Across America, drug overdose deaths from heroin and prescription painkillers are at an all-time high. The crisis has swept through rural towns, suburban communities, and downtown hubs, pulling in victims across every demographic and background. Examining the opioid epidemic in America means looking at how the scourge started, the vacuum that it rushed in to fill, how it changed the face of drug addiction in America, and what states are doing to fight back and save their people.

Prescription Nation

America’s opioid problem is a big one. The American Society of Interventional Pain Physicians notes that while the United States constitutes less than 5 percent of the world’s population, that 5 percent consumes 80 percent of the world’s opioids. Those numbers come with a massive cost. The Centers for Disease Control and Prevention estimates that over 52,000 Americans died of drug overdoses in 2015, and 63 percent of those fatalities were from the consumption of heroin or prescription painkillers, both chemically based on the morphine extracted from poppy plants. The 63 percent figure is an 11 percent increase from 2014, and almost three times the number of opioid-related deaths in 1999. According to The Economist, the death tolls tend to be highest in big cities, but the concentration is much denser in rural regions, such as Appalachia, the Midwest, and New England.

This means that the victims of the epidemic tend to be white and middle-class, a target demographic that has entirely changed the face (and complexion) of drug addiction in America. The Economist writes that a generation ago, the image of a heroin addict was that of an impoverished black person, sitting under a bridge and committing petty theft to keep the habit going. Today, however, more than half of heroin users across America are women, and 90 percent are white. They never set out to become heroin addicts; their problem started when they were prescribed prescription medication to treat an injury or to help them convalesce after surgery. Some were given the drugs as an off-label treatment for anxiety or depression. Yet others borrowed or helped themselves to the drugs in the medicine cabinets at school or in the house, believing that there was nothing dangerous about taking pills that had been legally bought.

But for how innocuous prescription painkillers can look, and for whatever legitimate circumstances they were prescribed, the damage they have done is such that New York magazine says, “The opioid epidemic is this generation’s AIDS crisis,” finding similarities in the death tolls and also the culture of silence and invisibility surrounding the stigma of addiction in the 21st century and being gay in the late 20th century. The comparison is also based on numbers; the number of lives claimed by overall overdoses in 2015 (52,000) is higher than the number of fatalities during the peak year for AIDS (51,000 in 1995).

Aggressive Healthcare

Heroin has always existed on the fringes, but the prescription painkiller boom of the late 1990s and early 2000s catapulted it into the mainstream. The Portland Press Herald explains that the medical community was pressured to develop more aggressive treatments for pain management. Pharmaceutical companies stepped up to the plate, and one of them, Purdue Pharma, combined revolutionary chemical formulations with unprecedented levels of marketing. Purdue was founded by a man who made Valium the first drug to break the $100 million revenue ceiling, relying on a combination of medical marketing and media promotion.

Purdue applied the same methods to their version of the oxycodone painkiller, which they marketed as OxyContin. The drug was released in 1996, and by the end of its first year on the market, sales were $45 million. In 2001, sales were $1 billion; by 2010, sales were $3 billion. In 14 years, through an army of sales representatives, massive bonuses, and forging lucrative connections with doctors, Fortune magazine writes that Purdue Pharma controlled 33 percent of America’s painkiller business.

OxyContin proved exceptionally popular among people working in blue-collar, labor-intensive fields; fishermen, loggers, coal miners, contractors, and factory workers alike all benefitted from one dose dispelling their pain for 12 hours. Not only was their physical distress taken care of, users fell in love with the powerful tranquility and relaxation that followed. Doctors were encouraged to prescribe more OxyContin (sometimes rewarded with free hotel accommodation, airfare, and personal gifts); patients were happy to receive a simple drug that took care of them better than anything else did.

The Truth Behind OxyContin

In reality, OxyContin wore off earlier than its marketed 12-hour reach, which Purdue sought to cover up by enticing doctors to simply prescribe more OxyContin, compelling patients to take more of the drug. However, some patients discovered that they didn’t have to wait for the 12-hour release to take effect; by crushing the pill and snorting it, they got the entire narcotic dose all at once, creating an instant craving for more. When this method caught on, especially in rural regions populated by laborers working in dying industries, OxyContin became known as “hillbilly heroin,” which gradually evolved into an umbrella term for all kinds of prescription medication (such as Vicodin and Percocet) abused by that demographic.

