Opinion: Fentanyl is still a crisis, and securing the border is not enough

Recent headlines offer a glimmer of hope in our country’s unrelenting overdose crisis.

Overdose deaths in the U.S. — which more than doubled over the last decade — made a decisive downturn in 2023. The 10 percent annual reduction in overdose deaths is especially pronounced in the Northeast and Midwest, where hurricane fentanyl first made landfall in the mid-2010s. But overdose deaths are continuing to rise in western states and among specific demographic groups, such as people over age 65.

The magnitude of the U.S. overdose crisis is almost impossible to fathom. It has claimed the lives of 1.3 million Americans since 1999, a number that exceeds our country’s losses in all foreign wars and eclipses the death toll of the COVID pandemic.

As a country, we have become all too familiar with the stories of loss. Two dead in Missoula, Montana. Two dead sisters in Memphis, Tennessee. Ten dead in Cincinnati, Ohio. One dead in Lancaster, Pa.

The fact that overdose deaths rose dramatically in the first Trump administration and have stayed above 100,000 per year in the Biden-Harris administration may explain why both presidential campaigns have largely ducked the topic.

When they do, they frame the fentanyl problem around our southern border, as we saw at the end of September when Vice President Harris visited a southern Arizona town and said that preventing fentanyl from crossing the border was a “ top priority .”

Cracking down on international drug traffickers is an important part of the solution, but focusing only on the border is an inadequate drug policy. Further driving down overdose deaths requires policies to help people who are already addicted.

The solution starts with treatment. Decades of research show that patients decrease their overdose risk by more than half once they start treatment with methadone or buprenorphine. But recent federal data suggest that just over half of U.S. adults who need treatment for opioid use disorder received it in the prior year, and only one-quarter received medications.

This actually represents progress given the legacy of undertreatment . The number of patients on medications has climbed steadily in recent years, but opportunities continue to be missed for people in crisis.

The Biden administration has advanced major policies to expand medication treatment, some of which build on efforts started under the Trump administration. This includes eliminating the requirement that doctors obtain a special license to prescribe buprenorphine, simplifying regulations to allow patients to start methadone at specialty clinics, and enhancing Medicaid funding for people transitioning out of jails and prisons, where overdose risk is highest.

The Biden administration also released guidance clarifying that the Americans with Disabilities Act protects the rights of patients to stay on medication treatment in settings like long-term care facilities and jails. They have prosecuted and won cases .

These successes are worth building on. The next president should tackle the reluctance of the healthcare system to make medication treatment the standard of care. Federal health care programs like Medicaid and Medicare can use the power of reimbursement to require hospitals and health systems to start treating opioid addiction and to enforce quality of care standards.

The starting point is abysmal. There is an overdose crisis among older Americans, yet after Medicare patients survive an opioid overdose, less than five percent receive medications in the following year.

While naloxone has become more mainstream in the last decade, other harm reduction approaches — proven to work in Europe and Canada — are heavily restricted in the U.S. This includes access to sterile syringes, test strips, and drug-checking programs that help people learn when there are new adulterants in the drug supply, like the animal tranquilizer xylazine.

Overdose prevention centers , where people can use previously purchased drugs under medical supervision, would prevent thousands of deaths among people who use alone. The one existing model in the United States in New York City has already reversed hundreds of overdoses , yet expanding this model to other communities will raise several legal challenges.

Pushing for a more comprehensive national overdose policy would take political courage, as it is much easier to strengthen law enforcement, not healthcare. But the federal government already has the capability and the tools to meaningfully reduce overdose deaths if it can overcome resistance to change, stigma, and disorganization.

Securing the border is not enough to stop the crisis — for solutions, we have to look within.

Brendan Saloner, Ph.D.( bsaloner@jhu.edu ) is a Bloomberg associate professor of American health in the Department of Health Policy and Management in the Bloomberg School of Public Health.

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