explanation of the problem. Such uses include the presence of fentanyl in other drugs in which case fentanyl is associated with any resulting deaths and other adverse effects of overdose or addiction.
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The presence of fentanyl in other drugs has been a major topic for discussion and research. A study conducted by Solis et al. revealed that the heroin that is contaminated with fentanyl causes brain hypoxia in addition to inducing brain hypothermia (1). Fentanyl takes credit for the health outcomes of the consumption of such heroin products (dubbed ‘street heroin’) because of the high potency. The intake of heroin-fentanyl mixtures, therefore, results in critical health complications that include lethality and a comatose state. Both fentanyl and heroin work by inducing respiratory depression resulting in systemic hypoxia. As such, consuming the mixture places the individual at the risk of acute neural disturbances and possible death. This study reveals that indeed the potency of fentanyl either individually or when mixed with other drugs is the major cause of fentanyl-related overdose fatalities.
Other studies that reveal that fentanyl is consumed in much higher rates as compared to other drugs. According to Daniulaityte et al., the consumption of street fentanyl in Ohio is high as approximately 90% of the participants tested positive for fentanyl-related drugs (or fentanyl mixtures) (3). The respondents were also unaware of the fentanyl analogues meaning that their consumption was uninformed. In comparison with heroin, fentanyl consumption on Ohio was higher (less than 50% as compared to the nearly 90% for the fentanyl-type drugs). These findings serve to explain that fentanyl consumption rate is higher in Ohio that heroin and other drugs. Additionally, fentanyl is largely consumed in mixtures of other drugs, including heroin. The study identified seven fentanyl analogues where more than 80% of the respondents tested positive for more than one analogue. As such, there is a higher likelihood of overdose of fentanyl through other drugs when the individuals accumulate the quantities of fentanyl consumed in different drugs. The argument here is that fentanyl is also consumed in large quantities, a fact that also explains the high rates of fatalities related to fentanyl overdoses.
The arguments proposed have been proven right meaning that fentanyl is more dangerous due to its potency and it is also consumed in comparatively higher quantities. A combination of these two factors makes fentanyl overdose a critical public health problem that requires a serious and strict approach to mitigating the resulting dangers. The alternative argument proposed earlier on regarding the use of fentanyl outside the prescription purposes has also been proven by the two studies examined above. In both cases, the fentanyl consumption is illegal and mixed with heroin where high potency makes it dangerous and other drugs or analogues (Solis et al. 2; Office of National Drug Control Policy, “National Drug Control Strategy”). None of these studies examines prescription drugs as they both use the term ‘street’ to refer to fentanyl sold for use in non-medication purposes. In non-prescription consumption, it can be argued that the safe prescription policy and CDC guidelines fall short in term of the efficacy in preventing fentanyl overdose risks. Extended scope of the drug policy would be required to achieve greater success in controlling the consumption of fentanyl.
Another aspect of the drug that presents special policy implications is the ease with which it is detected. According to Dai et al., some of the fentanyl analogues such as furanyl fentanyl and carfentanil (a veterinary drug) maintain the pharmacological effects of fentanyl while at the same time being difficult to detect using the standard toxicological tests (2). The threats are magnified by the fact that carfentanil is over 10000 times and fentanyl between 50 and 100 times more potent than morphine. When produced and sold illicitly, they pose some of the most serious health threats for the consumers and critical policy implications for the government. Dai et al. also express the concern that fentanyl and its analogues are easy to find in adulterated prescription drugs besides illicit drugs such as cocaine, methamphetamine, and heroin (2). The implication is that any person misusing these drugs would also be doing the same with fentanyl. The death occurs rapidly after overdose as the drug depresses the central and nervous system.
The question that needs to be posed to the policymakers is, therefore, whether they understand all these aspects of the drug while making regulation policies. In essence, a drug policy should be able to capture all elements of the drug and make it possible to arrest all potential leaks. In the case of fentanyl, there appears to be too many leaks that are hard to address through the safe prescription policy and the CDC guidelines. The regulation of fentanyl as a stand-alone drug would prove futile as the analogues would still be available in the market. The challenge for the policymakers, therefore, is determining the right scope of the policy and drug control procedures. Fentanyl’ consumption in its analogues and mixtures means that it is being illegally consumed while at the same time being legally consumed through prescription. If the current policies show any weaknesses, it is because drugs like fentanyl are too complex to be captured by a generic policy while at the same time a tailored policy would leave out several areas uncovered.
