The History of the Opioid Crisis

The modern opioid epidemic largely began due to unethical actions on the part of Purdue Pharma pushing the opioid OxyContin. It worsened with a rise in heroin use and then later synthetic opioid use (Fentanyl).  

How Did the Opioid Crisis Begin?

The start of the modern opioid crisis in the United States is usually attributed to the distribution of OxyContin, promoted by Purdue Pharma and approved by the Food and Drug Administration in the mid-1990s.[1] At the time it was marketed as a novel pain medication with low to no addiction potential. Purdue Pharma has been shown to have presented intentionally misleading descriptions of OxyContin to imply it was less addictive than it actually was, especially compared to other opioids. Their profit-driven motivations did real harm with consequences that continue to this day. As a result, many prescibers, presumably unaware of the harms and risk of addiction, prescribed this drug for a number of pain conditions, and the first wave of patients became dependent and often physically addicted to this medication and other prescription opioids. 

The Three Waves of the Opioid Crisis

The opioid crisis in the United States is typically considered to have come in three waves, the last of which continues today.[2] 

Wave 1: Rise in Prescription Opioid Overdose Deaths

The opioid epidemic started or at least reached true crisis levels in 1999, with the over-prescription of OxyContin (combined with Purdue Pharma’s misinformation campaign, described above). Other natural and semisynthetic opioids and methadone also started around this time. 

Wave 2: Rise in Heroin Overdose Deaths

Beginning in 2010, there was a large spike in patients using oxycodone pills that were then seeking cheaper opioid medications. Heroin is comparatively inexpensive and thus we saw a surge of people progressing from pill use to heroin use around this time. The rise of heroin therefore constitutes the second wave of the opioid epidemic.  Combined total deaths attributable to opioid overdose of any kind each year started to approach 10 per 100,000 deaths. 

Wave 3: Rise in Synthetic Overdose Deaths

The third wave of the opioid epidemic, which began around 2013, saw the widespread proliferation of powerful synthetic opioids like fentanyl, which is about 50 to 100 times stronger than morphine. Fentanyl is even cheaper to produce and sell than heroin, and thus dealers began making it widely available. In addition, it can be synthesized here in the US, largely eliminating the problem of transporting heroin (which is a derivative of the poppy plant) from other countries like Mexico.

However, due to their extremely high potency, fentanyl carries an even greater risk of overdose, and our rates of opioid overdoses spiked again with the rise of fentanyl in the drug supply [2] 

Who Is Affected by the Opioid Crisis?

On some level, the opioid crisis can be said to affect everyone, although many people don’t realize its true scale. It has certainly altered the way we think about pain and the treatment of that pain in the US, which affects us all at some point in our lives when we interface with our country’s health care system. 

Most Americans at this point know someone, whether peripherally or intimately, that has had a substance use disorder of some kind, and many of us have experienced substance use disorder among friends or even family members.

More people die each year due to overdose than the number of people who died in the entirety of the Korean War, the Vietnam War, or any armed conflict since the end of World War II.

At this point, the opioid epidemic is an issue that affects all of us, in many different socioeconomic brackets, many different races and ethnicities, and many different geographic locations both rural and urban. 

How Can We Stop the Opioid Crisis

In medicine, we really have four strategies for addressing the opioid crisis: [4]

• Restrict inappropriate use of prescription opioids
• Decrease the flow of illegal opioids into and throughout the country
• Connect people with evidence-based treatment for opioid misuse and opioid use disorder, both medications and behavior therapies 
• Implement harm reduction tools that reduce the risk of death, sickness, or injury linked to opioid misuse

The unfortunate reality is that policymakers often pursue these goals in a disjointed, uneven manner, focusing on the first two instead of the second two, which are much more evidence based. Whether due to personal beliefs, partisanship, or stigma, policy makers have focused on criminalization and prosecution of drug use at the exclusion of focusing on getting people medical treatment and behavioral health resources.

The best way to fight the opioid crisis is to first ask policy makers to address stigma: Our policy makers need to put aside how they feel personally about drug misuse and people who misuse drugs, and instead respond honestly to what the medical evidence shows about the need for treatment, not incarceration. The need for mental health resources, not legal repercussions. The need for harm reduction and not a demand for total abstinence. These are the evidence based policies that have been shown in countless studies to actually decrease the morbidity of drug misuse and the rates of recidivism and relapse. 

Solving a crisis on the scale of the opioid epidemic requires accepting the data that is available and adopting the strategies that have been shown to work. Lets focus on medication and access to treatment instead of on legal punishment or drug trafficking as the best strategy moving forward in addressing this country’s ongoing opioid epidemic.