While the cancer was still growing in the towns and farms of rural America, the rest of the country was swimming in prescriptions. Between 1991 and 2011, the number of prescriptions for opioid medications supplied by retail pharmacies went up from 76 million to 219 million, more than enough to provide every adult American with their own bottle. In 2002, only one in every six patients took a pill that was stronger than morphine; a decade later, it was one in three.

Replacement Heroin

Most of the people who abused their OxyContin never intended to become abusers, but the addictiveness of their medication caught them off-guard. For many, the transition from regular consumption to taking extra pills at once might not even have been noticed; for others, stealing someone else’s pills, or buying a batch online, might not have been thought of as so bad because OxyContin is legal, and nothing else made their pain go away. But through this, the dependence on their medication, chemically similar to heroin, kept growing and growing. Gazette Extra writes of a woman who became so dependent on her Vicodin that her body reacted negatively when she stopped taking the pills; she started abusing them because it was the only way she could function.

As the Portland Press Herald explains, when the prescriptions run out, heroin is a cheaper alternative that kills pain even more effectively. The same people who swear that they would never use heroin become so desperate for the euphoria and bliss of their medications that they cave and buy their first bag of heroin. In a report entitled “Prescription Nation 2016,” the National Safety Council explains that heroin is usually cheaper and easier to obtain than prescription medication. People tell themselves that this will be the only time they use it, but their brains are so quickly warped by the effects of heroin that the drug soon becomes their only source of pleasure, comfort, and relief.

Shame and Silence

As a result of this, opioid use (whether through heroin, prescription pills, or both) has spread like wildfire across all parts of the United States. In New Jersey, the number of people addicted to heroin is so high that together, they would constitute the fourth largest city in the state. The CDC estimates that 91 people die every day as a result of their dependence on opioids, amounting to 33,000 such fatalities in 2015. Not only was this the highest recorded figure for any year, it also outnumbers the death tolls from gun violence or car accidents.

Writing for the BBC, Chelsea Clinton observes that enough of a cultural and economic stigma remains toward topics of addiction (and the people who suffer through it) that as many as 80 percent of those experiencing opioid abuse do not get the treatment they need. For those living in rural areas, it may be that they cannot afford insurance or do not have access to hospitals, treatment facilities, or emergency services. For those in suburbia, there is a culture of shame that silences the requests for help or the acknowledgement of the role drugs and mental health play in overdose deaths. A funeral director in a suburban Cleveland county, whose business buries or cremates up to four opioid victims every month, said that more local families need to be honest about how their loved ones died, so other families can feel encouraged to intervene, ask for help, and make their communities more involved. Then, the teenagers and adolescents most at risk will be better connected to the services and people that could save their lives.

The age demographic is a sign of the changing nature of the opioid crisis. The initial wave struck primarily older clients who needed prescription pills for their chronic and cancer pain, but the problem has become so ubiquitous that a December 2016 report in JAMA Pediatrics notes that for more than 15 years, intentional and accidental opioid poisonings in children and adolescents have doubled. Many of them are student athletes in high contact sports (wrestling and football, for example) who sustain injuries and are prescribed a course of painkillers. Pressure to “play through the pain” (to avoid losing face with coaches, peers, and talent scouts), as well as to maintain lucrative scholarships, entices students to increase their doses (sometimes with the encouragement of coaches) or solicit additional pills. Researchers writing in the American Journal of Public Health noted that such athletes were 50 percent more likely to engage in “non-medical use of opioid medications” than students who did not participate in contact sports, or students who did not play sports at all. Forbes notes that the risk of off-label prescription drug abuse is even higher for teens who have pre-existing mental health issues.

Sea of Despair

For some communities, opioids are replacing alcohol and cigarettes as adolescent vices. Two high schools in rural Pennsylvania had six of their students overdose, and counselors worry that with heroin so readily available (sometimes costing as little as a fast food meal), many impulsive young people are drawn to its illicitness. In small towns, a local paramedic tells NPR, there is not much else to do, and when “heroin is everywhere,” it creates a perfect storm of desolation and drugs.

New research refers to this as a “sea of despair” that is plaguing the young white working class; the job market is weak, families are dysfunctional, and people are socially and culturally isolated. Finding comfort in eating disorders leads to unprecedented rates of obesity; finding comfort in prescription opioids and heroin leads to this demographic dying faster and younger than any other. West Virginia, ranked as one of the poorest states in the country, has become “ground zero for the opioid epidemic,” says The Fiscal Times. The state relied heavily on coal mining jobs, but once the local industry dried up, its residents (many of whom never had a college degree, which limited their job prospects) were dragged down by the economic slump and widespread unemployment.

