The Current Crisis
While humans have been using — and abusing — poppy-derived drugs for millennia, a dramatic upswing in American opioid consumption over the last two decades represents a major modern public health crisis. The United States is in the midst of what is considered to be the first widespread misuse of prescription painkillers.
Compared to the rest of the world, America’s prescription opioid consumption is startling on its own. It’s not a surprise that we are the biggest consumer of prescription opioids, but just how wide that margin is will give anyone pause: Representing only 5% of the world’s population, the US uses 75% of all prescription opioids produced globally.
Opioids are currently the most effective treatment for acute and chronic pain, and mainstream acceptance of this medicinal use directly precipitated the epidemic. The general public views prescription opioids as much safer than heroin and without the same level of social stigma. The additional consistency in dosage and purity further contributes to this false sense of security. As a result, these medications have become the entry point into addiction for a skyrocketing number of first-time drug users.
The popularity of prescription painkillers has dramatically altered the public perception of the “typical” opioid user, with the dramatic increase in usage rates among whites of all socioeconomic statuses receiving the most mainstream attention. Over the last 20 years, these drugs have blighted communities in isolated areas far from inner cities. Appalachia was (and still is) among the hardest hit regions and appropriately became the canary in the coal mine for the rest of the country. As of 2014, West Virginia remained the state with the highest drug overdose death rate in the nation.
Additionally, urban opioid treatment programs are now serving an older population. In 2012, patients ages 50–59 became the largest group treated for opioid addiction in New York City. This is a stark contrast to what was seen in 1996 when a majority of local opioid users receiving treatment were under 40.
The opioid addiction gender gap is also closing: While men experienced a 237% increase in prescription opioid overdose deaths between 1999 and 2010, that same rate rose by 400% among women.
While impoverished rural Americans may be the most visibly devastated, this group is far from alone in struggling with opioid use. Private health insurance — a luxury uncommon to this group — claims related to opioid dependence diagnoses rose by over 3,000% between 2007 and 2014. The opioid epidemic has reached middle-class and affluent suburban communities.
Although media focus has been on non-urban white populations, the truth is that there has been a bump in addiction prevalence among all demographics. Opioid addiction among young, urban Black and Latino men has not vanished — it just has not seen anything near the meteoric rise witnessed among individuals who are older, non-urban, white, and/or female.
Urban populations are also struggling with a related but distinct drug often ignored in discussions about “the” opioid epidemic — fentanyl. In Baltimore, overdose deaths linked to this potent synthetic opioid increased by 600% between 2013 and 2015. A miniscule amount of fentanyl (about as much as a few grains of sand) can lead to a fatal overdose, and it is more frequently finding its way into other street drugs. Frequently found in counterfeit pills that imitate more expensive but less powerful prescription opioids, fentanyl has become an epidemic of its own in cities across the US and Canada. Some public health officials worry it may soon become as ubiquitous as less potent painkillers.
A Mounting Body Count
However, it’s the high death rates across all opioid types that are the most dramatic and illustrative example of the epidemic’s toll on our nation. According to the CDC, an estimated 78 Americans die of opioid overdoses every day. That’s another preventable death every 18.5 minutes. Thanks to the opioid epidemic, unintentional drug poisoning has surpassed car crashes in becoming the biggest cause of accidental death. For perspective, these death rates more than doubled between 2000 and 2014 and are now comparable to HIV/AIDS-related deaths at the epidemic’s peak in the early 1990s.
Unfortunately, lessons are not being learned: One retrospective cohort study published this year revealed that 91% of overdose survivors were able to obtain a new prescription, frequently from the same doctor who prescribed the previous near-fatal bottle.
Link to Infectious Disease
The prescription opioid epidemic has been directly responsible for an increase in intravenous drug-associated infections. While a majority of users swallow whole pills, others smoke, snort, or inject these drugs. These quicker routes to the brain enhance the high but also comes with greater risks for overdose and addiction. Those who opt to inject also expose themselves to infection by bloodborne pathogens, including HIV and hepatitis C, which are on the rise in Appalachia.
