As the country’s deadly overdose epidemic continues to worsen, doctors are all but ruling out one contributing factor: overprescribing of painkillers.

According to a provisional count compiled by the Centers for Disease Control and Prevention, for the 12 months ending December 2022, drug-overdose deaths topped 109,000. That’s up from over 107,000 the year prior. 

The overdose epidemic is in large part due to the illicit drug supply, namely manufactured fentanyl, fentanyl analogs, stimulants and other substances.

Prescriptions have gone in the opposite direction, falling by nearly 50% nationally. Physicians and other healthcare professionals have reduced opioid prescribing in every state. 

Last year marked the 13th straight year the figure has dipped, observed the American Medical Association (AMA), whose substance use and pain care task force authored the report. 

The physician community “is working on multiple fronts to remove barriers to evidence-based care for patients with substance use disorders and pain,” noted Dr. Jesse Ehrenfeld, AMA president. 

“Progress in reducing deaths, however, has been incredibly difficult due to a combination of factors,” Ehrenfeld added.

Not the least of those is the rise in illicitly made fentanyl, methamphetamine and cocaine. The rise in overdose deaths due to synthetic fentanyl began in 2014, the physician group recalled. In 2019, cocaine and methamphetamine killed more people than heroin or prescription opioids. In 2020, deaths related to illicit fentanyl topped 56,000.

Reductions in prescribing have not stemmed the grim tide. From 2012 to 2022, per IQVIA data, opioid prescriptions declined from 260.5 million to 131.9 million. 

Yet, the deaths continued to pile up. During the COVID-19 pandemic, for instance, drug-overdose rates accelerated among both men and women of nearly all races, and from younger to older demographics. 

As of May of this year, overdose deaths had risen another 2.5% versus the prior 12-month period, according to preliminary CDC data updated in October. 

In most of those cases, synthetic opioids (excluding methadone) were the drug class most commonly implicated.

Now, Xylazine, or “tranq,” the veterinary tranquilizer which dealers use to cut fentanyl, presents the latest challenge. 

In 2021, the age-adjusted rate of drug overdose deaths involving xylazine was 35 times higher than the 2018 rate, increasing from 0.03 per 100,000 standard population to 1.06, AMA noted.

Other barriers Ehrenfeld pointed to include the continued stigma faced by individuals with a substance use disorder (SUD), and the fact that health insurers, “year after year, continue dragging their feet and are not stepping up to help patients access evidence-based care.”

Among its recommendations, AMA called on state insurance departments to “meaningfully enforce” mental health and SUD parity laws. The Mental Health Parity and Addiction Equity Act was enacted in 2008 to protect individuals with a mental illness or substance use disorder. But the law needs stronger teeth to compel compliance by plans.

More must also be done to address racial disparities and health inequities, the physician group added. Drug-related overdose and death disproportionately impact Black and Brown Americans. 

American Indian and Alaskan Native men aged 15 to 34 years old have been dying at the highest rate for younger men. Older Black men have perished at the highest rates overall. Underlying social needs, such as housing and transportation, have “amplified” the issue. 

Efforts should focus on removing barriers to care disproportionately experienced by these patients. AMA urged physicians to prescribe medications to treat opioid use disorder to their Black and Brown patients with an opioid use disorder.

This past year, the Food and Drug Administration approved an over-the-counter version of naloxone, which reverses the effects of narcotics. But barriers to methadone and buprenorphine — first-line therapy options for pregnant people with opioid-use disorder — still need to come down. Education for young people in avoiding the risks of overdose should increase, as well. 

All of which will require collaboration and partnership among state and federal policymakers, HCPs and other stakeholders.

“We must all work together to end the epidemic and relieve the suffering experienced by every community in the United States,” said Ehrenfeld.