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Opioids Aren't the Problem

If we want to save lives, we have to change the way we talk about drugs.

​Tatianna Paulino, the mother of A$AP Yams, made headlines on Sunday by sharing the deeply personal and important story of her son's drug-related death. Other outlets responded by reporting that Paulino had published a piece warning about "the dangers of opioid abuse." Problem is, this entirely misrepresents her message. In fact, Paulino says it would be too simple and too convenient to explain away her son's death as a drug problem. She also points out that the real problem was not opioid abuse, the way the attention-grabbing headlines almost always misrepresent it, but rather the combined use of opioids with other sedatives. She also clearly understands that young people will use drugs "whether we like it or not," particularly in stressful circumstances, like those A$AP Yams endured. Our job, as responsible adults, Paulino writes, is to "do all we can do to keep them safe and alive." This clarion call, in combination with frequent media misrepresentations of drug use and drug problems, spurred me to join forces with Tonic to provide realistic and accurate information about drugs and their use. We hope to minimize the drug-related hysteria that can lead to unnecessary anxiety and policies that are more harmful than the drugs themselves. We aim to maximize the dissemination of information that will help keep our citizens safe, even if they use drugs.


Thinking about the current so-called opioid epidemic within this frame, it is important to understand that the major concerns related to opioid use are: 1) opioid-sedative combination deaths; 2) acetaminophen toxicity; and 3) addiction. It is certainly possible to die from an overdose involving a single opioid drug, but this accounts for only about a quarter of opioid-related deaths each year.

1) Combining an opioid with another sedative, such as alcohol or a benzodiazepine (like Xanax or Klonopin), account for most opioid-related deaths. Rather than cast fear and uncertainty on opioids across the board, public health education campaigns would be more effective at saving lives if they advised opioid users to avoid combining opioids with other sedatives.

2) The latest data from the National Survey on Drug Use and Health shows that just over 300,000 people reported using heroin at least once in the past 30 days. (Note that this number is substantially lower than the number of individuals who reported use of marijuana, which came to about 22 million, prescription opioids, about 4 million, and cocaine, 2 million, over the same period). Instead, most individuals seeking a heroin-like high use prescription opioids recreationally. On the one hand this is a good thing, because the purity of street heroin is often poor due to adulterants added to increase the quantity of the product. Prescription opioids are usually a higher quality, as they are pharmaceutical-grade. But: Popular prescription medications like Percocet, Vicodin and Tylenol 3 contain a relatively low dose of an opioid in combination with a considerably larger dose of acetaminophen—and excessive acetaminophen exposure is the number one cause of liver damage in the United States. Some users may unwittingly risk liver damage by taking too many of these pills. We need to inform people not to overdo it on opioids containing acetaminophen because it can be more fatal than the low doses of opioids contained in these formulations.

3) The overwhelming majority of opioid users do not become addicts. One thorough review of the research put the rate of addiction among people prescribed opioids for pain at less than one percent. I recognize that this is inconsistent with the popular view. But the quicker we can dispel myths surrounding drug use, the better our focus on real concerns becomes. For instance, we know that one's chances of becoming addicted increases if one is young, unemployed and/or has co-occurring psychiatric disorders. That is why it is critically important for policies to ensure that people have jobs and affordable access to effective mental health services, rather than exclusively focusing on eliminating drugs from society. If we took this approach the number of people addicted to drugs would be substantially reduced.

Far less emphasis should be placed on hyping the dangers of opioids. Opioids have been used safely for centuries and are important instruments in the physician's toolbox; they are used medically to treat pain and suppress cough. We as society should recognize that drug use is an activity in which humans have engaged since they first inhabited the earth. We will always use drugs. My acknowledging this fact does not function as an endorsement but rather a realistic appraisal of the best available evidence to educate people and keep them safe. Exaggerating the harms of opioids, or any other drug, does little to ensure the safety of users. It merely diverts attention and resources away from the real concerns and decreases our ability to take the most appropriate steps in keeping people healthy and safe.

​Image: Chad Batka/Getty Images