Between the years 2006 and 2012, the states of Kentucky, Virginia, West Virginia, and Tennessee collectively experienced a 21.1% increased in admissions related to opioid dependency. Over the same time period, the incidence of acute hepatitis C infection more than tripled.
Another example of this phenomenon made headlines last year when Indiana experienced a major HIV outbreak with the small town of Austin at its epicenter. A total of 80 new cases were diagnosed in Austin in just a few months, bringing the total number of HIV-positive residents in the town to 190. With a population of roughly 4,200 people, Austin’s HIV prevalence was over 10 times the nation’s average.
The outbreak was directly linked to heavy IV opioid use in the town, specifically of a form of controlled-release hydrocodone called Opana. With a recent reformulation that made snorting the drug difficult, users turned to injecting Opana. Sharing needles was common, due in part to Indiana’s strict “drug paraphernalia” laws, which made obtaining and carrying clean needles difficult — and a potential felony charge. The outbreak waned after the introduction of a needle exchange program, which had previously been banned by state law with the (incorrect) assumption that providing clean needles would encourage IV drug use.
Well-meaning laws designed to curb prescription opioid abuse have resulted in a dangerous unintended consequence: Making prescription drugs more difficult to obtain has indeed reduced their misuse, but this strategy also lead to a sharp upturn in heroin use between 2010 and 2013. An estimated 80% of new heroin users were first addicted to prescription painkillers but switched to the cheaper, more accessible alternative, according to a Substance Abuse and Mental Health Services Administration report. This group then go on to use the two interchangeably.
As with opioids in general, addiction therapists have seen an interesting shift in the typical heroin user. This group has gone from troubled teenagers who turned to heroin as their first recreational drug to an older crowd with the average age shifting from 16 to 23. Heroin has likewise gone from a majority male (82.8%) drug in the 1960s to a more even split between genders in 2010. This new generation of heroin users are also predominantly white and living outside the inner city. Specifically, this population has gone from a roughly equal number of white and non-white users to over 90% white.
How it Happened
During the last two decades, opioids have been overprescribed at a scale similar to antibiotics. One 2012 study from the CDC found that 12 states had more opioid prescriptions than people, Alabama topping the charts at 143 prescriptions per 100 citizens. However, rather than being the root cause of the opioid epidemic, overprescription was (and still is) a symptom of wider problems that developed from a complex interplay of factors.
Changing Pain Management Philosophies
Starting in the 1980s, pain specialists began to favor an approach that included early detection and proactive treatment. While this practice is often a good thing in medicine, its indiscriminate application here resulted in patients who could have been managed with more conservative treatments being introduced to opioids earlier. The increased emphasis on better pain management shifted the discipline’s focus from cancer-related pain to broader applications — and opioid prescriptions from niche specialists to primary care.
In 2001, the Joint Commission on Accreditation of Healthcare Organizations’s first report on pain management emphasized that pain in the US was undertreated and suggested more frequent opioid use as a solution. According to the report, research indicated that the likelihood of abuse of such drugs was low. This report is often directly cited as being responsible for the uptick in prescriptions since, including inappropriate ones.
Following this shift, physicians were sometimes penalized for not prescribing opioids by way of low patient satisfaction scores. These scores were tied to how well pain was managed, but few physicians had adequate training in pain management. This lead to inexperienced doctors oversprescribing opioids at dosages that put patients at risk for addiction.
Many doctors eschewed the best practice guideline of lowest effective dose for the shortest length of time. Instead, it was not unusual for a month’s supply of high-dose opioid analgesic to be prescribed following minor outpatient surgery. While using the lowest effective dose of an opioid while recovering from serious surgery is unlikely to result in addiction, a person who takes opioids without accompanying pain will be more likely to experience euphoria and subsequent addiction.
This shift in treatment methodology is sometimes also attributed to health insurance company interests. Opioid prescriptions are relatively inexpensive compared to multiple specialists often necessary for effective interdisciplinary pain management. In this situation, encouraging physicians to prescribe opioids could be used as a cost-cutting strategy.
