I always find it helpful to recall that the US was the not the first country to be hit by fentanyl. Estonia, for instance, had a massive wave of fentanyl deaths that started before the US, without all the US prescription opioid consumption, and peaked sooner. Currently, their opioid supply has moved beyond fentanyl to derivatives that are even less safe.
It seems to me that the problem was not overprescription per se. Rather, as in Estonia, there seems to be spiral where opioids are seen as acceptable drugs of abuse (entering into the space of marijuana, alcohol, tobacco, and ecstasy), illicit suppliers elect to increase the addictiveness and potency of their drugs, and we end up with much more deadly drugs.
The biggest problem US docs created was removing the social stigma against opioid use and abuse. We created a perception that being addicted to opioids was no big deal, mostly safe, and something that people could do without losing all their social standing.
Does decriminalization work? Nowhere near as well as cultural barriers. Portugal, for instance, has safe injection and all the rest, yet it is experiencing a new wave of heroin use as old addicts return to heroin thanks a weakened economy. And lest we forget the difference in price for legitimate opioids and heroin/fentanyl is not all that high. Legitimate heroin supplies are going to cost at least as much as black market opioids so I suspect we will still have a lot of users who end up on fentanyl derivatives (for which there are no safe prescribing guidelines, nor even data for simple things like LD-50).
As with most major problems, the cause and solution are likely to be social. Historically, these sorts of epidemics die down as people die and the younger users decide to not try the things that killed all their older peers. Quite possibly all our “harm reduction” strategies and treatments will delay this process and leave more people dead; a first pass analysis of mass naloxone treatment suggested that it was associated with difference in difference increase in the opioid death rate due to increased use.
Unfortunately, I see no way out of the current situation that does not risk leaving many, possibly more than current rates, people dying.
That is from a commentator named Sure.