Opioid Crisis - Worst Drugs

The opioid crisis (also called opioid epidemic) refers to the rapid increase in the use of prescription and non-prescription opioids, along with non-medical illegal opioids such as heroin. Prescription opioids include Percocet, Vicodin, Oxycodone, OxyContin and fentanyl. They are known to be addictive if overused or taken for non-medical reasons, which as led to a dramatic increase in deaths from drug overdoses.

It is now the worst drug epidemic in American history; in 2015 it surpassed annual deaths from AIDS. One commentator considers it "this generation's AIDS Crisis." It accounts for more deaths annually than either car accidents or gun violence, and has the potential of turning into a global pandemic.

In 2015 there were 52,000 American deaths from all drug overdoses. Two thirds of them, 33,000, were from opioids, compared to 16,000 in 2010 and 4,000 in 1999. The epidemic has continued to worsen: in 2016, deaths from overdoses increased over the previous year by 26% in Connecticut, 35% in Delaware, 39% in Maine, and 62% in Maryland. The governor of Maryland declared a State of Emergency in March 2017 to combat the epidemic. While CDC director Thomas Frieden has said that "America is awash in opioids; urgent action is critical."

Background

Main causes and effects

Opioid addiction has mostly been an American problem. Between 1991 and 2011, prescriptions of painkillers in the U.S. grew from 76 million to 219 million per year. Among the opioid pills prescribed are Percocet, Vicodin, Oxycodone or OxyContin. Along with that increase in volume, the potency of the opioids also increased. By 2002, one in six drug users were being prescribed drugs more powerful than morphine; by 2012 the ratio had doubled to one in three.

In the late 1990s many Americans developed chronic pain, estimated to affect around 100 million people or a third of the US population. This led to a push by drug companies and the federal government to expand the use of painkiller opioids. But when some patients continue to take the medication beyond what a doctor prescribes, whether to minimize pain or to enjoy the euphoric feelings it gives, it can mark the beginning stages of a deadly addiction. Over time, tolerance develops and a person needs to use more to get the same effect. Dependence, or addiction, occurs when a person relies on the drug to prevent withdrawal symptoms.

To remedy that growth, in 2010 the government began cracking down on pharmacists and doctors who were over-prescribing opioid pain killers. But this led to the unintended consequence of users turning to illegal heroin, an even more addictive drug, as a substitute. Some addicted patients were also being denied opioid prescriptions as doctors tried to cut back painkiller drug abuse.

In Maine, new laws were imposed which capped the maximum daily strength of prescribed opioids and which limited prescriptions to seven days. But some doctors were then concerned that patients would turn to using street drugs like heroin to extend their use of painkillers. Heroin is significantly more potent and cheaper than prescription opioids. As a result, by 2015 while deaths from prescription opioids had increased by 15% nationwide, for heroin users it had increased 23%.

Despite the increased use of painkillers, however, there has been no change in the amount of pain reported in the U.S. Nonetheless, the current opioid epidemic has become the worst drug crisis in American history. More than 33,000 people died from overdosing in 2015, nearly equal to the number of deaths from car crashes, with deaths from heroin alone more than from guns. It is also leaving thousands of children suddenly needing foster care after their parents have died from an overdose.

Fentanyl as newest opioid

Fentanyl, a newer synthetic opioid painkiller, is 50 to 100 times more potent than morphine and 30 to 50 times more potent than heroin, with only 2 mg becoming a lethal dose. Fentanyl-laced heroin has become a big problem for major cities, including Philadelphia, Detroit and Chicago. As a result, its use has caused a spike in deaths among users of heroin and prescription painkillers, while becoming easier to obtain and conceal. Some arrested or hospitalized users are surprised to find that what they thought was heroin was actually fentanyl.

According to the Centers for Disease Control and Prevention (CDC), death rates from synthetic opioids, including fentanyl, increased over 72% from 2014 to 2015. In addition, it reports that the total deaths from opioid overdoses may be under-counted, since they do not include deaths that are associated with synthetic opioids that are used as pain relievers. The CDC now presumes that a large proportion of the increase in deaths is due to illegally-made fentanyl; as the cause of overdose deaths do not distinguish pharmaceutical fentanyl from illegally-made fentanyl, the actual death rate could therefore be much higher than reported.

Those taking fentanyl-laced heroin are more likely to overdose because they don't know they also are ingesting the more powerful drug. In March 2017, New Jersey police arrested a person possessing nearly 31 pounds (14 kg) of fentanyl (14 kg would yield 7 million lethal doses.) Among those who died from overdosing on fentanyl is singer Prince.