In 1996, Purdue Pharma introduced the first controlled-release opioid on the market, offering 12–24 hours of continuous pain relief. OxyContin’s marketing campaign emphasized its supposedly low addiction potential, assuring physicians that the drug was safe and effective for the treatment of chronic pain.
However, the large amount of pure oxycodone without other irritating medications, such as acetaminophen, proved to be extremely attractive for those already addicted to opioids. Within 48 hours, this group discovered that the tablet could be crushed for for immediate release. Despite this development, Purdue Pharma continued to market OxyContin as having low potential for abuse. While Purdue developed an abuse-deterrent formulation that prevented the full dose from being released at once, it wasn’t available until 2010. Even then, the feature could be bypassed with more labor-intensive methods. By 2012, OxyContin had a market share of 30% and abuse of the drug continued to soar.
Roughly a decade after OxyContin hit the market, the federal government filed suit against its manufacturer in United States of America v. The Purdue Frederick Company, Inc. Purdue pled guilty to charges of misleading doctors about the safety and addiction potential of its product and settled for $630 million, a fraction of the drug’s yearly revenue at the time.
Following the settlement, the attorney general of Kentucky filed an additional lawsuit in 2007. Kentucky has been one of the states hardest hit by the opioid epidemic, with OxyContin prescription and subsequent opioid addiction widespread among injured coal miners. After nearly a decade, the case finally settled in December 2015 with Purdue paying another $24 million.
But Purdue was guilty of something even more disturbing than misleading physicians. The company began tracking high volume OxyContin prescriptions when abuse of the drug was running rampant, identifying patterns that suggested drug abuse and trafficking. While this system had the potential to save lives, Purdue did not share this information with law enforcement until years later.
Other Healthcare System Failures
While it may be tempting to place all the blame on just two relatively narrow factors, a host of other issues within the US healthcare system gave the opioid epidemic fertile ground in which to flourish:
- The ability of patients to obtain multiple and contraindicated prescriptions in the first place revealed poor and non-existent coordination of care. A lack of basic communication between health professionals is a trend that hurts all patients.
- Gaps in healthcare access lead patients with chronic pain to self-medicate, leading to addiction.
- Even patients with some form of insurance are often unable to see a pain management specialist and instead rely on primary care doctors.
- Drug addiction co-occurs with many other mental illnesses. A lack of access to mental healthcare puts these patients at high risk. Additionally, untreated or poorly controlled anxiety and mood disorders are themselves risk factors for addiction.
- Through heavy restrictions, the federal government has made the study of medical cannabis extremely difficult. Medical marijuana has been shown to be safe and effective for the treatment of certain types of chronic pain. These effects may be less potent than opioids, but this is also paired with greater safety and significantly lower abuse potential. The DEA has also refused to reclassify marijuana, which is currently a Schedule I drug alongside heroin.
- Punitive sentencing and the War on Drugs in general drove those with opioid addiction underground and away from treatment, leading to longer-lasting and frequently fatal addiction.
Unfortunately, the high number of addicts in need of medical treatment has since increased the burden on an already strained healthcare system.
What Policymakers Are Doing to Address It
In recent years, government regulatory agencies at both the federal and state level are beginning to take action, tightening access to prescription opioids. Many states have enacted laws that dole out harsher penalties to dealers, traffickers, and doctors rather than users. Dealers in particular have begun to face manslaughter and murder charges from selling to a person who used their product to overdose.
Health and Human Services Opioid Initiative
The United States Department of Health and Human services launched its Opioid Initiative in March 2015. The stated goal of the program is to both address the opioid epidemic and investigate new evidence-based strategies in the treatment and prevention of drug addiction. Since then, the federal government has taken a number of steps to address the epidemic, including:
- Awarding $10.7 million to the 11 states most affected by the epidemic through the Medication-Assisted Treatment for Prescription Drug and Opioid Addiction program.
- Releasing updated detailed guidelines for managing chronic pain with opioids last March through the CDC.
