The US is currently in the midst of an opioid crisis that has been getting worse for the past 20 years. According to the National Institute on Drug Abuse, more than 47,000 people died of opioid overdoses in 2017. That number includes overdoses from prescription opioids, heroin, and the synthetic opioid fentanyl. Roughly 1.7 million Americans have a substance use disorder related to prescription opioids and about 652,000 people had a heroin use disorder, which may also overlap with prescription opioid use.
There have also been serious secondary effects of the opioid crisis, including an increase in the number of newborn babies with neonatal abstinence syndrome, or babies going through opioid withdrawal as a result of their mothers using opioids during pregnancy. IV drug use has also led to the spread of infectious diseases such as HIV and hepatitis C.
The opioid crisis is clearly a public health emergency. The Centers for Disease Control and Prevention, or CDC, estimates that misuse of prescription opioids alone cost the US about 78.5 billion dollars a year in terms of healthcare costs, lost productivity, addiction treatment costs, and criminal justice involvement.
More than that, the opioid crisis has had devastating effects on countless individuals and families. According to a poll by the American Psychiatric Association, nearly one in three Americans know someone who is or has been addicted to opioids. The silver lining is that because so many people are personally affected by the opioid crisis, there has been a lot of political will to address it. This widespread contact has also helped reduce the stigma of addiction. About 80 percent of people in the poll said they believe people can recover from opioid addiction, up from 73 percent just a year before.
A Crisis in Three Parts
According to the CDC, more than 399,000 Americans died from opioid overdoses between 1999 and 2017–a really staggering number. However, the opioid crisis isn’t a single, monolithic trend, but rather it happened in three waves. In the first wave, overdose deaths from prescription opioids began increasing as a result of increased prescriptions in the 1990s. The second wave, beginning around 2010, saw a sudden increase in heroin overdoses. The third wave was a sudden increase in overdose deaths involving synthetic opioids, such as fentanyl, beginning in 2013.
These waves are connected in complex ways that are still being researched. Broadly, what appears to have happened is that the rise in prescriptions exposed many people to opioids who might never have used them. Some of those people became addicted and some of them went on to use heroin and fentanyl, which are cheaper and don’t require a prescription. Those who didn’t become addicted may have found themselves with a surplus of opioid painkillers on their hands, some of which were diverted for recreational use, increasing the general supply. For example, a teenager gets his wisdom teeth out and is given a month’s supply of Vicodin. He takes it for three or four days until the pain abates, then he sells the rest to friends and classmates. Considering roughly five million people get their wisdom teeth out each year, that can add up to quite a few pills floating around.
The Big Pharma Marketing Push
It’s no accident that opioid prescriptions began to rise in the 1990s. People had been using various poppy extracts for millennia but by the mid-twentieth century, opioids had become stigmatized. In the 1980s, there was growing recognition that medical professionals weren’t taking their patients’ pain seriously enough. Opioid use was at that time mostly restricted to terminal cancer patients but some doctors began advocating the use of opioids to treat chronic pain. Unfortunately, this ignored the important differences between pain caused by cancer and pain from other causes. In 1995, the American Pain Society launched an influential “pain as the fifth vital sign” campaign, which was supported by the Veterans Health Administration. Soon, doctors were mandated to provide adequate pain treatment, for which they typically relied on opioids.
This is where the pharmaceutical companies come in. Seeing this trend toward greater pain management, they promoted their opioid painkillers as safe and effective, with minimal risk of addiction. Between 1997 and 2002, OxyContin prescriptions went from 670,000 to 6.2 million–an almost 10-fold increase.
You might think this was just good positioning, that drug makers were just benefiting from the climate of increased awareness of the need for pain treatment. To a certain extent, that is true but the marketing practices of some firms were problematic, to say the least. For example, Purdue Pharma aggressively marketed OxyContin in a number of ways. They hosted all-expenses-paid conferences, which were attended by more than 5000 doctors, nurses, and pharmacists. They also collected huge amounts of data on doctors and specifically targeted the doctors who were most liberal in prescribing opioids. They offered large bonuses to salespeople who sold more OxyContin. Perhaps most disturbingly, they started a patient coupon program that offered patients a free, limited prescription to a seven to thirty day supply of OxyContin. By the end of the program, about 34,000 coupons had been redeemed. This whole time, Purdue representatives were insisting OxyContin was less addictive than other opioids, despite knowing this was false.