Poor healthcare infrastructure left West Virginia with the highest rate of drug overdose deaths in the country. In only two years, from 2011 to 2013, 33.5 of every 100,000 people died as a result of drugs, while the national average was only 13.4.

423 Million Pills

Exacerbating the problem is the presence of “pill mills,” illegal operations run by organized drug trafficking rings. Doctors and pharmacists (or people pretending to be doctors and pharmacists) will sell bags of prescription pills to desperate clients, sometimes conducting only a token medical examination for the pretense of appearing to be a legitimate clinic. Payment is only done in cash by customers who drive in from hundreds of miles away because they know they can get their pills without having to answer too many (or any) questions.

Pill mills are good business for smugglers and for drug manufacturers too. Between 2007 and 2012, three major companies sent 423 million opioid painkillers to West Virginia, making a total of $17 billion. Nine million pills were sent to one “pharmacy,” in reality a pill mill in a town of just 392 people. A local journalist explained to NPR that the drug manufacturers ship the pills because they received requests from doctors, and the actual dispensation of the pills is not their responsibility. Perhaps not coincidentally, six of the state’s 55 counties have the highest opioid-based death tolls across the United States. In six years, almost 2,000 people fatally overdosed on Vicodin and OxyContin pills in those six counties.

However, the entire state is feeling the effects. A program to provide burial assistance for needy families has run out of money because it cannot handle the number of deaths. A spokesman for the Indigent Burial Program refused to speculate the role the opioid epidemic might have played in the problem, but a member of the West Virginia Funeral Directors Association blamed the “skyrocketing” drug-related deaths for stretching the program to its limits.

Other states in America are grappling with what the opioid epidemic has done to their own counties and communities. In a single weekend, 14 people in Ohio’s Cuyahoga County died from heroin or prescription painkiller overdoses. Between January and February 2017, more than 60 percent of the autopsies conducted at the Montgomery County Coroner’s office confirmed fatalities due to drug overdoses, so much so that the office is running out of space to store the bodies. The director of the coroner’s office told The New York Times that for the first time in their history, he has had to ask a local funeral parlor to temporarily take in four bodies. The director said that the coroner’s office has “never experienced this volume of accidental drug overdoses in our history.”

The Opioid Epidemic in Texas

In Texas, authorities worry that the true toll of the epidemic in the Lone Star State is much higher than their estimates. The former commissioner of the Department of State Health Services told a 2016 Senate committee that Texas has one of the lowest prescription drug fatality rates in the country, but this data was based only on certain painkillers and excluded a number of prescription drugs. The report did not contain information from medical examiners.

The Houston Chronicle writes that this oversight makes assessing the scope of the crisis in Texas harder, but the realities are nonetheless undeniable. While the official number of deaths specifically blamed on opioid painkillers was 622 in 2013, local medical examiners reported 798 deaths related to prescription drugs in that same year in only 17 out of Texas’s 254 counties. Reports by coroners in Harris, Travis, Tarrant, El Paso, and Dallas Counties, and a number of smaller counties, suggest that “many more” people died because they overdosed on prescription drugs than the state’s official tally. For example, state government counted 17 deaths from painkiller overdoses in Travis County (which includes Austin) 2013; the Travis County Medical Examiner’s Office personally counted 114 deaths in that same year.

Undercounting Overdose Deaths

Harris County, with a population of 4.1 million (the most populous county in the state, the third most populous county in America, and home to Houston, the state’s largest city and fourth largest city in the country) counted 275 deaths involving prescription drugs in 2013; the state of Texas itself reported 179 fatalities in 2013. Of the 275 deaths, six took place in less than 48 hours. On average, “death by overdose happens almost every day” in Harris County.

Experts worry that the state’s “flawed methods” undercut the severity of the problem and contribute to the difficulty in reaching out to people who may need help. That may be difficult in a state the size of Texas, especially when so many counties don’t have medical examiners of their own; instead, they employ justices of the peace, elected or appointed judicial officers who may or may not have the medical training to distinguish between a patient dying of natural causes while on a prescription medication regimen and a patient’s death being directly related to an overdose of prescription medication. Some of those counties have small budgets, thereby reducing the amount of time that can be spend on a proper postmortem examination. Under pressure from families, some justices will not document the true cause of death on a death certificate, further obfuscating the reach of the opioid crisis in those jurisdictions.