- Encouraging more than 60 medical schools and 191 nursing schools to introduce and/or improve curricula to make it in line with the CDC Guideline
- Awarding over $30 million in Prescription Drug Overdose grants through the CDC to states for improving opioid prescription safety, which has lead to enhancement and overhaul of many Prescription Drug Monitoring Programs (PDMPs).
- Releasing a bulletin through the Centers for Medicare and Medicaid Services in January 2016 that addressed best practices for combating prescription drug overdose, misuse, and addiction.
- Awarding $94.2 million to underserved addiction treatment centers across the country in March 2016.
- Approving Probuphine, a buprenorphine implant for opioid dependence through the FDA.
- Expanding access to naloxone, an opioid blocker used to treat overdoses and prevent misuse by way of direct funding. The FDA also approved an easier-to-use intranasal spray, with an over-the-counter version in development.
However, as the most current data is from 2014, will not know the effects of these measure for quite some time.
Additional Federal Funding
Earlier this year, President Obama requested approval of $1.1 billion in funding to address opioid epidemic in FY 2017 and 2018. Thid includes $1 billion for addiction treatment and $500 million to expand state-level prescription overdose prevention strategies. The Appropriations Committee approved a 2017 Labor, Health and Human Services Funding Bill in July that included $581 million to address opioid epidemic, $525 million more than FY 2016. This includes $500 million for the state grant program but also includes a continued ban on funding needle exchanges.
Florida: A Case Study in Public Policy
Each state (with the sole exception of Missouri) has set up its own PDMP to track controlled substance prescriptions, looking for signs of misuse. The goal of these programs is to help pharmacists and prescribers identify at-risk patients and uncover drug diversions rings. Many states are also enacting “pill mills” laws and spending millions on their enforcement, but are these programs effective?
Considered by some to be the epicenter of the opioid epidemic, Florida found itself overrun by pill mills: illegitimate pain management clinics known for liberally handing out prescriptions regardless of actual medical need. To combat the issue, Florida passed anti-pill mill legislation that:
- Required pain management clinics to register with the state.
- Specified that such clinics must have a physician-owner.
- Created requirements for inspection of these clinics.
- Established prescribing and dispensing requirements, along with certain prohibitions for clinic physicians.
Florida’s pill mill law went into effect in July 2011. Since then, the state has seen a slight but statistically significant decrease in opioid that has been paired with a possible 25% decline in oxycodone-related deaths. A paper published October 2015 tracked opioid prescription and use between July 2010 through September 2012: one year prior to implementation of the pill mill law followed by a 3 month implementation period and one year after. The researchers saw a 1.4% decrease in prescriptions and a 5.6% decrease in morphine milligram equivalent per transaction. These decreases were observed only among doctors and patients with high prescribing and usage rates, which could be interpreted as a victory in reining in pill mills.
Unfortunately, most actions so far has centered around restricting access. Restricting access does not solve the underlying issues that cause addiction. Furthermore, the effectiveness of PDMP and anti-pill mill legislation may prevent future addiction, but these measures have also resulted in addicts turning to heroin. Although funding recovery treatment is a step in the right direction, a more holistic approach may be needed to address the root causes of the epidemic.
Additionally, patients who do not abuse these drugs have found obtaining their medications much more difficult. While researchers are looking for drugs that are just as effective as opioids without addiction potential at all, this holy grail still a long way off. Taking opioids out of the hands of the people who should have them isn’t a solution.
Policy makers may do well to address just why 50 million American adults are living with severe and chronic pain:
- A lack of accessible healthcare sometimes leads to treatable progressive diseases go unchecked, resulting in — sometimes permanent — unnecessary pain.
- Many people living with chronic pain face stigma at both the social and medical level. For those who responsibly use prescribed opioids, the addiction epidemic has only enhanced this stigma.
- A frequent cause of chronic pain are injuries resulting from unsafe working conditions. Young men who worked as manual labor in their teens and twenties begin to rely on opioids for pain relief in their thirties and may deal with these issues through the rest of their lives. More strict adherence to safety guidelines would go a long way to prevent these conditions.