In 2007, Purdue Pharma pleaded guilty to misleading the public about OxyContin’s addiction risk and was fined 600 million dollars, one of the largest fines ever against a pharmaceutical company. Several of the company’s top executives also pleaded guilty to criminal charges and paid a total of 34.5 million dollars in additional fines. In comparison, between 1995 and 2001, OxyContin made about 2.8 billion dollars for Purdue. That wasn’t the end of Purdue’s troubles, though. Last year, the company filed bankruptcy to protect itself from more than 2600 state and federal lawsuits related to its role in the opioid crisis. It’s important to note that while Purdue has gotten most of the attention, it’s not the only drug company on the hook for the opioid crisis. Johnson & Johnson, Mallinckrodt, Teva, and large distributors such as McKesson, and Cardinal Health, among others, have recently agreed to settle lawsuits.
Because of the general concern for treating pain and aggressive marketing by drug companies, opioid prescriptions continued to rise through the late 1990s and 2000s. As noted above, this fueled the opioid crisis in two ways: first, by exposing more patients to powerful opioids and second, by making prescription opioids more widely available. Many of the prescriptions were made in a sincere attempt to address patients’ pain issues, and in many cases, hospitals feared losing federal funds if they didn’t treat pain adequately, which gave doctors an incentive to err on the side of overprescribing.
However, in many cases, these overprescribing practices continued long after it was clear they were contributing to the opioid problem. For example, researchers from Johns Hopkins School of Public Health examined nearly 350,000 opioid prescriptions, written by nearly 20,000 surgeons between 2011 and 2016–when it was already clear that opioid addiction had become a public health emergency. Some surgeons prescribed as many as 100 opioid pills in the week after surgery–far more than the recommended 10 pills for most comparable procedures and even the 30 pills recommended following cardiac bypass surgery.
Of particular concern is prescribing opioids to children and teens, since early exposure to drugs increases the risk of substance use issues later on. There have been many cases of teens becoming addicted to opioids following surgery for sports injuries and for wisdom tooth extraction. One study found that teens who were prescribed opioids following wisdom tooth extraction were nearly three times more likely to develop an opioid use habit than teens who weren’t. The risk was compounded by other factors such as preexisting depression or anxiety.
The relationship between opioid prescriptions and opioid use disorder is the subject of ongoing research but according to the National Institute on Drug Abuse, between four and six percent of people who misuse prescription opioids eventually transition to heroin and about 80 percent of heroin users started with prescription opioids.
While the sheer volume of opioids prescribed in the 1990s and 2000s was the primary cause of the opioid crisis, other factors may have made it worse. One significant factor may be unemployment. There is a well-known correlation between high unemployment and high rates of fatal opioid overdoses, particularly in areas like West Virginia, Ohio, and New England. What those correlation means continues to be a topic of lively debate. We’re not yet sure if the two factors are directly related or, if so, which direction causation primarily runs. For example, one influential study found that high rates of opioid use made more people drop out of the workforce, while critics of this theory plausibly argue that this is largely coincidence and the underlying factors remain elusive.
Whether causality might run the other way is equally uncertain. One influential study found that opioid deaths among working-age adults increased in counties where automotive assembly plants recently closed, lending credibility to the popular “deaths of despair” hypothesis. This is the idea that an increase in deaths from suicide and drug and alcohol use stems at least in part from a loss of meaning. This may be caused by a number of factors, including social isolation and lack of economic opportunity, including high unemployment. Losing a job, especially when there’s little prospect of finding another, is a significant blow. The longer you remain unemployed, the more likely you are to become depressed, which is a major risk factor for substance use. It’s worth remembering that the Great Recession happened in 2008, right in the middle of the opioid crisis, doubling the national unemployment rate to just over 10 percent.
Some jobs are associated with higher addiction risks. For example, lawyers are at especially high risk for mental health issues and substance use issues because of the high stress and long hours they work. One study found that lawyers were about twice as likely to have an alcohol use disorder and four times as likely to have depression compared to the general public.
