The drug epidemic currently tearing through large parts of the US began with the best intentions from doctors and a profit-driven campaign from pharmaceutical companies.
Back in the 1990s, doctors agreed — and many still do — that America has a serious pain problem: Tens of millions of Americans experienced debilitating pain, and it was left untreated. So they looked for a solution — and, fueled by a misleading marketing push from pharmaceutical companies, landed on opioid-based painkillers, widely known by brand names such as OxyContin, Percocet, and Vicodin. The drugs proliferated.
But this led to unintended, devastating results. Prescription painkiller abuse went up, and overdose deaths linked to the drugs did as well. Then as policymakers and doctors took notice of widespread painkiller abuse, they pulled back access to the drugs. But federal data now shows many of these addicts didn't just quit the drugs altogether — some instead moved to another opioid, heroin.
The result: In 2013, more than 16,200 deaths were linked to opioid painkillers, and another 8,200 were linked to heroin. That makes opioid painkillers the deadliest drug in America after tobacco and alcohol. And both painkillers and heroin made up more than half of all 44,000 drug overdose deaths, which now kill more people than AIDS did at the height of the HIV/AIDS epidemic in the 1990s.
It's a big public health crisis. And, surprisingly, policymakers are treating it as a public health crisis — whereas previous drug epidemics invited harsh tactics typical of the war on drugs, like increased prison sentences for drug possession, the current crisis is being handled as a problem that requires more access to treatment programs. That reflects not just the opioid epidemic's unique beginnings, but a general shift in how the country views the decades-old drug war.
The desire to treat pain led to a devastating epidemic
America has a pain problem. About 100 million Americans suffer from chronic pain, according to a 2011 report from the Institute of Medicine. This might seem like an excessive number — roughly one-third of all Americans — but it includes everyone in the chronic pain spectrum, from the silent sufferer who deals with constant back pain to the patient who can no longer move because the pain all over her body is just too much.
As the blog Skeptical Scalpel notes, there isn't a single medication that will relieve all pain for all patients. But there was a huge push in the 1990s and 2000s — through, for example, the federal government's flawed "Pain as the Fifth Vital Sign" campaign andpharmaceutical-backed advocacy efforts — that doctors do something about pain, even when there wasn't much that could be done.
This push allowed — as Keith Humphreys, an opioid and addiction expert at Stanford University, explained — pharmaceutical companies to take advantage of the pain problem: Despite the lack of good evidence that opioid painkillers can treat chronic pain and evidence that these drugs are addictive and dangerous, pharmaceutical companies saw an opportunity for profit, and they marketed opioids to doctors as a safer way to treat pain than other medications.
Pharmaceutical companies' claims were, of course, completely inaccurate, and Purdue Pharma, producer of the opioid OxyContin, would later pay hundreds of millions of dollars in fines for their false claims. Opioid painkillers carry a significant risk of addiction and overdose, especially for long-term users who build up a tolerance of the high and use more and more of the drug without building as much resistance for the respiratory effects that lead to overdose.
But many doctors, under pressure to treat pain more seriously, bought into the messaging from those decades and prescribed a ridiculous amount of painkillers to patients. In 2012, US physicians wrote 259 million prescriptions for opioid painkillers — enough to give a bottle of pills to every adult in the country. And these pills don't just end up in patients' hands, instead proliferating to black markets, landing in the hands of teens who rummaged through parents' medicine cabinets, and so on.
Federal and state governments, aware of the problem, began going after doctors and pharmacists who provided painkillers too leniently, threatening them with incarcerationand the loss of their medical licenses. Ideally, doctors will still be able to provide painkillers to patients who really need them — after, for example, evaluating whether the patient has a history of drug abuse. But doctors who weren't conducting even such basic checks are being told — not just through the crackdown, but via health-care organizations and public education campaigns — to give more thought to their prescriptions.
Despite increased awareness and the crackdown, there are still signs of some doctors doing a lot of overprescribing. A Centers for Disease Control and Prevention reportfound that a small minority of prescribers are responsible for most opioid prescriptions, although there's a lot of variation from state to state. For example, the top 1 percent of prescribers wrote one in four opioid prescriptions in Delaware, while the top 1 percent of prescribers wrote one in eight such prescriptions in Maine.
Still, the crackdown has appeared to stabilize the number of painkiller overdose deaths in the past few years, but it also led to a major downside: an increase in heroin abuse and deaths.
Painkiller-linked deaths have stabilized, but heroin-related deaths appear to be rising
When opioid addicts couldn't fulfill their cravings with painkillers, many turned to an opioid that is, despite its status as an illegal substance, cheaper and more accessible than the legal medicine: heroin. So as painkiller overdoses leveled off at about 16,000 in recent years, heroin deaths skyrocketed from just over 3,000 in 2010 to more than 8,200 in 2013, according to CDC data. Though all heroin users didn't necessarily start with painkillers, it's the transition from painkillers to heroin, Humphreys and other experts say, that led to the recent dramatic spike in heroin abuse.
Heroin is even deadlier than opioid painkillers — it's far more potent, and far more addictive. So even if a small number of painkiller users moved on to heroin, it would still, on a per-person basis, lead to far more deaths.
What's worse, painkiller and heroin users tend to mix opioids with other substances — like alcohol and cocaine — that exacerbate the risk of an overdose. A 2003 study found roughly half of heroin-related deaths involved alcohol, and the CDC found that 31 percent of prescription painkiller-linked overdose deaths in 2011 were also linked tobenzodiazepines, a legal anti-anxiety drug. So as people used painkillers and moved on to heroin, they continued using all these other substances that made their risk of overdose much, much higher — and it's showing in the numbers.
