Opioid Crisis

Introduction

Los Angeles community health organizers help a federal Drug Enforcement Administration agent move boxes of pills and prescription drugs, which will be discarded to prevent misuse as part of the agency's 20th National Prescription Drug Take Back Day in April. More than 93,000 Americans died of drug overdoses in 2020, the most in U.S. history. (AFP/Getty Images/Patrick T. Fallon)

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Overview

In early February, 16-year-old Sammy Berman Chapman was bored after almost a year of quarantining at home because of COVID-19. The high school football player went on the social media platform Snapchat to exchange photos and videos with friends. Then he communicated with someone selling a menu of illicit drugs.

Chapman slipped unnoticed out of his Santa Monica, Calif., home and met a drug dealer. He thought he was buying Xanax, an anti-anxiety medication, according to his parents.

Dr. Laura Berman — who lost her teenage son, Sammy, to an overdose of drugs that she said he bought from someone on Snapchat — protests in June with family and friends of other overdose victims near the headquarters of Snap Inc., makers of the social media app. The company said it was “committed to working with law enforcement … in all instances where Snapchat is used for illegal purposes.” (AFP/Getty Images/Patrick T. Fallon)

A few days after his purchase, Chapman talked with his mother, Dr. Laura Berman, an M.D. and relationship therapist, about a potential summer internship. Then he told his father he wanted a cheeseburger and went into his room to play video games. An hour later, his parents found him dead on the floor. Chapman had swallowed a drug laced with fentanyl, heroin's synthetic cousin and up to 100 times more potent.

“My beautiful boy is gone,” Laura Berman wrote on Instagram. “My heart is completely shattered, and I am not sure how to keep breathing. I post this now only so that not one more kid dies. We watched him so closely. Straight A student. Getting ready for college. Experimentation gone bad.”1

For almost three decades, opioid-related drug overdoses have been a national scourge, driven first by prescription opioids, then heroin and now fentanyl, a drug synthesized in a lab from the morphine molecule. Fentanyl is then mixed with black market drugs, including heroin, cocaine or — as Chapman's family learned — counterfeit versions of medications, such as Xanax.

The COVID-19 pandemic, with its economic, physical and social stresses, is exacerbating the opioid crisis. As the nation imposed social distancing measures last year to combat the spread of the coronavirus, and as job losses piled up, many Americans turned to alcohol and drugs to cope, with 13 percent of people saying they either tried illicit drugs for the first time or increased their usage of them, according to the American Psychological Association.2

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Further, many people who had been in programs to treat addiction could not access key services, such as in-person counseling or obtaining clean needles. About 10.1 million people reported that they misused opioids in 2019, according to the 2019 National Drug Use Survey conducted by the federal Substance Abuse and Mental Health Services Administration.3

Overdose deaths in the United States, driven largely by fentanyl, reached a record of about 93,331 last year — a 29 percent increase from 2019, according to provisional data by the Centers for Disease Control and Prevention (CDC). Of those deaths, almost 75 percent, or 69,710, were related to an opioid overdose. The decades-long toll is staggering: Between 1999 and 2020, more than 900,000 people died in the United States from a drug overdose, and a majority involved an opioid, the CDC found.4

“This is the worst illegal drug epidemic in U.S. history,” says Keith Humphreys, a Stanford University professor of psychiatry and behavioral sciences and a former drug policy adviser to former President Barack Obama.

Opioids are a class of drugs derived from the opium-producing poppy plant. Some, such as oxycodone and fentanyl, are used as painkillers and for anesthesia, but they also can include illegal narcotics such as heroin. Since the late 1990s, people have been increasingly abusing both medically prescribed opioids and illegal narcotics.

Now that the pandemic is entering a different phase, public health leaders are turning their attention back to opioids and are finding a dire situation.

“One of the things we worried about during the pandemic was the opioid crisis brewing out there and that it was going to be worse and an even bigger problem when we emerged,” says Dr. Marcus Plescia, chief medical officer for the Association of State and Territorial Health Officials. “What we've been worried would happen, is happening.”

The epidemic has affected some regions of the country more than others. Between 2005 and 2017, six states experienced the largest clusters of overdose deaths: Indiana, Kentucky, Ohio, Pennsylvania, Tennessee and West Virginia. Another large cluster of overdose deaths occurred in Arizona, California, Colorado, Nevada, New Mexico and Utah. These hot spots are in regions where people have reported economic and mental stress, such as declining employment and rising poverty, according to University of Cincinnati researchers, who published a report in May.5

A man passes an abandoned building in Portsmouth, a small city in southern Ohio whose population and economy were ravaged by opioid abuse. Between 2005 and 2017, Ohio and five other states — Indiana, Kentucky, Pennsylvania, Tennessee and West Virginia — experienced the largest clusters of U.S. overdose deaths. (Getty Images/The Boston Globe/Craig F. Walker)

Overall, state and territorial governments say the opioid epidemic has cost them $630 billion since 2007 and that cost could balloon to $2 trillion over the next 20 years, according to lawsuits filed by almost every state attorney general against the opioid industry.6 The figures are based on estimates of medical care for opioid users, judicial and child welfare system costs, prevention and costs to treat addiction.

Among public health experts, lawmakers and patient advocates, a long-running debate is intensifying: What should be done about opioids? One obvious solution is to restrict the prescribing of painkillers. States began cracking down on opioid usage in the past decade, and the number of prescriptions plummeted from a peak of 255.2 million in 2012 to 153.3 million in 2019, according to the CDC.7

But some physicians and patient advocates argue that the pendulum has swung too far, saying patients with severe chronic pain — such as those with cancer and sickle cell anemia — cannot always get the opioids they need.8

Others urge federal and state governments to move people into treatment programs rather than prison. They also advocate helping addicts use drugs more safely by providing them with clean needles and resources to test their drugs for fentanyl. Critics of this approach, including many in law enforcement, respond that such efforts will merely encourage more drug use.

Looming over the crisis is fentanyl. Illicit fentanyl is making its way into the United States primarily from Mexico, through established drug trafficking networks, which use the U.S. Postal Service and drug couriers.9

“Fentanyl is the game changer,” said James Hunt, former special agent in charge of the Drug Enforcement Administration. “It's the most dangerous substance in the history of drug trafficking. Heroin and cocaine pale in comparison to how dangerous fentanyl is.”10

Mexican cartels, which have a decades-old heroin network in the United States, continue to flood the black market with drugs, including nonnarcotics like cocaine and methamphetamines, laced with fentanyl. Fentanyl can be manufactured more cheaply than heroin and substituted for more expensive drugs such as heroin or pressed into counterfeit pills and is known to supercharge the highs from drugs. Through their heroin networks, cartels move the drugs across the southern border and only a small amount is needed to feed demand.

“The majority of the drugs that are in this country come across the entire southwest border, from Brownsville [Texas] to San Diego,” Antonio Garcia, executive director of the South Texas High Intensity Drug Trafficking Area testified to the Senate Judiciary Committee on June 22. “The problem that we face … is the fact that the fentanyl is being mixed with pretty much every” drug.11

In 2017, President Donald Trump declared the opioid epidemic a national emergency, drawing public attention to the crisis and loosening federal and state restrictions on public dollars that could be used toward fighting the epidemic. The Trump administration also expanded substance use disorder treatment coverage and enhanced the Postal Service's ability to detect and stop narcotics illegally entering the country through the mail. For a brief time, the rate of overdose deaths dropped, before resuming its climb after 2018 and spiking in 2020 as the pandemic arrived.12

“We've lost steam” during the pandemic, says Plescia, the Association of State and Territorial Health Officials' medical director. “We had a situation where our state leadership was very, very engaged and being proactive [about opioids] and then they were pulled away and distracted by COVID-19.”

President Biden has begun to take steps to address the crisis. In July, he nominated Dr. Rahul Gupta to head the White House Office of National Drug Control Policy. Gupta would be the first physician to hold this post.13

The agency, which establishes policy goals and priorities for the federal government, said earlier this year that it will focus on reducing the misuse of prescription drugs, encouraging law enforcement to make greater use of drug courts and treatment rather than prison and expanding access to medication that can stem the cravings of opioids. For the first time, the agency is also putting its support behind harm reduction, an approach that helps drug users reduce the risk of dying rather than stopping them from using drugs.14

“The administration is messaging the right priorities,” says Brendan Saloner, associate professor of health policy and management and mental health at Johns Hopkins' Bloomberg School of Public Health.

As public health experts, politicians and others debate the overdose crisis, here are some of the questions being asked:

Have regulators done too much to restrict legal access to prescription drugs?

More than 20 percent of Americans said they experienced chronic pain in 2019, and about 7.4 percent said it was severe enough to impede their quality of life, according to the CDC.15 But those with severe chronic pain are finding it increasingly difficult to obtain opioids.

Hank Skinner, 79, shown with his wife, Carol, 78, of Alexandria, Va., relies on a fentanyl patch to treat chronic pain in his shoulders that dates from a car accident years ago. A 2016 guidance from the Centers for Disease Control and Prevention is making it harder for patients to acquire opioids, some health experts say. (Getty Images/The Washington Post/Salwan Georges)

The reasons are many, health experts say. Over the past decade, states have implemented a variety of measures to address the opioid epidemic, including establishing prescription drug monitoring programs and passing legislation to regulate so-called pill mills — doctors' offices, pain clinics and other providers that dispense large amounts of prescription drugs, usually narcotics, for nonmedical reasons. They say Florida is illustrative of how the states responded to the epidemic. About a decade ago, thousands of people traveled to Florida not to visit Walt Disney World but to buy prescription opioids from pill mill clinics.16

Pill mills proliferated in Florida between 2003 and 2010 and often operated in outdoor malls, where parking lots would fill with cars from other states.

The clinics' doctors would make a cursory evaluation and then send patients to an onsite pharmacy where they could buy narcotics. People brought them home to sell to neighbors, spreading the opioid epidemic in communities. In 2010, 90 of the nation's top 100 opioid prescribers were Florida doctors and 85 percent of the nation's prescriptions for oxycodone — the main ingredient in OxyContin — were written in that state.

“You could think about the [opioid] manufacturers as having lit the fire, and the distributors and pill mills were really pouring gas on the fire,” said Dr. Andrew Kolodny, co-founder of Physicians for Responsible Opioid Prescribing and medical director of opioid policy research at Brandeis University's Heller School for Social Policy and Management.17

Then Florida began cracking down. In 2010, the state passed a pill mill law, requiring clinics to register with the state and set limits on their prescribing. In 2011, the state established a prescription drug monitoring program to identify patients who were being prescribed controlled substances. A key aim was to stop people from doctor-shopping to seek drugs illegally.

The number of pill mills and inappropriate prescriptions declined, likely saving about 1,000 lives by reducing overdose deaths in the state, according to a 2016 study published in the American Journal of Public Health.18

“Findings from this study indicate that laws regulating pain clinics and enforcement of these laws may, in combination, reduce opioid overdose deaths,” the study's authors wrote.

Other states followed in Florida's footsteps. As of June, all 50 states and the District of Columbia have implemented prescription drug monitoring programs, and about a dozen have passed pill mill laws. Thirty-six states have implemented additional policies, such as limiting the number of days that a person can receive an initial supply of opioids — ranging from three to seven days — as well as capped dosage amounts.19

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But for some physicians and patient advocates, regulators have acted excessively.

