Opioid epidemic

From 1999 to 2016 it is estimated 453,300 Americans have died from opioid use.[6] What the U.S. Surgeon General dubbed "The Opioid Crisis" was theorized to have been caused by the over-prescription of opioids in the 1990s,[7] which led to the CDC Guideline for Prescribing Opioids for Chronic Pain, 2016[8] and the resulting impact on medical access to prescription opioids "outside of active cancer treatment, palliative and end of life." Opioids initiated for post-surgical pain management have long been debated as one of the causative factors in the opioid crisis, with misuse/abuse estimated at 4.3% of people continuing opioid use after trauma or surgery.[9]

When people continue to use opioids beyond what a doctor prescribes, or when opioids are over-prescribed, whether to minimize pain or induce euphoric feelings, it can mark the beginning stages of an opiate addiction, with a tolerance developing and eventually leading to dependence, when a person relies on the drug to prevent withdrawal symptoms.[10] Writers have pointed to a widespread desire among the public to find a pill for any problem, even if a better solution might be a lifestyle change, such as exercise, improved diet and stress reduction.[11][12][13] Opioids are relatively inexpensive, and alternative interventions, such as physical therapy, may not be affordable.[14]

In the late 1990s, around 100 million people or a third of the U.S. population were estimated to be affected by chronic pain. This led to a push by drug companies and the federal government to expand the use of painkilling opioids.[15] In addition to this, initiatives like the Joint Commission began to push for more attentive physician response to patient pain, referring to pain as the fifth vital sign. This exacerbated the already increasing number of opioids being prescribed by doctors to patients.[16] Between 1991 and 2011, painkiller prescriptions in the U.S. tripled from 76 million to 219 million per year, and as of 2016 more than 289 million prescriptions were written for opioid drugs per year.[17]^: 43

Mirroring the growth of opioid pain relievers prescribed is an increase in the admissions for substance abuse treatments and opioid-related deaths. This illustrates how legitimate clinical prescriptions of pain relievers are being diverted through an illegitimate market, leading to misuse, addiction, and death.[18] With the increase in volume, the potency of opioids also increased. By 2002, one in six drug users were being prescribed drugs more powerful than morphine; by 2012, the ratio had doubled to one in three.[15] The most commonly prescribed opioids have been oxycodone and hydrocodone.

The epidemic has been described as a "uniquely American problem".[19] The structure of the US healthcare system, in which people not qualifying for government programs are required to obtain private insurance, favors prescribing drugs over more expensive therapies. According to Professor Judith Feinberg, "Most insurance, especially for poor people, won't pay for anything but a pill."[20] Prescription rates for opioids in the US are 40 percent higher than the rate in other developed countries such as Germany or Canada.[21] While the rates of opioid prescriptions increased between 2001 and 2010, the prescription of non-opioid pain relievers (aspirin, ibuprofen, etc.) decreased from 38% to 29% of ambulatory visits in the same time period,[22] and there has been no change in the amount of pain reported in the U.S.[23] This has led to differing medical opinions, with some noting that there is little evidence that opioids are effective for chronic pain not caused by cancer.[24]

Hydrocodone, one of the most popular opioids

Naloxone injection kit, pictured at a train station in Calgary, Canada

In 1993, an investigation by the chief coroner in British Columbia identified an "inordinately high number" of drug-related deaths, of which there were 330. By 2017, there were 1,473 deaths in British Columbia and 3,996 deaths in Canada as a whole.[46]

Following the United States, Canada was identified in 2015 as the second-highest per-capita user of prescription opioids.[47] In Alberta, emergency department visits as a result of opiate overdose, attributable to both prescription and illicit opioids, specifically fentanyl and fentanyl analogues, rose 1,000% in the previous five years. The Canadian Institute for Health Information found that while a third of overdoses were intentional overall, among those ages 15–24 nearly half were intentional.[48] In 2017, there were 3,987 opioid-related deaths in Canada, 92% of these deaths being unintentional. The number of deaths involving fentanyl or fentanyl analogues increased by 17% compared to 2016.[49] Between April and December 2020, there was an 89% increase in opioid related deaths in comparison to 2019.[50] Saskatoon, Saskatchewan experienced a record month in opioid overdoses in May 2020 caused, authorities explained, by a combination of ever-amplifying toxic drugs and the COVID-19 pandemic's quarantine keeping individuals from family and needed mental health services. Over 28,800 Emergency Medical Services (EMS) responded to possible opioid related health crises between January and December 2020 after the COVID-19 pandemic began.[51] In May 2020 Medavie Health Services provided over 250 ambulance services for overdoses, administering the opioid antagonist nasal spray Narcan (naloxone) in record numbers.