Fentanyl has surpassed heroin as a killer in several locales: the CDC identified 998 fatal fentanyl overdoses in Ohio in all of 2014, which is the same number of deaths for the first five months of 2015. In Cleveland, a person was caught selling blue fentanyl pills disguised to look like doses of the milder opioid painkiller, oxycodone. The U.S. attorney for Ohio stated:

One of the truly terrifying things is the pills are pressed and dyed to look like oxycodone. If you are using oxycodone and take fentanyl not knowing it is fentanyl, that is an overdose waiting to happen. Each of those pills is a potential overdose death.

While Mexican cartels are a main source of heroin smuggled into the U.S., for fentanyl, Chinese suppliers provide both raw fentanyl and the machinery necessary for its production, according to medical publication STAT. In British Columbia, police discovered a lab making 100,000 fentanyl pills each month, which they were shipping to Calgary, Alberta. 90 people in Calgary overdosed on the drug in 2015. In Southern California, a home-operated drug lab with six pill presses was uncovered by federal agents; each machine was capable of producing thousands of pills an hour.

Earlier decades

In the 1950s, while heroin addiction was known among jazz musicians, it was still fairly unknown by average Americans, many of whom saw it as a frightening condition. That fear extended into the 1960s and 1970s, although it became common to hear or read about drugs such as marijuana and psychedelics, which were widely used at rock concerts like Woodstock. But heroin and opioid addiction began to make the news when famous people such as Janis Joplin, John Belushi, Jim Morrison and Lenny Bruce, whom most people didn't know were addicted, died from overdoses.

During and after the Vietnam war, heroin addiction grew when addicted soldiers returned from Vietnam, where heroin was easily bought. It also increased within low-income housing projects during the same time period."The Nixon White House panicked," writes Caldwell. In 1971 some congressmen released an explosive report on the growing heroin epidemic among U.S. servicemen in Vietnam; it found that ten to fifteen percent of the servicemen were addicted to heroin, which led President Nixon to declare drug abuse "public enemy number one". By 1973 there were 1.5 overdose deaths per 100,000 people.

Then followed the crack epidemic from cocaine in the mid to late 1980s. The death rate was worse, reaching almost 2 per 100,000. In 1982, Vice President George H. W. Bush and his aides began pushing for the involvement of the CIA and U.S. military in drug interdiction efforts.

In comparison, the present opioid epidemic is killing 10.3 people per 100,000. In some states it is far worse: over 30 per 100,000 in New Hampshire and over 40 in West Virginia. And with the ongoing opioid epidemic, opinions about drug abuse have changed. The arguments about heroin and opioid use, once supported by strong moral codes, whether social, cultural, or legal, have become weaker.

Increasing international scope

Opioid addiction is also now a serious problem outside the U.S., mostly among young adults. The majority of deaths worldwide from overdoses were from either medically prescribed opioids or illegal heroin. In Europe, prescription opioids accounted for three-quarter of overdose deaths among those between ages 15 and 39. Some now worry that the epidemic could become a worldwide pandemic if not curtailed.

That concern not only relates to the drugs themselves, but to the fact that in many countries doctors are less trained about drug addiction, both about its causes or treatment. Silvia Martins, an epidemiologist at Columbia University, explains:

Once pharmaceuticals start targeting other countries and make people feel like opioids are safe, we might see a spike [in opioid abuse]. It worked here. Why wouldn’t it work elsewhere?

Demographics

Perscription drug abuse among teenagers in Canada, Australia and Europe were at rates comparable to U.S. teenagers. In the Middle East countries of Lebanon and Saudi Arabia, and in parts of China, surveys found that one in ten students had used prescription painkillers for non-medical purposes. Similar high rates of non-medical use were found among the young throughout Europe, including Spain and Great Britain.

In the U.S., addiction and overdose victims are mostly white and working-class. Geographically, those living in rural areas of the country have been the hardest hit as a percentage of the national population.

There has also been a difference in the number of prescriptions written by doctors in different states. In Hawaii, doctors wrote about 52 prescriptions for every 100 people, whereas in Alabama, they wrote almost 143 prescriptions per 100 people. Researchers suspect that the variation results from a lack of consensus among doctors in different states about how much pain medication to prescribe. Nor does a higher rate of prescription drug use lead to better health outcomes or patient satisfaction, according to studies.

Governmental measures

During a joint address to Congress in late February 2017, President Trump pledged to stop the flow of illegal drugs entering the country from Mexico. "Our terrible drug epidemic will slow down and ultimately stop," he promised. He also said the government would expand treatment for addicts. Others, such as Chelsea Clinton, agrees that there is an opioid epidemic and notes that 80% to 90% of those who need treatment for addiction don’t get it. The human cost of addiction and overdose in 2013 was costing an estimated at $78.5 billion each year.

