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How Did the Opioid Epidemic Start? The History of the Opioid Crisis

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By Claire Wilcox, MD
Sep 15, 2021

The history of the use of opioids in the United States

The opioid epidemic has been a major problem in the United States, especially over the last 25 years, causing suffering and death on a broad scale. The number of drug overdose deaths has quadrupled from 1999 to 2019, the majority of which are attributable to opioids. Almost half a million people died of opioid overdoses during this 20 year period and the rates continue to increase.

The three waves of the opioid crisis

Opioid use first became problematic in the US during the Civil War, when soldiers were treated with morphine for injuries, many of whom developed opioid dependence. In the 1910s and 20s, restrictions were placed on opioid use, and although opioid use disorder has been a problem ever since, it really took off in the latter part of the 20th century. 

Wave one

The first wave began with increased prescribing of opioids in the 1990s following a call by leaders in the medical field for increased pain treatment, and greater emphasis being placed on patient satisfaction. The pharmaceutical industry took advantage of this trend, and drug companies aggressively marketed their opioid medications, targeting physicians, while also downplaying addiction risks. Overdose deaths involving prescription opioids (natural and semi-synthetic opioids and methadone) have been on the rise since at least 1993.

Wave two

The second wave began in 2010 which brought rapid increases in overdose deaths involving heroin – death rates from heroin doubled from 2010 to 2012. At the same time, deaths from prescribed opioids declined slightly but still remained more than twice as high as heroin. It is believed that many patients likely progressed from opioids prescribed for pain to illicit use of prescribed opioids and then finally to heroin because the latter is less expensive, easier to obtain, and gives a more potent high: Three quarters of regular heroin users reported that their first regular opioid was a prescription drug. Patients often report that they began illicit opioid use when their doctor stopped prescribing or moved away.

Wave three

The third wave began in 2013 with significant increases in overdose deaths involving synthetic opioids, such as illicitly manufactured fentanyl. Greater rates of DEA seizures of these compounds (426% increase from 2013-2014) were seen during this time, too. These synthetic opioids were and are primarily distributed by criminal organizations, which sell them as counterfeit prescription pills or mix them with heroin or other illicit drugs like cocaine, with or without the purchaser’s knowledge

Fentanyl and its analogs (carfentanil) are as much as 10,000 times more potent than morphine, which makes the risk of overdose exceedingly high, even when just taken by mouth. Synthetic opioids account now for more than half of overdose deaths. Benzodiazepines, cocaine, or methamphetamine are also found in more than half of people who die from opioid overdoses, recent reports indicate. 

How is the opioid epidemic different from other drug problems?

There are several reasons opioids stand out from the other illicit drugs. One is that opioids are therapeutic medicines, used for the treatment of acute and chronic pain. In the case of opioid use disorder, people often start with a prescription from their doctor, whereas other illicit drug use disorders might start in the context of teenage rebellion or deviant behavior. 

Second, if overused, opioids can be deadly: There is a significant risk of overdose due to respiratory suppression, whereas the risk of overdose from cocaine, methamphetamine and cannabis are lower, albeit still present. That said, now that synthetic opioids are being added to other illicit drugs by drug syndicates, there is an even higher risk of overdose from drugs like cocaine, because they can be laced with these high potency opioids. Furthermore, the addition of benzodiazepines and alcohol to opioids increase the risk of overdose from the opioids even more. 

Who does the opioid epidemic affect?

The opioid epidemic affects many different demographics including teens, seniors, veterans, chronically ill patients and the LGBTQ community. Death rates have increased over the last decades in all age groups and across socioeconomic groups.

The opioid problem is so pervasive now because the pathway to addiction frequently starts with a common medical complaint (pain) which affects everyone. This is in contrast to those who developed opioid use disorder in the 1960s, where 80% reported they started with heroin

A simple prescription can lead to a downward spiral. About 10% percent of people using an opioid for chronic pain develop an opioid use disorder, and about 5% who misuse prescription opioids transition to heroin. The compulsion to use can become so overpowering that procuring the drug takes over all other priorities in someone’s life regardless of the person’s background or demographics.

That said, there are some notable risk groups in the current epidemic. For example, 80% of individuals who overdose are Causasian (although the rate of increase appears to be high in African American populations with semisynthetic opioids). Overdose risks are especially high in rural areas and regions where there are lots of construction and manufacturing jobs and for those without college degrees. Also, higher rates of opioid prescribing occur in groups of people with anxiety and depression, who have a heightened risk of developing a use disorder, than in those without (20% versus 5%). The demographics of heroin mirror these changes: in the past heroin use was primarily seen in inner-city, minority populations, but now it has a more widespread distribution.

Combating the opioid epidemic

The CDC’s strategy to mitigate the problem is to research trends in a rapidly changing landscape, facilitate cooperative agreements between states for data collection and public health efforts, provide guidance for providers and health systems on safe opioid prescribing, partner with community leaders and law enforcement, and increase public awareness through education. Greater public and provider education about the safe prescribing of opioids, effective treatments for opioid use disorder (often referred to as medication for addiction treatment or medication-assisted treatment (MAT)) and how to access them, the importance of naloxone for overdose prevention and the concerning increase in high potency fentanyl use will save lives.

Patients and providers should also do their part to prevent the continued spread of the opioid epidemic. Acute and chronic pain are better managed with non-opioid strategies. People should encourage their doctors to only prescribe opioids as a last resort.

A new hope for OUD management 

Taking medication to promote recovery from opioid use disorder (MAT) reduces craving, prevents relapse, improves productivity and prevents death from overdose. Numerous studies indicate that taking one of the three primary classes of medication long-term (naltrexone, methadone, buprenorphine-containing) is much more effective than only taking medication to get through acute withdrawal, even if 12 step meetings or counselling visits are attended after detoxification. 

Bicycle Health provides Suboxone (buprenorphine/naloxone) through telehealth, offering patients with opioid use disorder convenient consultations with licensed providers. It is an excellent option for people looking for evidence-based, affordable, and accessible treatment.

To learn more about the success rates of Bicycle Health’s telemedicine OUD treatment, call us at (844) 943-2514 or schedule an appointment here.

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