All of this means that it becomes “often impossible” to know how many people died from a prescription overdose, says the deputy chief medical examiner of Harris County’s Institute of Forensic Sciences. State and local law enforcement are doing what they can to crack down on the pill mill industry in Texas, but deaths “happen all the time,” in the words of the daughter of a Houston man who accidentally overdosed in 2013. Since his obituary did not mention his cause of death, his closest friends remain oblivious to how he died.

A professor of pathology tells the Houston Chronicle that if the trend of undercounting opioid deaths continues, “more people will die.”

Fentanyl

In some specific areas of the country hit by the opioid epidemic, researchers and officials have unearthed an underlying cause of multiple overdoses that take place in a short period of time: the arrival of an illegal drug with a significantly high potency. In terms of opioids, that drug is the painkiller fentanyl.
Fentanyl is a synthetic opioid painkiller, chemically similar to morphine but hundreds of times more potent. It is a “cousin” of heroin, says Stat News, but far deadlier. While it would take 30 milligrams of heroin to kill an adult male, it takes just 3 milligrams of fentanyl to be lethal.

As a Schedule II prescription drug, fentanyl is legal via prescription in the United States, albeit under severe restrictions; this has created a market for diversion (using prescribed drugs for recreational or illegal purposes). Dealers and manufacturers mix heroin with fentanyl, attracting addicts who are desperately craving another fix and who are drawn to the lure of a new drug that is even more potent (and literally deadlier) than anything they have ever known. A professor at the Yale School of Medicine notes that people who abuse opioids might “congregate” in certain areas to be closer to more potent drugs when they become available, thus causing a regional spike in overdose deaths.

The Third Wave

This has made fentanyl the “third wave” of the opioid epidemic, says Medscape and Science magazine writes that the introduction of fentanyl has worsened the crisis. The 72 percent increase in opioid-related deaths from 2014 to 2015 (5,544 to 9,581 people) is partly due to black marketers selling fentanyl as part of their trade, and addicts compelled to seek out a substance that is infinitely more powerful than the prescription opioids that started their habit and the heroin that followed. In some parts of the country, like Long Island, fentanyl has displaced cocaine as the deadliest drug. As a Cincinnati Drug Enforcement Administration agent explained to Science, underground drug manufacturers in China find it easier to use fentanyl to create and sell their product, as opposed to “waiting for a field of (opium) poppies to grow and harvest.”

In 2016, the DEA persuaded the China Food and Drug Administration to add fentanyl, and several similar substances, to its own list of controlled substances. Almost immediately, however, black market drug manufacturers altered their fentanyl formulas, adding new and different chemical groups and creating variants that are so new that the respective government agencies do not know enough about them to pass laws on them.

Therefore, in the same way that county officials struggle to keep an accurate count of the overdose deaths under their care, many medical examiners across the country do not yet have the resources to analyze fatalities for fentanyl abuse (or whatever variation of fentanyl the deceased had consumed), meaning that a number of fentanyl-related deaths go unrecorded, and ignorance of the drug spreads. In states experiencing a surge in fentanyl fatalities, examiners have noted that many of the deceased had active opioid prescriptions, leading researchers to conclude that “people are getting exposed to opioid [medications], and going on to fuel their addiction through heroin and fentanyl.”

The Fentanyl Effect

In Ohio, for example, there was a 500 percent increase in deaths related to fentanyl consumption in a single year, from 84 in 2013 to over 526 in 2014. State and federal officials discovered that 62 percent of all the people who overdosed on heroin or fentanyl had been prescribed at least one opioid medication in the seven years prior to their death. Ten percent of the people who overdosed on heroin, and 20 percent of the people who overdosed on fentanyl, were on a prescription for an opioid-based medication when they died.

In March 2017, the director of the Center for Disease Control’s National Center for Injury Prevention and Control told the House Energy and Commerce Committee’s Oversight and Investigations Subcommittee that people who abuse prescription opioids (either recreationally, or through psychological dependence) “are at an increased risk for heroin use – and now, fentanyl use also, whether wittingly or unwittingly.” The epidemiological threat posed by fentanyl being part of the opioid crisis has caused the life expectancy for a newborn baby in the United States to be down for the first time since 1993, according to US News & World Report.