In addition to states increasing regulations on opioid prescribing, the CDC in 2016 issued guidelines for health care providers on when to initiate and continue opioid prescriptions. More than 300 medical experts, including three former White House “drug czars,” say the guidelines harm patients with severe chronic pain, who had been taking high doses of opioids and were able to function normally.20

“I think we've gone too far” with limiting prescriptions, says Dr. Stefan Kertesz, professor of preventive medicine at the University of Alabama, Birmingham. The 2016 CDC statement “was enshrined in a series of actions by governmental and nongovernmental entities that fundamentally changed care” in a way that is not beneficial to some patients, he says.

Patient advocates say insurers have used the CDC guidelines to deny reimbursement, and doctors are turning patients away. They say these patients in pain are being forced into opioid withdrawal, causing extreme pain and, in some cases, driving them to consider suicide.21

“What we created was an overarching incentive structure … to change a patient's care against their will,” says Kertesz. “For some people they will be OK, but for another contingent, they will wind up in worse pain or experiencing emotional distress or dying by suicide or attempting to make up for the loss of the prescription opioid with something else, whether it's alcohol or another prescribed drugs or even heroin.”

Data show that 4 percent to 6 percent of people who misuse opioids transition to heroin and 80 percent of those who use heroin began by misusing opioids, according to the National Institute on Drug Abuse.22

In 2019, the CDC released a statement saying the guidelines' intention was to stop physicians from excessively prescribing opioids, not to force patients to be tapered off them.23

Some experts defend all the regulations as necessary, noting that prescription drug abuse remains widespread. Of the 10.1 million Americans who said they misused opioids, 1.6 million were new misusers of pain medication, according to the 2019 National Survey on Drug Use and Health.24

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“We are still prescribing more than any other country on Earth,” says Kolodny. “Far too many people are becoming newly addicted.”

Should people be incarcerated for using illegal drugs?

Fifty years after President Richard Nixon called drugs “public enemy number one” and declared a war on drugs, a majority of Americans want to end the fight and move on, experts say. In June, for example, a poll by the American Civil Liberties Union and two other groups found that 66 percent of voters support “eliminating all criminal penalties for drug possession.”25

And many voters in November 2020 approved ballot questions to do so. Four states — Arizona, Montana, New Jersey and South Dakota — approved the legalization of recreational marijuana, joining 11 other states. Oregon went the furthest, choosing to become the first state to decriminalize possession of small amounts of heroin, cocaine, LSD and methamphetamines, among other drugs, which became punishable by only a civil fine of $100. Washington state made drug possession a misdemeanor in May.26

President Biden has said that “people should not be incarcerated for drug use but should be offered treatment instead” and plans to develop criminal justice reforms to reflect that position, according to the White House Office of National Drug Control Policy.27

Support for Oregon's stance on drugs is growing, health experts say. The opioid epidemic is credited with starting the movement because the majority of those who were prescribed the medication and became addicted received the drugs from a doctor, not a dealer, according to these experts. Polls show that nearly half of Americans know a family member struggling with addiction.28

“What the opioid epidemic did, because it didn't begin with illicit substances, but rather with drugs prescribed by their doctors, was shift Americans' understanding of addiction,” says Dr. Shabbar I. Ranapurwala, an associate professor of epidemiology at the University of North Carolina, Chapel Hill. “People have started to see it as an illness and not something that people should be punished for.”

The so-called war on drugs, continued by every president after Nixon, was supposed to deter drug use but has not, studies have found. A large body of research gathered over decades shows that stiffer prison sentences for drug crimes do not deter misuse and have not lowered drug use, overdose deaths or drug arrests, according to a 2018 Pew Charitable Trusts analysis of federal and state law enforcement, corrections and health agency data.29

Instead, the crackdown on drug use has filled prisons. The number of those incarcerated in federal and state prisons on drug-related charges was nearly 300,000 in 2018, up from less than 25,000 in 1980.30 These inmates are disproportionately people of color, demonstrating that the judicial system enforces drug laws unevenly, says Sheila Vakharia, deputy director of the department of research and academic engagement for the Drug Policy Alliance, a nonprofit that advocates for reforming drug laws.

“Drug possession is already essentially decriminalized for a vast majority of upper-class, white people who are privileged enough not to be policed,” says Vakharia. “They don't face a patrol coming down their street telling them to empty their pockets,” as often occurs in minority communities. She argues that drug decriminalization would bring more equity to the justice system.

Many in law enforcement oppose decriminalization. Justin Smith, sheriff in Larimer County, Colo., says based on his 30 years of experience, decriminalizing drugs could worsen the overdose crisis.

A man injects heroin into his foot near an encampment of drug users in an area of Philadelphia known as the railroad gulch, which is considered ground zero for the city's opioid epidemic. For many individuals, the addiction process started slowly, with a doctor's prescription for pain pills after an accident or surgery. (AFP/Getty Images/Dominick Reuter)

“We are creating an environment where there are no consequences,” says Smith. “We are saying to people they can do what they want, for however long they want, until they decide they are ready for treatment — and sometimes that is many, many years down the road.”

Smith says drug courts provide a better model.

“Drug courts hold people to expectations, and for some people that is what they need to get clean,” he says.

The United States has more than 3,500 drug courts where judges give defendants who have been arrested on a nonviolent drug charge a choice: Go to jail, or enroll in a drug treatment program supervised by the court.

Drug courts are run by the states with federal support, and each has its own approach. Typically, the one- to two-year program includes a daily regimen of recovery services, drug tests and court hearings. A team of medical treatment providers, probation officers and other addiction specialists work with enrollees, and all are overseen by a judge. Those who stay in recovery for the term of the program “graduate” and move on.31

Evidence of drug courts' effectiveness is mixed, however. Some data show that drug courts have reduced community crime by 8 percent to 26 percent. Other studies found that recidivism was reduced in the range of 7.5 percent to 45 percent and those who graduated were more likely be employed and less likely to have a substance use disorder than those who did not enroll in a drug court program. But studies of the programs tend to focus only on those who graduate from drug court — and only about 50 percent complete the drug court program.32

Others say if the goal is to end the opioid epidemic, the criminal justice system should not be involved. Arrest on a drug charge can set off a catastrophic chain of events, including the loss of employment, inability to obtain housing and the loss of custody of children — all factors that can worsen someone's substance use disorder, says Tracie Gardner, vice president of policy advocacy at the Legal Action Center. Studies in two states showed that, compared with the general public, people incarcerated are 40 to 129 times more likely to die from an overdose in the two weeks after they are released from prison.33

“For what other health conditions do we punish people instead of treating them?” says Gardner. “We aren't addressing the overdose epidemic with jail. They need support and treatment for their addiction.”

To slow the opioid epidemic, should government enable safer use of drugs?

With fentanyl a growing danger, public health officials are increasingly embracing a controversial approach called harm reduction. The strategy helps people continue their drug use while reducing their risk of dying or acquiring an infection.

“Harm-reduction programs say, ‘OK, you're using drugs,’” said Daliah Heller, director of drug use initiatives at Vital Strategies, a global public health organization. “How can we help you stay safe and healthy and alive first and foremost?34

This year Congress signaled its support of the approach. The American Rescue Act passed in March included $30 million for states to put toward harm-reduction strategies. Biden has said expanding harm-reduction policies nationally is a priority; he is the first president to adopt that position.35

The administration's harm-reduction position is a “major break with the past,” said Vanda Felbab-Brown, a senior fellow at the Brookings Institution, a Washington think tank.36

The harm-reduction strategy with the most evidence of success is called a syringe service program. About 375 syringe service clinics across the country provide sterile equipment to individuals who inject drugs.37 The clinics are usually staffed by peer specialists who have recovered from substance use disorders and can be a gateway to recovery by helping people find treatment who may not otherwise have been seeking it. The availability of sterile syringes also helps reduce the community transmission of infectious diseases caused by intravenous drug use, such as HIV and hepatitis C. In some locations, the clinic distributes testing strips so that people can determine whether their drugs contain fentanyl.

The World Health Organization, the United Nations and the CDC say research shows syringe programs stop infectious disease outbreaks and increase the likelihood that someone will seek treatment. In Seattle, a syringe program demonstrated that new participants were five times more likely to enter treatment than those who did not come to the clinic, according to a study published in the Journal of Substance Abuse Treatment. 38

“These sites meet people where they are at,” says Legal Action Center's Gardner. “It lets people know they are supported and cared about, and sometimes that is what is needed to help people into treatment.”

Many sites also give out naloxone, a drug that reverses opioid overdoses. Naloxone, known by the brand name Narcan, can be administered through a nasal spray or injection. To encourage naloxone usage, 47 states and the District of Columbia have passed Good Samaritan laws to protect people who give naloxone to someone overdosing.39

Syringe services, however, generate strong opposition in some communities. Six years ago, public health officials in Scott County, Ind., a rural community of 24,000, asked the state to set up a syringe service clinic, after people addicted to opioids contracted HIV. Then-Gov. Mike Pence, who had long opposed syringe programs on the grounds they promoted drug use, signed an executive order allowing one to open, and the outbreak was curtailed.

But the clinic remained controversial, and in June, Scott County's commissioners voted to close the site.

“I know people that are alcoholics, and I don't buy him a bottle of whiskey,” said county Commission President Mike Jones, in explaining in why he voted to end the program. “I have a hard time handing a needle to somebody that I know they're going to hurt their self with.”40

Earlier this year, West Virginia passed a law imposing new restrictions on syringe clinic operations after some politicians complained the facilities were attracting drug users. North Carolina legislators are considering restricting clinics in their state, too, after Asheville residents complained on social media that a syringe program was leading to increased crime and litter in the community.41

Some health experts say the syringe clinics do not really help people get into treatment because there are not enough treatment options. Of the 21.6 million Americans who said they need help with substance use, just 4.2 million received treatment, the 2019 National Survey on Drug Use and Health found.42

A primary barrier to treatment is cost. Drug treatment programs range from $5,712 to $17,434 per patient, depending on whether it is offered through a for-profit or nonprofit program, according to a February study in the journal Health Affairs. Under the Affordable Care Act, Medicaid provides coverage for addiction, but 12 states have not expanded their coverage to single, childless adults, putting treatment out of reach for many.43

“We aren't going to get control of this epidemic unless we massively expand treatment for opioid addiction,” says Physicians for Responsible Prescribing's Kolodny. “And the treatment has to be easier to get than a bag of dope.”

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Background

The “Joy Plant”

Opium, the poppy plant ingredient from which opioids are derived, has been used in medicine for thousands of years.

In 3400 B.C., Sumerians in the Middle East referenced the “joy plant.” Writings dating to about 300 B.C. describe how slicing the bud of a poppy plant would result in the oozing of a milky paste that could produce euphoric and painkilling effects. In 1500 B.C., Egyptian doctors described how to prepare seeds from the poppy plant and use opium to sooth fussy babies. During the Roman Empire, Galen, a doctor who came to be known as the father of Western medicine, described using opium to stimulate sleep, calm the nerves, induce comfort, reduce melancholy and make pain disappear.44

Opium's dangers were noted as well. Ancient physicians wrote that opium could kill a person or cause drug dependence. Whole societies became entangled in opium, too. In the 1800s, the British twice waged war on China to force it to import opium. During the Victorian era, opium became fashionable to use among British poets, writers and artists, inspiring the work of poets Samuel Taylor Coleridge and Percy Bysshe Shelley.