Fentanyl Policy, Control, and Regulation in Ohio
Ohio, being one of the most affected states by the opioid pandemic (or, in this case, the fentanyl pandemic), would be expected to exhibit rigorous policy initiatives to help mitigate the risks involved. Besides the federal drug policies, controls, and regulations, it is interesting to examine how the individual states handle the challenge considering that each state probably faces some unique drug concerns. In Ohio, two of the most apparent efforts to deal with the opioid crisis are the pill mill laws and the Ohio Department of Health’s new strategies of fighting the fentanyl and opiate crisis developed in 2016-17. A closer examination of these two initiatives will reveal their efficacy and potential challenges faced regarding their implementation.
One of the major ways that the United States deal with drugs is through prohibition which is a strategy founded on the assumption that eliminating drugs will eliminate their abuse. The pill mill laws were enacted in Ohio to offer strict regulations on the use of opioids by clinics for pain management purposes. The pill mill laws, the clinics are prevented from issuing prescriptions for opioids without a medical indication. Ohio is one of the 11 U. S. stats that have pill mill law and, alongside Tennessee, has been the only state where drug-specific fatality data were available (Brighthaupt et al. 1). Additionally, the two states were the only ones where the pill mill law was the only regulation designed to restrict opioid prescription implemented on a two-year period. Such efforts can be appreciated as a deliberate effort to address a real-life public health threat.
Concerns expressed by researchers, however, are that restricting prescription fentanyl would result in increased overdoses in heroin and illicitly produced synthetic fentanyl analogues. A study conducted by Brighthaupt et al. showed that in the two states, the pill mill laws had no effect on the overall deaths resulting from heroin, prescription, or syntheic opioid overdoses. The researchers expressed a multi-pronged approach which included (but not limited to) the pill mill laws necessary to effectively solve the opioid crisis. The same concern has been mentioned earlier on; that is – the generic policy may have several setbacks while a tailored policy would potentially leave out other pathways to the access and abuse of fentanyl. The complexity of the opioid crisis, therefore, manifests itself when laws such as the pill mill laws are implemented.
Before disproving the pill mill laws, it is important to understand how they are framed, their scope, and how they are intended to function. An explanation of these aspects is presented by Rutkow et al. who propose that more states should indeed implement the pill mill laws as they have a huge potential of curbing the opioid crisis in the United States (240). Each state implements the laws differently in terms of the definition of the pain clinic, pain clinic ownership, state oversight, and dispensing limitations. In Ohio, the pain clinics treat a majority of the chronic pain patients using controlled substances. The clinic ownership is required to supervise all activities of all individuals providing treatments for chronic pain in addition to meeting additional pain management certifications. The state involvement is largely through the annual licensure verification and the State Medical Board. These characteristics mean it is possible to regulate all prescription drugs. The laws, however, fail to address the issue of synthetic and illicit produced and sold drugs.
The second policy initiative to address the opioid crisis in Ohio new strategies published by the Ohio Health Department to fight the fentanyl and opiate crisis in Ohio. The strategies are termed as a comprehensive approach to fighting drug overdose and abuse. The new strategies outlined in the publication include stepping up the efforts of law enforcers in drug interdiction, boosting access to addiction treatment, raising the penalties for fentanyl trafficking and collaborating with communities in local efforts. Additionally, the state seeks to increase both awareness and accessibility of overdose-reversing drugs (naloxone) and to expand the use of the state’s opioid prescription guidelines (Ohio Department of Health). These strategies are tailored to address the fentanyl crisis in the state and, similar to the pill mill laws, have their drawbacks in terms of their scope. In other words, strategies seek to enhance the regulation of prescription opioids leaving out the illegal drugs of fentanyl and its analogues. To reiterate, a better approach with multiple dimensions and ain improved scope may help achieve better results.
Besides the state laws and policies, it is important to examine other efforts of opioid control such as programs and their efficacy and barriers to implementation. According to Winstanley et al., Ohio’s Opioid Overdose Prevention Programs (OOPPs) were initiated and funded by the state to help fight the opioid crisis (42). The first program was opened in 2012 and the second one in 2013. Several others began in 2014 and all of them distributed nasal naloxone and offered education on overdose prevention. Since then, the OOPPs have expanded rapidly in Ohio but their implementation has been faced by a number of barriers including the cost of naloxone. There are not many studies that have examined why such programs fail to have complete success with the opioid crisis. However, it can be argued here that the programs a shallow in scope and that their implementation fails to be backed by the necessary scientific research.
As will be discussed in the policy implications, the complexity of opioids such as fentanyl will require the states to fully understand how the drugs work and the many ways that they can be accessed. Naloxone and other treatments may help reduce the fatality rates from overdoses. However, the fact that fentanyl can remain undetected coupled with the fact that fentanyl causes a rapid death means there will be cases when the treatments will arrive too late to have any effect (Dai et al. 2). New policies, strategies, regulations, and controls that factor in all the aspects of the drug may be needed to address the opioid crisis more effectively.
