You can’t turn on the news today without seeing something about the nation’s opioid crisis. Deadly painkillers and heroin are ravaging communities across the country, children are finding and overdosing on their parents’ candy-shaped prescriptions and fentanyl—a synthetic opioid 50 times more powerful than morphine—is causing an unprecedented number of overdoses. Headlines describe tragedy after tragedy.
We are in the middle of one of the deadliest drug epidemics in our country’s history. Whether you’re a pain management physician who believes there is a place for opioids in treatment or an advocate in the addiction treatment field who believes the risks outweigh the benefits and opioids should never be allowed on the market, one thing is certain: the history of the opioid epidemic is a long and complicated one.
Timeline of Opioid Use in the United States
The earliest records of opium use date back to poppy cultivation in Mesopotamia around 3400 B.C. Derivatives of opium have been in use medicinally since the 1500s, though use in the U.S. began in the early 1800s. Spanning multiple centuries, the timeline of how opioids came to be so widespread in American medicine reveals a convoluted history that began with good intentions and mercy and was twisted by corporate greed that exploited the human body’s natural responsiveness to opioids.
German chemist Friedrich Sertürner isolates opium’s active ingredient and names it morphine; morphine quickly becomes recognized as a universal cure-all
Merck, the eventual pharmaceutical giant, begins selling morphine commercially
Following the influx of Chinese to America during the gold rush, opium dens begin to spring up around San Francisco
Civil War Era
Morphine is widely used on battlefields to treat pain; many veterans of the war subsequently fall victim to opioid addiction
An estimated 80,000-100,000 Americans are addicted to opium. Horace Day pens a report referencing thousands of opium users of the time who are dying of blood poisoning, speaking to the complexity of the matter when he wrote that they “ought to be able to say something as to the good and the evil there is in the habit”
The country’s first drug control law passes, banning opium smoking in opium dens
Bayer & Co. begins commercially producing and aggressively marketing heroin, a synthetic morphine derivative, as a “wonder drug”; heroin use increases as people discover heroin’s effects are stronger when injected
Bayer advertises liquid heroin as the best cure for childhood bronchitis and as a household cough suppressant; at a time when tuberculosis is responsible for 1 in 4 of all deaths, advertisements claim heroin ensures an immaculate bill of health
The Harrison Narcotics Tax Act passes, imposing a tax on the production and sale of derivatives of opium or coca leaves
Physicians are now aware of the highly addictive nature of opioids and medical use declines
Congress passes a law banning the manufacture, distribution or importation of heroin
A letter published without peer review in the prestigious New England Journal of Medicine claims that “the development of addiction is rare in medical patients with no history of addiction,” based on a briefly examined sample of patients who received limited narcotics in controlled settings; medical opioid use begins increasing as pharmaceutical companies misleadingly point to the letter as a voucher of safety
Pain specialist Dr. Portenoy releases a study of 38 patients, claiming opioid pain therapy is safe and sparking a movement to increase pain management practices and to include opioids
OxyContin bursts onto the scene; pharmaceutical reps from Purdue Pharma make a splash in the medical field with presentations backed by selective research, OxyContin-branded gifts and a campaign centered around humane pain relief. Opioid prescriptions increase from 2 million a year to 11 million
2000 to Present
Opioid abuse and overdoses double between 1998 and 2008
An estimated 6.2 million Americans are abusing opioids
Opioids lead to 730,000 emergency department visits in 2009, almost double from 2004
Of the 21.5 million people with a substance use disorder, 1.9 million cases involve pain relievers and .6 million involve heroin; 3 out of 4 people with a heroin use disorder report their addiction began with prescription opioids
52,404 fatalities in 2015 make drug overdose the leading cause of accidental death in the U.S.; 20,101 overdose deaths are related to prescription opioids and 12,990 are related to heroin
The Role of Big Pharma
Even with this timeline, you have to go behind the scenes to see how we’ve gotten to where we are today. In 2015, physicians wrote nearly 300 million prescriptions for opioids, accounting for 80 percent of global opioid use. More Americans died of opioid overdose in 2016 than died during the entire Vietnam War.
