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Overdosing on Regulation: How Government Caused the Opioid Epidemic


Opioid overdose deaths have risen dramatically in the United
States over the past two decades. The standard explanation blames excessive prescribing by physicians and
aggressive marketing by pharmaceutical companies, beginning in the

This explanation — “more prescribing, more deaths­”
— has spurred increased legal restrictions on opioid
prescribing. Most states now have Prescription Drug
Monitoring Programs (electronic prescription databases that attempt
to reduce doctor shopping), and many states cap prescription doses. The federal government
limits opioid production and raids pain management facilities
deemed to be overprescribing. In October, the federal government
enacted legislation that increases monitoring
of prescribers and funds hospitals that attempt to reduce
prescribing. Supporters believe these restrictions will reduce the
supply of prescription opioids and thereby decrease overdose

The evidence suggests, however, that the opioid overdose
epidemic has resulted from too many restrictions on prescribing,
not too few. In a recent paper for the Cato Institute, we document this
“more restrictions, more deaths” explanation for the
opioid overdose epidemic.

The risk of overdose from proper medical use of prescription
opioids is low: in published studies, the rate of opioid addiction
in chronic pain patients has averaged less than 8 percent. Patients receiving long-term
stable doses rarely overdose because they quickly develop

Worse, regulations push users from prescription opioids to
diverted or illicit opioids, which are far more dangerous. Quality
control is poor in underground markets because reliable suppliers
cannot legally advertise their goods and consumers cannot sue for
damages from faulty or mislabeled products. Diverted or illicit
drugs do not come with warning labels, and users cannot discuss
safe use with their physicians. Underground opioid markets are also
more likely to supply hyper-potent products, such as heroin or
fentanyl. Consumers cannot easily determine the potency of such
products and so face elevated risks of overdose.

Since 2011, rapidly increasing deaths from heroin and synthetic
opioids such as fentanyl have driven up the opioid overdose death rate
despite reduced prescribing. In 2017, heroin
and synthetic opioids accounted for more than three quarters of all
opioid overdose deaths. Many young heroin users reporttransitioning to heroin from prescription
opioids when these became more difficult to acquire.

Attempts to curb overdoses by reducing the abuse potential of
prescription opioids have proven counterproductive. In 2010, Purdue
Pharmaceuticals introduced an abuse-deterrent version of OxyContin,
which made the drug less appealing to opioid abusers. Regulations
limiting access to other prescription opioids caused many users to
then substitute to heroin, leading to
an increase in heroin-overdose rates.

The federal government also restricts maintenance treatment for
opioid dependence (e.g., via methadone or buprenorphine),
contradicting decades of literature showing that maintenance treatment
reduces opioid-related mortality and illicit drug use. Reduced
access to maintenance also pushes users to underground opioid

A simple first step in decreasing the risks of illicit or
diverted opioids is to increase legal access to prescription
opioids. For example, the federal government could scale back
regulation of maintenance treatment and remove rules that limit
prescribing. Federal and state governments could also end raids on
pain management facilities. These reforms would decrease the risks
from opioid dependence and reduce the harms associated with
underground consumption.

The federal government could also make opioids “more
legal” by shifting them to less regulated schedules of the
Controlled Substances Act. In the extreme case, opioids would be
over-the-counter, meaning available for purchase without a
prescription. While reduced regulation can decrease underground
opioid consumption, outright legalization would eliminate the
underground market entirely. Individuals who purchase and consume
opioids would do so in a safer setting, reducing the dangers of

Evidence from other countries suggests that increased legal
access to opioids reduces deaths and improves health outcomes. In
1995, France removed patient caps and licensing requirements for
the prescription of buprenorphine maintenance treatment, leading to
a fivefold reduction in heroin deaths and an estimated
3,900 lives saved. When Portugal decriminalized all drugs in 2001,
it had the highest overdose rate in Western Europe. Drug-related
deaths and HIV diagnoses attributed to injecting declined substantially, and Portugal now has
the lowest overdose rate in Europe.

Prescription opioid regulations should address all their costs
and benefits. Even if increased prescribing heightens the frequency
of opioid dependence, opioids helps patients who suffer from severe
or chronic pain. Indeed, decreased prescribing in recent years has
driven a number of patients to suicide. The
benefits of decreased regulation almost certainly outweigh the

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A public policy research organization dedicated to individual liberty, limited government, free markets, and peace.

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