Origins of the Opioid Crisis

A vast number of doctors and writers have detailed the origins of the opioid crisis. However, there are some disagreements as to the true root cause of the crisis. Teresa A. Rummans M.D., a psychiatrist at the Mayo Clinic, details how the good intentions of doctors have been a major cause of the opioid crisis in her article in the Mayo Clinic Proceedings, “How Good Intentions Contributed to Bad Outcomes: The Opioid Crisis.” Nabarun Dasgupta PhD, MPH, is a senior research scientist at the University of North Carolina Chapel Hill. His article in the American Journal of Public Health “Opioid Crisis: No Easy Fix to Its Social and Economic Determinants” argues that the opioid crisis was not caused by a single factor, but could have begun for a multitude of reasons. The National Institute on Drug Abuse is a federal organization which has been tasked with finding solutions to drug abuse since its inception in 1974. In its article “Opioid Overdose Crisis,” the evolution of the opioid crisis is traced back to the early 90’s when opioids became more readily available to the general public for chronic pain. The Henry J. Kaiser Foundation is a nonprofit organization which focuses on major healthcare issues affecting the United States. Its data table “Opioid Overdose Deaths by Race/Ethnicity” details the number of overdose deaths by state, ethnicity, and year ranging from 1999 through 2017. In their article in the Encyclopedia of Drugs, Alcohol, & Addictive Behavior titled “Opioid Dependence: Course of the Disorder Over Time," Pamela Korsmeyer and Henry R. Kranzler detail risk factors for addiction, effects on the brain, and how easy it is for one to become addicted to opioids. Thomas R. Kosten, M.D. is the founding Vice Chair for Addiction Psychiatry of the American Board of Psychiatry and Neurology. His article “Opioid dependence treatment: options in pharmacotherapy” in the journal Expert Opinion on Pharmacotherapy details why opioids are so physically addictive; in particular, how they stimulate the pleasure centers in human brains similar to the way the pleasure centers are stimulated when one has sex or eats food. Claire Felter is a journalist for the Council on Foreign Relations; she holds a bachelor's degree in international relations from Tufts University and a master’s degree in journalism from Boston University. In her article “The U.S. Opioid Epidemic” she details not only the statistics behind the outbreak but the international influence that caused such a crisis.

The American opioid crisis is a public health debacle that has been ravaging millions of Americans for decades. However, in recent years there has been an incredibly dramatic spike in opioid use for nearly every demographic. In 1999, there were approximately 7000 overdose deaths caused by opioids. By 2017, the number of deaths has increased by 600% with over 47,000 deaths being attributed to opioids. There have been 3 distinct spikes in overdose deaths in the United States. The first spike began in the 1990’s when doctors and pharmaceutical companies began prescribing and producing massive amount of opioid-based medications for chronic pain. Overdose deaths attributed to prescription medicine began increasing at this time and continue to this day. The second spike began in 2010 due to the increased production of global heroin and a growing opioid dependant population in the United States. From 2010 through 2017 heroin overdose deaths increased by more than 500% (CDC). The third and hopefully final spike began in 2013 with the rise of synthetic opioids. Synthetic opioids, such as fentanyl and tramadol, are man-made drugs that mimic naturally occurring opioids like codeine and morphine. From 2013 to 2017 synthetic opioid overdose deaths have increased by over 900% and now account for nearly half of all opioid overdose deaths in the United States.

Despite the perception that opioid users are generally from rural communities, the use of opioids is constant throughout every community in the United States. Forty one percent of drug overdose deaths occur in urban counties, 26% in the suburbs, 18% in small metropolitan areas, and 15% in rural communities (Dasgupta 184). This crisis is affecting the lives of every single American no matter their socioeconomic status. In particular, Native Americans are disproportionately affected by overdose deaths as their access to life-saving opiate reversal drugs is extremely limited. That being said, the group that has been hit the hardest by the crisis is middle-aged whites without a college degree. This group is the first in American history outside of war time to have a shorter expected lifespan than their parents. This dramatic decrease in lifespan is a direct result of the prevalence of opioids throughout the country as well as diminishing economic opportunity for those without a college degree.

Every day, more than 130 people in the United States die after overdosing on opioids (National Institute on Drug Abuse). Shockingly, Americans are now more likely to die from an opioid overdose than in a motor vehicle accident. The sheer number of deaths and the damage caused by opioids has forced the White House to acknowledge the crisis and create a plan for action. On October 26, 2017 President Donald Trump declared the opioid crisis a national Public Health Emergency under federal law: “I am directing all executive agencies to use every appropriate emergency authority to fight the opioid crisis,” the President said. It is becoming impossible for Americans to avoid the grim reality of the opioid crisis.

While it is largely accepted that the pharmaceutical companies are responsible for the creation of the opioid crisis, a multitude of factors have created the current public health epidemic. That being said, pharmaceutical companies are not relieved from blame. Their role in creating the crisis cannot be overstated.

