A steady rise in opioid abuse has become more than an alarming trend, it is now a national crisis that must recognized. In years between 1999 and 2015 there were more than 183,000 deaths related to prescription opioid overdoses. These types of drugs can be identified as the main reason that deaths among a specific demographic, whites without a college degree, have risen substantially while death rates in other groups continue to fall. In the 1990s opioid abuse and overdose was rare but in recent years it has begun to account for 29 percent of all overdose deaths making it one of the most common drug related deaths especially in older age groups of 45-54 years old. What has caused such a sharp increase in the misuse of prescription opioids? There are different sides to this story but understanding the history and growing prevalence of these types of drugs can help us understand why this has happened in the U.S.
The Beginning of Opioid Use
The use of opioids to treat pain has been a part of medical community since the early 1900s when morphine was used to treat civil war soldiers for their injuries. When heroin was introduced as a new “wonder drug” in 1898 it wasn’t long before people discovered the addictive properties inherent in the medicine and it eventually became illegal in 1924. In the 1970s, prescription opioids like Percocet and Vicodin were introduced but doctors at the time were taught to strictly avoid prescribing the highly addictive medication to patients as much as possible. However, a letter in the New England Journal of Medicine in 1980 pushed back on the belief that these drugs were dangerous and addictive. The article claimed that out of the nearly 12,000 patients they studied, the development of addiction was rare among those who had no history of addiction or drug abuse. The authors of the study at the time believed death from use of the drug was also rare with less than 1 percent of the patients having adverse reactions.
Rebranding Opioids for Profit
Within a few years, the attitude among doctors regarding the use of opioids for pain treatment began to change and many believed that opioid maintenance therapy was completely safe for patients with chronic pain. In the 1990s there was a move to start making pain management more of a priority. The firm Purdue Pharma started testing a new drug called Oxycontin to act as a long-term painkiller and it went on the market in 1996. The introduction of this medication on the market, many believe, triggered the very beginning of the rising opioid use in the states. Purdue used aggressive marketing tactics to push Oxycontin, producing promotional videos that made dubious claims about the drug and distributing more than 15,000 of them to be used in physicians’ waiting rooms. From 1995 to 96, the number of painkiller prescriptions in the U.S. increased by 8 million and following the release of the Purdue video, they ultimately increased by 11 million. Since the company began marketing painkillers in 1995, Purdue Pharma has earned an estimated $35 billion in revenue.
Purdue Pharma continued to push the drug, taking out ads in medical journals to market Oxycontin in the early 2000s. They also sponsored a book by the Joint Commission to be used as a part of doctors’ required continuing education seminars which cited several studies suggesting that concerns about addiction side effects for painkillers were inaccurate and exaggerated. Their advertisements eventually got the company and three of its executives prosecuted by the justice department for a felony related to false marketing later in 2007. They were charged with misbranding the drug and downplaying the possibility of addiction, for which the executives pled guilty and settled with the U.S. government for $635 million. However, by then the damage had already been done in terms of changing the minds of both doctors and patients about the use of prescription opioids and purveying the myth that addiction was a non-issue.
Rising Numbers in the U.S.
Advertisements and marketing tactics led to an explosive growth in the use of prescription opioids at unprecedented rates. Between the years of 1991 and 2011 the number of opioid prescriptions supplied by American retailers increased from 76 million to 219 million. Throughout the 2000s, the number of overdose deaths related to prescription opioids skyrocketed from 200 to more than 1000 per month. Now nearly 91 Americans die every day from an opioid overdose. The number are a sobering reality that are now causing people to take action against the drug abuse that is ravaging the country. Following their public admission of guilt, the makers of Oxycontin have been making the drug more difficult to crush which they hope with act as an abuse deterrent. The FDA and CDC have also started taking steps to address the opioid abuse epidemic. The director of the CDC wrote in the New England Journal of Medicine that opioids kill patients more frequently than any other medication, a stark contrast to the article written in 1980 that began the shift toward using painkillers.
Addiction Growth in Rural Areas
A number of misleading studies and Purdue Pharma’s unscrupulous marketing tactics certainly triggered the beginning of the opioid epidemic but there are other factors that determine where and why these addictions are occurring. Although it is a nationwide problem, opioid abuse rates and overdose deaths are especially high in states with large rural populations like Maine, Kentucky, Ohio and West Virginia. Tracing back the origins of the opioid epidemic you find that media reports of Oxycontin misuse first surfaced in rural America. The drug was marketed much more aggressively in rural communities than in cities especially in the areas surrounding Appalachia. Opioid drugs are much more available in rural areas where there are higher prescription rates overall. Prescription painkillers may have been marketed more heavily in these areas because they tend to have older populations and more issues with chronic pain and injury due to the prevalence of heavy manual labor jobs.