That doesn't mean cracking down on painkillers was a mistake. It appears to have slowed the rising number of painkiller deaths, and may have prevented doctors from prescribing the drugs to new generations of potential addicts. So the crackdown did lead to more heroin deaths, but it will hopefully prevent future populations of drug abuse, which could have suffered even more overdose deaths. That's why, though they knew it could lead to a temporary spike in heroin use, state and federal agencies came down on painkillers.
The rise in heroin deaths wasn't unexpected
The results of a government crackdown on opioid painkiller prescriptions were long a concern in medical circles and among drug policy experts, who warned it could lead to a rise in heroin abuse. But it's only recently that research granted legitimacy to the concerns: A study in JAMA Psychiatry found many painkiller users were moving on to heroin, and a 2015 CDC analysis found people who are addicted to prescription painkillers are 40 times more likely to be addicted to heroin.
"We always were concerned about heroin," Kevin Sabet, a former senior drug policy official for the Obama administration, told the Huffington Post. "We were always cognizant of the push-down, pop-up problem. But we weren't about to let these pill mills flourish in the name of worrying about something that hadn't happened yet. … When crooks are putting on white coats and handing out pills like candy, how could we expect a responsible administration not to act?"
The unintended consequence is a very typical result of governments' anti-drug efforts. It's called the balloon effect: When the government cracks down on one source of supply for drugs, people don't just stop using. Instead, they find another source — and the cycle continues. This effect has been observed not just with the crackdown on opioid painkillers, but with anti-drug efforts in Latin American countries — after the governments there cracked down on the illicit drug trade in the 1990s and 2000s, it simply shifted to other parts of Central and South America. This effect is one of the primary reasons the war on drugs has failed to significantly curtail drug trafficking.
But in the case of opioid painkillers, the consequence was new heroin users and deaths in sometimes unexpected places. Unlike the heroin epidemic of the 1960s and 1970s and the crack cocaine epidemic of the 1980s, the current epidemic isn't a mostly urban problem: The places reporting the biggest struggles with painkillers and heroin — likeWest Virginia, Vermont, and New Hampshire — tend to be very rural and very white. So this wasn't just a new drug epidemic, but a crisis that was hitting regions of the country that hadn't experienced this sort of thing on such a massive scale before.
As Sabet acknowledged, the government knew this was a possibility — but the feds still thought it was worth cutting off the supply of painkillers to prevent doctors and pharmacists from creating even more generations of painkiller addicts.
This didn't quite deal with all existing opioid users, who are now dying by the tens of thousands each year, increasingly of heroin. To deal with that, policy experts and lawmakers are turning to public health policies — drawing a strong contrast with the tough-on-crime approach that followed other drug epidemics in the past few decades.
Unlike previous crises, this drug epidemic is (mostly) inspiring a public health response
Federal and state governments have, particularly since the 1970s, tended to respond to drug epidemics with tough-on-crime measures. President Richard Nixon launched the modern war on drugs in 1971 in part as a response to the heroin epidemic of the time, which Nixon characterized as a "deadly poison in the American life stream." And President Ronald Reagan massively increased drug penalties in the 1980s as part of a response to the crack cocaine epidemic, which helps explain why possession of crack received a prison sentence 100 times as harsh as possession of the pharmacologically similar cocaine.
But the opioid painkiller and heroin epidemic is by and large resulting in a different type of response. Although some officials (particularly in Louisiana) have reacted to their heroin crises with a tough law enforcement approach, most federal and state officials have encouraged treating the epidemic as a primarily public health problem.
The public health approach is in line with both public and expert opinion. Polls show that most Americans prefer treating drugs as a public health issue, not a criminal one. Andmany experts, including the International Narcotics Control Board, have asked for a greater focus on public health policies to curtail demand for drugs.
Local and state governments have paid attention. Various state legislatures controlled by Democrats and Republicans have, for example, passed laws allowing police to carry naloxone, which reverses opioid overdoses. Some police chiefs have gone as far asrefusing to arrest heroin users, instead guiding them to rehabilitation and treatment. And governors from both parties, including New Jersey Gov. Chris Christie and West Virginia Gov. Earl Ray Tomblin, have characterized the epidemic as an urgent public health problem.
The opioid epidemic has been at the center of much of this reform, but it's actually part of a much broader shift in the states' approach to drugs. Faced with growing prison costs and the failure of the drug war to significantly curtail drug abuse, states have cut back on old tough-on-drugs tactics by, for example, pushing low-level offenders to specialized drug courts that attempt to put drug addicts in treatment and rehabilitation instead of jail and prison. These are policy changes that should, at least in theory, benefit anyone with a drug problem, but painkiller and heroin addicts will be among the first to claim the results of reform due to the ongoing epidemic.
The Obama administration, too, has embraced the public health approach. Led by Michael Botticelli, a recovering alcoholic, the White House Office of National Drug Control Policy has stepped up spending on treatment and prevention programs. It's called on drug courts to allow people to use anti-addiction medications such as methadone and Suboxone, which stop the effects of opioid withdrawal without producing the kind of euphoric high that leads to addicts chasing more and more of the drug. It's dedicated$2.5 million to fight heroin abuse. And the US Department of Health and Human Services — notably, the public health branch of the federal government — set aside $133 million to fight opioid abuse.
"The main distinction with this plan is the general acknowledgment that substance use is a public health issue," Botticelli told me in 2014, speaking to his office's budget. "We can't arrest our way out of the problem, and we really need to focus our attention on proven public health strategies to make a significant difference as it relates to drug use and consequences to that in the United States."
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