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There is an ongoing opioid epidemic (also known as the opioid crisis) in the United States, originating out of both medical prescriptions and illegal sources. The epidemic began in the United States in the late 1990s, according to the Centers for Disease Control and Prevention (CDC), when opioids were increasingly prescribed for pain management, resulting in a rise in overall opioid use throughout subsequent years.[2]
In the United States, there were approximately 109,600 drug-overdose-related deaths in the 12-month period ending January 31, 2023, at a rate of 300 deaths per day.[3] From 1999 to 2020, nearly 841,000 people died from drug overdoses,[4] with prescription and illicit opioids responsible for 500,000 of those deaths.[5] In 2017 alone, there were 70,237 recorded drug overdose deaths; of those deaths, 47,600 involved an opioid.[6][7] A report from December 2017 estimated that 130 people die every day in the United States due to opioid-related drug overdose.[8] The great majority of Americans who use prescription opioids do not believe that they are misusing them.[9]
The problem is significantly worse in rural areas, where socioeconomic variables, health behaviors, and accessibility to healthcare are responsible for a higher death rate.[10] Teen use of opioids has been noticeably increasing, with prescription drugs used more than any illicit drug except cannabis: more than cocaine, heroin, and methamphetamine combined.[11]
Background
Opioids are a diverse class of strong, addictive, and inexpensive drugs, which include opiates (i.e., morphine and codeine), oxycodone (OxyContin, Percocet), hydrocodone (Vicodin, Norco), and fentanyl. Traditionally, opioids have been prescribed for pain management, as they are effective for treating acute pain but are less effective for treating chronic pain. Clinical guidelines advise that opioids should only be used for chronic pain if safer alternatives are not feasible, as their risks often outweigh their benefits.[12]
The potency and availability of opioids have made them popular as both medical treatments and recreational drugs.[8][13][14] In 2018, the U.S. opioid prescription rate was 51.4 prescriptions per 100 people, equivalent to more than 168 million total opioid prescriptions.[15] However, these substances also have high risks of addiction and overdose, and long-term use can cause tolerance and physical dependence.[16] When people continue to use opioid medications beyond what a doctor prescribes, whether to minimize pain or induce euphoric feelings, it can mark the beginning stages of an opioid addiction.[17] Also, in 2018, after being prescribed an opioid medication, about 10.3 million people ended up misusing it, and 47,600 people died from an overdose.[8] More than 650,000 Americans have died of drug overdoses since the opioid epidemic began.[18]
Waves of the opioid epidemic
The Centers for Disease Control and Prevention describe the U.S. opioid epidemic as having arrived in three waves.[5] However, recent research indicates that since 2016, the United States has been experiencing the fourth wave of the opioid epidemic.[19][20][21] The epidemic began with the overprescription and abuse of prescription drugs.[22] However, as prescription drugs became less accessible in 2016 in response to CDC opioid prescribing guidelines,[23] there was an increase in demand and accessibility to cheaper, illicit alternatives to opioids such as heroin and fentanyl.[24]
First wave
The first wave, which marked the start of the epidemic, began in the 1990s due to the push towards using opioid medications for chronic pain management and the increased promotion by pharmaceutical companies for medical professionals to use their opioid medications. During this time, around 100 million people in the United States were estimated to be affected by chronic pain; however, opioids were only reserved for acute pain experienced secondary to cancer or terminal illnesses.[25] Physicians avoided prescribing opioids for other medical conditions because of the lack of evidence supporting their use, the concern of opioids having addictive properties, and the fear of being investigated or disciplined for liberal opioid practices.[26] However, in 1980, a letter to the editor featured in the New England Journal of Medicine (NEJM) challenged these notions. The letter advocated for more liberal use of opioids in pain management, which the World Health Organization eventually supported.[27] In addition, medical organizations began to push for more attentive physician responses to pain, referring to pain as the "fifth vital sign." This was coupled with the promotion of opioids by pharmaceutical companies who insisted that patients could not become addicted. Opioids became an acceptable treatment for a wide variety of conditions, leading to a consistent increase in opioid prescriptions. From 1990 to 1999, the total number of opioid prescriptions grew from 76 million to approximately 116 million, making them the most prescribed class of medications in the United States.[28][29]
Mirroring the positive trend in the volume of opioid pain relievers prescribed is an increase in admissions for substance use disorder treatments and opioid-related deaths. This illustrates how legitimate clinical prescriptions of pain relievers are being diverted through an illegitimate market, leading to misuse, addiction, and death.[30] With the increase in volume, the potency of opioids also increased. By 2002, one in six drug users was prescribed drugs more powerful than morphine; by 2012, the ratio had doubled to one in three.[31] The most commonly prescribed opioids have been oxycodone and hydrocodone.