Large pharmaceutical companies like Purdue Pharma put billions of dollars each year into marketing their products as safe, effective and non-addictive. At the same time, these organizations have powerful lobbies that influence legislation, which provides a dismal insight into why, with so many people dying every day, our government isn’t doing more.
The government has taken several small and seemingly insignificant actions to impact the opioid epidemic, including forcing Purdue Pharma to add an anti-abuse element to OxyContin to reduce the ability to crush or snort it.
Studies show that although this reduced abuse of the drug, it did very little to slow the epidemic. One opioid user said, “Most people that I know don’t use OxyContin to get high anymore… They have moved on to heroin (because) it is easier to use, much cheaper and easily available.”
The study also showed that 66 percent of those surveyed switched to other opioids. Still, makers of some of the other opioid drugs on the market maintain that their products are safe, and the government regulatory agencies continue to allow the prescription of these drugs with little oversight.
In 2011, Dr. Portenoy, the doctor who wrote one of several studies that claimed there was little risk of addiction in using opioids to treat chronic pain, spoke out about his own role in the epidemic, saying that if he had an inkling then of what he knows now he would not have spoken the way he did. He reported, “we often left evidence behind” and “it was clearly the wrong thing to do”.
Why Do People Use Opioids?
Three out of four heroin addicts started out misusing prescription opioids before turning to heroin. This startling fact that has recently come to the forefront of our attention raises the question, why would anyone start using opioids to begin with?
Humans, and all animals for that matter, are pleasure-seeking by nature and look for ways to escape from or avoid unpleasant feelings at all costs. These feelings can be physical or emotional, and come as a result of injury, grief, loss or other trauma that has gone untreated.
If you ask 100 people with opioid use disorder why they started and how they became addicted, you will likely get 100 different answers. For some, their addiction started with a prescription for back pain and eventually became physically dependent upon it, some began using to treat a different kind of pain: the pain of unpleasant thoughts, feelings or memories.
Like all controlled substances, opioids have addictive qualities that make them habit forming, but not everyone who uses them becomes addicted, leading some to the hotly debated conclusion that it isn’t necessarily the substance—it’s the person using the substance. One such proponent of this position is addiction specialist, Dr. Carl Hart.
Dr. Hart stands firmly in this position behind empirical evidence he cites, including the fact that only 25% of all people who use heroin at least once in their lifetime become addicted. His theory is that those who do become addicted and continue to suffer in their addiction do so because they don’t have a more valuable incentive to stop.
He found in his own study that when a person who is addicted is offered a reward great enough, they will almost always choose the reward over the substance; it is then our job to help people understand the value in the reward of recovery. Hart believes that the recent emphasis on the opioid crisis is a way to increase law enforcement budgets and will ultimately result in the criminalization and policing of drug addiction and bringing no positive change, like the crack epidemic in the 80s and 90s.
Whether you agree with this position on the language or not, the statistics about the increase in opioid addiction are clear—they are staggering.
Just When You Thought It Couldn’t Get Any Worse
As pressure from the FDA and DEA have mounted on doctors who overprescribe, doctors have started to track drug-seeking patients and cutting them off from their prescriptions, forcing many to turn to the street for their fix. With the high cost and scarcity of pills on the black market, many turn to heroin as it is both cheaper and easier to find.
This is a huge part of the recent spike in heroin abuse and addiction. To make things worse, there has been a recent boom of synthetic opioids that are flooding the streets and causing an unprecedented number of overdoses. The Centers for Disease Control and Prevention (CDC) has gone so far as to refer our current state as an “opioid overdose epidemic”. From the CDC:
Drug overdose deaths and opioid-involved deaths continue to increase in the United States. The majority of drug overdose deaths (more than six out of ten) involve an opioid.1 Since 1999, the number of overdose deaths involving opioids (including prescription opioids and heroin) quadrupled2. From 2000 to 2015 more than half a million people died from drug overdoses. 91 Americans die every day from an opioid overdose.
