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Five Studies: Understanding America's Opioid Crisis

After 20 years of skyrocketing addiction rates, how can the United States get its pill problem under control?
(Photo: David Smart/Shutterstock)

(Photo: David Smart/Shutterstock)

Between 2000 and 2014, American rates of death from opioid overdose have tripled from three deaths per 100,000 people to nine per 100,000. That added up to 28,647 deaths in 2014. While the number of heroin overdoses has climbed steeply, the vast majority of the lethal overdoses involve prescription opioids—and the heroin crisis is itself closely tied to prescription drugs, since many users become addicted to a prescription opioid before switching to the street drug.

As Daniel J. McGraw reported for Pacific Standard in November, the crisis is largely a product of loosening prescribing guidelines for pain medication, along with effective marketing campaigns by pharmaceutical companies. But that doesn’t mean the solution is easy or obvious.

The question of how to balance the need to help suffering patients against the threat of addiction has troubled the medical profession for centuries. Back around the turn of the 20th century, America faced another upsurge in addictions brought on by medical overprescribing. The pendulum swung the other way until the beginnings of the current opioid boom in the 1990s. Today, doctors and public policymakers must determine how to get addicts into treatment that’s really effective, and how to stop the prescribing problems that got us into the situation to begin with.



Addiction to opium products is a centuries-old problem. In 1782, one observer found that Quaker women in Nantucket "have adopted the Asiatic custom of taking a dose of opium every morning; and so deeply rooted is it, that they would be at a loss how to live without this indulgence." Still, in the early 1800s, the drug was used to treat a huge range of complaints, from burns to cholera. Around that time, the new discipline of organic chemistry began allowing pharmaceutical manufacturers to break opium down and engineer stronger drugs. Then, around 1865, the hypodermic syringe began to be widely used. Doctors at the time believed that, because injection allowed for a smaller effective dose, this method involved less risk of addiction. In 1898, chemists invented a brand new pharmaceutical product: heroin.

Narcotic addiction became a major public policy issue in the early 20th century, with both experts and the public blaming doctors for much of the problem. Modern drug control policies, starting with the 1914 Harrison Narcotics Act, made it harder for doctors to prescribe opioids to addicts and spurred safeguards with the medical profession against excessive use of the drugs.

—"Latrogenic Addiction: The Problem, Its Definition and History," David F. Musto, Bulletin of the New York Academy of Medicine, Vol. 61, No. 8, October, 1985



In 1992, a federal report found that the fear of opioid addiction had prevented up to half of patients from getting adequate pain management after surgery, and other agencies and professional associations echoed that concern. Around the same time, the medical profession began recognizing chronic pain without malignant symptoms as a legitimate problem that deserved treatment. Swooping in to serve the growing market for pain prevention, pharmaceutical companies started aggressively marketing opioid products like OxyContin and fentanyl patches in ways the Food and Drug Administration later decided were misleading. Between 1991 and 2013, the number of opioid prescriptions in the United States rose from 76 million to almost 207 million. Primary care physicians in particular wrote a growing number of prescriptions, despite not necessarily having much training in substance abuse. Internet pharmacies also made it easy for patients to get opioids without a prescription until lawmakers closed that loophole in 2008. Rising addiction to prescription opioids led to heroin abuse as users looked for a cheaper option.

"The Epidemic of Prescription Opioid Abuse, the Subsequent Rising Prevalence of Heroin Use, and the Federal Response," A.B. Kanouse and P. Compton, Journal of Pain & Palliative Care Pharmacotherapy, Vol. 3, No. 29, April 2015



The FDA has approved three medications to treat opioid addiction: methadone, buprenorphine, and naltrexone. All of them work by binding to opioid receptors, curbing drug cravings and blocking the effects of drugs like heroin. Using these kinds of medications doubles the probability that opioid users being treated for their addictions will remain abstinent throughout the course of treatment. Methadone maintenance is still the "gold standard" of care, but it requires that patients take the drug daily under medical observation, and it has side effects including sedation, constipation, and cognitive impairment. Buprenorphine is similar but with less severe side effects. A combination of buprenorphine and another drug known as naloxone can also be taken without supervision because it's difficult to abuse. Naltrexone comes in an extended release form that needs to be injected just once a month, but studies suggest it’s somewhat less effective in preventing relapse and potentially more dangerous than the other two drugs.*

"Medication-Assisted Treatment of Opioid Use Disorder: Review of the Evidence and Future Directions," Hilary Smith Connery, Harvard Review of Psychiatry, Vol. 23, No. 2, March/April 2015



Of the 2.5 million Americans who abused or were addicted to opioids in 2012, fewer than one million received medication-assisted treatment (MAT) with methadone, buprenorphine, or naltrexone. Less than half of private-sector treatment programs offer MAT, and even among those that do offer it, only about a third of patients receive it. The rules of public and private insurance plans typically limit coverage for medication treatment, with caps on dosages prescribed, annual or lifetime ceilings, authorization requirements, limited coverage for counseling, and "fail first" criteria that demand that MAT be a last resort. Many treatment-facility managers and staff also prefer an abstinence model. That’s despite evidence in favor of MATs including a study of heroin overdose deaths in Baltimore that found the number of fatal overdoses dropped 50 percent when methadone and buprenorphine treatment became more available.

"Medication-Assisted Therapies—Tackling the Opioid-Overdose Epidemic," Nora D. Volkow, Thomas R. Frieden, Pamela S. Hyde, and Stephen S. Cha, New England Journal of Medicine, Vol. 29, No. 370, May 2014



State governments play a major role in addressing the way opioids are prescribed. Like much of the country, Washington loosened its prescription-painkiller regulations in the late 1990s. Opioid prescriptions there grew 500 percent from 1997 to 2006. In 1995, 24 people died from overdosing on prescription drugs. In 2004, that number jumped to 351. Starting around 2006, officials began taking action. Medicaid staff instituted safeguards to stop people from getting multiple prescriptions from different providers. State agencies developed dosing guidelines. The state legislature repealed permissive rules and replaced them with new requirements. The University of Washington created a telemedicine program to provide more access to pain experts. The changes in Washington seem to have had an impact: Rates of chronic opioid use among workers’ compensation recipients dropped, and, among the state’s Medicaid enrollees, average doses declined. Between 2008 and 2012, deaths from prescription opioid overdoses in the state dropped 27 percent.

"A Comprehensive Approach to Address the Prescription Opioid Epidemic in Washington State: Milestones and Lessons Learned," Gary Franklin, Jennifer Sabel, Christopher M. Jones, Jaymie Mai, Chris Baumgartner, Caleb J. Banta-Green, Darin Neven, and David J. Tauben, American Journal of Public Health, Vol. 105, No. 3, March, 2015


*Update — February 8, 2016: This story has been updated to more accurately reflect the chemical synthesis of buprenorphine with naloxone.