In the 19th century, doctors also began using new versions of opium called morphine and heroin. They were effective treatments for pain that could be delivered by the newly invented hypodermic syringe. At the time, there were no regulations on how drugs could be sold or used by doctors, and morphine became widespread because few alternative treatments for illness and pain existed.45

A pamphlet advertises a patent medicine in 1901. Companies sold these over-the-counter products that often contained opium, morphine, cocaine or alcohol to an unknowing public, many of them women seeking help with such issues as menstrual cramps. (Getty Images/Transcendental Graphics/Contributor)

“Doctors were really impressed by the speedy results they got” with morphine, said David T. Courtwright, author of Dark Paradise: A History of Opiate Addiction in America. “It's almost as if someone had handed them a magic wand.”46

Doctors frequently gave their middle- and upper-income female patients morphine for menstrual cramps and morning sickness and to help with “nervousness.” Businesses jumped into the pharmaceutical market, too. Companies sold products over the counter, called “patent medicines,” that contained, unbeknownst to the public, opium, morphine, cocaine and alcohol. Products sold included cough drops with heroin and cough syrup laced with morphine.

Companies aggressively marketed these products, sending advertisements through the mail. They also handed out free samples and promotional trinkets; ran national newspaper campaigns with patient testimonials; and installed outdoor signs promoting their products. Historians estimate that by the end of the 19th century, around 300,000 Americans had opium use disorders, many of them women.47

Growing public concern about opioid addiction and the safety of patent medicines led the government to step in. President Theodore Roosevelt signed the 1906 Pure Food and Drug Act, which forced drugmakers to disclose their ingredients and prohibited drugs' misbranding. Once consumers understood what was in over-the-counter products, many stopped buying them.

Roosevelt also created the first version of a White House anti-drug office, called the U.S. Opium Commission. He named Hamilton Wright, an Ohio physician, to run it. Wright, who could be considered the United States' first “drug czar,” said opium “has become one of the most fertile causes of unhappiness and sin in the United States.”48

Wright successfully pushed for passage of the 1914 Harrison Narcotics Tax Act, the nation's first sweeping drug law. The law forced makers and distributors to register with the government and limited doctors to using opium “in the course of their professional practice.” Many physicians stopped providing opium to patients altogether.

Historians say the moves, along with the advent of World War I in 1914, reduced opium consumption in the early 20th century but did not end addiction or drug use. People who had been using opium products before the law passed still needed opium and had to seek out drugs illegally. New York City, which had been the center of legal heroin manufacturing, became the center of illicit heroin trafficking in the 1920s. Its trans-Atlantic ports and networks enabled drugs to be smuggled into the United States from Europe and Asia and then throughout the nation.49

Continuing opium use was enough of a concern that the federal government in 1930 created a special drug enforcement agency — the Federal Bureau of Narcotics, the precursor to today's Drug Enforcement Administration — to enforce the Harrison Act. Thousands of people were imprisoned for drug use.

Drug Farm

Opioids work because they connect to brain receptors processing the body's own painkillers known as endorphins. While endorphins may last for minutes, opioids can boost the body's natural ability to block pain and promote calm for hours. Over time, the drug rewires the brain, and the body craves stronger and stronger doses to feel a sense of equilibrium. The body needs more of it to relieve pain, get high and stave off withdrawal.

Doctors call it “peaks and troughs,” where someone feels tremendous bliss and then despondence as the drug works its way through the body. Withdrawal from opioids is a painful and long process. Some say it is akin to an extreme and long-lasting flu. Symptoms include intense anxiety, agitation, sweating, nausea, diarrhea and abdominal cramping.

“The brain begs for opioids because taking opioids is the new normal,” says Dr. Charles Gressard, chancellor professor in the counselor education program at the William & Mary School of Education. “That is why opioid addiction is so tenacious.”

Many aspects of the medical profession's understanding of addiction evolved from the nation's long conflict over whether it should punish or treat those who misuse drugs.

As the country was ramping up its drug laws in the early 20th century, Congress also wanted to address the plight of those who were already addicted. Lawmakers in 1929 created a prison in Lexington, Ky., to rehabilitate drug users. It was called the Narcotic Farm.50

Beat Generation author William S. Burroughs was among the writers, artists and musicians who spent time at the Narcotic Farm in Lexington, Ky., a federal prison and treatment center established in 1929 to rehabilitate drug users. It became a key center for drug addiction research and informed the medical community's understanding of substance abuse disorders. (Getty Images/Michael Ochs Archives)

Run by the U.S. Public Health Service, the facility was built to be part prison and part research and treatment facility for substance use disorders. As part of therapy, patients could tend farm animals and work vegetable gardens. The crops and animals were used to feed staff and patients. Many New York writers, artists and musicians caught using heroin were sent to the facility. Writer William S. Burroughs recounted his experience there in his first novel, Junky. Jazz musicians Chet Baker and Sonny Rollins, as well as actor Peter Lorre, went there, too.51

The farm became a key center in research into drug addiction and treatment. Much of what is understood in addiction medicine today began with research at the farm, according to Sam Quinones, author of Dreamland: The True Tale of America's Opiate Epidemic. Doctors tested every major opium drug on prisoners, including Dilaudid, Demerol, Darvon, codeine and Thorazine. They also developed scales for measuring addiction, the severity of withdrawal symptoms and the addictiveness of many drugs.

The Narcotic Farm closed in the 1970s when addiction treatment became more widely available. But it transformed the medical establishment's understanding of addiction — namely, that those with substance use disorders are “people suffering from a chronic, relapsing disorder that affects public health,” said Nancy Campbell, the co-author of the book The Narcotic Farm. 52

As the Narcotic Farm wound down, the federal government shifted its focus toward using law enforcement as a deterrent against drug use. Nixon declared his war on drugs in 1971. In the 1980s and 1990s, Presidents Ronald Reagan, George H.W. Bush and Bill Clinton signed legislation to expand prison sentences for drug-related offenses and increased federal spending on police enforcement and prisons. President George W. Bush emphasized using the criminal justice system for “compassionate coercion” to push people into treatment.53

By 2014, the middle of Obama's first term as president, public opinion had begun shifting toward interest in rehabilitation instead of punishment. Gallup Polls show that 51 percent to 66 percent of Americans wanted to legalize marijuana.54

Modern Opioid Epidemic

Almost a century after the United States' first opioid epidemic, another emerged.

The story started as it did before. Well-meaning doctors wanted to help their patients with pain. In the 1980s the palliative care movement was gaining steam in medicine. Doctors who saw terminally ill cancer patients suffering from pain started using morphine to ease discomfort. Patient advocates involved in the HIV/AIDS epidemic began urging more aggressive use of painkillers in treatment.

Two studies galvanized the movement.

In 1980, The New England Journal of Medicine published a letter titled “Addiction Rare in Patients Treated with Narcotics.” It was co-authored by a Boston University Medical Center physician who said he had analyzed the records of 11,882 hospitalized patients who received opioids, and only four were reported to have become addicted. The letter contained no supporting data.55 Then in 1986, two palliative care doctors published a study in the journal Pain of 38 cancer patients who had received opiates as part of their multiyear care, The study said only two patients had become addicted to the drug and both had a prior history of substance use disorder.56

These two studies would be cited repeatedly over the next two decades by medical organizations and the opioid industry when marketing opioids to patients for chronic noncancer pain.57

Prescriptions for opioids began to increase throughout the 1980s and started to surge in the mid-1990s when pharmaceutical companies introduced new opioid products. Purdue Pharma, a leading drugmaker owned by the Sackler family, led the way.

In the early 1990s, Purdue Pharma developed OxyContin. OxyContin's main ingredient is oxycodone, a drug that is almost twice as potent as morphine. The company wrapped the drug in a time-release coating that was supposed to reduce the highs and lows of opium and therefore make it less addictive. The company further tried to make the capsule difficult to break to prevent misuse. However, addicts figured out how to crush the capsule and then snort or inject the drug. The Food and Drug Administration approved OxyContin for sale in late 1995.

Purdue Pharma then embarked on one of the most aggressive sales efforts in drug history, paving the way for many opioids to be broadly prescribed for pain in the years after. Dozens of lawsuits filed over the past 15 years said that company sales representatives used the two studies from the 1980s to misrepresent OxyContin to doctors as a painkiller with low risks of addiction. The sales reps argued that people with chronic pain were needlessly suffering, and OxyContin could not only safely relieve physical suffering but also reduce anxiety and enable faster recovery.

Purdue Pharma targeted its sales to rural and suburban communities, where primary-care doctors were unfamiliar with the opioid hydrocodone, according to court documents. These communities, especially in West Virginia and Ohio, became hot spots for opioid overdoses.58

Purdue Pharma funded organizations that fanned across the country to destigmatize the medical community's use of opioids for pain. Advocacy groups that Purdue Pharma funded urged states to change their rules to allow doctors to prescribe opioids more liberally.

The company's salesforce also provided coupons that doctors could give patients for free 30-day prescriptions of OxyContin. These Purdue Pharma-funded groups urged hospitals to emphasize that pain assessment should be monitored along with the vital signs of patients' temperature, pulse, breathing rate and blood pressure. Pain came to be called “the fifth vital sign.” Insurers began measuring physician practices and hospitals for quality of care based on how they were managing patients' pain levels.59

The market for opioids exploded. In 1996, OxyContin sales were $48 million. By 2000, sales had surged to almost $1.1 billion.60

Other drug companies jumped into the pain market, including Israeli-based Teva Pharmaceutical Industries and Ireland-based companies Mallinckrodt and Endo Pharmaceuticals. Between 2006 and 2014 — the most recent data available — drug distributors sent more than 100 billion oxycodone and hydrocodone pills to American pharmacies, according to a Washington Post analysis of Drug Enforcement Administration data.61

Data on overdose deaths document the rising toll. In 1996 when Purdue Pharma began marketing OxyContin, the CDC recorded 9,838 accidental drug poisonings that resulted in death. By 1999, drug deaths had nearly doubled, reaching 16,849. By 2006, 10 years after OxyContin was on the market, overdose deaths totaled 34,425.62

As deaths piled up, the medical community reassessed its embrace of opioids. It had become clear that these medications were not as safe as advertised. In 2007, the U.S. attorney for western Virginia, where opioid use was widespread, charged Purdue Pharma with fraudulent marketing because of its claim that the addiction potential was low. The company pleaded guilty to one felony count of “misbranding.” Three company executives pleaded guilty to misdemeanor charges of the same offense, and the company paid a $634.5 million fine.63

Deputy Fire Chief Terry Walsh helps an 18-year-old heroin user in Portland, Maine, in 2015. For almost three decades, opioid-related drug overdoses have been a national scourge, driven first by prescription opioids, then heroin and now fentanyl. (Getty Images/The Washington Post/Linda Davidson)

In 2011, the CDC officially declared a prescription drug epidemic caused by opioid painkillers and began the process of setting new guidelines for physicians to reduce opioid prescribing. Purdue Pharma fought the CDC's process from the start, according to Patrick Radden Keefe, author of Empire of Pain: The Secret History of the Sackler Dynasty. 64

The CDC issued guidelines to doctors in 2016 that said opioids were appropriate for patients who were in active cancer treatment or were receiving palliative or end-of-life care. It did not recommend that doctors start opioids as routine therapy for chronic pain, but advised that if clinicians chose to do so, they should weigh, with the patient, the expected benefits for both pain relief and function against risks of addiction and side effects.65

Citing a national emergency in 2017, Trump secured $6 billion from Congress over two years to impose restrictions on opioid prescribers, provide more addiction treatment and support and expand law enforcement action focused on the illicit drug market.66 In 2018, Trump signed the Substance Use-Disorder Prevention that Promotes Opioid Recovery and Treatment (Support) Act, a sweeping law that expanded substance use disorder treatment coverage and appropriated money to enhance the Postal Service's ability to detect and stop narcotics from entering the country through the mail.67

For a brief time, the data showed improvement. Between 2017 and 2018, the rate of overdose deaths fell 4 percent. Public health experts say that rising public awareness of the crisis, fewer opioid prescriptions and an increased access to treatments were helping stem the crisis. But then deaths rose again between 2018 and 2019 and worsened over the past year because of the pandemic and fentanyl.68

Over the past decade, states, counties and cities have filed dozens of lawsuits against not only Purdue Pharma but also other drug manufacturers, distributors and pharmacies, arguing that they all contributed to the epidemic.

