with more than 115 people fatally overdosing on opioids every day, according to the National Institute on Drug Abuse (NIDA).
The opioids in question that are behind the climbing death toll are prescription opioids such as OxyContin and Vicodin, as well as the illicit drug heroin and synthetic opioids like fentanyl. Together, these drugs have created an overlap of use, abuse, and addiction, leading to record rates of all three, as well as overdose deaths.
The rampant overprescribing of prescription painkillers and the increasingly widespread availability of potent opioids like heroin and fentanyl, combined with a lack of adequate resources, understanding of the mechanics of addiction, and emphasis on both prevention and treatment, have created the perfect storm that is the opioid epidemic.
Opioids are analgesic drugs that generally used to treat and manage chronic pain, mimicking the natural opioids created by the body to help regulate stress and pain and how the body processes it. Once opioids like heroin enter the brain, they bind to opioid receptors and activate them, which means that they stimulate them into overproduction, flooding the brain and central nervous system with opioids.
This surplus of opioids creates blocks around the brain stem and spinal cord, masking pain signals with much greater strength and efficiency than the brain and body could ever do naturally, creating intense feelings of pain relief, relaxation, and sedation.
Opioids also affect a chemical in the brain called dopamine, which helps regulate important functions like cognition, emotion, motivation, and reward. The brain releases dopamine in order to train you to perform necessary survival actions such as eating and sleeping.
The influx of opioids raises the dopamine levels in a part of the brain known as the limbic system, creating the rush of euphoria associated with an opioid high and teaching the brain that this dopamine spike is the reward for the performed activity: using opioids.
Because the body cannot naturally compete with the dopamine response provided by opioid use, the more someone abuses OxyContin, heroin or other opioids, the more using becomes someone’s highest priority, pushing away nearly every other activity that could potentially provide dopamine.
And as the body and brain grow more tolerant to opioid use, larger and larger amounts are needed to effectively mask the symptoms of chronic pain as well as trigger the necessary amount of dopamine.
This is how the debilitating grip of opioid addiction takes hold, causing significant physical and psychological damage, but more often leading to a fatal overdose before someone can suffer the health consequences associated with long-term use.
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The most recent data on opioid crisis statistics collected from the U.S. Centers for Disease Control and Prevention (CDC), as well as NIDA, paints a grim picture of the current state of the opioid epidemic. What we know as of March of 2018 includes:
Unfortunately, identifying the root of the opioid crisis is not a simple process with one clear answer. There were many factors that contributed to the current epidemic that we are now dealing with in the United States, and it is a combination of these factors that keep it raging on despite efforts to stop it.
In terms of prescription opioids specifically, experts will generally point to the mid to late 1990s as the beginning of the country’s widespread troubles with opioid misuse. Pharmaceutical companies were in the process of introducing new prescription painkillers onto the market, most notably OxyContin, which was produced by a company called Purdue Pharma.
Purdue Pharma and other companies like them made it a point to reassure both consumers and the medical community that OxyContin and similar medications were much safer than their predecessors. They also aggressively marketed them as having very low potential for abuse and addiction.
However, as we now know, quite the opposite was true. But, due to a lack of education and understanding on behalf of both doctors and patients, it was not until after extensive diversion, misuse, as well as the rapid rise of prescription opioid addiction and overdose rates that everyone began to realize that pharmaceutical companies had vastly understated the addictive potential of their product.
In fact, in 2007, roughly a decade after OxyContin was first made available, Purdue Pharma was taken to court by the federal government and convicted of criminal charges, including the misleading and subsequent defrauding of physicians and consumers by making false claims about OxyContin. As a result, Purdue Pharma was forced to pay 600 million dollars in fines.
But really, the damage was already done, and opioid abuse and addiction in the United States were well on their way to becoming a full-blown, countrywide epidemic.
Heroin is by no means a new problem in this country—all manufacturing, import, and sale of heroin have been banned since 1924. However, over the past fifteen years, as prescription opioid addiction rates skyrocketed, heroin addiction and overdose statistics began to rise as well.
For decades, the stereotypical image people had of someone addicted to heroin was someone out on the street, homeless and desperate. This image is no longer the picture of the “typical” heroin user, although people in areas of economic depression, especially rural regions with a lack of adequate resources, are still a very high risk of heroin use.
Today, however, it is understood that those suffering from heroin use disorders are in just about every strata of race, age group, and socioeconomic class.
According to the CDC, there were five times as many fatal overdoses from heroin in 2016 compared to 2010, and that more than 170,000 people tried heroin for the first time in 2016. So how did this happen?
Ironically, the rise of heroin use is in part due to efforts to crack down on the overprescribing and availability of prescription opioids. As new restrictions have made obtaining large amounts of prescription opioids more difficult and expensive, heroin has become the cheaper, more easily-accessed alternative.
In the 2014 NSDUH survey of people in treatment for opioid dependence, among those surveyed who had first misused opioids before transitioning to heroin, an overwhelming 94 percent said they switched because prescription painkillers had become more expensive and harder to get than heroin.
And indeed, the price of heroin has declined significantly in the last few decades. A gram of heroin, which, depending on its purity, can provide roughly 200 uses, cost over 2,500 dollars in 1982. Today, a gram of heroin is less than 600 dollars. As for availability, according to the U.S. Drug Enforcement Agency (DEA), heroin is the second easiest drug to obtain in the U.S., beat out only by marijuana, which is available for legal purchase in many parts of the country.