Second wave
The second wave of the opioid epidemic began around 2010 and is characterized by the surge in heroin use and overdose deaths.[5] Between 2005 and 2012, the number of people who used heroin nearly doubled, growing from 380,000 to 670,000 individuals. In 2010, there were 2,789 fatal heroin overdoses, representing an almost 50% increase compared to previous years.[32][33] This sharp increase can be attributed to the availability of heroin in the United States and its decreasing prices, which enticed a significant portion of individuals already dependent on opioids to switch to a more potent and cost-effective alternative.[34] During this same period, there was also a reformulation of OxyContin that made it more difficult to crush and misuse, although the precise impact of this reformulation on the rise in heroin use remains uncertain.[35]
Third wave
According to the CDC, the third wave of the opioid epidemic began in 2013;[22] and concluded in 2016.[19][22][21] This wave coincided with a significant increase in overdose deaths involving synthetic opioids, particularly illegally produced fentanyl.[37][38] During this period, deaths related to prescription opioids increased marginally, while heroin-related deaths remained relatively stable.[22] The demographic affected during this wave was younger, less frequently male, and more likely to be white and rural compared to the previous waves.[39] However, it's worth noting that the third wave also witnessed an increase in opioid-related overdoses among Black and Hispanic individuals in urban areas who use drugs.[40] The rise in fentanyl-related deaths is attributed to the fact that fentanyl is 50 to 100 times more potent than morphine, and it is often mixed into heroin or cocaine to increase potency at a low cost.[41] Considering that Black Americans tend to consume cocaine more frequently than heroin or other prescription opioids compared to white populations, the increase in deaths is linked to the greater prevalence of fentanyl-laced cocaine.[42]
Fourth wave
The fourth wave, which is reported to have begun in 2016, is characterized by polysubstance use and increased use of stimulants like methamphetamines and cocaine.[19][20][21][43] The availability and use of illicit fentanyl continue to be the leading cause of fatalities, but the recent rise of polysubstance use (defined as the practice of using multiple drugs at once or in succession) and stimulants is linked to the increased fatality rate with the ongoing opioid epidemic.[19] Between 2012 and 2018, there was a threefold increase in mortality related to cocaine use and a fivefold increase in mortality related to psychostimulants like methamphetamine. This increase has primarily been observed in male populations from non-Hispanic American Indian, non-Hispanic Black, and non-Hispanic White populations.[19] Researchers attribute the increase in illicit drug use to the CDC's recommendations to reduce opioid use through measures like tapering opioid prescribing.[21][43]
Causes
The epidemic was described by Rolling Stone as a "uniquely American problem."[44] The structure of the U.S. healthcare system, in which people not qualifying for government programs are required to obtain private insurance, favors prescribing drugs over more expensive therapies. According to Professor Judith Feinberg, "Most insurance, especially for poor people, won't pay for anything but a pill."[45] Prescription rates for opioids in the United States are 40 percent higher than the rate in other developed countries such as Germany or Canada.[46] While the rates of opioid prescriptions increased between 2001 and 2010, the prescription of non-opioid pain relievers (aspirin, ibuprofen, etc.) decreased from 38% to 29% of ambulatory visits in the same period,[47] and there has been no change in the amount of pain reported in the United States.[48] This has led to differing medical opinions, with some noting that there is little evidence that opioids are effective for chronic pain not caused by cancer.[49]
The annual opioid prescribing rates have been slowly decreasing since 2012,[50] but the number is still high. There were about 58 opioid prescriptions per 100 Americans in 2017. Characteristics of jurisdictions with a greater number of opioid prescriptions per resident include small cities or large towns, cities with more dentists and primary care doctors per capita, cities with a higher percentage of white residents, cities with a higher uninsured/unemployment rate, and cities with more residents who have diabetes, arthritis, or a disability.[51]
Several studies have been conducted to find out how opioids were primarily acquired, with varying findings. A 2013 national survey indicated that 74% of people who recreationally use opioids acquired their opioids directly from a single doctor, friend, or relative who received their opioids from a clinician.[52] Among pharmacies, the most prolific distributor was Walgreens, which bought 13 billion oxycodone and hydrocodone pills from 2006 through 2012 (about twenty percent of all such pills in US pharmacies).[53] Though aggressive opioid prescription practices played the biggest role in creating the epidemic, the popularity of illegal substances such as potent heroin and illicit fentanyl has become an increasingly large factor. It has been suggested that decreased supply of prescription opioids caused by opioid prescribing reforms directed people who were already addicted to opioids to illegal substances.[54]
In 2015, approximately 50% of drug overdoses were not the result of an opioid product from a prescription, though most recreational users' first exposure had still been by lawful prescription.[52] By 2018, another study suggested that 75% of people who use opioids recreationally started their opioid use by taking drugs obtained in a way other than by legitimate prescription.[55]
-
The top line represents the yearly number of benzodiazepine deaths that involved opioids in the United States. The bottom line represents benzodiazepine deaths that did not involve opioids.[1] -
Opioid involvement in cocaine overdose deaths. Yellow line is cocaine and any opioid. Light green line is cocaine without any opioids. Yellow line is cocaine and other synthetic opioids.[1] -
History
There were fewer than 3,000 overdose deaths in 1979, when a heroin epidemic was raging in U.S. cities. There were fewer than 5,000 recorded in 1988, around the height of the crack epidemic. More than 64,000 Americans died from drug overdoses last year , according to the U.S. Centers for Disease Control and Prevention.