In 2017, the suits filed by 2,600 plaintiffs were consolidated into an ongoing multidistrict case overseen by an Ohio federal judge. Two dozen state attorneys general filed their own individual suits against drugmakers, distributors and pharmacies, and two states — Massachusetts and New York — also named members of the Sackler family, who own Purdue Pharma and were in charge of spearheading the aggressive OxyContin marketing campaigns.69

Under pressure from all the litigation, Purdue Pharma filed for bankruptcy protection in September 2019.70

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Current Situation

Twin Crises

More than halfway through 2021, strapped public health leaders are fighting two crises — the COVID-19 pandemic and drug overdoses.

“Public health departments that had been engaged in the opioid epidemic rightfully diverted their resources to pandemic response … and there were consequences,” says Kabaye Diriba, senior program analyst on opioids for the National Association of County and City Health Officials, citing the loss of personnel for outreach and other services.

Some states and communities are more engaged than others in the drug overdose fight. In Arizona, where one lawmaker lost her son to a drug overdose, the Legislature passed a bill making it legal for people to use fentanyl strips to test their drugs for traces of the synthetic opioid. In Montana, which reported 22 drug overdose deaths tied to fentanyl in the first five months of 2021, the state is stepping up public education efforts to warn people that street drugs could be poisoned with fentanyl.71

In San Diego, where overdose deaths are surging, city leaders changed their rules to make it legal for anyone to carry a spray version of naloxone, the anti-overdose drug.

“One of the hardest things with this problem is, there's not just one magic thing you can do tomorrow and the problem goes away,” said San Diego County Supervisor Nathan Fletcher. “It is very difficult. It requires us to do a lot of things faster, in a much more aggressive way, to try to make an impact.”72

But fighting the pandemic and getting the broader population vaccinated against COVID-19 remains the priority of state public health department leaders, according to Plescia, of the Association of State and Territorial Health Officials.

“State health departments are tracking the opioid epidemic and are interested in moving things forward,” says Plescia. “But even that is limited because even if [those who work on the opioid epidemic] can get the attention of health leadership, the rest of government and society hasn't been in a position to put a lot of emphasis and resources toward this.”

Some states and cities are reporting that the recent surge in drug overdoses is disproportionately affecting communities of color. In Missouri, during the first half of 2020, overdose deaths among Black people rose 64 percent, compared with 40 percent among white people. Philadelphia doctors said overdoses increased more than 50 percent for Black people and decreased for whites.73

In Massachusetts, the confirmed opioid-overdose death rate increased 69 percent in 2020 among Black non-Hispanic males.

“The disparities in overdose trends among Black men underscore the need to continue our public health-centered, data-driven approach to the opioid epidemic that is disproportionately impacting high-risk, high-need priority populations,” said Massachusetts Public Health Commissioner Monica Bharel.74

Biden Administration

To address racial inequities, the White House Office of National Drug Control Policy said the agency would identify public health data gaps to better target drug resources toward diverse communities, as well as look for opportunities to increase funding to address health inequities. Further, the administration plans to establish an interagency working group to develop policy priorities for criminal justice reforms.75

“We've never had advancing racial equity as part of the [office's] priorities before, and we are really excited about this,” said Cecelia Spitznas, acting U.S. drug demand reduction coordinator at the office.76

A woman from a substance use support group listens as Boston officials discuss litigation against the pharmaceutical industry. Johnson & Johnson and three opioid distributors agreed in July to pay $26 billion to settle thousands of state, city and county lawsuits, in exchange for release from liability concerning the epidemic. (Getty Images/The Boston Globe/David L. Ryan)

Other drug policy priorities include expanding access to medication treatments; increasing efforts to reduce youth substance use; expanding the number of health providers who treat substance use disorder and recovery support services; increasing access to harm reduction services; and reducing drug trafficking. In March, President Biden directed nearly $4 billion from the American Rescue Act be used to expand prevention and treatment programs. His budget request for fiscal 2022 to fight the opioid epidemic is $41 billion.77

The administration also relaxed regulations on buprenorphine, a drug that helps people hooked on opioids curb their withdrawal symptoms. The ability to prescribe buprenorphine is restricted to health providers who receive training and a waiver from the Drug Enforcement Administration. The administration waived the training requirement as an incentive for more doctors to prescribe the drug. In addition, the administration changed federal rules to allow organizations that receive federal grants to buy fentanyl strips for drug testing.78

In July, Biden nominated Gupta, who served as West Virginia's health commissioner between 2015 and 2018, to run the Office of National Drug Control Policy. In West Virginia, Gupta pioneered the use of an overdose fatality review process, in which the state analyzed every overdose death to determine risk factors that the state could use to develop policy for addressing the epidemic. The overdose fatality review model is now used in about a dozen states.

“With his experience and expertise in public health policy and medical services, Dr. Gupta is a well-qualified public servant to lead the Office of National Drug Control Policy,” said Dr. William Haning, president of the American Society of Addiction Medicine.79

In Congress, there has been a flurry of activity aimed at the opioid epidemic, including introducing bills to expand Americans' access to medication such as buprenorphine and to behavioral health treatments. Other legislation seeks to address racial disparities in treatment programs for addiction, increase restrictions on opioid prescribing and extend the Trump administration's classification of illicit fentanyl analogues — drugs that mimic the pharmacological effects of fentanyl — as Schedule I drugs. Drugs listed as Schedule I include heroin, LSD and other drugs that have no accepted medical use and a high potential for abuse.

Reps. Bonnie Watson Coleman, D-N.J., and Cori Bush, D-Mo., introduced the Drug Policy Reform Act of 2021, which would eliminate criminal penalties for possession of opioids, heroin and other drugs that are for personal use; expunge criminal records; prohibit housing and employment discrimination based on past drug arrest; and shift the regulatory authority for drug laws from the Justice Department to the Department of Health and Human Services.

“When we ultimately realized that most of the opioid abuse was happening in white communities, we recognized substance use and abuse as the issue of help, not of criminality,” said Watson Coleman of her bill. “This needs to be addressed with treatment options and methodologies and counseling and things of that nature, not incarceration.”80

With a huge policy agenda on its plate, however, Congress is unlikely to pass any sweeping drug policy reform legislation in 2021, political analysts say.

Opioid Lawsuits

After years of legal wrangling, Johnson & Johnson and three opioid distributors — McKesson, AmerisourceBergen and Cardinal Health — reached a $26 billion deal in July to settle thousands of state, city and county lawsuits, in exchange for release from liability concerning the epidemic.

The settlement establishes a framework for money to flow to communities to be used for treating and preventing substance use disorders, but the agreement still must be approved by states and localities. The settlement does not include lawsuits against other drug manufacturers, pharmacies or retailers that have been sued for their role in the epidemic.81

In a statement, the three distributors said: “While the companies strongly dispute the allegations made in these lawsuits, they believe the proposed settlement agreement and settlement process it establishes are important steps toward achieving broad resolution of governmental opioid claims and delivering meaningful relief to communities across the United States.”82

Meanwhile, one case that is being tried against the opioid distributors in West Virginia and another in California against drugmakers will continue.83

On a separate track, dozens of state attorneys general filed suits. In June, the state of New York began its trial against a number of opioid companies, including Teva Pharmaceuticals, Endo Pharmaceuticals and Allergan Finance.

Letitia James, attorney general of New York state, joined other attorneys general in suing opioid manufacturers for their role in the epidemic. New York's trial began in June, and attorneys say the outcome will set a precedent for how other state lawsuits against opioid companies are resolved. (AFP/Getty Images/Timothy A. Clary)

Lawyers say the outcome of the New York trial will set a precedent for how other state lawsuits against opioid companies are resolved.

“If they can resolve this in New York, that will go a long way to a national settlement,” said Stephen Acquario, executive director of the New York State Association of Counties, an advocacy organization for the state's 62 county governments. “A lot of people around the country are watching this.”84

Purdue Pharma is not a defendant in any of the trials because of its Chapter 11 bankruptcy protection filing in 2019. It offered to pay $10 billion to settle all the suits against it. In July, 15 state attorneys general reached an agreement with the company to resolve their cases in exchange for $4.5 billion, the public release of company documents showing its role in the opioid epidemic and the end of the Sackler family's ownership of the company. The settlement will likely clear the way for Purdue Pharma to emerge from bankruptcy, experts say.85

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Outlook

Epidemic's Long Reach

Drug control experts say the opioid crisis may remain out of control for years to come because the supply of illegal fentanyl is so lucrative for drug traffickers and because millions of people are addicted to opioids or living with the consequences of having been addicted.

Sellers in China, a major source of the chemicals needed to make fentanyl, supply ingredients to the Mexican cartels through air and sea routes and are difficult to trace. Further, the drug cartels are making use of the internet. The anonymity afforded by cyberspace means that people can, more than ever, easily buy and sell illicit and tainted drugs from the comfort of their homes, experts say.

“We expect the threat from transnational organized crime networks supplying potent illicit drugs … to remain at a critical level,” said the 2021 report from the Office of the Director of National Intelligence, which specified that Mexican drug traffickers are smuggling drugs with ingredients from South America and Asia. “The pandemic has created some challenges for traffickers, mainly due to restrictions on movement, but they have proven highly adaptable, and lethal overdoses have increased.”86

Physicians who work with substance use disorder patients also say that the legacy of the opioid epidemic will linger for decades in terms of family members lost, health care costs incurred, economic losses compiled and the millions of people who will be living with addiction.

“We're looking at decades to undo the harms and, of course, there are many harms that can never be undone,” says Anna Lembke, a psychiatrist and the chief of the Stanford University Addiction Medicine Dual Diagnosis Clinic. “You can't undo death, and you really can't undo addiction. You can treat it, but you can't really undo it.”

Still, public health experts are hopeful that the policy emphasis embraced by the Biden administration and Congress toward measures that would treat addiction and restrict opioid use will reduce demand for drugs and stop the rising number of overdoses.

“There is no law of gravity that says overdose death numbers have to come down, but I am an optimist, so I'd like to say we are going to be in a better place in five years,” says Johns Hopkins' Saloner.

Experts point to the decline in overdose deaths between 2017 and 2018 as an indication that public health efforts can work and that the most vulnerable populations, such as young people and those recently released from prison, can be reached before they overdose.

“If we put all these pieces together, I think little by little we can hopefully in five to 10 years turn this around,” says Dr. Yngvild K. Olsen, medical director of the Baltimore City-based Institutes for Behavior Resources Inc./REACH Health Services and past president of the Maryland/DC Society of Addiction Medicine. “With so many people dying every day, clearly the pressure will be on to have this happen much faster than that.”

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Pro/Con

Have federal regulators done too much to restrict legal access to prescription drugs?