One of the main reasons for heroin’s significant drop in price and rise in availability is the emergence of a dangerous synthetic opioid analog known as fentanyl.
Fentanyl functions in the same way as other opioids, but is incredibly potent, more than 20 to 50 stronger than heroin and up to 100 times stronger than morphine, depending on the purity. It is almost impossible to overstate the danger of fentanyl, which carries a high risk of fatal respiratory depression even for those who are tolerant to the effects of opioids. The amount of fentanyl necessary to trigger an overdose is so small that you could fit roughly a dozen lethal doses on the face of a penny.
Fentanyl’s role in the opioid crisis is defined by the fact that it is incredibly cheap and easy to synthesize, significantly more so than heroin. This has led to illegal drug labs cutting heroin with fentanyl more frequently and in increasingly large amounts in order to keep prices low and provide a steady output of product.
It also means that there is no way for someone to tell how much of the heroin they’re buying is actually fentanyl. In fact, fentanyl is sometimes substituted entirely for heroin. So what happens is that people addicted to heroin will buy what they assume is heroin, take their usual dosage, and overdose, often fatally.
Part of the reason behind this staggering spike is that fentanyl was such an unknown that it was not part of a typical toxicology screen and frequently went undetected. This means that there is a high likelihood of fentanyl being at least partially responsible for a significant number of opioid overdose deaths that went unrecognized before fentanyl became more of a known quantity that was actively screened for.
According to the 2017 National Drug Threat Assessment (NDTA), there were six times as many fentanyl seizures by law enforcement in 2016 compared to 2014, and according to a DEA brief from May of 2018, fentanyl is the most prevalent synthetic opioid in the United States.
Despite no longer being able to fly under the radar, fentanyl has managed to become and remain so widespread due to the ease with which it can be mailed directly from China to the U.S. and, conversely, how difficult it is for law enforcement to trace it across a purposefully long and confusing chain of custody back to its source.
All of this seems to indicate a problem of mass proportions that can feel as though it is beyond fixing. But in the face of these odds, major steps are being taken to fight back against the opioid crisis and turn the tide of overdose deaths.
In the wake of the president’s declaration of the opioid crisis as a public health emergency, the U.S. Department of Health and Human Services (HHS), the National Institutes of Health (NIH), and NIDA have combined their resources and announced that their strategy for combating the crisis would focus on five major priorities:
The first three points of focus on are being carried out as part of a program called the HEAL (Helping to End Addiction Long-term) Initiative, which was launched in June. The initiative involves working with the biopharmaceutical industry to gather more data on pain and effective pain therapies to find management alternatives that do not involve opioid use.
HEAL also intends to build on basic addiction treatment models and research, pouring more resources into testing and development, as well as creating a better integration between behavioral addiction treatment therapies and medication-assisted treatment (MAT) for opioid addiction.
MAT as a form of harm-reduction has proven to be extremely effective in treating opioid dependence, providing maintenance therapy that helps prevent relapse and acts as an incentive for people to remain in treatment long enough to experience the benefits of behavioral therapy, addiction education, and other addiction recovery program mainstays.
On the point of overdose-reversal drugs, the medication known as Narcan has seen a good amount of success in reversing potentially fatal opioid overdoses and saving lives. Efforts are being made so that law enforcement, first responders, and other emergency services are equipped with Narcan and educated on how to administer it properly.
It is important to note, however, that Narcan is not a cure-all for opioid addiction. It reverses an overdose, but unless followed up with treatment, does nothing in preventing someone from overdosing again.
Some critics of the drug have also claimed that Narcan might even be seen as promoting risky drug use by providing a safety net for those who overdose. This, however, is just another reason why these federal initiatives need to be focused on expanding treatment options and accessibility.
Meanwhile, in the hopes of stemming the amount of fentanyl being shipped into the U.S., Beijing has recently reclassified once-legal substances such as fentanyl, carfentanil, and other similar analogs as controlled substances, making it much more difficult to send them out of China.
A similar measure was enacted in 2015 when China scheduled over 100 other synthetic drugs, which resulted in a significant decrease in their availability in the U.S. This success will hopefully also prove to be the case with restricting fentanyl.
Overall, as opioid crisis statistics show, a significant amount of work remains in order for the country to see any kind of real change in the rates of addiction and overdoses.
Meier, B. (2007, May 10). In Guilty Plea, OxyContin Maker to Pay $600 Million. from https://www.nytimes.com/2007/05/10/business/11drug-web.html
National Institute on Drug Abuse. (2018, March 06). Opioid Overdose Crisis. from https://www.drugabuse.gov/drugs-abuse/opioids/opioid-overdose-crisis
National Institutes of Health. (2018, April). HEAL Initiative. from https://www.nih.gov/research-training/medical-research-initiatives/heal-initiative
U.S. Drug Enforcement Administration. (2017, October). 2017 National Drug Threat Assessment. from https://www.dea.gov/sites/default/files/2018-07/DIR-040-17_2017-NDTA.pdf
U.S. Department of Health and Human Services. (2018, March). What is the U.S. Opioid Epidemic? from https://www.hhs.gov/opioids/about-the-epidemic/