The Opioid Epidemic: How a Bad Medical Decision Spiraled Out of Control

Anton Gulko for Health Empowerment Coalition

Overdose deaths reached record high in the yearlong period ending in April 2021. The U.S. Centers for Disease Control and Prevention (CDC) reported that over 100,000 Americans died of overdose, a nearly 30% increase from the year before.¹ Opioids are the leading cause of this rise. In particular, fentanyl, a synthetic opioid, alone accounted for nearly 64% of all overdose deaths that year.¹ Despite this staggering increase, opioid addiction is not a new phenomenon in the United States. The crisis is often referred to as the opioid epidemic, and its roots can be traced back to the failure of the U.S. healthcare system to foresee long-term consequences of opioid use.

To better understand how the events leading to the opioid epidemic unfolded, we should first discuss what opioids are and how they work. The first known natural opioids, also called opiates, were extracted from opium poppy flowers and include morphine and codeine.² Subsequently, pharmaceutical companies synthesized more potent opioid derivatives, such as heroin, oxycodone, and fentanyl. All opioids share a common mechanism of action by mimicking the effects of endorphins, the neurotransmitters which our bodies produce to reduce feelings of pain. Opioids bind to specific receptors in the brain to block pain signals and induce euphoria by elevating dopamine levels in the reward system of the brain.³ Both of these effects contribute to their addictive properties. At higher doses, opioids are known to suppress effects of noradrenaline, neurotransmitter that mobilizes the brain and body for action, leading to reduced blood pressure and respiratory depression which can culminate in a loss of consciousness and even death.³

Although a controlled, short-term use of opioids can be relatively safe, prolonged use greatly increases the risk of adverse effects. Our bodies have evolved to adapt to the ever-changing environment around us and within us. In the case of opioid use, our bodies adapt by becoming less sensitive to opioids and decreasing production of endorphins.⁴ This mechanism contributes to the development of tolerance, and larger doses of opioids are then needed to elicit the same effect. This never-ending cycle leads to addiction and further increases the risks of adverse effects, such as cardiac arrest. One reason why opioid addiction is so common is that people who develop tolerance seek opioids not to get high but to avoid feeling sick from lowered levels of endorphins. This period is known as withdrawal.

The Center for Disease and Control and Prevention (CDC) posits that the U.S. opioid epidemic came from three distinct waves.⁵ The first wave began with increased opioid prescription in the 1990s following the push by pharmaceutical companies to use the drugs for chronic pain management.⁶ During this time, the addictive properties of opioids and other narcotics were well known in the medical community, and they were reserved to treat acute pain in patients suffering from terminal illnesses.⁷ However, these notions were challenged by pharmaceutical companies that downplayed the addictiveness of their opioid drugs and by some physicians who advocated for more liberal use of opioids to treat chronic pain.⁶ As a result, medical and public views of pain treatment shifted away from careful consideration to aggressive encouragement. In the absence of appropriate scrutiny by the medical community and regulatory agencies such as the U.S. Food and Drug Administration (FDA), opioids quickly became the most prescribed class of medication in the United States.⁸

The second wave of the opioid epidemic began in 2010 with a rapid increase in deaths from heroin overdose.⁵ Following a 533% increase in opioid prescriptions from 1997 to 2005, the number of reported prescription opioid overdoses skyrocketed.⁹ Some pharmaceutical companies attempted to reformulate their opioids to reduce risks of abuse and overdose; however, it was already too late. Many people who were already addicted to opioids and had a high tolerance for the drug found a way to transition to cheaper and stronger alternatives like heroin. According to the National Survey on Drug Use and Health from 2013, 4 out of 5 active heroin users reported that their addiction began with medically prescribed opioids and continued after the prescriptions ended.¹⁰

The third wave of the opioid epidemic began in 2013 and is ongoing. This period is characterized by a steep increase in overdose deaths involving illicitly-manufactured fentanyl.⁴ Unlike other synthetic opioids, fentanyl is particularly dangerous, as it is 50 to 100 times more potent than any other opioid, with a lethal dose of just 2 mg.¹¹ Pharmaceutical fentanyl is approved for treating severe pain associated with advanced stages of cancer. However, because of low manufacturing cost and extreme potency, it is often mixed with heroin and other street drugs without the user's knowledge. As a result, the number of accidental overdose deaths involving synthetic opioids were twelve times higher in 2019 than in 2013.¹¹ Taken together, the White House estimated that the cost of prescription opioid overdoses, dependence, non-medical use, and lost productivity cost the United States nearly $504 billion in 2015 alone.¹²

The way to address the opioid epidemic is by focusing resources on treating people who are already addicted and raising awareness in local communities. Naloxone is a medication approved by the FDA to temporarily reverse opioid overdose. It is an opioid receptor antagonist that binds to the same receptors as opioids and reverses or blocks their effects.¹³ NARCAN Nasal Spray, the brand name of naloxone, is available to buy from your pharmacy without a prescription and is fully covered by most medical insurances. Another drug that is used to treat opioid addiction is methadone. It is a weak opioid derivative that reduces the painful symptoms of opioid withdrawal without causing any euphoria.¹⁴ Methadone is often used in conjunction with comprehensive medication-assisted programs that provide counseling and social support to address the root causes of addiction.¹⁵ In contrast to other programs, this approach focuses on addressing underlying problems leading to addiction, such as under-employment and concentration of poverty, making the patients less susceptible to relapse.

