How the Opioid Epidemic Came to Be

The book Dreamland: The True Tale of America’s Opiate Epidemic (Quinones, 2015) traces the interwoven threads and historical events that, combined, created the significant eruption of opioid misuse, opioid use disorder, and opioid-related deaths in the U.S. The number of individuals using heroin, as well as the number with opioid use disorder where heroin was the substance used, more than doubled in the years between 2002 and 2014 (NIDA, 2018). While the timeline presented in the analysis began in 1804 with the distillation of morphine from opium for the first time, the story gained momentum during the 1990s with:

• Xalisco Boys heroin distribution system evolved across multiple cities and states in the U.S.
• OxyContin (time-released oxycodone) becomes available and heavily marketed for treating chronic pain
• first “pill mills” (as pain clinics) emerge on the scene
• health care providers are urged to assess and manage pain as “the fifth vital sign.”

The development and marketing of new (lucrative) opioid formulations, combined with prescribers’ inadequate training about addiction, sincere wish to alleviate patients’ pain, and dependence on positive patient evaluation ratings contributed to opioid overprescribing practices, not to mention ethically questionable “pill mill” practices (NAS, 2017). As the number of opioid prescriptions dispensed in the U.S. nearly tripled from 1991 to 2011, there was a parallel near-tripling in the number of opioid-related deaths (NIDA, 2018). The intense (and apparently misleading) opioid marketing practices of various drug companies has led to a series of multi-billion dollar lawsuits against the companies by individuals surviving opioid addiction, family members of individuals who died from opioid use, and communities facing staggering costs from law enforcement, emergency response, and health/mental health/addiction care services required in response to increased opioid misuse. Concurrently, Mexican and Columbian heroin sources expanded dramatically across the U.S., making an easily injectable white powder form of heroin easily accessible and relatively low-cost: major factors in heroin use initiation by many individuals (NIDA, 2018). Fentanyl entering the country through Mexico and China are also major contributors to the crisis.

According to the timeline, concerns about overdose deaths began to be expressed in the early 2000s; while heroin addiction and overdose had historically been recognized as problems in urban, minority communities, the problem was emerging in new populations, new geographical areas, and explosively larger numbers. In 2008 drug overdose surpassed auto fatalities as the leading cause of accidental death in the U.S (Quinones, 2015). For instance, in Ohio’s Franklin County, the number of accidental drug overdose deaths increased by 71% during the four years between 2012 and 2016 (https://adamhfranklin.org/opiateactionplan/). By 2014, concern about the addictive behavior pattern of shifting from pain pills to heroin was evident, too (Quinones, 2015). It is possible that making opioid drugs (OxyContin in 2010, for example) more difficult to misuse—harder to dissolve or crush for injection or “snorting”—may have contributed to an increase in heroin use (Evans, Lieber, & Power, 2017). Again in Ohio’s Franklin County, the number of persons infected with Hepatitis C (often associated with intravenous drug use) increased by 68% between 2012 and 2016 (https://adamhfranklin.org/opiateactionplan/).

On the illegal drug market, fentanyl is a favored product because what might cost 1-2 cents to purchase from suppliers (the front end of the distribution chain) might end up being sold “on the street” for $10-$20 (the back end of the distribution chain) (NAS, 2017). By comparison, heroin might be less expensive than pharmaceutical opioids on the front end of the distribution chain, fentanyl is much less expensive than heroin, making it a far more lucrative product in which to traffic (NAS, 2017).

Strategies to address the opioid problem traditionally fall into 4 general categories (NAS, 2017):

1. create abuse-deterrent formulations (non-addictive forms) and alternative pain management strategies that may include behavioral health interventions with or without medication;
2. reduce supply/access/availability through efforts such as restricting lawful access through DEA scheduling, influencing prescribing practices and imposing prescription drug monitoring programs, training healthcare practitioners about substance misuse and substance use disorders, preventing diversion from legal to illegal use (e.g., with easy to access, regular drug take-back programs to eliminate access to leftover drugs), and addressing pharmaceutical company marketing practices;
3. reduce demand through patient and public education campaigns, promote access to evidence-supported treatment for OUD, initiate treatment engagement efforts with individuals who experience overdose, need for emergency department care, or other health-related consequences; and,
4. reduce harmful consequences associated with use, such as overdose prevention and response efforts (e.g., dissemination of opioid overdose reversal training and kits), supervised drug injection sites, disperse tools for checking “street” drugs for fentanyl, wound care education for individuals engaged in injection use, providing immunity from prosecution for possession of substances or paraphernalia when first responders treat an overdose event.

A combination of supply, demand, practitioner and public education, and legal/policy actions may be turning the tide. As previously noted, the trend statistics appear to have declined somewhat during 2018 compared to the most recent prior years. Persistence of vigilance is necessary, however, to ensure a continued decline with the hope of continuing to reverse the epidemic. Of concern, for example, are the previously presented data on youthful perceptions of the potential harm being lower than the perceptions of harm held by current adults.