Understanding the Opioid Crisis in the United States: Part 2

Welcome back for the second part of a multi-part series on the opioid crisis in the United States. Part 1 was an overview and addressed the current picture of the opioid crisis. Today’s post will address two main topics:

• What are opioids?
• How did we get to a crisis point with opioids?

Before we go any further on the opioid crisis, let’s pause and define what an opioid is. Opioids were initially derived from opium poppy, and they currently come in three forms: naturally occurring (as in opium, codeine and morphine), modified versions of those chemicals (semi-synthetic opioids, like oxycodone [Oxy-Contin®] or heroin), and fully synthetic opioids (like fentanyl). Medically, their purpose is to treat significant pain, though they’ve been used to treat bad coughs and diarrhea.

Something I want to emphasize is that opioid medication, when used appropriately, is crucial for those in pain. Opioids are key tools used by medical professionals, to the point that four opioid medications are on the UN List of Essential Medications (see here, for an overview). I will circle back to this later with help from readers, but recent and ongoing efforts to restrict access to opioids for those in pain – or to remove them entirely – is ham-handed and often cruel.

Unfortunately, though, opioid medications are not used only to treat pain; they also can cause euphoria, ease anxiety and promote sleep. Or, put another way, people can use them to get high, relax and sleep. These three (high, relax and sleep) are side effects, and not everyone experiences them. I’ve received opioid medication after surgery and only felt less pain and sleepier. Just as responses to opioid medication are individual and idiosyncratic, so are the experiences of pain, pain thresholds and pain related to injuries. Some people can have surgery and very quickly switch to ibuprofen, and some cannot. Neither is “tougher” than the other. They’re just different people, with different injuries or reactions to surgery, different reactions to pain and different reactions to medication. Judging “toughness” doesn’t help anyone.

Another important note is that opioid medication is not the only contributor to the opioid epidemic. Illicit (sometimes called “street”) substances include heroin and illicitly made and sold fentanyl. Illicit fentanyl and its derivatives are particularly scary because of their potency, but we’ll dive into fentanyl in the next post.

From the early 2000s to roughly 2016 (we addressed overdose from 2017 to now in the first post of this series), drug overdoses climbed in two phases. First, there was a steady increase from about 2000 to 2014 in all overdose deaths (see Figure 1 of this helpful page from the National Institute on Drug Abuse, which I’ll be using for the rest of the post). Figure 2 shows that a major contributor to that increase was from prescription medication, but that prescription opioid overdoses leveled off somewhat by 2011. Heroin deaths were the second phase of the increase, with sharp changes starting around 2011. Finally, fentanyl-related overdose skyrocketed from 2013, and it is now the leading contributor of opioid overdoses today.

So, what likely caused the initial phases of the opioid overdose crisis was prescription opioid medication. What caused that? A major part was caused by overprescribing of such medication. Also, once individuals became physically dependent on opioid medication, any reductions in dose caused withdrawal symptoms, sometimes causing use of illicit opioids to prevent withdrawal. As I’ll address in the next post on fentanyl and its derivatives, simply reducing opioid prescriptions won’t solve the problem. Unfortunately, it’s more complex than that.