North America's first safe injection site, Insite, opened in the Downtown Eastside (DTES) neighborhood of Vancouver in 2003. Safe injection sites are legally sanctioned, medically supervised facilities in which individuals are able to consume illicit recreational drugs, as part of a harm reduction approach towards drug problems which also includes information about drugs and basic health care, counseling, sterile injection equipment, treatment referrals, and access to medical staff, for instance in the event of an overdose. Health Canada has licensed 16 safe injection sites in the country.[52] In Canada, about half of overdoses resulting in hospitalization were accidental, while a third were deliberate overdoses.[48]

OxyContin was removed from the Canadian drug formulary in 2012[53] and medical opioid prescription was reduced, but this led to an increase in the illicit supply of stronger and more dangerous opioids such as fentanyl and carfentanil. In 2018, there were around one million users at risk from these toxic opioid products. In Vancouver Jane Buxton of the British Columbia Centre for Disease Control joined the Take-home naloxone program in 2012 to provide at risk individuals medication that quickly reverses the effects of an overdose from opioids.[54]

Approximately 80 percent of the global pharmaceutical opioid supply is consumed in the United States.[55] It has also become a serious problem outside the U.S., mostly among young adults.[56] The concern not only relates to the drugs themselves, but to the fact that in many countries doctors are less trained about drug addiction, both about its causes or treatment.[23] According to an epidemiologist at Columbia University: "Once pharmaceuticals start targeting other countries and make people feel like opioids are safe, we might see a spike [in opioid abuse]. It worked here. Why wouldn't it work elsewhere?"[23]

Many deaths worldwide from opioids and prescription drugs are from sexually transmitted infections passed through shared needles.[57] This has led to a global initiative of needle exchange programs[58] and research into the varying needle types carrying STIs. In Europe, prescription opioids account for three‐quarter of overdose deaths, which represent 3.5% of total deaths among 15-39-year-olds.[56] Some worry that the epidemic could become a worldwide pandemic if not curtailed.[23] Prescription drug abuse among teenagers in Canada, Australia, and Europe was comparable to U.S. teenagers.[23] In Lebanon and Saudi Arabia, and in parts of China, surveys found that one in ten students had used prescription painkillers for non-medical purposes. Similar high rates of non-medical use were found among the young throughout Europe, including Spain and the United Kingdom.[23] In 2017, 1049 people had a death related to opioids in Spain[59]

While strong opiates are heavily regulated within the European Union, there is a "hidden addiction" with codeine. Codeine, though a mild painkiller, is converted into morphine in the liver.[60] "It's a hidden addiction,' said Dr Michael Bergin of Waterford Institute of Technology, Ireland. 'Codeine abuse affects people with diverse profiles, from children to older people across all social classes."[60]

The worry surrounding the potential of a worldwide pandemic has affected opioid accessibility in countries around the world. Approximately 25.5 million people per year, including 2.5 million children, die without pain relief worldwide, with many of these cases occurring in low and middle-income countries. The current disparity in accessibility to pain relief in various countries is significant. The U.S. produces or imports 30 times as much pain relief medication as it needs while low-income countries such as Nigeria receive less than 0.2% of what they need, and 90% of all the morphine in the world is used by the world's richest 10%.[73]