Prior to the 1980’s, medical treatment for chronic pain was sparse. Individuals treated for chronic pain would be treated with cognitive behavioral therapy or in some cases hypnosis (Dasgupta 182). Pharmaceutical companies were quick to realize that with an increasing elderly population there was a market to capitalize on and began lobbying for the use of opioids. A 1980 paragraph from the New England Journal of Medicine claims that the use of opioids is safe beyond acute pain relief. The journal supports this claim with data from an unnamed study which says that only four out of 12,000 patients became addicted to opioids after use. This paragraph is subsequently “referenced over six hundred times in support of using opioids for chronic pain” (Rummans 345). The release of this five sentence paragraph became a catalyst the medical community needed to begin to treat chronic pain as a legitimate illness. Use of opioids was soon being advocated by physicians, pain organizations, and even the World Health Organization. It was beginning to seem like a new era of pain relief, and all involved were reaping the benefits. Pharmaceutical companies were enjoying incredible profit margins, physicians were being faced with fewer complaints from their patients, and patients saw their pain seemingly disappear.

By the early 2000’s pain relief was becoming a truly massive business. Pharmaceutical companies were garnering record high profits with the help of prescription opioids. Additionally, market withdrawals of popular opioid alternatives due to cardiovascular risk and acetaminophen toxicity created a great amount of concern about the use of non opioid pain relievers. (Dasgupta 182) Opiate producing pharmaceutical companies used this concern to even further expand their empire by creating incredibly lucrative physician kickback schemes and speaking tours in promotion of opioids. Despite the promotion, pharmaceutical companies were aware of the potential dangers of creating potent prescriptions modeled after a group of the most dangerous and deadly drugs ever created while the greater public remained largely ignorant of the pain cause by pain relievers. Soon enough, thousands of individuals were becoming increasingly addicted to opioid painkillers such as Codeine, Hydrocodone, and Fentanyl among many others. As potent as these painkillers are, the high achieved from synthetic and illicit opioids pales in comparison. Users began rapidly making the transition and death tolls began to soar: “80 percent of opioid abusers had a prescription for opioids before the start of their addiction… Fifty percent of opioid abusers who did not have a previous opioid prescription had a family member who did” (Rummans 348). Illicit opioids are also now more available than ever before, making it incredibly simple for one to attain the once rare drugs.

Availability has spiked primarily due to the growing scale of Mexican poppy farms used by drug cartels. Eight cartels control nearly all of the production and distribution of heroin that enters the United States. These cartels typically smuggle narcotics across the United States’ southern border in passenger vehicles or tractor trailers. Meanwhile, most of the fentanyl coming to the United States is produced in China and sent to cartels in Mexico for U.S. distribution. Chinese authorities “have struggled to adequately regulate thousands of chemical and pharmaceutical facilities operating legally and illegally in the country” according to a 2017 report issued by a congressionally mandated commission (Felter). With the growing scale of production operations for illicit opioids, it appears that this crisis is bound to continue to escalate.

Although prescription opioid painkillers were initially driving the crisis, by 2015 there were an equal number of deaths caused by illicit, synthetic, opioids which included heroin and fentanyl. As prescription opioid deaths level off, deaths from illicit agents continue to rise. While it may seem harsh to focus the blame for illicit use on pharmaceutical companies rather than drug dealers, opioids flooding into the homes of Americans introduced millions to even more addictive and harmful substances.

While the immediate implications of the opioid crisis are deadly to users, the crisis is forcing the hand of the United States government to modernize their antiquated health care systems and policies. The US Surgeon General released several resources in an attempt to educate the public about the catastrophic effects opioids can have on individuals. In addition, he created an online pledge that prescribers can take to indicate their support for prescribing opioids more carefully. Many other federal organizations have followed his lead and have created in depth educational resources. These resources primarily detail the signs of opioid addiction or how to administer life saving medicine to one who has overdosed. While these resources are helpful, they will not change the entire course of the epidemic. This is a common problem governmental agencies have, wishfully thinking that education or punishment will decrease drug use rather than taking steps to change the laws and culture that created the drug use. If major changes are not made in the near future opioid overdose will become the 8th most common cause of death in the United States by 2020. (Henry J. Kaiser Family Foundation)

If the United States wants to change the course of the crisis entirely they must begin to implement a system similar to that of Portugal’s in the early 2000’s. In the 1990’s Portugal was in the midst of a crippling heroin epidemic so devastating that Lisbon was crowned the heroin capital of Europe. This all changed after a law implemented in 2001 that focused on rehabilitation rather than punishment. With the backing of the medical community the law decriminalized the use and possession of up to 10 days worth of drugs for individual use. Instead of being sent to prison individuals caught by police are sent to a local three person panel. This panel usually consists of a lawyer and 2 medical professionals who will determine whether or not an individual is addicted and suggest treatment as needed. This law has dramatically reduced heroin deaths and has promoted a healthier culture for all Portuguese citizens. According to a New York Times report the number of heroin users has dropped from over 100,000 to 25,000 since the creation of the law. Portugal now has the lowest drug mortality rate in Western Europe and is a fifteenth of the current rate in the United States. Additionally, HIV diagnoses caused by injection have dropped by over 90 percent.

If the United States continues to favor a system of education and punishment rather than clinical treatment the opioid crisis will only continue to spiral out of control. It is important to understand that addiction is a chronic disease not a crime. The belief that opioid dependency is merely a drug problem leads many addicts on a desperate search to rid themselves of the drug as quickly as possible. If abstinence is achieved without acknowledging the brain disease components of addiction, abstinence will be short lived (Kosten 176). The reluctance of the United States to create change for a healthier and happier population has cost millions of dollars and the lives of thousands of Americans.

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