Because drug smuggling is highly profitable and drugs are easily hidden, some experts are concerned that stopping drug smuggling will prove to be extremely difficult. They have been smuggled by various methods, such as being hidden in cars and trucks. Smugglers have also used boats, tunnels, drones, submarines, and homemade bazookas to get them across the border.

As the number of opioid prescriptions between 1991 and 2011 rose by 300%, drug cartels began flooding the United States with heroin. For opioid users, it made heroin cheaper, more potent, and often easier to acquire than prescription medications. That easier accessibility became one of the main factors leading many to using heroin.

The number of heroin users in the U.S. aged 12 or older has nearly tripled since 2002, with heroin overdose death rates more than tripling since 2010. According to the State Department: "Unless countries that are sources of production put resources towards fighting these illicit crops and those responsible for their spread, heroin and opioids will continue to fuel corruption, lawlessness, and public health crises worldwide."

Mexico is considered the main supplier to the U.S. market of heroin, methamphetamine, and marijuana, with most heroin consumed in the United States produced from opium poppies grown in Mexico. Mexican heroin production increased over 600% in four years, from an estimated 8 metric tons in 2005 to 50 metric tons in 2009. And between 2010 and 2014, the amount seized at the border more than doubled.

In Maryland, as an urgent response to the crisis, Governor Larry Hogan, on March 1, 2017, declared a State of Emergency to combat the rapid increase in overdoses. The declaration would increase and speed up coordination between the state and local jurisdictions. In 2016 approximately 2,000 people in the state had died from opioid overdoses.

Local governments are also becoming involved in trying to control their opioid crisis. Officials in Everett, Washington filed a lawsuit against the manufacturer of OxyContin, a leading opioid pain medication, claiming the manufacturer was negligent for allowing drugs to be illegally trafficked to residents and failing to prevent it. The city wants the company to pay the costs of handling the crisis.

The U.S. Surgeon General has listed some statistics which describe the extent of the problem:

• 78 Americans die every day from an opioid overdose.
• In 2014, more than 10 million people in the United States reported using prescription opioids for nonmedical reasons, and close to 2 million people older than 12 years met diagnostic criteria for a substance use disorder involving prescription opioids.
• There has been a quadrupling of prescriptions for opioids since 1999, but there has not been an overall change in the amount of pain that Americans report.
• As many as one in four patients receiving long-term opioid therapy in a primary care setting struggles with addiction.

Efforts to reduce abuse

In 2011, the Obama administration released a white paper describing the administration's plan to deal with the crisis. The administration's concerns about addiction and accidental overdosing have been echoed by numerous other medical and government advisory groups around the world.

As of 2015, prescription drug monitoring programs exist in every state but one. These programs allow pharmacists and prescribers to access patients’ prescription histories in order to identify suspicious use. However, a survey of US physicians published in 2015 found that only 53% of doctors used these programs, while 22% were not aware that the programs were available to them. The Centers for Disease Control and Prevention (CDC) was tasked with establishing and publishing a new guideline, and was heavily lobbied.

In 2016, the CDC published its Guideline for Prescribing Opioids for Chronic Pain, recommending that opioids only be used when benefits for pain and function are expected to outweigh risks, and then used at the lowest effective dosage, with avoidance of concurrent opioid and benzodiazepine use whenever possible. Silvia Martins, an epidemiologist at Columbia University, has suggested getting out more information about the risks:

The greater “social acceptance” for using these medications (versus illegal substances) and the misconception that they are “safe” may be contributing factors to their misuse. Hence, a major target for intervention is the general public, including parents and youth, who must be better informed about the negative consequences of sharing with others medications prescribed for their own ailments. Equally important is the improved training of medical practitioners and their staff to better recognize patients at potential risk of developing nonmedical use, and to consider potential alternative treatments as well as closely monitor the medications they dispense to these patients.

Famous people who died from heroin overdose

Philip Seymour Hoffman, River Phoenix, John Belushi, Janis Joplin, Lenny Bruce, Jim Morrison, Sid Vicious, Mitch Hedberg, Cory Monteith, Layne Staley, Brad Renfro, Jean-Michel Basquiat, Bradley Nowell, Dee Dee Ramone, Peaches Geldof, Elisa Bridges, Bridgette Andersen, Paula Yates, Debbie Linden, Robert Pastorelli, Robbin Crosby, Zac Foley, Tim Buckley, Hillel Slovak, Kristen Pfaff, Howie Epstein, Lucy Grealy, Mike Bloomfield, Max Cantor, Dick Twardzik, Frankie Lymon, Trevor Goddard, Jeanne Eagels, Tim Hardin, Glenn Quinn, Jimmy McCulloch, James Hayden, Megan Connolly, Robert Bingham, David Lerner, Paul Demayo, Brian Cole, Michael Cooper, Pete Farndon