We can be ready for an opioid crisis

Expert opinion from University of Otago - Ōtākou Whakaihu Waka

Opinion: Although opioid use rates are rising in Aotearoa New Zealand, we have an opportunity to prevent an opioid crisis – let’s not waste the time we have left.

Opioid overdose is in the news again as two recent New Zealand studies found overdose rates ticking upwards in Aotearoa.

Rates have been steadily increasing over the past 10 years, and last year the NZ Drug Foundation warned that the country wasn’t ready for the inevitable increase in opioids, and opioid overdoses, that are coming.

Fentanyl, an opioid many times more potent than morphine and heroin is a concern, while other unidentified opioids that are more potent than fentanyl have also entered domestic supply.

A recent report from the United States government states that New Zealand is likely to be the target of more concerted opioid trafficking in the future.

While these developments paint a rather bleak picture, we are at an advantage due to the fact that other countries are further along than us in their own opioid overdose crises, and thus can provide some data for consideration as we try to build a bulwark against the worst impacts of opioids here.

The US is in the throes of a decades-long opioid crisis, with more than 100,000 overdose deaths last year alone. Researchers are dedicated to trying to understand the causes of this crisis and identifying general risk factors.

A recent US study reviewed 56 articles from 2013 to 2022 and identified county-level predictors of drug overdose mortality (over half dealt only with opioid overdose). The studies vary widely in methodology and location, but the review sheds light on a number of factors involved in drug overdose, factors that we should pay attention to as we take stock of our own drug preparedness.

First, perhaps surprisingly, there was no consistent effect of race on overdose mortality. Some studies found positive associations, while others found negative associations, with some finding no association.

Second, across studies, economic factors such as unemployment rate, income, rent precarity and eviction rates, and indices of deprivation and economic decline and distress were all significant predictors of overdose mortality.

Third, factors related to overall health, accessibility of healthcare and the availability of drug treatment and support services were all significant predictors of overdose mortality. In general, counties that approached drug use from a health perspective and had robust support services in place had better outcomes.

Finally, pharmaceutical and opioid industry factors such as prescription and marketing rates, and opioid-related industry payments (speaking fees for doctors, meals, consulting fees, etc) were significant predictors of overdose mortality.

Academic discussions around causes of overdose mortality are often framed in terms of economic markets. Influences such as opioid prescription rates and marketing (to the public and specifically to doctors) are termed supply-side factors, while unemployment, economic deprivation, and income are characterised as demand-side factors. There is a great deal of disagreement as to the causal role of supply vs demand side factors in overdose mortality.

Unfortunately, framing opioid overdose as an economic exchange abstracts the lives, livelihoods, and deaths of individuals in terms of impersonal and apolitical market forces and hides the reality of the social and economic systems that have produced the conditions in which the opioid crisis has taken hold and continues to thrive.

Specifically, pitting supply-side arguments, focused on the movements of pharmaceuticals and opioid industry players, against demand-side arguments focused on socio-economic factors, conveniently avoids the elephant in the room: neoliberal capitalism.

It was the adoption of wide-scale neoliberal economic reforms in the US beginning in the 1980s under the Reagan administration that deregulated businesses, liberalised trade, and crushed organised labour. Over the next few decades, jobs in manufacturing were offshored and former industrial centres hollowed out. Healthcare was increasingly privatised, and public services, including affordable healthcare and community supports, were gutted.

Into this powder keg was thrown the match of opioids. Deregulation and lack of oversight allowed unscrupulous pharmaceutical companies, such as Purdue Pharma, the makers of oxycontin, to market and push their drugs with impunity, pumping millions of pills into communities that had been decimated by job losses and economic depression (in some places there were more prescriptions than adult residents).

Thus, the impact of neoliberal economic reforms can account for both supply-side and demand-side factors in producing the US opioid overdose crisis.

Overall, the socio-economic factors that increase risk of overdose can be understood in terms of what the psychologist Bruce Alexander calls dislocation. Dislocation refers to any event or circumstance that leaves people feeling isolated, disconnected, and unable to form or maintain meaningful relationships and social bonds. Individuals and communities who suffer dislocation are at increased risk of a number of addictions and health conditions, including drug abuse and overdose.

Modern capitalist society produces massive dislocation. The increased dispossession, exploitation, and commodification lead to forced competition, isolation, and fractured relationships, putting individuals and communities at risk. Indigenous peoples, already dealing with the impacts of generations of colonialism, are vulnerable to double dislocation.

As the Reverend Māori Marsden, a minister, government advisor, and tohunga, who was scathing in his critique of government adoption of neoliberal social and economic reforms, put it: “Already at the bottom of the heap, Māoridom has been shoved even further out on the socio-economic limb…”

The antidote to dislocation is solidarity/community or kotahitanga/hāpori. In fact, in the studies reviewed, a factor identified as ‘social capital’ emerged as a protection against overdose mortality. Social capital indexes the strength of community relationships and trust, reciprocal cooperation and civic engagement, and a feeling of belonging. Not only was this factor protective in and of itself but it was found to mediate the effects of other factors, including economic and health impacts. In other words, solidarity was protective against dislocation and overdose mortality regardless of the cause.

These results suggest that every effort should be made to cultivate social capital and reinforce solidarity in communities across Aotearoa.

As a longer-term political project, we can aim to reverse the impacts of several decades of neoliberal social and economic reforms. The current coalition Government’s cuts to public services, including massive planned layoffs, increased ‘flexibility’ for employers at the expense of workers, cuts to welfare services, and proposed changes that will increase poverty and precarity – all factors that increase risk of overdose mortality – must be vigorously and vocally opposed.

In the short term, we can focus our efforts on adopting an evidence-based health-focused approach to drug policy. We can also work to increase availability and accessibility of healthcare and other support services.

On a more fundamental level, we can strive for solidarity. This means rejecting the divisive political framing of society as an ‘us vs them’ binary, recognising and embracing our shared humanity, and standing in solidarity against and rejecting social and economic systems that reduce our shared and intertwined lives to a zero-sum game of personal interest and benefit maximisation. Such solidarity will strengthen our communities, towns, and cities, and will stand us in good stead to weather an opioid crisis or anything else that may come our way.