America’s opioid epidemic is the worst in the industrialized world, killing nearly as many people as car crashes every year. Over the past two decades, thousands of people died from unintentionally overdosing on prescription or illicit painkillers, and millions more became dependent on them. As a result, public health and medical officials from communities and governmental entities across the United States are working to remedy this dangerous public health crisis.
The Opiod epidemic has a long and complicated history, and solutions won’t come easy.
Here’s what you should know.
Opioids encompass a range of drugs that affect the pain and reward centers of the brain. Some of these drugs are made from plants, while others are synthetic.
When managed appropriately, opioids like oxycodone, fentanyl, and morphine can be used safely. But because of how these drugs affect the pain and pleasure receptors in our brain, it’s possible to become dependent on them. Often the more you use them, the more you need them, and people can begin misusing the drugs as a result.
Opioid misuse is a serious public health issue that takes the lives of 91 Americans every day. The number of drug overdose deaths related to opioids skyrocketed in the early 2000s—quadrupling since 1999—with no signs of the epidemic losing steam.
It’s also costly. The price of the epidemic reached an estimated $78.5 billion dollars in 2013, but nothing compares to the lives lost. According to a projection from STAT News, unless something is done quickly to curb the rise of opioid misuse, as many as half a million people could be killed by these drugs in the next decade.
Using prescription drugs when they haven’t been prescribed is one of the most common ways people misuse opioids, but in recent years illicit versions of an opioid called fentanyl and other similar drugs flooding the market have made getting addicted even more deadly. Without proper management or medical supervision, users can risk overdosing. And with further cuts expected to Medicaid and the Affordable Care Act, it’s anticipated that more people will lose their health insurance and access to medical care—driving some to seek illicit versions of the drugs and exacerbating an already dire situation.
Who Is Being Affected?
Not everyone who uses opioids misuses them or becomes dependent. When properly dosed and under medical supervision, prescription painkillers can be administered safely. It’s when usage isn’t monitored or when the drugs have been illicitly manufactured that people can develop Opioid Use Disorder (OUD).
OUD looks different in different people. For some, it could simply mean craving opioids or taking more than intended, but for others, OUD results in closing off the world or letting your life fall apart because of your opioid use. If you don’t have a medical professional helping you keep dosage under control or ensure the opioid you’re using is safe, you run the risk of overdosing.
And this happens far too often. Drug overdoses are currently the leading cause of death in people under 50 in the United States, and six in 10 drug overdoses involve opioids. While this problem is widespread throughout the country, certain areas are more prone to opioid overdoses than others. The Rust Belt, Appalachia, and New England see higher rates of drug overdoses than the Plains, for example.
Young people appear to be disproportionately impacted by the epidemic. According to a 2016 report by the Substance Abuse and Mental Health Services Administration, an estimated 2.5 million young adults aged 18 to 25 misused opioids in the past year—the highest of any age group.
What’s perhaps most concerning among public health professionals is the number of teenagers involved. Nearly 900,000 adolescents aged 12 to 17 misused opioids in 2016. And while this is down from nearly one million in 2015, the number is still alarming, especially considering that most adolescents who misuse these drugs get them for free from friends or relatives.
While young people disproportionately misuse opioids, older adults aren’t immune. An additional 1.8 million Americans in their 50s misused the drugs in 2016, an increase from roughly 1.7 million in 2015.
Gender also appears to play a role. Currently, men are more likely to die due to an overdose of prescription painkillers, but that seems to be changing. Between 1999 and 2010, the number of women who died from prescription painkillers increased 400 percent, compared to a 237 percent increase in comparable deaths among men. Women are also more likely than men to be prescribed and use opioids for pain, making them a particularly vulnerable group when it comes to this epidemic. The overwhelming majority of people who take opioids—even illicit versions like heroin—do so because they are in pain due to things like cancer or a severe injury.
How We Got Here: A Short History
Prior to the 1980s, medical personnel was trained to give as few opioids as possible for pain because of fears of dependence. As a result, people with chronic pain were seriously undertreated. Throughout the 1980s, a series of articles were published pushing back at the notion that pain medications would result in dependence and encouraged doctors, instead, to reconsider their practice of avoiding long-term use of opioids to treat chronic pain.
The pendulum swung. With the encouragement of pharmaceutical companies, more doctors began prescribing opioids for their patients, and America saw a huge spike in the number of unintentional overdose deaths from prescription painkillers. In the late 1990s, alarms went off, and the pendulum began to swing back the other way. Doctors once again scaled back prescriptions out of caution. In 2006, doctors wrote 72.4 opioid prescriptions for every 100 people in the United States. Ten years later that number fell to 66.5 per 100 people in 2016.