Mike Strobe, AP medical writer[56]
| External audio | |
|---|---|
 Treating America's Opioid Addiction Part 1: The Narcotic Farm and the Promise of Salvation | |
| Part 2: Synanon and the Tunnel Back to the Human Race | |
| Part 3: Searching for Meaning in Kensington, Science History Institute |
Opiates such as morphine have been used for pain relief in the United States since the 1800s, and were used during the American Civil War.[57][58] Opiates soon became known as a wonder drug and were prescribed for a wide array of ailments, even for relatively minor treatments such as cough relief.[59] Bayer began marketing heroin commercially in 1898. Beginning around 1920, however, the addictiveness was recognized, and doctors became reluctant to prescribe opiates.[60] Heroin was made an illegal drug with the Anti-Heroin Act of 1924, in which the US Congress banned the sale, importation, or manufacture of heroin.
In the 1950s heroin addiction was still fairly uncommon among average Americans, many of whom saw it as a frightening condition.[61] The fear extended into the 1960s and 1970s, although it became common to hear or read about drugs such as cannabis and psychedelics, which were widely used at rock concerts like Woodstock.[61]
Heroin addiction began to make the news around 1970 when rock star Janis Joplin died from an overdose. During and after the Vietnam War, addicted soldiers returned from Vietnam, where heroin was easily bought. Heroin addiction grew within low-income housing projects during the same time period.[61] In 1971, congressmen released an explosive report on the growing heroin epidemic among US servicemen in Vietnam, finding that ten to fifteen percent were addicted to heroin. "The Nixon White House panicked," wrote political editor Christopher Caldwell, and declared drug abuse "public enemy number one".[62] By 1973, there were 1.5 overdose deaths per 100,000 people.[61]
Modern prescription opiates such as Vicodin and Percocet entered the market in the 1970s, but acceptance took several years and doctors were apprehensive about prescribing them.[59] Until the 1980s, physicians had been taught to avoid prescribing opioids because of their addictive nature.[60] A brief letter published in the New England Journal of Medicine (NEJM) in January 1980, titled "Addiction Rare in Patients Treated with Narcotics", generated much attention and changed this thinking.[63][64] A group of researchers in Canada claim that the letter may have originated and contributed to the opioid crisis.[63] The NEJM published its rebuttal to the 1980 letter in June 2017, pointing out among other things that the conclusions were based on hospitalized patients only, and not on patients taking the drugs after they were sent home.[65] The original author, Hershel Jick, has said that he never intended for the article to justify widespread opioid use.[63]
In the mid-to-late 1980s, the crack epidemic followed widespread cocaine use in American cities. The death rate was worse, reaching almost 2 per 100,000. In 1982, Vice President George H. W. Bush and his aides began pushing for the involvement of the CIA and the US military in drug interdiction efforts, the so-called War on Drugs.[66] The initial promotion and marketing of OxyContin was an organized effort throughout 1996–2001, to dismiss the risk of opioid addiction.[67]
Purdue Pharma hosted over forty promotional conferences at three select locations in the southwest and southeast of the United States. Coupling a convincing "Partners Against Pain" campaign with an incentivized bonus system, Purdue trained its salesforce to convey the message that the risk of addiction was under one percent, ultimately influencing the prescribing habits of the medical professionals that attended these conferences.[67] Consulting firm McKinsey & Company reached a nearly $600 million settlement with 49 of 50 U.S. states in 2021 over the firm's role in driving opioid sales for Purdue Pharma and other pharmaceutical companies.[71] In 2016, the opioid epidemic was killing on average 10.3 people per 100,000, with the highest rates including over 30 per 100,000 in New Hampshire and over 40 per 100,000 in West Virginia.[61]
According to the Substance Abuse and Mental Health Services Administration's National Survey on Drug Use and Health, in 2016 more than 11 million Americans misused prescription opioids, nearly 1 million used heroin, and 2.1 million had an addiction to prescription opioids or heroin.[72]
While rates of overdose of legal prescription opiates have leveled off in the past decade, overdoses of illicit opiates have surged since 2010, nearly tripling.[73]