Most importantly, people can only achieve meaningful recovery if they have a supportive and accepting community. Nevertheless, preconceived notions and stigma attached to addiction and the recovery process often stand in the way of progress. The U.S. Department of Health and Human Services outlines several steps that you can take to help increase awareness in your community.¹⁶ Step one: educate your community members on the physical and mental burdens that come with addiction and recovery. Step two: educate your community on medication-assisted treatment and how social support can benefit one with his or her recovery. Step three: promote safe drug disposal habits to reduce access to non-medical opioid use. Finally, step four: encourage people to seek out medical attention for an overdose, especially if your state has enacted a 911 drug immunity law.

References:

1. Ahmad F.B., Rossen L.M., Sutton P. Provisional drug overdose death counts. National Center for Health Statistics. 2021. https://www.cdc.gov/nchs/nvss/vsrr/drug-overdose- data.htm

2. Marciano M.A., Panicker S.X., Liddil G.D. et al. Development of a Method to Extract Opium Poppy (Papaver somniferum L.) DNA from Heroin. Sci Rep 8, 2590. 2018. DOI: 10.1038/s41598-018-20996-9

3. Pathan H., Williams J. Basic opioid pharmacology: an update. British journal of pain. 2012; 6(1), 11–16. DOI: 10.1177/2049463712438493

4. Mayo Clinic. (n.d.). Diseases Conditions: How opioid addiction occurs. https:// www.mayoclinic.org/diseases-conditions/prescription-drug-abuse/in-depth/how-opioid-addiction-occurs/art-20360372

5. Center of Diseases Control and Prevention, National Center for Injury Prevention and Control. (n.d.). Opioids: Understanding the Epidemic. https://www.cdc.gov/opioids /basics/epidemic.html

6. Marks J. H. Lessons from Corporate Influence in the Opioid Epidemic: Toward a Norm of Separation. Journal of bioethical inquiry. 2020; 17(2), 173–189. DOI: 10.1007/s11673-020-09982-x

7. Rayport M. Experience in the management of patients medically addicted to narcotics. J Am Med Assoc. 1954 Oct 16;156(7):684-91. DOI: 10.1001/jama.1954.02950070012004

8. Volkow N.D. America’s Addiction to Opioids: Heroin and Prescription Drug Abuse. National Institute on Drug Abuse Archives. 2014; https://archives.drugabuse.gov /testimonies/2014/americas-addiction-to-opioids-heroin-prescription-drug-abuse

9. Mars S.G., Bourgois P., Karandinos G., Montero F., Ciccarone D. "Every 'never' I ever said came true": transitions from opioid pills to heroin injecting. Int J Drug Policy. 2014;25(2):257-266. DOI: 10.1016/j.drugpo.2013.10.004

10. Muhuri P.K., Gfroerer J.C., Davies M.C. Associations of Nonmedical Pain Reliever Use and Initiation of Heroin Use in the United States. Center for Behavioral Health Statistics and Quality. 2013. https://www.samhsa.gov/data/sites/default/files/DR006/DR006/ nonmedical-pain-reliever-use-2013.htm

11. Center of Diseases Control and Prevention, National Center for Injury Prevention and Control. (n.d.). Opioids: Fentanyl. https://www.cdc.gov/opioids/basics/fentanyl.html

12. CNBC. (n.d.). The true cost of opioid epidemic tops $500 billion, White House says. https://www.cnbc.com/2017/11/20/the-true-cost-of-opioid-epidemic-tops-500-billion-white-house-says.html

13. Substance Abuse and Mental Health Services Administration. (n.d.). Naloxone. U.S. Department of Health and Human Services. https://www.samhsa.gov/medication -assisted-treatment/medications-counseling-related-conditions/naloxone

14. University of Arkansas for Medical Sciences. (n.d.). What is Methadone? Psychiatric Research Institute. https://psychiatry.uams.edu/clinical-care/cast/what-is-methadone/

15. Substance Abuse and Mental Health Services Administration. (n.d.). Medication-Assisted Treatment (MAT). U.S. Department of Health and Human Services. https://www.samhsa.gov/medication-assisted-treatment

16. Center for Faith-Based and Neighborhood Partnerships. (n.d.). Opioid Toolkit: Increase Awareness. U.S. Department of Health and Human Services. https://www.hhs.gov/about/ agencies/iea/partnerships/opioid-toolkit/increase-awareness/index.html

Author: Anton Gulko

Edited by: Annaleigh Burgess, Emily Lin, and Darshana Banka

The Health Empowerment Coalition is a student-led organization that aims to empower individuals across the United States to improve their health literacy and take charge of their health. The views expressed in this article are the authors’ own and do not reflect the official opinions of the institutions at which they work and study. Additionally, the content in this article is not intended to provide medical advice.