[INTERVIEW] Korea advised not to follow US model in war on drugs

Jesus, a drug producer, shows an image of fentanyl on his phone in this March 2022 file photo. Reuters-Yonhap

US expert warns of negative consequences of regulating prescription opioids amid drug overdose concerns in Korea

This is the first in a two-part series about controlled substance abuse to highlight its fatal consequences on public health ― ED.

By Kang Hyun-kyung

Controlled substance abuse and its fatal consequences have become a common headache for policymakers in Korea and the United States, since doctor shopping or visiting multiple physicians to obtain multiple prescriptions recently emerged as a major public health problem in Korea.

The United States has been grappling with the opioid epidemic for decades. Since 2000, more than 500,000 people have died in the U.S. due to opioid overdose. And the situation became worse during the coronavirus pandemic.

Opioid overdose deaths have increased dramatically since 2019. In 2021 alone, over 100,000 people died in the U.S. due to opioid overdose. Among others, heroin and synthetic opioids, such as fentanyl, have become the leading contributors to the surge in opioid overdose deaths.

In Korea, an appetite suppressant phentermine was prescribed to 1.28 million patients in 2021 alone ― over 240 million pills in total. That boils down to an average prescription of 191 pills per patient.

Phentermine is a stimulant with various serious side effects. According to Drugs.com, an overdose of phentermine can be fatal. The prescription of fentanyl to teens and patients in their twenties has dramatically increased in recent years.

In Korea, controlled substance overdose is a relatively recent phenomenon and specific data about mortality rates are currently unavailable.

However, substance overdose is likely to develop into a public health crisis, like the current opioid epidemic in the United States if it is not tackled early.

The two countries' shared experience in controlled substance overdose, albeit with different types of drugs, raises a question about the possible policy implications for Korea: Can U.S. policy responses be replicated in Korea to prevent overdose deaths?

Jeffrey Miron, a professor of economics at Harvard University

Jeffrey Miron, a senior lecturer and director of Undergraduate Studies at the Department of Economics at Harvard University, says the U.S. government's policy measures were ineffective and therefore cannot be a model for Korea in its war on drugs.

Among others, he claims that regulations on prescription opioids have caused the situation to go from bad to worse, rather than improving it.

"My position is that opioid deaths result mainly because, in an underground market, consumers do not have good information on the potency and quality of the goods they consume," he said in a recent email interview with The Korea Times. "Opioid deaths are increasing because the black market version of heroin and other opioids are often laced with fentanyl, which is extremely potent, and consumers have no easy way to determine potency and adjust their dosage."

In the United States, opioid deaths have continued to increase since the 1990s due to an increase in the prescription of opioids and pharmaceutical companies' aggressive marketing efforts.

To combat the overdose of prescription opioids, the U.S. government and Congress have introduced a range of legislations to limit access to opioids.

Many U.S. states have introduced drug-monitoring programs designed to curtail doctor shopping and overprescribing. The U.S. government raided pain management facilities that prescribe high quantities of opioids.

In 2017, the U.S. Department of Justice launched the Opioid Fraud and Abuse Detection Unit as a three-year pilot program to strengthen monitoring of physicians and pharmacies deemed to be dispensing "disproportionately large amounts of opioids."

Its data-analytics team tried to "identify physicians who wrote opioid prescriptions at a rate that far exceeds their peers, the average age of patients receiving prescription opioids and how many doctors' patients died within 60 days of an opioid prescription."

In April, Korea created a team at the Ministry of Food and Safety consisting of experts in the public and private sectors to strengthen monitoring and oversight of prescription opioids and opioid overdose, a measure similar to the U.S. Department of Justice's 2017 program.

In the wake of the restrictions, prescription drug use in the United States went down. Opioid deaths continued to rise between 2016 and 2019, but the annual rate of increase in deaths slowed.

The Congressional Budget Office's report released in September 2022 stated uncertainty of whether the slowdown in mortality rates reflects the effectiveness of the U.S. government's measures.

"It is difficult to determine whether the observed changes in deaths and the use of prescription opioids can be attributed to the laws," the report said.

Plastic bags of fentanyl are displayed on a table at the U.S. Customs and Border Protection area at the International Mail Facility at O'Hare International Airport in Chicago, Illinois, in this 2017 file photo. Reuters-Yonhap

Miron is critical of restrictions on prescription opioids. He claims that the medical use of opioids is not a major cause of addiction and overdose deaths.

He said restrictions on legal opioid access, ironically, contributed to increasing opioid deaths as patients, facing difficulty in getting prescriptions, switched to illicit drugs such as heroin and illicitly manufactured fentanyl. The highly potent and uncontrolled alternative medicine led to an increase in opioid overdose mortality, according to Miron.

The situation has gone from bad to worse.

COVID-19 has triggered another wave of opioid deaths in the United States. Opioid overdose mortality rates surged during the pandemic. In 2020, 68,630 people died from opioid overdoses. The figure went up again to 107, 477 in 2022.

A popular narrative points to Americans' worsened mental health, social isolation and jobless rates during the pandemic, as the key factors that contributed to the dramatic rise in opioid deaths in the United States.

But Miron disagrees.

"Those factors may well have exacerbated the situation. But the opioid overdoes rate had been increasing for a good 15-20 years before COVID, so I doubt the pandemic was the major factor," he said. "Similarly, the upward trend accelerated around 2011, well before COVID. That was probably because of new restrictions on oxycontin."

He claimed that crackdowns on drug trafficking will also reveal limitations to curbing opioid deaths.

"I don't think international or domestic efforts have anything more than minor effects on reducing trafficking. The history of virtually all prohibitions is that they reduce the outlawed activity only a little while reducing quality control significantly and causing violence and corruption," he said.

He made the remark when asked to comment on the latest international crackdowns on illicit drugs.

The United States joined hands with law enforcement of the European Union and South America in "Operation SpecTor" to disrupt fentanyl and opioid trafficking on the dark web. It resulted in record arrests and the seizure of 117 firearms and 850 kilograms of drugs that include 64 kilograms of fentanyl or fentanyl-laced narcotics.

Miron warns of rising crime rates following crackdowns on illicit drugs.

When law enforcement interferes with underground drug markets, supply chains and related "agreements" between underground participants are disrupted, he said.

"This means more disputes over territory, prices and so on (as in any market). But in underground markets, the participants cannot resolve with courts and use violence instead." Hence, the rise of homicide crimes, he said.

The liberal economist calls for scaling back government regulations on prescription opioids.

"The best response is to reduce or eliminate the legal restrictions on producing, selling and purchasing opioids so that these are bought and sold in an aboveground, legal market," he said. "Ideally, this would mean outright legalization, but there are also partial measures that would shift demand away from the black market. For example, increasing the ability for physicians to prescribe, or for expansion of opioid maintenance therapies under which users get a regular dose from a doctor or clinic."

A vial containing two milligrams of fentanyl, which will kill a human if ingested into the body, is shown at the Drug Enforcement Administration (DEA) Special Testing and Research Laboratory in Sterling, Va., in this 2016 file photo. AP-Yonhap