Pro Stefan G. Kertesz, M.D. Professor of Medicine, University of Alabama, Birmingham; Physician, Birmingham VA Healthcare System. Written for CQ Researcher, August 2021 Any regulatory intrusion into medical care should advance a compelling goal while doing the least harm. If it fails that standard, it should be rejected. On opioids, this standard was not met. The U.S. opioid crisis is grave. A historic proliferation of prescribed opioids, peaking in 2012, contributed to the population that developed opioid addiction. However, the regulatory response overreached and misapplied a 2016 guideline from the Centers for Disease Control and Prevention (CDC). The guideline emphasized opioid dose control as the key to safety. Although the CDC said the guideline should not be used for regulation or law, many governmental and nongovernmental organizations ignored that assertion. For example, the U.S. Department of Health Human Services' Office of the Inspector General (OIG) adopted a dose threshold to establish appropriate opioid prescribing levels for doctors. The OIG misquotes the CDC to say that prescribers should “avoid increasing dosages” to higher than the equivalent of 90 milligrams of morphine per day. The OIG does not include the CDC's qualifying phrase that physicians may exceed a dose of 90 if they “carefully justify” it. The OIG's reports suggest they are referring physicians for criminal investigation, based on the threshold. That same threshold was embraced by other agencies to rate quality of care. This created an incentive for physicians to reduce opioid dosages and even stop prescribing them altogether. Did these actions help to advance a compelling public health goal? Answering that requires a measure of nuance. I agree that a reduction in opioid prescribing was overdue. The pre-2012 excesses harmed patients and their communities. Opioids are effective for acute pain, but have always been a mixed bag in the long term. When decisions concerning serious illness require nuance, we want physicians to deliberate over risks and benefits with patients. Federal and nonfederal initiatives intruded unhelpfully here. Recent analyses of Medicare show physicians abruptly stopped prescribing opioids. The Food and Drug Administration said this practice can cause death by suicide and overdose. I have seen both outcomes. Other studies show opioid restrictions have affected patients in hospice and with sickle cell disease, two groups the CDC sought to exclude in its guidelines. Finally, adults who require opioids are increasingly unable to find any doctor to care for them. And yet, opioid overdoses still go up. If one were to ask how to harm some of the most vulnerable patients in the country, our policies helped make that happen.

Con Andrew Kolodny, M.D. Medical Director of Opioid Policy Research, Brandeis University. Written For CQ Researcher, August 2021 According to a recent report by the Congressional Research Service, the United States consumes far more prescription opioids than other countries. The report explained that “U.S. health care providers prescribe opioids more frequently, at higher doses, and throughout more stages of pain treatment — including as a first-line treatment — than their European counterparts. Use of higher-potency opioids — with greater morphine milligram equivalents (MMEs) per dose — appears especially high in the United States compared with other countries.” If the federal government was overregulating access to prescription opioids why would our prescription opioid use exceed every other country on earth? The Food and Drug Administration (FDA), the Centers for Disease Control and Prevention (CDC) and the Drug Enforcement Administration (DEA) all have a role to play in responding to the opioid crisis but when it comes to regulating medical practice, they have little influence because health care is mainly regulated by states. These federal agencies are not able to restrict legitimate opioid prescribing, even if they wanted to. The FDA, however, does have the authority to regulate drug companies that manufacture opioids. Unfortunately, for more than 25 years, the agency failed to properly enforce laws that govern approval and marketing of prescription opioids. And even as the opioid crisis worsened over the years, the FDA never corrected mistakes and policies that were fueling the problem. Three years ago, Dr. David Kessler, who had been the FDA commissioner in the 1990s, acknowledged on “60 Minutes” that the FDA made a horrible mistake when it approved OxyContin in 1995 and when it permitted opioid manufacturers — not just Purdue Pharma, the maker of OxyContin — to promote opioids as safe and effective for long-term use. When opioids are taken daily for weeks and months and years, evidence shows that they are not safe or effective. Yet the FDA failed to prohibit opioid manufacturers from promoting long-term use of their products for conditions where risks are likely to outweigh benefits. The CDC issued a guideline on opioid prescribing for primary-care doctors in 2016, which called attention to the lack of evidence supporting use for chronic pain and urged prescribers to limit doses and duration. Not surprisingly, the opioid industry, using front groups, public relations firms and “key opinion leaders,” fought hard against the CDC's recommendations. After failing to block release of the CDC guideline, the opioid industry focused its effort on making the CDC guideline appear controversial. One federal agency that has authority to prohibit illegal opioid prescribing is the Drug Enforcement Agency. But its ability to put pill mills put of business was weakened in 2016, by the Ensuring Patient Access and Effective Drug Enforcement Act, which made it much harder for the agency to suspend a DEA registration, even when evidence of illegal activity is clear. Clearly, federal regulators have not gone too far to restrict access to prescription opioids. That this question is even asked suggests that the opioid industry continues to skew perceptions of a public health crisis it helped create.

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Discussion Questions

Here are some issues to think about regarding the opioid crisis:

• The opioid crisis is not a new problem; it began in the 1990s. Why is it getting worse?

• What role is fentanyl playing in the crisis and where does it come from? Do pharmaceutical companies or Mexican cartels deserve more of the blame for the burgeoning crisis?

• Has opioid addiction affected your community and if so, how, and how severely? Do you think the crisis will lessen as the pandemic winds down?

• “Harm reduction” advocates the safe use of drugs and seeks to keep users alive, rather than focusing on pressing them to abstain. Another strategy involves prescribing medication to help wean people off opioids and lessen withdrawal symptoms. Do you feel these are effective strategies, or will they merely encourage more drug use?

• On the legal front, has the government's so-called war on drugs worked? Has punishment deterred people from abusing opioids? Is there a racial disparity in the way authorities handle drug violations?

• Should communities expand the use of drug courts, which combine both treatment and punishment?

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Short Features

Experts: Opioids Can Help People Get Off Opioids

Dr. Marvin Seppala used to be a traditionalist. To help users kick their drug habit, he believed treatment needed to emphasize complete abstinence.

Dr. Marvin Seppala, chief medical officer at the Hazelden Betty Ford Foundation in Center City, Minn., supports using medications to help substance abuse patients: “We have to look at the data and base our treatment on the best way to save lives.” (Addiction/Recovery eBulletin)

But while working at Beyond Addictions, a now-defunct Beaverton, Ore., treatment center, Seppala noticed that giving patients an opioid-based medication called buprenorphine seemed to better prevent relapses or overdoses than the old approach he used as medical director at a Minnesota clinic.

From that point on, Seppala started offering medication as an option to patients with opioid use disorder.

“It's hard to argue when you have patients dying of overdoses,” said Seppala. “We said, ‘This is truly a crisis. We can't base our service on philosophy; we have to look at the data and base our treatment on the best way to save lives.’”1

About half of the nation's addiction treatment centers currently provide medication to patients to reduce the painful withdrawal symptoms and cravings that compel many people to keep using opioids.

Evidence has accumulated that providing one of three opioids approved by the Food and Drug Administration — methadone, buprenorphine or naltrexone — to someone with an opioid use disorder reduces the risk the person will relapse and die of an overdose, according to a 2019 National Academy of Sciences report. Without treatment, someone with a substance use disorder is 20 times more likely to die of an overdose, infectious disease or by suicide, the report said.2

Researchers say the brain's chemistry helps explain why.

Methadone and buprenorphine are opioid “agonists,” meaning that they bind to and activate the opioid receptors, mimicking a biological response like heroin, OxyContin or another morphine-based drug. Methadone is a full agonist: It completely occupies the opioid receptor and lasts for 24 to 36 hours, drastically reducing the euphoric highs and compulsive behavior associated with opioids. Buprenorphine is a partial agonist. It does not fully occupy the opioid receptor, but it still dampens morphine euphoria. Both drugs are used to help people manage the body's craving for more drugs.3

Naltrexone, by contrast, is an opioid “antagonist”: It blocks the opioid receptor, preventing the euphoria of opioids. The drug is most often used to prevent relapses and is sometimes prescribed to be taken with buprenorphine to help with cravings and the potential for relapse.4

Dr. Nora Volkow, director of the National Institutes of Health's National Institute on Drug Abuse, a federal research agency, says the medication approach acknowledges that substance use disorder is a brain disease caused by opioids and is treatable.

But about half of the country's addiction treatment centers do not utilize medication as part of drug recovery. For example, Unity Behavioral Health in Florida said that although medication can help someone during the withdrawal process, medication does not necessarily help a person move beyond addiction.

“While it might seem drastic, abstinence treatment is generally the most effective approach,” said the treatment center's website. And “the safest way to prevent a relapse is to avoid substance use entirely.”5

Some people fighting addiction agree. Damion Davis, 49, who lives in San Francisco, has struggled with addiction for decades and has attended multiple Bay Area treatment programs where medication assistance is standard therapy. But he kept relapsing until he was able to find a transitional housing program where he and others undergoing treatment agreed not to use alcohol or drugs.

“Abstinence is the only way you can help yourself,” Davis said.6

Nevertheless, the number of treatment programs offering methadone, buprenorphine or naltrexone is expanding, demonstrating that medication is becoming a more standard option in addiction treatment. As of 2020, 36 percent of the 16,066 treatment centers in the United States — including hospital and tribal-based treatment centers, as well as hospitals that offered outpatient clinics and programs — provided at least one medication assistance option, up from 9 percent in 2010, according to the Substance Abuse and Mental Health Services Administration, a federal agency.7

Many public health experts say as drug overdoses skyrocket, even more health providers need to offer medication as an option to patients with substance use disorder.

“We need to drastically expand access to medication treatment services” if the United States is going to get hold of the opioid epidemic, says Dr. Yngvild K. Olsen, medical director of the Baltimore City-based Institutes for Behavior Resources Inc./REACH Health Services and past president of the Maryland/DC Society of Addiction Medicine.

Reasons for the lack of availability are many. Besides concern that medication assistance is replacing one addiction for another, federal laws limit who can prescribe buprenorphine and methadone. State laws require health providers to get preauthorization from private insurers and Medicare and Medicaid before they can prescribe. Others limit the amount of medication that can be prescribed.

Further, communities of color say there is a long-standing stigma involving methadone. By law, methadone can only be dispensed at treatment clinics certified by the Substance Abuse and Mental Health Services Administration, and most are in impoverished neighborhoods. Patients who receive methadone are disproportionately Black, and clinics require them to get the medication each day, in person at the clinic. Patients are also limited in the amount they can take home and must undergo frequent urine drug screenings.

“Black communities have viewed methadone as a form of social control,” wrote Barbara Andraka-Christou, who studies substance abuse as an assistant professor at the University of Central Florida.8

President Biden has pledged to expand medication treatment options to those with substance use disorder. Toward that end, the administration in April relaxed federal rules to allow more medical practitioners to prescribe buprenorphine to patients. The new rules eliminate a training requirement and allow nurse practitioners, physician assistants and certified nurse midwives to prescribe buprenorphine.

“The need for more accessible medication-based services has never been more urgent than it is today,” said Tom Coderre, acting deputy assistant secretary for mental health and substance use at the Substance Abuse and Mental Health Services Administration.9

— Bara Vaida

[1] Christine Vestal, “Treating addicts: The tension between drug treatment and abstinence,” The Washington Post, Jan. 18, 2016, https://tinyurl.com/aum65cwc.

[2] “Medications for Opioid Use Disorder Save Lives,” National Academy of Sciences, Engineering and Medicine, 2019, https://tinyurl.com/277275wv.

[3] “Medications for Opioid Use Disorder Improve Patient Outcomes,” Pew Charitable Trusts, Dec. 17, 2020, https://tinyurl.com/5azuzzpc.

[4] “Naltrexone,” Substance Abuse and Mental Health Services Administration, Sept. 15, 2020, https://tinyurl.com/det7tcr9.

[5] “Why Abstinence Addiction Treatment is Best,” Unity Behavioral Health, https://tinyurl.com/p5fu4ycp.