However, when it comes to opioid use, people who work in construction and mining seem to have the greatest risk. In one study, researchers analyzed data from more than 293,000 adults from the National Survey on Drug Use and Health. They found that people who worked in construction trades and extraction were most prone to misusing opioids–about 3.4 percent, compared to about 2 percent of other workers. There are a number of reasons for this. Perhaps most importantly, these jobs are physically demanding and workers often have to work despite pain ranging from soreness to moderately severe injuries. What’s more, these jobs are often in unsafe and unpredictable conditions, adding to the daily stress. Often, people who work in these industries travel for work and spend weeks at a time, away from family and friends, adding loneliness to the hazards of the job. Workers may take opioids with or without a prescription to cope with these difficulties. Often, opioids are a quick fix to keep a worker on the job in remote areas. Mining and timbering are especially common jobs in West Virginia, the state that always leads the US in fatal opioid overdoses.
Fentanyl is a cheap and potent synthetic opioid that is about 50 to 100 times more potent than morphine. It is mostly responsible for the sharp increase in opioid-related deaths in the past five years or so. The graph of fatal overdoses by opioid type between 2000 and 2017 makes this especially clear. Deaths from prescription opioids level off starting in 2011 and deaths from heroin begin a steep but linear rise starting around 2010. However, starting in 2013, fatal overdoses from synthetic opioids begin an exponential rise and by 2017, twice as many people die from synthetic opioids as from heroin.
Cheap, typically illegally manufactured fentanyl has flooded the market. People often use it because it is cheaper than heroin and they get addicted to it quickly because it is so potent. It is also frequently added to other drugs, including cocaine and heroin, without the user’s knowledge in order to intensify the high and keep the cost down. Often, buyers don’t really know what they’re getting. Perhaps the most famous example of this is Prince, who died of an overdose after taking what he thought was Vicodin but was really a counterfeit drug laced with fentanyl.
Limited Treatment Options
The last major factor is the lack of convenient and affordable treatment options. Many of the areas hardest hit by the opioid crisis have decentralized rural populations. That includes West Virginia, Ohio, New England, areas in the South, and, increasingly, areas in the midwest. While there are plenty of treatment options in even mid-sized cities, you may be lucky to find a single AA meeting in a remote small town, much less intensive treatment program, a quality therapist, or a doctor certified in addiction medicine. You may have to drive an hour for even basic services, a problem that may be compounded by difficult terrain. That means that people who may be at higher risk for slipping into the trap of addiction also have fewer opportunities to escape.
What’s being done?
As noted above, the silver lining of the opioid epidemic is that people really understand the urgency of the problem and are more willing to embrace therapeutic measures rather than the punitive approach of the war on drugs. As a result, there have been a number of measures introduced at the local, state, and federal levels. The opioid crisis is a complicated problem and will need many kinds of solutions. Some of these include harm-reduction measures, such as needle exchanges and safe-injection sites. Research shows these are effective for reducing overdose deaths and slowing the spread of infectious diseases but they nevertheless remain controversial. One more widely embraced measure has been to make the overdose-reversing drug naloxone more widely available without a prescription. First responders, as well as family members of people with opioid use disorder, can keep this drug handy and reverse an overdose in a matter of minutes.
There are also more ambitious programs at the state and federal levels. The hub-and-spoke system, for example, has effectively reduced overdose deaths in Vermont by bringing care to more isolated populations. At the federal level, Congress passed the SUPPORT Act in 2018. It’s a large bill with many initiatives, including more federal money for research, allowing MediCare and MedicAid to pay for more treatment options, closer prescription monitoring, and supporting telemedicine to provide people in rural areas more opportunities to consult with addiction physicians.
The opioid crisis is a huge problem and it will likely take years before overdose rates fall back to 1990 levels, if they ever get there at all. It’s certainly an easier problem to create than to solve. What’s clear is that there are solutions at both the individual level and the national level. If you or someone you love is struggling with opioid use, recovery is possible. At Steps Recovery Centers, we use the time-tested 12-steps as the basis of our individualized treatment program. To learn more about our treatment options, call us today at 385-236-0931 or explore our website.