Implications for State and National Drug Policy
The fentanyl crisis in Ohio is an embodiment of how challenging it can be to address complex drug issues. The probationary policy in such a case may fail to yield the expected results because of the many pathways to the access and abuse of drugs like fentanyl. A risk management approach has been suggested by observers such as Rummans et al. who express that more person-centred and population-based approached should be adopted to reduce the risks of opioid disorders (348). Additionally, they have recommended the adoption of more evidence-based practices in the management of chronic pain to help minimise the number of opioid prescriptions in the pain management clinics. Such approaches, however, may still leave certain gaps in addressing more sophisticated drugs like fentanyl. As has been highlighted earlier on, the current policy is based on the assumption that the opioid overdoses are largely from prescription drugs. However, studies showing that the consumption of fentanyl through illicit analogues should change the assumption and help change the policy scope to address all other pathways to the access and abuse of fentanyl.
Evidently, the policymakers need to pay more attention to the illegal production of consumption of fentanyl and its analogues. The characteristics of fentanyl examined earlier on are evidence that safe prescription policies are inadequate. Fentanyl can be consumed in over 14 analogues most of which are detected after death by coroners and medical examiners (O’Donnell et al. 767). Therefore, it means that the policies should cover all drugs that can be contaminated by fentanyl if there is any hope of effectively regulating its abuse and overdose. The presence of the analogues coupled with factors such as detectability and individuals misusing more than one fentanyl analogues is an indicator that an overdose can be through the consumption of drugs with highly potent fentanyl.
The success of various programs and initiatives such as the creation of the Governor’s Cabinet Opiate Action Team created in 2011 should be emulated in policy development and other strategies in fighting the opioid crisis. The action team implemented a multi-faceted strategy promoting responsible opioid use, reducing their supply, supporting the prevention of overdose, and expanding access to naloxone among other actions (Penm et al. 148). Since its inception, the state has recorded 81 million fewer opioid doses as compared to the 782 million dispensed in 2011. Such progress should encourage further action teams to address other gaps left. Arguably, illegal fentanyl could be the largest cause of overdose and related deaths. Similar action teams focusing on the illegal production and consumption of fentanyl and its analogues would also yield similar results in terms of reduced consumption and abuse of the drug.
Research and development is a critical strategy and consideration for policymaking. Such a recommendation has been made by Rummans et al. who acknowledge the complexity of the drug abuse and the lack of adequate knowledge regarding the drugs (347). It has been mentioned earlier on that a good policy is one whose scope is broad enough to fill all the gaps. Research and development efforts should help the policymakers understand the full extent of the fentanyl problem and allow them to broaden the policy scope. Additionally, research and development will help in strategy formulation and initiatives like the action teams can address more related issues. The main recommendation here would be to follow studies such as Daniulaityte et al. that address the high rates of consumption and Dai et al. that explain the fentanyl and fentanyl analogues and their roles in opioid overdose deaths. These studies will help define the full scope of the opioid crisis and inform the formulation of more effective policies.
Lastly, enforcement efforts should offer an alternative approach to addressing the opioid crisis. The studies like Dai et al. inform illicit drug sources that can be addressed through national and state law enforcement like the Drug Enforcement Agency (DEA). The current safe prescription policies address only the overdose emanating from prescribed drugs and fail to tackle the problem of the ‘street’ fentanyl. Law enforcement officers can help conduct the necessary investigations regarding the sources of illegal fentanyl and to help the federal and state government enforce the prohibitionary policies. Essentially, such an approach could be adopted by any country in the world. The case study of Ohio and the fentanyl crisis reveals the challenges any state or country could face as a result of the complexity of the opioid crisis.
Conclusion
The war on drugs is considered a failure because the problem is far from being completely solved. If such is the case then this research paper helps explain why drug policy remains insufficient in dealing with the opioid crisis. A case study of Ohio, a U. S. state with the fifth-highest rate of overdose fatalities in the country, serves as an example of how the complexities of abuse render even the best policies ineffective. Fentanyl is selected as the case study drug because it is both legally and illegally consumed. The conundrum, therefore, is manifested by the fact that safe prescription policies may work perfectly but the progress of the policy initiative hindered by the illicit production of fentanyl and its analogues. The extremely high potency of fentanyl, the presence of fentanyl in more than one drugs (non-prescription) are a few of the characteristics of the drugs that make its abuse a pandemic. Multi-pronged approaches and strategies would be needed if the government is to see any success in fighting the crisis.
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