As the rate of valid medical prescriptions dropped, the rate of illicit and unprescribed opioids went up. When prescribed opioids ran dry or became too expensive, some patients turned to heroin as a cheaper alternative. In 2010, officials began to register spikes in heroin overdoses, followed a few years later by overdoses from illicitly-manufactured fentanyl (IMF). As one problem appears to be getting under control, another rushes to take its place in a veritable game of whack-a-mole.
Demographics have shifted as well. Overdoses from opioids used to primarily affect white people in their 30s and 40s, but signs are pointing to shifts in those demographics as younger people begin to experiment with and misuse prescription and illicit painkillers.
How We Can Fix It: A Public Health Perspective
Like many public health issues, there’s no easy solution to the opioid epidemic. Combating the misuse of these drugs will take a multi-disciplinary approach that includes everyone from single individuals to massive government entities.
Provider and Patient Education
An integral part of scaling back misuse of prescription painkillers will have to include educating patients taking these drugs on the importance of proper management and medical supervision, and the risks of dependence and overdose. Patients should also receive further counseling on how to correctly safeguard their prescriptions to avoid pills being misused by friends or family—especially teenagers.
Furthermore, the majority of people who use opioids say they do so because it helps them manage chronic pain. Depending on the intensity of the pain, the discomfort could potentially be managed with over-the-counter pain relievers like acetaminophen (Tylenol) or ibuprofen, or non-medication therapies like physical therapy or hypnotherapy. Some argue that teaching doctors and patients about possible alternative pain management strategies could help reduce the number of opioids being prescribed by exhausting all non-opioid options first and leaving prescription painkillers as a last resort.
Other systemic issues can become risk factors for unintended overdoses, such as multiple doctors writing scripts or multiple pharmacies filling opioid prescriptions. By keeping tabs on what is being prescribed, how much, and to whom, it could reduce the risk of prescription painkillers being misused. Some states have already started implementing such monitoring programs to much success, though the data and reporting features can vary from state to state.
It’s not just about prescriptions, however. The number of overdose deaths due to illicit opioids like heroin has skyrocketed over the past several years. More data on these drugs, including who is using them and where they are being distributed, can help officials better understand how and where to target resources most efficiently.
It’s not enough to cut off the supply of opioids. You also need to find help for people who have already become dependent. Ironically, one of the most effective ways to overcome an opioid use disorder is to use less harmful opioid medications as part of a process known as Medication Assisted Treatment (MAT). Three such medications have been approved by the Food and Drug Administration to treat opioid dependence: buprenorphine-naloxone, buprenorphine, and extended-release naltrexone.
While the effectiveness of these medications can vary, studies have shown them to reduce the physiological reliance on opioids and help those in active treatment overcome dependence. MAT, however, shouldn’t be the only course of treatment. Because dependence can have both physiological and cognitive components, treatment programs see far more success if they address all aspects of dependence.
Treating substance use issues isn’t just life-saving, it’s also a good financial investment. It’s estimated that for every $1 spent on substance use treatment in the United States, we could save between $4 and $7 in crime-related costs.
Even with all of the above strategies in place, these things will take time, and there will inevitably be individuals who continue to misuse opioids despite the best efforts of the medical and public health communities. A small, but important, tactic could be to provide families and friends of users with rescue kits in the event of an overdose to reduce the risk of death.
Where We Go From Here
In October of 2017, President Donald Trump asked the U.S. Department of Health and Human Services to acknowledge the issue by declaring the opioid epidemic a public health emergency. The White House’s opioids commission issued a report not long after outlining key recommendations on where to go from here, including suggestions for programmatic and policy changes to be enacted by the White House administration and Congress.
Other government entities have already put forward their intentions of how they can combat the epidemic. For its part, the FDA outlined an action plan from a regulatory standpoint. The seven-point plan includes forming an advisory committee, adding warning labels on prescription opioids, and requiring pharmaceutical companies to research the long-term impact of using opioids.
The Centers for Disease Control and Prevention (CDC) also issued guidelines for physicians before, during, and after writing an opioid prescription. In them, the agency encourages doctors to pursue other types of treatments first, such as physical therapy and steroid injections, and use opioids only as a last-resort treatment for pain.
Innovative solutions at the state level have shown early promise as well. Massachusetts, for example, has expanded access to treatment medication through a nurse manager model that allows doctors to treat more patients than if they were the primary managers. Another program in Maryland leverages social workers as support for medical teams to reach more people and reduce treatment waitlists.
These programs will be increasingly important as changes are proposed and made to the Affordable Care Act and government assistance programs like Medicaid. Because medical supervision is critical to helping patients manage their pain safely and effectively, access to affordable healthcare will be an important component of any and all efforts to combat the epidemic.