[6] Mallory Moench, “Many San Franciscans in jail struggle with addiction. Would this polarizing treatment option help them?” San Francisco Chronicle, May 12, 2021, https://tinyurl.com/brxc8eyv.

[7] “National Survey of Substance Abuse Treatment Services (N-SSATS): 2020: Data on Substance Abuse Treatment Facilities,” Substance Abuse and Mental Health Services Administration, June 2021, p. 1, https://tinyurl.com/35nb67su.

[8] Barbara Andraka-Christou, “Addressing Racial And Ethnic Disparities In The Use Of Medications For Opioid Use Disorder,” Health Affairs, June 2021, https://tinyurl.com/yv6ahjvt.

[9] Amy Goldstein, “Biden administration eases restrictions on prescribing treatment for opioid addiction,” The Washington Post, April 27, 2021, https://tinyurl.com/bxffwh6n.

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Researchers Seek a Nonaddictive Painkiller

In California's parched central valley lies the town of Davis, an agricultural community that is home to the University of California (UC) School of Veterinary Medicine. It is also the place from which a new generation of nonaddictive painkillers for humans might emerge.

Since 2019, the U.S. National Institutes of Health (NIH) has granted more than $6 million to EicOsis, a company co-founded by Bruce Hammock, a professor in UC-Davis' Department of Entomology and Nematology.10 He has been using the money to develop a promising compound for neuropathic pain — pain caused by damage to nerves — that has been tested on the horses, dogs and cats that come to the veterinary school for care.

Bruce Hammock, a distinguished professor in entomology and nematology at the University of California, Davis, received a $6 million federal grant to develop a nonaddictive painkiller. It has been tested on the horses, dogs and cats that come to the university's veterinary school for care. (University of California, Davis/Kathy Keatley Garvey)

“In the vet school, we can work with animals that are presented to the clinic with real pain,” says Hammock, who adds that the compound reduces pain connected to inflammation. “That is a huge difference” from the mouse model of drug testing, which relies on “artificially created pain.”

EicOsis is one of many companies getting support from the NIH's Helping to End Addiction Long-Term (HEAL) initiative, a more than $1.5 billion program funded by Congress in 2018 to search for solutions to the opioid epidemic, including new treatment options and developing nonaddictive painkillers.11

Researchers have long sought a drug that mimics the powerful painkilling effect of an opioid without producing its euphoric and addictive side effects. Their lack of success speaks to the complexity of the brain and pain's important connection to humanity's existence.

“Our survival [as a species] has been aided by our avoidance to pain and our recognition that pain is bad,” says Rebecca Baker, director of the HEAL initiative. “So, it's very hard to eliminate it.”

Opioids work because they connect to opioid receptors in the brain that trigger the body's natural painkillers — endorphins. They also trigger dopamine, which links to the brain's reward system and helps the body feel pleasure. The reduction in pain caused by the body's natural endorphins may last for only a few minutes, while opioids can make it last for hours.

When the opioid is withdrawn, many people feel intense discomfort, sensitivity to pain and deep melancholy.

“The problem is that the pain system and the reward system, in the opioid space [in the brain], are basically linked at the hip,” says Dr. Walter J. Koroshetz, director of the NIH's National Institute of Neurological Disorders and Stroke. “You can't really separate out the two of them.”

More than 20 percent of the adult population say they experienced chronic pain in 2019, meaning they experience pain daily or almost every day. More than 7 percent of them said it affects their quality of life.12 But pain is a multifaceted psychological, emotional, sensory and physical experience, so treating it is complex, health experts say. Science has not determined why an injury can result in only short-term pain for one individual but produce long-term suffering in others.

Based on research, the Centers for Disease Control and Prevention is not recommending the initial use of opioids for long-term, chronic pain.

One large study conducted in 2018 showed that, compared with a placebo, opioids were associated with small improvements in pain, physical functioning and sleep quality, but also with increased vomiting, drowsiness, dizziness and nausea. A smaller 2018 study compared opioids to nonopioid medications such as Advil and found they did not significantly improve pain or function for patients with chronic osteoarthritis.13

Current medications may not work well on chronic pain because of the differing biological mechanisms that cause pain, according to researchers. Joint inflammation, such as can be found with osteoarthritis, can cause stiffness and aching pain. Blood sugar anomalies that occur in diabetes and damage nerve endings can cause sharp, tingling pain.14

“The research community has come to understand over the past five or 10 years that not all pain is the same, that lower back pain is different than sickle cell associated pain or diabetic neuropathy pain,” says Baker. “Our best shot at effectively managing those pain conditions is understanding the biology of what is going on.”

Researchers are looking at chemicals, genes and parts of the brain that are not connected to opioid receptors.

EicOsis' drug works by targeting the body's own pain-relieving mechanisms. Hammock identified an enzyme that drives pathological pain in disease. EicOsis' researchers then developed a drug targeting the enzyme, stimulating compounds in the body that reduce pain.

One of EicOsis' first patients was a horse that had come to UC-Davis with equine laminitis, an inflammation around the hoof. Traditional treatments were not working, and the horse was scheduled to be euthanized, so Hammock gave the horse the EicOsis drug. The horse recovered and is still alive a decade later.15

EicOsis began clinical trials on humans this past year to determine safety, but it likely has several more years of testing ahead of it.

Hammock remains hopeful. “Very few have gotten as far as we have,” he says.

— Bara Vaida

[10] “Development of a Soluble Epoxide Hydrolase Inhibitor to Spare or Replace Opioid Analgesics,” National Institutes of Health, https://tinyurl.com/46djuubw.

[11] “NIH HEAL Initiative: Research in Action, 2021 Annual Report,” National Institutes of Health, May 14, 2021, https://tinyurl.com/wn8kmf8u.

[12] Carla E. Zelaya et al., “Chronic Pain and High-impact Chronic Pain Among U.S. Adults, 2019,” Centers for Disease Control and Prevention, November 2020, https://tinyurl.com/syxa5pvc.

[13] Deborah Dowell, Tamara M. Haegerich and Roger Chou, “CDC Guideline For Prescribing Opioids for Chronic Pain — United States, 2016,” Centers for Disease Control and Prevention, March 18, 2016, https://tinyurl.com/ujy78rx5; Jason W. Busse et al., “Opioids for Chronic Noncancer Pain: A Systematic Review and Meta-analysis,” Journal of the American Medical Association, Dec. 18, 2018, https://tinyurl.com/fsc96fu2; and Erin E. Krebs et al., “Effect Of Opioid vs Nonopioid Medications on Pain-Related Function in Patients With Chronic Back Pain or Hip or Knee Osteoarthritis Pain: The SPACE Randomized Clinical Trial,” Journal of the American Medical Association, March 6, 2018, https://tinyurl.com/hp9wm6aj.

[14] Anthony King, “Analgesia without opioids,” Nature, Sept. 11, 2019, https://tinyurl.com/8sfah9f4.

[15] Cathie Anderson, “The answer to the opioid crisis? UC Davis researcher will soon test his non-addictive pain drug,” The Sacramento Bee, April 29, 2019, https://tinyurl.com/984b7cep.

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Bibliography

Books

Lemke, Anna, Drug Dealer MD: How Doctors Were Duped, Patients Got Hooked, and Why It's So Hard to Stop, Johns Hopkins University Press, 2016. A Stanford University professor of medicine explains doctors' roles in creating the opioid epidemic and what they can do about it.

Macy, Beth, Dopesick: Dealers, Doctors, and the Drug Company That Addicted America, Little, Brown & Co., 2018. A former Roanoke Times reporter tells the story of drug addiction in western Virginia and how it is illustrative of the national opioid epidemic.

Quinones, Sam, Dreamland: The True Tale of America's Opiate Epidemic, Bloomsbury Press, 2016. A Los Angeles Times correspondent explores the origins of the prescription opioid crisis and describes innovations in heroin trafficking that make the drug more accessible.

Radden Keefe, Patrick, Empire of Pain: The Secret History of the Sackler Dynasty, Picador, 2021. A New Yorker staff writer tells the tale of the rise and fall of the family who owned Purdue Pharma, the maker of OxyContin, an opioid that is almost twice as potent as morphine.

Westoff, Ben, Fentanyl Inc.: How Rogue Chemists Are Creating the Deadliest Wave of the Opioid Epidemic, Atlantic Monthly Press, 2019. A freelance investigative reporter dives deep into the illicit markets for fentanyl and other drugs to explain why overdose figures are rising.

Articles

Achenbach, Joel, and Lenny Bernstein, “Opium crackdown forces pain patients to taper off drugs they say they need,” The Washington Post, Sept. 10, 2019, https://tinyurl.com/2amheysa. Patients with chronic pain complain they are being forced off their medications.

Cuno-Booth, Paul, “‘A chance to choose life’: For some, drug courts break cycle of addiction and crime,” SentinelSource.com, Jan. 9, 2021, https://tinyurl.com/bwv2k3s8. A journalist tells the story of how one woman got her life back through a drug court, which prescribed an intense treatment program.

Galofaro, Claire, “In pandemic, drug overdose deaths soar among Black Americans,” The Associated Press, June 24, 2021, https://tinyurl.com/3s7wrc8s. Black Americans are dying from drug overdoses at higher rates than whites during the pandemic.

Goodnough, Abby, “Helping Drug Users Survive, Not Abstain: ‘Harm Reduction’ Gains Federal Support,” The New York Times, June 27, 2021, https://tinyurl.com/wy53y7v3. As overdoses surge during the pandemic, Congress is funding programs to distribute clean needles and other supplies to help drug users reduce their health risks.

Mullen, Shannon, et al., “Crack vs. Heroin: An unfair system arrested millions of blacks, urged compassion for whites,” Asbury Park Press, Dec. 2, 2019, https://tinyurl.com/v6xw65sr. Reporters take an in-depth look at how mandatory prison sentences for crack cocaine disproportionately harmed Black Americans.

Westervelt, Eric, “Oregon's Pioneering Drug Decriminalization Experiment Is Now Facing The Hard Test,” NPR, June 18, 2021, https://tinyurl.com/247bsr4w. Oregon, which has high rates of drug and alcohol addiction, is radically changing the way it treats users.

Reports and Studies

“Annual Threat Assessment of the US Intelligence Community: 2021,” Office of the Director of National Intelligence, April 9, 2021, https://tinyurl.com/4zzpzfnc. Mexican drug cartels are a key source of fentanyl and heroin and a threat to U.S. national security, according to a federal assessment.

“Biden-Harris Administration's Statement of Drug Policy Priorities for Year One,” Executive Office of the President, Office of National Drug Policy Control, April 1, 2021, https://tinyurl.com/59wxevv9. The Biden administration outlines its drug policy priorities for 2021, including expanding access to treatment services.

Krebs, Erin E., et al., “Effect of Opioid vs Nonopioid Medications on Pain-Related Function in Patients with Chronic Back Pain, or Hip or Knee Osteoarthritis Pain,” Journal of the American Medical Association, March 6, 2018, https://tinyurl.com/hp9wm6aj. One of the first definitive studies on painkillers shows that opioids work no better, or maybe worse, than nonopioids in treating chronic osteoarthritic pain.

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The Next Step

Biden Administration

Herman, Steve, “Biden Vows to Continue Encounter with China Over Opioids,” Voice of America, July 22, 2021, https://tinyurl.com/w9rf8a55. President Biden criticized China for failing to stem the country's export of opioids, particularly fentanyl, to Mexico, where cartels smuggle the drug into the United States.

Holmes, Kristen, “Biden in standoff with Democratic senators over who should lead FDA,” CNN, July 14, 2021, https://tinyurl.com/y6u8epkb. Senate opposition to the potential nomination of Dr. Janet Woodcock to head the Food and Drug Administration has hardened, as criticism has grown of the agency's handling of the opioid crisis during her current tenure as acting head.