Breaking the Stigma Ceiling

If there is anything positive that has come out of the opioid crisis, it is that one of the realities of drug addiction – that it is based on race or socioeconomic class – has been shattered. However, that ceiling took a very long time to break. NPR asks if the broad demographic of the prescription painkiller crisis constitutes a crime problem or a health problem in light of the fact that for generations, when heroin users were mostly black and low-income, there was no concept of using medicine and rehabilitation to help them. As much as 64 percent of the news coverage of the drug pandemic mentions arrests being made; only 3 percent covers expanding treatment options for those caught with heroin and/or diverted prescription pills. An assistant professor at Johns Hopkins clarified that for a generation, the general public (and the news media) operated under the presumption that “drug abuse of any kind [is] a moral failing.” That kind of attitude has been “pretty persistent and hard to overcome,” but the staggering numbers and sheer breadth of the opioid epidemic has challenged many preconceived notions about drug abuse and addiction.

As Vice magazine puts it, the introduction of fentanyl into the wave of opioid abuse is “changing everything we thought we knew about drugs, and who uses them.” Because of how strong and how versatile it is, fentanyl has broken down the stigma of abuse and reframed the entire conversation about what can and should be done to help addicts. A March 2017 study from JAMA Psychiatry notes that the “surge of opioid use, addiction and overdoses” is driven by white Americans; a demographic that, according to CNN, is responsible for “the greatest rise in heroin use.”

The racial element has not gone unnoticed. A professor of health policy at the School of Public Health at Boston University told Modern Healthcare that “black [Americans] have been under-treated for pain for decades,” and it was only after pharmaceutical corporations targeted white consumers in the 1990s and early 2000s that the opioid epidemic started to grow. When black Americans were seen as the primary consumers of heroin (and other drugs), local and federal governments pushed for zero-tolerance and tough-on-crime policies. In 1989, for example, President George H.W. Bush called for “more prisons, more jails, more courts [and] more prosecutors” as part of an Address to the Nation on National Drug Control Strategy.

But with opioid medications turning hundreds of thousands of people on to heroin and compelling these people to seek out even deadlier drugs, the politicians of today are advocating a far more progressive approach to drug control. Jeb Bush, the former governor of Florida and grandson of President George H.W. Bush, described drug abuse as “heartbreak.” He said that the stigmas and boundaries around addiction had to be removed, so people struggling with addiction can seek treatment for their “illness” without having to fight shame and humiliation. Commentators wondered if Jeb Bush’s daughter’s arrests for prescription and recreational drug abuse might have influenced the generational change in approach.

One of those changes is a focus on saving the lives of people who are overdosing instead of arresting them on sight. Many police departments across the country, like those in Gloucester, Massachusetts, and Seattle, Washington, are directing heroin addicts to treatment and using a nasal spray that reverses overdoses and literally saves lives. Seattle is also on the cusp of piloting a program that would allow heroin addicts to inject themselves under medical supervision. The controversial “safe injection sites” reduce the risk of addicts contracting blood-borne diseases (such as HIV and hepatitis) from using contaminated needles and allows for discarded needles to be safely collected and disposed of immediately instead of being left in public places. The sites are also staffed by trained healthcare professionals, who can intervene in the event of an overdose, offer on-the-spot counseling and help if needed, and whose job it is to inform and educate addicts about treatment options.

Small Steps in a Long Journey

Reversing overdoses and providing onsite counseling to addicts have been hailed by public health advocates as necessary steps to save more vulnerable people from the effects of the opioid epidemic in America, but experts warn that much more needs to be done. The Yale School of Medicine professor who spoke to CNN said that the nasal spray method “treats the acute episode [of overdosing], but doesn’t address the underlying condition” behind what led a person to heroin, especially if there is a history of prescription drug abuse that preceded the heroin habit. Breaking down the underlying condition would mean examining the vast socioeconomic and cultural causes behind “the disease [that is] killing white Americans,” in the words of the Washington Post.

Two Princeton economists cited how the collapse of the predominantly white, working-class generation of the 1970s created a void that was filled in part by conservative religious beliefs, alcohol abuse, and unhealthy eating habits. The other part was filled by pharmaceutical companies convincing these people – many of them elderly, many of them having worked physically punishing jobs for years, many of them laid off from declining industries, many of them with limited education and job prospects, many of them living in remote and isolated parts of the country, and many of them feeling abandoned and forgotten by a faster-paced, more urban-focused America – that they needed an endless supply of powerful, addictive medication to feel happy again.

Once the poison spread into the suburbs, it infected new generations and demographics of Americans. It created a market for heroin on a scale unlike any the country had ever seen before, and one that has completely redefined the nature of drug abuse and addiction as a public health problem. If ending the opioid epidemic in America will ever happen, addressing the underlying causes behind that apocalypse will require policy changes and innovations that will play out over decades, but that hard and slow work will be what saves the next generation of Americans from this widespread issue.