America's opioid epidemic has resulted in an "opiophobia" that is stirring conversations among some Western legislators and philanthropists about adopting a "war on drugs rhetoric" to oppose the idea of increasing opioid accessibility in other countries, in fear of starting similar opioid epidemics abroad.[74] The International Narcotics Control Board (INCB), a monitoring agency established by the U.N. to prevent addiction and ensure appropriate opioid availability for medical use, has written model laws limiting opioid accessibility that it encourages countries to enact. Many of these laws more significantly impact low-income countries; for instance, one model law ruled that only doctors could supply opioids, which limited opioid accessibility in poorer countries that had a scarce number of doctors.[75]

In 2018, deputy head of China's National Narcotics Commission Liu Yuejin criticized the U.S. market's role in driving opioid demand.[76]

In 2016, the medical news site STAT reported that while Mexican cartels are the main source of heroin smuggled into the U.S., Chinese suppliers provide both raw fentanyl and the machinery necessary for its production.[77] In British Columbia, police discovered a lab making 100,000 fentanyl pills each month, which they were shipping to Calgary, Alberta. 90 people in Calgary overdosed on the drug in 2015.[77] In Southern California, a home-operated drug lab with six pill presses was uncovered by federal agents; each machine was capable of producing thousands of pills an hour.[77]

In 2018, a woman died in London after getting a prescription for tramadol from an online doctor based in Prague who had not considered her medical history. Regulators in the UK admitted that there was nothing they could do to stop this from happening again.[78] A reporter from The Times was able to buy opioids from five online pharmacies in September 2019 without any contact with their GP by filling in an online questionnaire and sending a photocopy of their passport.[79]

Alternative drug options for opioids include over the counter pain medication such as Ibuprofen, Tylenol (acetaminophen/paracetamol), and Aspirin or steroid options.[80][81] A German study comparing legal opioid use between different countries concluded that a high consumption of oxycodone could be attributed to the non-availability of the drug metamizole, a non-opioid painreliver which is heavily used in some countries such as Germany and Austria, but which is banned in others such as the USA and Canada.[82]

Along with drug alternatives, many other alternatives can provide relief through physical activities. Physical therapy, acupuncture, injections, nerve blocks, massages, and relaxation techniques are physical activities that have been found to help with chronic pain.[80] New pain management drugs like cannabis and cannabinoids have also been found to help treat symptoms of pain.[80] Many treatments like cancer treatments are using these drugs to help manage pain.[80]

People that are addicted to opioids can have many changes in behavior. Some of the common signs or symptoms of addiction include spending more time alone, losing interest in activities, quickly changing moods, sleeping at odd hours, getting in trouble with the law, and financial hardships.[83] People that notice any of these behaviors in a peer or in oneself, are usually advised to consult a physician.[83]

Opioid use disorder can be treated in a number of different ways: Medication assisted treatment pathways offer methadone, Suboxone (Buprenorphine/naloxone) and Vivitrol (naltrexone).[84] Cognitive behavioral therapies and counseling are proven effective, as well as digital care programs to increase abstinence rates.[85][86]

A number of methods for the prevention of opioid addiction have been used and suggested. One method is the creation of anti-opioid advertisements. In the 1990s, advertisements depicting drug-seeking people purposefully slamming their arms into doors and crashing their cars, were unsuccessfully targeted at teens.[87]

These ads were unsuccessful because they emphasized the risk of danger, pain, and death caused by opioids.[87] While this tactic would make adults acknowledge the risks and stop using opioids, teenagers need to see that executives just use them as interchangeable customers.[87] The makers of these ads feel that since the internet allows teenagers to view gruesome things anyway, it is perfectly acceptable to subject them to images of self-mutilation in order to protect their lives.[88] It is felt that thirty seconds of gruesomeness is a small price to pay for sparing a lifetime (however short) of opioid abuse and its accompanying poverty and crime.[88] These advertisements, which started in the 1980s, are continuing to play on television today, utilizing donated advertisement time. The goals of the most recent advertisements are to show teenagers that addiction can begin after only five days and that feeding this addiction can consume a person's entire life.[89]

• Diseases of despair – including opioid overdose
• Opioid epidemic in the United States
• Timeline of the opioid epidemic

• Pryma, Jane. 2022. "Technologies of Expertise: Opioids and Pain Management's Credibility Crisis." American Sociological Review.