Ruoff, Alex, “Fentanyl Deaths Fuel Pressure on Biden to Toughen Enforcement,” Bloomberg, July 20, 2021, https://tinyurl.com/sueev6dc. A bipartisan group of senators proposing a bill that would ban fentanyl wants the Biden administration to weigh in on the legislation before moving forward.

Lawsuits

“Arkansas to receive $216 million in opioid lawsuit settlement,” KATV, July 26, 2021, https://tinyurl.com/rjvvdn23. Arkansas state and local governments will split a $216 million settlement from pharmaceutical manufacturer Johnson & Johnson and three distributors to resolve complaints over the companies' role in creating and fueling the opioid crisis.

“Closing Arguments Held In Opioid Lawsuit In West Virginia,” KDKA-CBS Pittsburgh, July 28, 2021, https://tinyurl.com/n6mcjazt. Attorneys gave closing arguments in a West Virginia lawsuit against three major U.S. drug distributors, in which the plaintiffs are seeking $2.5 billion in damages for a community of 100,000 that has been ravaged by opioid addiction.

Mattise, Jonathan, and Travis Loller, “Attorney: $35M settlement was opioid firm's best, last offer,” The Associated Press, ABC News, July 29, 2021, https://tinyurl.com/yzxzs62z. An attorney who helped Tennessee reach a $35 million settlement with the opioid manufacturer Endo Pharmaceuticals said he did so to avoid the possible complications of a jury verdict and appeal, including the potential for the company to declare bankruptcy.

Prescriptions

Keilman, John , “Physician convicted of illegally prescribing opioids says the DEA has turned doctoring into ‘another aspect of the war on drugs,’” Chicago Tribune, July 27, 2021, https://tinyurl.com/34rv3sxj. A doctor convicted of prescribing controlled substances without a medical purpose is pushing for the liberalization of drug laws, as some experts worry high-profile convictions will deter doctors from prescribing opioids.

Lewis, Scott , “President signs Sen. Kennedy's opioids act into law,” KLFY, July 29, 2021, https://tinyurl.com/z7pembn6. Beginning in 2022, a new law mandates that Veterans Affairs medical centers must have drop boxes for patients to discard unused opioids and other medications.

Lloreda, Claudia López , “In the same health system, Black patients are prescribed fewer opioids than white patients,” Stat News, July 21, 2021, https://tinyurl.com/yv7j6jr4. A recent study found that 90 percent of 310 health systems prescribed higher opioid dosages to white patients than to Black patients.

State Action

“$2M for training, jobs in Maine locales hit by opioid crisis,” The Associated Press, July 28, 2021, https://tinyurl.com/kh5th5dd. The federal government awarded $2 million to the Maine Department of Labor to create jobs for residents in nine counties that have been hurt by the opioid crisis.

Berger, Eric, “Missouri to Join Nation in Monitoring Prescriptions. But Will It Work?” U.S. News & World Report, July 23, 2021, https://tinyurl.com/34uar3bs. Missouri became the last state to create a drug prescription monitoring system to curb opioid addiction.

Brewer, Ray, “New Hampshire still has long way to go to address opioid crisis, governor says,” WMUR, July 22, 2021, https://tinyurl.com/4z23ke4d. New Hampshire Gov. Chris Sununu, a Republican, said his state is one of the few places where opioid overdoses did not increase during the pandemic because the state had already opened many recovery centers, but added that “we are not resting on our laurels.”

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Contacts

American Society of Addiction Medicine
11400 Rockville Pike, Suite 200, Rockville, MD 20852
301-656-3920
asam.org
Organization that represents doctors who specialize in treating those with substance use disorders.

National Association of Addiction Treatment Providers
1120 Lincoln St., Denver, CO 80203
888-574-1008
naatp.org
Association that represents treatment providers.

National Harm Reduction Coalition
243 5th Ave., #529, New York, NY 10016
communications@harmreduction.org
harmreduction.org
Advocacy group for people who use illicit drugs.

National Institute on Drug Abuse
3 White Flint North, 11601 Landsdown St., North Bethesda, MD 20852
301-443-6245
drugabuse.gov
Federal research organization that focuses on drug addiction and abuse.

National Pain Advocacy Center
PO Box 4172, Boulder, CO 80302
303-909-3175
nationalpain.org
Nonprofit that advocates for pain treatment to remain a part of health care services.

Physicians for Responsible Opioid Prescribing
London, Ohio
612-568-7183
supportprop.org
Group dedicated to reducing opioid-related overdoses and death.

Shatterproof
101 Merritt 7 Corporate Park, 1st Floor, Norwalk, CT 06851
1-800-597-2557
shatterproof.org
National nonprofit dedicated to ending drug addiction.

U.S. Centers for Disease Control and Prevention
1600 Clifton Road, Atlanta, GA 30329
404-639-3286
cdc.gov/opioids/basics/epidemic.html
Federal agency that conducts research on public health, including opioid use.

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Footnotes

[1] Sam Catanzaro, “Santa Monica Teen Dies From Fentanyl Overdose After Contacted by Dealer on Snapchat,” Santa Monica Mirror, Feb. 11, 2021, https://tinyurl.com/yb7mdszz; Christi Carras, “TV therapist Laura Berman mourns son's fatal overdose: ‘I was so furious,’” Los Angeles Times, Feb. 9, 2021, https://tinyurl.com/396xwzcf; Marni Hughes, “After teen son's deadly overdose, doctor warns about social media's role in buying and selling drugs,” Fox News, Feb. 11, 2019, https://tinyurl.com/5etfjyfs; and “My Teenage Son Was Targeted By A Drug Dealer On Snapchat And Died From An Overdose,” YouTube, Feb. 23, 2021, https://tinyurl.com/z6ed3w83.

[2] Ashley Abramson, “Substance use during the pandemic,” American Psychological Association, March 1, 2021, https://tinyurl.com/twcahsvp.

[3] “The National Survey on Drug Use and Health: 2019,” Substance Abuse and Mental Health Services Administration, September 2020, slide 9, https://tinyurl.com/djhevv9z.

[4] “Vital Statistics Rapid Release: Provisional Drug Overdose Death Counts,” Centers for Disease Control and Prevention, July 14, 2021, https://tinyurl.com/4kfrvsap; Lenny Bernstein and Joel Achenbach, “Drug overdose deaths soared to a record 93,000 last year,” The Washington Post, July 14, 2021, https://tinyurl.com/ebe6s3s.

[5] Andrés Hernández et al., “‘Know your epidemic, know your response:’ Epidemiological assessment of substance use disorder crisis in the United States,” Plos One, May 26, 2021, https://tinyurl.com/2sj5zyja.

[6] Geoff Mulvihill, “States say opioid crisis has cost them $630B since 2007,” The Associated Press, Aug. 17, 2020, https://tinyurl.com/6m97j2mv.

[7] “U.S. Opioid Dispensing Rate Maps,” Centers for Disease Control and Prevention, Dec. 7, 2020, https://tinyurl.com/2udsvx9c.

[8] Jan Hoffman and Abby Goodnough, “Good News: Opioid Prescribing Fell. The Bad? Pain Patients Suffer, Doctors Say,” The New York Times, March 6, 2019, https://tinyurl.com/59fpuwv9.

[9] “Annual Threat Assessment of the US Intelligence Community,” Office of the Director of National Intelligence, April 9, 2021, https://tinyurl.com/f9y8rn4.

[10] Ben Westhoff, Fentanyl Inc.: How Rogue Chemists Are Creating the Deadliest Wave of the Opioid Epidemic (2019), p. 108.

[11] “Hearing On Crack Cocaine Sentencing,” C-SPAN, June 22, 2021, https://tinyurl.com/3ncdm5tk.

[12] “Ongoing Emergencies and Disasters,” Centers for Medicare and Medicaid Services, Jan. 23, 2020, https://tinyurl.com/y44k25un; Marianna Sotomayer, “Trump signs sweeping opioid bill with vow to end ‘scourge’ of drug addiction,” NBC News, Oct. 24, 2018, https://tinyurl.com/2j44xfs3.

[13] “President Biden Announces 11 Key Nominations,” The White House, July 13, 2021, https://tinyurl.com/rw964p9f.

[14] “The Biden-Harris Administration's Statement of Drug Policy Priorities for Year One,” Office of National Drug Control Policy, Executive Office of the President, April 1, 2021, https://tinyurl.com/2cpfwb4c.

[15] Carla E. Zelaya et al., “Chronic Pain and High-impact Chronic Pain Among U.S. Adults, 2019,” Centers for Disease Control and Prevention, November 2020, https://tinyurl.com/syxa5pvc.

[16] Terry Spencer, “Florida ‘pill mills’ were ‘gas on the fire’ of the opioid crisis,” The Associated Press, July 20, 2019, https://tinyurl.com/2vs49dtc.

[17] Ibid.

[18] Alene Kennedy-Hendricks et al., “Opioid Overdose Deaths and Florida's Crackdown on Pill Mills,” American Journal of Public Health, February 2016, https://tinyurl.com/wfwc976e.

[19] “Opioid prescription limits and policies by state,” Ballotpedia, July 19, 2021, https://tinyurl.com/xj24ryc8; Sarah Haas, “Parsons signs SB 63, creating statewide prescription drug monitoring program,” Daily Journal, June 9, 2021, https://tinyurl.com/wejdbubc; and S.C. Brighthaupt et al., “Effect of pill mill laws on opioid overdose deaths in Ohio & Tennessee: A mixed-methods case study,” Preventive Medicine, September 2019, https://tinyurl.com/hkruyz6b.

[20] Hoffman and Goodnough, op. cit.

[21] Ibid.

[22] “Opioid Overdose Crisis,” National Institute on Drug Abuse, March 11, 2021, https://tinyurl.com/2btu284b.

[23] Deborah Dowell, Tamara M. Haegerich and Roger Chou, “CDC Guideline for Prescribing Opioids for Chronic Pain — United States, 2016,” Centers for Disease Control and Prevention, March 18, 2016, https://tinyurl.com/ujy78rx5; Jason W. Busse et al., “Opioids for Chronic Noncancer Pain: A Systematic Review and Meta-analysis,” Journal of the American Medical Association, Dec. 18, 2018, https://tinyurl.com/fsc96fu2.

[24] “The National Survey on Drug Use and Health: 2019,” slides 9 and 11, op. cit.

[25] “American Attitudes On The War On Drugs,” American Civil Liberties Union, June 9, 2021, https://tinyurl.com/rddusrh2; Eric Westervelt, “Oregon's Pioneering Drug Decriminalization Experiment Is Now Facing The Hard Test,” NPR, June 18, 2021, https://tinyurl.com/abn9tw3t.

[26] Jonah Bromwich, “This Election, a Divided America Stands United on One Topic,” The New York Times, Nov. 5, 2020, https://tinyurl.com/37v25ma6; Rachel La Corte and Gene Johnson, “New Washington state law makes drug possession a misdemeanor,” The Associated Press, May 13, 2021, https://tinyurl.com/3vtdppcr.

[27] “The Biden-Harris Administration's Statement of Drug Policy Priorities for Year One,” op. cit.

[28] Zack Budryk, “Almost half of Americans have dealt with substance abuse in family: Gallup,” The Hill, Oct. 14, 2019, https://tinyurl.com/azzk8zsj.