Poverty and Addiction
There are also differences in what drives prescription abuse in rural areas particularly in terms of quality of life. Compared to urban areas, rural residents tend to have lower income and educational attainment, worse self-rated health and a shortage of drug treatment programs. Economic struggles and high rates of unemployment have contributed greatly to the rise of opioid use in rural areas, many of which have lagged behind in recovery compared to urban areas since the 2008 recession. Many believe that the chronic economic stress that people in these communities experience is a driving factor in why they have higher rates of abuse. They may be self-medicating to ease some of the stress and depression that comes with living in poverty.
Limited Access to Treatment
Overdose death rates in rural areas are significantly higher than those in urban communities, partially because of higher rates of abuse but also as a result of service deficits in treatment. Getting treatment for addiction is much harder in rural areas than it is in the city because there is limited access to medications and fewer medical professionals available to prescribe and administer them. Patients with addictions seeking medication-assisted treatment often must drive hours to get prescriptions for substitute drugs like Buprenorphine or methadone. Doctors in these areas are often helpless to assist patients who have addictions to prescription medication. Even recent policies intended to reduce overdose deaths such as the requirement for EMTs to use the overdose reversal drug, Naloxone, have had little impact in these areas. Rural areas have much longer response and transport times and they often rely on volunteer or low-skilled staff as first responders.
Rural communities have fewer drug treatment programs which means that people struggling with addiction often get put on long-waiting lists before they have access to any help. People on waiting lists are forced to remain active in their addiction until they can be provided with treatment, leaving them vulnerable to overdose. There is also a low number of drug treatment courts in rural towns which would help provide treatment for drug offenders to be rehabilitated. Drug courts have expanded substantially in recent years but this increase has been much slower outside of urban communities and they are still relatively rare in rural towns. These areas also deal with more stigma around drug addiction causing some people to avoid seeking help or prematurely discontinue their treatment for fear of being labeled as an addict. It is more difficult to remain anonymous is small towns where everyone knows each other and may judge people for having an addiction.
Taking Steps To Fight Abuse
The issues of opioid abuse, not only in rural areas but all over the U.S., have become a national crisis and combatting the problem is now at the forefront of politics. Throughout their presidential campaigns, both Hillary Clinton and Donald Trump ran by promising Americans that they would do all they can to reduce opioid addiction and overdose in the country. President Trump recently filled out his White House commission tasked with fighting opioid abuse led by Jersey Governor Chris Christie. Trump promised throughout his campaign that he would increase access to treatment and provide people with more opportunities to enter rehab centers. Opioid activists are concerned about a delay in response from Trump since he took office in January and were especially angered when they discovered that the White House planned to cut 94% of the budget for the Office of National Drug Control Policy. However, Trump’s opioid task force called the Commission Combating Drug Addiction and the Opioid Crisis plans to study the steps that lawmakers and federal officials can take to reduce rates of abuse. The commission is charged with identifying existing federal funds used to combat addiction, assessing the current availability of treatment services and overdose reversal as well as reporting on best practices for addiction prevention.
Federal Funding for Opioid Addiction
Another step taken by the government toward combating opioid abuse comes from new federal funds granted to states. Federal funding streams have recently emerged in the form of $485 million in grant funds awarded to all 50 states by the U.S. department of Health and Human Services. This is the first of two rounds of funding that is intended to increase access to treatment, reduce unmet need and reduce overdose related deaths. Governors will be asked to identify best practices within their state to combat opioid addiction. The first round of funding has been provided to states for immediate assistance with the opioid epidemic while the second round will go toward programs that are clinically sound and effective based on the study of best practices that provide positive results. Another grant called the Substance Abuse Prevention and Treatment Block Grant will provide $371 million dollars in 2017 for primary prevention services and the CDC will fund 44 states to help prevent overdose.
Although there have been many misconceptions in the past about the effects of prescription drugs, the U.S. government and more pharmaceutical companies are acknowledging the need to change the growing trend of opioid abuse. The epidemic has been caused over a period of time by myths and deception in regards to opioid addiction combined with communities hit hard by economic issues and lack of treatment access. Steps toward fighting abuse should combine prevention through education regarding the dangers of opioid painkillers and expanding treatment options for areas that are in need of more access to rehabilitation. Government funds may help to have some positive impact on cities and towns throughout the country that have been devastated by the scourge of addiction. It will take time and effort to return to numbers prior to the opioid explosion of the mid 90s but every step toward reducing rates of opioid addiction and overdose deaths will help the U.S. eventually recover from this national crisis.