We now know that overdoses from prescription opioids are a driving factor in the 15-year increase in opioid overdose deaths. Since 1999, the amount of prescription opioids sold in the U.S. nearly quadrupled2, yet there has not been an overall change in the amount of pain that Americans report3,4. Deaths from prescription opioids—drugs like oxycodone, hydrocodone, and methadone—have more than quadrupled since 19995.
Life Saver or False Sense of Safety?
One of the solutions Dr. Hart offers to the epidemic is to make naloxone more readily available and for our current administration to go after pharmaceutical companies who have hiked the prices as opioid use has increased. Given the spike in opioid use and overdose in the last 15 years, the use of naloxone (commonly known by the brand name Narcan or Evzio)—a life-saving drug that blocks the effects of opioids and reverses an overdose—has also increased.
Once limited to only first responders and medical professionals, anyone with an opioid use disorder can now be prescribed naloxone and carry it with them to be used in the event that they overdose. Today, everyone from police officers to addiction treatment professionals to drug addicts themselves are carrying naloxone and reviving people across the country every day, narrowly escaping death.
3.2 million prescriptions of Naloxone were given in 2015, and administered more than 12,000 times last year, just in the state of Ohio. In 2014, 208 people died from overdoses in the state of Maine alone. That year, emergency responders in Maine saved 829 lives with naloxone. However, most uses go unreported.
According to a national survey conducted by the CDC, in 83% of case of naloxone use, the drug is given by other drug users, the people most likely to be on the scene, not by emergency responders. A new model of the injectable that gives verbal prompts, called Evzio, allows someone without any medical training or experience to give the drug to someone who has overdosed.
This recent rise in the general public’s use of naloxone raises a new question of whether the availability and accessibility of the drug has had a counter effect of giving some addicts a false sense of immortality. The fear factor of overdose has been eliminated knowing that with a simple injection or nasal spray, they can be brought back to life.
This truly is a fallacy now that the prevalence of naloxone-resistant synthetic opioids like fentanyl and carfentanil are increasing—both intentional and unintentional with heroin often being unknowingly laced with fentanyl. Because of the increased half-life of these synthetic compounds, some drug addicts have died from overdose despite multiple unsuccessful naloxone injections.
One Step Forward, Two Steps Back
In the midst of this seemingly endless crisis, many people found a glimmer of hope in 2016—when we saw the largest spike in overdose deaths—as, then Surgeon General, Vivek Murthy was publicly and explicitly fighting to hold doctors responsible for unethical pain management practices, over-prescription of opioids, and forcing them to make referrals to treatment a priority.
Murthy wrote an open letter to physicians, which you can read here, chronicling the path that led to the current opioid epidemic including the role medical professionals have played, and offered a three-pronged solution to address it:
“First, we will educate ourselves to treat pain safely and effectively. A good place to start is the enclosed pocket card with the CDC Opioid Prescribing Guideline. Second, we will screen our patients for opioid use disorder and provide or connect them with evidence-based treatment. Third, we can shape how the rest of the country sees addiction by talking about and treating it as a chronic illness, not a moral failing.”
This statement alone, being made publicly, was incredibly impactful in reducing the stigma and supported the federal requirement of insurance policies to cover treatment of substance abuse. Unfortunately, President Trump quickly replaced Surgeon General Murthy, stopping these efforts in their tracks. In addition to this, Trump had an opportunity—under substantial public pressure—to properly address the crisis on the national stage; however, he missed the mark.
In October of 2017, Trump declared a nationwide public health emergency to fight the opioid crisis, rather than issuing a national disaster declaration. To the lay person, this sounded like a victory; however, the difference between these two declarations is that one comes with financial support—the latter—while the former does not.
It is unclear what actions will be taken to address this crisis at a national level, but many state and local governments are taking steps in their own communities—but funding is limited, and continues to decrease with the Trump administration’s cuts to Medicaid. With an issue as large and far-reaching as this, it is going to take a concerted effort from communities and governments at every level.