[29] German Lopez, “How Obama quietly reshaped America's war on drugs,” Vox, Jan. 19, 2017, https://tinyurl.com/6pvf7pcd; “Data show no relationship between prison terms and drug misuse,” Pew Charitable Trusts, March 8, 2018, https://tinyurl.com/s453z2zz.

[30] “Data show no relationship between prison terms and drug misuse,” ibid.

[31] “Drug Courts,” Office of Justice Programs, U.S. Department of Justice, November 2020, https://tinyurl.com/evhevxdj.

[32] Kevin Bliss, “Experts Divided on Drug Court Effectiveness,” Prison Legal News, April 1, 2021, https://tinyurl.com/4r8yv5tm; Meredith Emigh, “The Efficacy of Drug Courts,” EPB Society, Sept. 17, 2017, https://tinyurl.com/53yacppb.

[33] “Overdose deaths and jail incarceration: National trends and racial disparities,” Vera, https://tinyurl.com/5efxe3j5.

[34] Abby Goodnough, “Helping Drug Users Survive, Not Abstain: ‘Harm Reduction’ Gains Federal Support,” The New York Times, June 27, 2021, https://tinyurl.com/36vu5d8d.

[35] “Biden-Harris Administration Calls for Historic Levels of Funding to Prevent and Treat Addiction and Overdose,” The White House, May 28, 2021, https://tinyurl.com/jajaaxmj; “The Biden-Harris Administration's Statement of Drug Policy Priorities for Year One,” op. cit.

[36] Vanda Felbab-Brown, “Biden takes a reformist drug strategy, but the challenge of supply countries remains,” Brookings Institution, April 19, 2021, https://tinyurl.com/2bchpncs.

[37] “NASEN: A Dave Purchase Initiative,” www.nasen.org, accessed July 29, 2021, https://tinyurl.com/meumacew.

[38] “Summary of Information on The Safety and Effectiveness of Syringe Services Programs (SSPs),” Centers for Disease Control and Prevention, May 23, 2019, https://tinyurl.com/t89tmhxn; H Hagan et al., “Reduced Injection Frequency And Increased Entry And Retention in Drug Treatment Associated with Needle-Exchange Participation In Seattle Drug Injectors,” Journal of Substance Abuse Treatment, October 2020, https://tinyurl.com/3n9uefrn.

[39] “Drug Misuse: Most States Have Good Samaritan Laws and Research Indicates They May Have Positive Effects,” Government Accountability Office, March 29, 2021, https://tinyurl.com/v5t886cy.

[40] Mitch Legan, “Indiana Needle Exchange That Helped Contain A Historic HIV Outbreak To Be Shut Down,” NPR, June 3, 2021, https://tinyurl.com/3hb8bw62.

[41] “Judge scraps order halting West Virginia needle exchange law,” The Associated Press, July 16, 2021, https://tinyurl.com/wpesd8e3; Taylor Knopf, “Behind needle exchange bill, a spat between Asheville site and its new neighbors,” North Carolina Health News, April 20, 2021, https://tinyurl.com/jh6emysx.

[42] “Key Substance Use and Mental Health Indicators in the United States: Results from the 2019 National Survey on Drug Use and Health,” Substance Use and Mental Health Administration, September 2020, pp. 50-51, https://tinyurl.com/24h8npfa.

[43] Tamara Beetham et al., “Admission Practices And Cost of Care For Opioid Use Disorder At Residential Addiction Treatment Programs in the U.S.,” Health Affairs, February 2021, https://tinyurl.com/yvvrde7y; Anna Bailey et al., “Medicaid Is Key to Building a System of Comprehensive Substance Use Care for Low-Income People,” Center on Budget and Policy Priorities, March 18, 2021, https://tinyurl.com/ky5keaj5.

[44] “The Opium Kings,” Frontline, 1998, https://tinyurl.com/3rcr7jzk; Svend Norn, Poul R Kruse and Edith Kruse, “History of Opium, Poppy and Morphine,” Dansk Medicin Historisk Arbog, 2005, https://tinyurl.com/mby6tfm2.

[45] Patrick Radden Keefe, Empire of Pain: The Secret History of the Sackler Dynasty (2021), chp. 15.

[46] Erick Trickey, “Inside the Story of America's 19th-Century Opiate Addiction,” Smithsonian Magazine, Jan. 4, 2018, https://tinyurl.com/9wsbtc3t.

[47] “Balm Of America: Patent Medicine Collection,” National Museum of American History, https://tinyurl.com/yw7teyum; Nick Miroff, “From Teddy Roosevelt to Trump: How drug companies triggered an opioid crisis a century ago,” The Washington Post, Oct. 17, 2017, https://tinyurl.com/42ar5ax9.

[48] Nick Miroff, “From Teddy Roosevelt to Trump: How drug companies triggered an opioid crisis a century ago,” The Washington Post, Oct. 17, 2017, https://tinyurl.com/42ar5ax9.

[49] Peter Katel, “Opioid Crisis: Can Recent Reforms Curb the Epidemic?” CQ Researcher, Oct. 7, 2016, https://tinyurl.com/jjna97tt.

[50] Sam Quinones, Dreamland: The True Tale of America's Opiate Epidemic (2015), p. 76.

[51] Charles Q. Choi, “Reaping a Sad Harvest: A ‘Narcotic Farm’ That Tried to Grow Recovery,” Scientific American, Oct. 24, 2008, https://tinyurl.com/7tec25f7.

[52] Ibid.

[53] German Lopez, “The war on drugs, explained,” Vox, May 8, 2016, https://tinyurl.com/vxp72fxs.

[54] “Illegal drugs — 1969 to 2020,” Gallup, https://tinyurl.com/t9pjrss4.

[55] Jane Porter and Hershel Jick, “Addiction Rare in Patients Treated with Narcotics,” The New England Journal of Medicine, Jan. 10, 1980, https://tinyurl.com/5ev7kx7u.

[56] Russell K. Portenoy and Kathleen M. Foley, “Chronic use of opioid analgesics in non-malignant pain: report of 38 cases,” Pain, May 1986, https://tinyurl.com/anabmx3v.

[57] Keefe, op. cit.; Quinones, op. cit.

[58] Ibid., chp. 17.

[59] Ibid., p. 215; Quinones, op. cit., pp. 94-99.

[60] Art Van Zee, “The Promotion and Marketing of OxyContin: Commercial Triumph, Public Health Tragedy,” American Journal of Public Health, February 2009, https://tinyurl.com/a9bbevab.

[61] Aaron C. Davis, Shawn Boburg and Robert O'Harrow Jr., “Little-known makers of generic drugs played central role in opioid crisis, records show,” The Washington Post, July 27, 2019, https://tinyurl.com/yka6vepz; “Drilling into the DEA's pain pill database,” The Washington Post, Jan. 17, 2020, https://tinyurl.com/2k5u9w8v.

[62] “Compressed Mortality Figures 1979-1998,” Wonder Database, Centers for Disease Control and Prevention, July 29, 2021, https://tinyurl.com/4tnjvzc9; “Multiple Cause of Death, 1999-2019 Results, Drug Overdose Deaths of US Residents by Year,” Centers for Disease Control and Prevention, Dec. 16, 2019, https://tinyurl.com/tce2n8yw.

[63] Katel, op. cit.

[64] “Prescription painkiller overdoses at epidemic levels,” Centers for Disease Control and Prevention, Nov. 1, 2011, https://tinyurl.com/2zyuaunb; Keefe, op. cit., p. 345.

[65] Dowell, Haegerich and Chou, op. cit.

[66] Natalia Gurevich, “Opioid Addiction: Is the Crisis Abating?” CQ Researcher, July 24, 2019, https://tinyurl.com/3tdzdy7m.

[67] Sotomayer, op. cit.

[68] “Vital Statistics Rapid Release: Provisional Drug Overdose Death Counts,” Centers for Disease Control and Prevention, July 14, 2021, https://tinyurl.com/4kfrvsap.

[69] Julie Carr Smyth and Geoff Mulvihill, “Explainer: $26B opioid settlement big step, but not the end,” The Associated Press, July 20, 2021, https://tinyurl.com/awyshw5t.

[70] Jan Hoffman, “15 States Reach a Deal With Purdue Pharma, Advancing a $4.5 Billion Opioids Settlement,” The New York Times, July 8, 2021, https://tinyurl.com/szn47bcx.

[71] “Governor Ducey Signs Legislation to Help Prevent Fentanyl Overdoses,” Office of the Governor Doug Ducey, May 19, 2021, https://tinyurl.com/79zdsuy7; Amy Beth Hanson, “Montana warning of increase in fentanyl-related overdoses,” The Associated Press, June 28, 2021, https://tinyurl.com/7w9jtjvn.

[72] Gary Warth, “As fentanyl overdoses spike, county gives public tool to save lives,” San Diego Union-Tribune, May 21, 2021, https://tinyurl.com/57benekb; Lisa Halverstadt, “Officials Scramble to Address Skyrocketing Fentanyl Deaths,” Voice of San Diego, May 20, 2021, https://tinyurl.com/ab8wp6wj.

[73] Claire Galofaro, “In pandemic, drug overdose deaths soar among Black Americans,” The Associated Press, June 24, 2021, https://tinyurl.com/4u6p26vp; “Opioid Overdoses Spike in Black Philadelphians, But Drop in White Residents Since COVID-19,” Penn Medicine News, Jan. 21, 2021, https://tinyurl.com/2dj57bu8.

[74] “Opioid-related deaths soar among Black residents,” The Associated Press, May 12, 2021, https://tinyurl.com/tu3jyza7.

[75] “The Biden-Harris Administration's Statement of Drug Policy Priorities for Year One,” op. cit.

[76] “Addressing the Growing Overdose and Addiction Epidemic,” NIHCM Foundation, May 24, 2021, https://tinyurl.com/3rytx3tw.

[77] “Biden-Harris Administration Calls for Historic Levels of Funding to Prevent and Treat Addiction and Overdose,” op. cit.

[78] Amy Goldstein, “Biden administration eases restrictions on prescribing treatment for opioid addiction,” The Washington Post, April 27, 2001, https://tinyurl.com/mx4av8fa.

[79] “ASAM Applauds Nomination of Dr. Rahul Gupta to Lead ONDCP,” American Society of Addiction Medicine, https://tinyurl.com/42zte8ec.

[80] “Why drugs must be decriminalized: A Q&A with Rep. Bonnie Watson Coleman,” The Star Ledger, June 23, 2021, https://tinyurl.com/2s53akxp.

[81] Smyth and Mulvihill, op. cit.

[82] Jan Hoffman, “Drug Distributors and J&J Reach $26 Billion Deal to End Opioid Lawsuits,” The New York Times, July 21, 2021, https://tinyurl.com/ub2xtsa4.

[83] Ibid.

[84] Sarah Maslin Nir, “Major Trial Against Opioid Suppliers Begins in New York,” The New York Times, June 29, 2021, https://tinyurl.com/2yyvcje3; Michael O'Keeffe, “New York opioids trial set to go before a jury in Suffolk,” Newsday, June 27, 2021, https://tinyurl.com/4fcu7wck.

[85] Jan Hoffman, “15 States Reach a Deal With Purdue Pharma, Advancing a $4.5 Billion Opioids Settlement,” The New York Times, July 8, 2021, https://tinyurl.com/yu8ff2j4.

[86] “Annual Threat Assessment of the US Intelligence Community,” op. cit.

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About the Author

Bara Vaida is a Washington-based freelancer with more than 25 years' experience as a journalist, primarily covering health care policy issues. She has worked for Agence France-Presse, Bloomberg News, National Journal and Kaiser Health News. She also has published articles in, among others, Cancer Today, Stateline, WebMD and Washingtonian magazines.

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