And if they had continued access to those pills they wouldn't be hitting the black market, getting fentanyl, and dying. Eventually, with support and help, they could start to wean off directly or with methadone or suboxone. But no, we can't have that. Instead our government and society prefers to let people die and then pretends like dismantling one company and taking their money is going to help. It's not going to help a single addict.
They're not zero, but single digit percent times single digit percent is generally considered a small percent. The math works out to 0.32-0.72% total, taking either the low end of both ranges or the high end of both. I think anyone should agree that in an absolute mathematical sense, 0.3-0.7% is a "low percent."
In this specific context? Sure, it's subjective and reasonable people can disagree.
Tl;dr: About 80% of heroin users started on prescription opioids. This sounds bad, but actually the conversion rate from opioid on-label use to abuse is pretty low and the conversion from pill abuse to heroin is even lower.
* Rate of conversion from on-label opioid prescription to addiction ("opioid use disorder") is lowish; this metastudy[1] claims 8-12% on average, but the 95% CI is anywhere from 3-17% and I'm not sure what they're measuring the percentage of (i.e., long-term prescriptions might both be more represented in the data and have higher conversion rates) — I doubt 8-12% of people who get 3 days of vicodin for their wisdom teeth extraction develop an opiate use disorder. They also point out that some studies showed misuse rates below 1% and "significant variability remains in this literature." We should expect these rates to fall as tighter prescription quantities from the last several years impact "leftover" pill rates.
* The rate of conversion from prescription opioid addiction to heroin is low; 4-6% per the government.[2]
* Overall opioid-involved overdose annual deaths in the US rose from 8000 in 1999 to 47600 in 2017; of those, the prescription-involved number rose by 13600 deaths (+300%), from 3400. Conversely, the non-prescription-involved deaths rose from by 26000 deaths (+465%), from 4600.[3](Figs 3-4) 26000/39600 = ~66%. (The population has also grown about 17% over that period, but that doesn't change the calculus too much.)
* Therefore: the overall growth pattern in opioid deaths in the last two decades is largely accounted for by heroin and other non-Rx use, which are a tiny population with a very high (and rising) death rate. The rising death rate is mostly due to the surge in black market sale of fentanyl as "heroin."[3] (esp. figures 4-5 and associated text) (Perhaps as a result of DEA and other restriction on the supply of the relatively safer, but less dense, heroin, and restriction on supply of the vastly safer prescription opioids.)
* Notably, the number of non-fentanyl-involved prescription opioid-involved deaths has actually been in decline since 2011![3] (fig. 4.), despite a rising population. Let me echo that since it's really important: prescription opioid-involved overdose, ex fentanyl, both in number and per capita rate, HAS BEEN IN DECLINE SINCE 2011! Why doesn't any news story on opioids in the US headline with that? The primary reason the overall prescription opiate-involved death rate hasn't tracked that decline is rising co-(ab)use with illicit fentanyl, and its relatively higher death rate.
If we could wave a magic wand and wipe (illicit) fentanyl off the earth, our annual opioid death rate would fall by something like half.
That magic wand is allowing doctors to prescribe safe opiates to addicts, providing safe places they can use, and providing support and means to quit. It's not magic. Many places around the world are doing it. Eliminate the black market and you eliminate those deaths. Our government and society are simply not interested in eliminating those deaths. Places like Portugal, Switzerland, Vancouver bc have been waving that magic wand for decades.
Sure, that's one harm reduction technique that works as long as doctors (and Governments) are willing to prescribe the amount of opioids that addicts want. I touched on the same technique in an earlier, longer form version of the same comment (in response to a slightly different thread the other day):
Given we don't have a magic wand, what can we do? Obviously we can't stop fentanyl
from entering our borders or being synthesized illicitly here. We can (and have)
leaned on illicit fentanyl-producing countries like China and Mexico to make those
businesses less lucrative. We can do harm reduction things for the vulnerable
population — which is mostly heroin users. We could legalize heroin with a
prescription for existing addicts?
Harm reduction stuff: Provide free/cheap testing for fentanyl adulteration? Make
naloxone available without prescription, on the shelf, for cheap or free, and
encourage businesses and residents to keep some around, even if they aren't users and
don't know any users? Maybe provide monitored, safe injection sites where addicts
overdosing can be assisted immediately if needed but are not arrested or forced into
any overbearing programs. Maybe even supply quality- and quantity-controlled heroin
to these addicts for use on-site to reduce likelihood of overdose and even allow
people to taper off if they want to.
It's still nearly equally magical to wishing fentanyl away in that effecting such a policy is incredibly difficult politically (US, anyway).
Pick any level of government. This doesn't really have populist mandate even in Blue states and you can be damn sure Republican Governors are going to reject any "give drugs to addicts" proposal on their desk, if it even makes it through state legislatures. Meanwhile, Congress is stalled with a Democrat-controlled house and a Republican Senate that won't pass any laws. I don't see Trump taking ... positive executive action on this, either.
Maybe some harm reduction can be done at the municipal level, but that probably leaves some of the worst hit parts of the country (rural areas in Red states) without help.
Yeah we're going to continue to kill hundreds of thousands more people before this will even start to be discussed by politicians because our politicians are incredibly stupid and closed minded. But maybe if enough people die, things will change, possibly through voter referendums. I never thought legal marijuana would be a thing, yet it is (federal laws notwithstanding). Once people in states with referendums get tired of their friends and family dying by the thousands, maybe they'll act. Current politicians sure won't. But these primitive morons will eventually die themselves, hopefully sooner rather than later, and hopefully their replacements will be slightly less idiotic, more pragmatic, or perhaps even compassionate. Stranger things have happened. That's why we must continue to advocate for the only solution that has been proven to work despite the challenge of getting it implemented. One day we will look upon the drug war and its perpetrators the way we look at Nazis now. Or our children or grandchildren will. That I'm certain of. How far down the line, no one knows.
Sorry, that wasn't really the idea I was trying to express at all. The two points are "using opioids as prescribed by Dr" => "using the same opioids in a way that was not prescribed."
I know off-label is specific industry jargon and it doesn't mean the way I tried to use it; sorry for the confusion.
Totally agree that chronic pain is a hard problem and tolerance effects make opioids a non-ideal long term solution. That said, I am neither a Doctor nor a researcher in the pharma industry so I don't have a lot of helpful suggestions for anything better than opioids today.