In 2020, about 70,000 people in the United States died from an opioid overdose. The so-called opioid epidemic is one of the biggest public health crises of our time, with millions of people addicted to prescription and illicit opioids. According to a report from the Stanford-Lancet Commission released earlier this year, 1.2 million people in the US and Canada could die from opioid overdose by the end of the decade unless immediate action is taken.
The current opioid crisis began in the 1990s when pharmaceutical companies persuaded the Food and Drug Administration (FDA) that the opioid painkiller OxyContin was less addictive than other opioids. The FDA approved the medication and health institutions across the country began to prescribe it liberally. Millions of Americans became addicted to the drug, leading to the first wave of deaths related to legal prescription opioids.
The second wave of deaths was caused by a ripple effect on the heroin market. People addicted to prescription opioids became new customers for the heroin market, leading to its expansion. In recent years, the development of illegal but extremely potent synthetic opioids like fentanyl has driven a third wave of deaths. Fentanyl, a lethal substance 100 times stronger than morphine and 50 times stronger than heroin, is often mixed with other drugs without the user’s knowledge, with devastating consequences. Currently, we are seeing the effects of all three waves on top of one another. In 2020, we saw the highest ever number of opioid overdose deaths.
The consequences of the opioid crisis are pervasive. As well as overdose deaths, opioid addiction is associated with homelessness, family disruption, lost productivity, and unemployment. The annual economic impact of illicit drug use is estimated at $193 billion, including healthcare, lost work hours, and criminal justice processes.
The Covid-19 pandemic exacerbated the crisis. The isolation and anxiety caused by lockdowns drove drug and alcohol abuse, while certain services became even less accessible, including for the most vulnerable. A 2021 report found that over 1500 people had died on the streets of Los Angeles during the pandemic, around 40% of which were attributable to a drug overdose. At the same time, the Covid pandemic distracted the public and institutions from the opioid epidemic, which continued to grow unchecked.
While the whole nation is now affected by the crisis, there are significant differences between states. Opioid dispensing rates are highest in Southern states like Alabama, Tennessee, and Louisiana (though rates are now decreasing across the country). Opioid overdose death rates, on the other hand, are highest in northeastern states – particularly West Virginia, Kentucky, and Washington D.C.
The worst-hit communities are ones where there are crises of unemployment and concentrations of poverty. States and regions that have suffered from de-industrialization and economic decline have the highest rates of suicides and opioid-overdose deaths.
The crisis demands an urgent response – so what needs to be done?
Most people agree that effective regulation of the pharmaceutical industry is among the most important steps to take. The industry is motivated by profit, so may conduct insufficient research – or misrepresent its results – to get its drug on the market. After a drug has been approved, it’s often the task of the industry to work with prescribers to determine how to assess and mitigate risk. Meanwhile, lobbyists from the industry influence the decisions of politicians – as do individual donations from manufacturers.
As well as curbing the industry, there needs to be an investment in strategies for treatment, care, education, and prevention. It’s essential to implement better prescribing practices among healthcare workers, to ensure that addictive drugs are only prescribed when necessary, in safe dosages, and for appropriate lengths of time.
Effective and accessible treatment for people who have developed addictions is equally crucial. For a start, we need to combat the stigma surrounding addiction which often acts as a barrier between individuals and treatment. There should be equality of access to treatment that does not depend on wealth, race, or other socioeconomic factors. While there are currently parity laws which demand that insurance providers cover services for mental health conditions (including substance use disorders) to the same extent as they cover physical health conditions, these laws are often broken, and steps need to be taken to prevent this.
The public health system only holds part of the responsibility for combatting the crisis. They need to work with the criminal justice system to improve access to treatment for people in incarceration. Currently, 85% of people in prisons have an active substance use disorder or were incarcerated for crimes related to drugs, but only 5% of people with opioid disorder in prisons receive treatment. This needs to change – both to prevent re-offending and to offer people the chance to rebuild their lives.
Moreover, prevention interventions in families and communities that start from an early age are essential to stemming the crisis in the long term. Early life adversity and exposure to drugs and alcohol at home are key risk factors for developing an addiction. At-risk families should receive effective support from social services that prevent the development of addictions, as should teachers and schools.
The opioid crisis has left a deadly legacy – but is there any good news? While the death rates from opioid overdose are yet to fall, the number of opioid prescriptions dispensed has decreased dramatically. The number of prescriptions per 100 people has fallen from 81.3 in 2012 to 43.3 in 2020. There will be a time lag before we see the results – a time lag that generally makes it difficult to assess the effectiveness of policies until years later.
Moreover, the Affordable Care Act and expansion of Medicaid have increased the accessibility of opioid disorder treatment to those on lower incomes, leading to lower rates of overdose. Moreover, an estimated 25 million people are now in recovery, having rebuilt their lives and relationships with those around them. This figure alone is something to celebrate and an inspiration for the future.