While there seems to be no end to the opioid epidemic in sight, all hope is not lost. We are seeing more preventative and responsive measures to curb the deaths associated with opioid use, including the increase in access to: life-saving drugs like naloxone, training and education, and effective treatment. One course of action being taken by the government is an attack on the source, through lawsuits against Big Pharma and sanctions against unethical doctors.
These measures don’t seem to be slowing down the rate of opioid use disorder or the amount of drugs available on the street as they flood in from Mexico, Canada and China. The hope seems to lie in the societal and legislative support for the treatment of opioid use disorder and its underlying causes, with conversations happening at every level about the need to expand treatment.
One of the revelations in the drug treatment industry has been the emergence of Medication Assisted Treatment (MAT)—the integration of prescription opioid receptor partial anogist and antagonist medications like Buprenorphine and Naltrexone. Taken by mouth, injection or implant, these prescription drugs help reduce cravings in people with opioid use disorder and act on or block opioid receptors to eliminate the effect of opioid use on the brain and negating the potential for life-threatening respiratory depression.
For many, the use of MAT has been the life-saving factor, however, its use is still not widely accepted in the addiction treatment industry, and is the great divide, embraced by only a select few in a field which remains mainly abstinence based.
Medication Assisted Treatment is not a silver bullet to end the opioid epidemic, and it certainly is not the answer for everyone. Although the integration of these medications into therapy is referred to as the “Gold Standard of Care” by the medical field and strongly encouraged by the Substance Abuse and Mental Health Services Administration (SAMHSA), very few treatment centers offer MAT.
However, in combination with effective group and individual therapy, MAT has its place for people with chronic relapse and chronic overdose to finally be able to sit in a therapeutic setting and get something out of the information they are receiving. Some of these medications also provide pain relief to people suffering from chronic pain.
As with most prescription drugs, some of the medications used in MAT are addictive and are often misused, so it is important that they are prescribed responsibly and closely monitored by a medical doctor who has knowledge of addiction and who will remain involved in the person’s treatment, including being a part of a multidisciplinary team of professionals involved in a person’s treatment.
Seeing the need for expansion of MAT, legislation was passed in 2017 allowing Nurse Practitioners and Physicians Assistants to prescribe medications like Suboxone and Subutex.
Because prescription opioids or heroin are being replaced by another substance with MAT, the overwhelming majority of people who work in addiction don’t see its place in treatment beyond detox. However, there are certain cases where a longer taper of these drugs or a medication maintenance treatment program can be the difference between life and death.
Roots Through Recovery is an example of an outpatient treatment program that supports the responsible integration of medication assisted treatment into the care plan of some individuals. These clients meet regularly with a board-certified physician who works closely with the treatment team to ensure dosage is correct and that clients are managing their medication responsibly and safely.
Where We Go from Here
There is no one singular action or step that is going to be the deciding factor in the fight to end the opioid epidemic, but rather it requires a combination of critical steps and open minds from addicts, treatment providers and lawmakers. These steps include:
Prevention and Early Intervention – A realistic plan to shift our society away from one that has come to rely on shame, guilt and self-medication toward one of acceptance, support and alternative approaches.
Restrictions on Prescription Opioids – No doubt there is a place for opioids in the treatment of pain, but clear guidelines and restrictions on their use should be implemented.
Reframing of our Understanding of “Pain” – Pain is a real thing, and doctors have a responsibility to treat it to keep patients comfortable, but when we consider context, pain is over-reported (site the study of soldiers versus ER patients).
Trauma-Informed Addiction Treatment – As mentioned, many of the people suffering from addiction began self-medicating other kinds of pain, including past trauma. Trauma often goes unidentified and untreated, which manifests itself both psychologically and physically.
Acceptance of Medication Assisted Treatment (MAT) – Until the behavioral health field comes around to accepting the place of medication in the treatment of addiction, we are going to continue to see the dismal outcomes we see currently.