In a 2015 report, the US Drug Enforcement Administration stated that "overdose deaths, particularly from prescription drugs and heroin, have reached epidemic levels."[74]: iii Nearly half of all opioid overdose deaths in 2016 involved prescription opioids.[1][75] From 1999 to 2008, overdose death rates, sales, and substance use disorder treatment admissions related to opioid pain relievers all increased substantially.[76] By 2015, there were more than 50,000 annual deaths from drug overdose, causing more deaths than either car accidents or guns.[77]
In 2016, around 64,000 Americans died from overdoses, 21 percent more than the approximately 53,000 in 2015.[78][79][80] By comparison, the figure was 16,000 in 2010, and 4,000 in 1999.[81][82] While death rates varied by state,[31] in 2017 public health experts estimated that nationwide over 500,000 people could die from the epidemic over the next 10 years.[83] In Canada, half of the overdoses were accidental, while a third were intentional. The remainder were unknown.[84] Many of the deaths are from an extremely potent opioid, fentanyl, which is trafficked from Mexico.[85] The epidemic cost the United States an estimated $504 billion in 2015.[86]
In 2017, around 70,200 Americans died from drug overdose. 28,466 deaths were associated with synthetic opioids such as fentanyl and fentanyl analogs, 15,482 were associated with heroin use, 17,029 with prescription opioids (including methadone), 13,942 with cocaine use, and 10,333 with psychostimulants (including methamphetamine).[87]
In 2021, there was an increase in overdose deaths; more than 106,000 drug-related overdoses occurred, including deaths caused by both illegal and prescribed opioids. Of this, 70,601 deaths were caused by synthetic opioids primarily fentanyl. Additionally, 32,537 overdose deaths involved stimulants like cocaine or psychostimulants with abuse potential (primarily methamphetamine).[88]
Between 2017 and 2019, rappers Lil Peep, Mac Miller, and Juice Wrld died of drug overdoses related to opioids. William D. Bodner of the Drug Enforcement Administration's Los Angeles field division and special agent in charge of the investigation into Miller's death said in a statement, "The tragic death of Mac Miller is a high-profile example of the tragedy that is occurring on the streets of America every day."[89]
In 2023, the Biden administration announced a crackdown on Mexican drug cartels smuggling fentanyl into the United States.[90] The Biden administration also targeted Chinese companies importing chemicals used to make fentanyl.[91][92] Rahul Gupta led White House efforts to combat the opioid epidemic.[93]
Heroin
Between 4 and 6% of people who misuse prescription opioids turn to heroin, and 80% of heroin addicts began abusing prescription opioids.[94] Many people addicted to opioids switch from taking prescription opioids to heroin because heroin is less expensive and more easily acquired on the black market.[95]
Women are at a higher risk of overdosing on heroin than men.[96] Overall, opioids are among the biggest killers of every race.[97]
Heroin use has been increasing over the years. An estimated 374,000 Americans used heroin in 2002–2005, and this estimate grew to nearly double where 607,000 of Americans had used heroin in 2009–2011.[98] During the first two waves of the opioid epidemic, heroin use increased among non-Hispanic Whites but decreased among non-White groups; additionally during this time, the vulnerability for overdose shifted to younger age groups.[19] In 2014, it was estimated that more than half a million Americans had an addiction to heroin.[99]
Oxycodone
Oxycodone is the most widely used recreational opioid in the United States. The US Department of Health and Human Services estimates that about 11 million people in the US consume oxycodone in a non-medical way annually.[100]
Oxycodone was first made available in the United States in 1939. In the 1970s, the FDA classified oxycodone as a Schedule II drug, indicating a high potential for non-medical use and addiction. After its 1995 approval by the FDA by Deputy Director Curtis Wright IV,[101] Purdue Pharma introduced OxyContin, a controlled release formulation of oxycodone[67] in 1996. However, drug users quickly learned how to simply crush the controlled release tablet to swallow, inhale, or inject the high-strength opioid for a powerful morphine-like high. In fact, Purdue's private testing conducted in 1995 determined that 68% of the oxycodone could be extracted from an OxyContin tablet when crushed.[67]
In 2007, Purdue paid $600 million in fines after being prosecuted for making false claims about the risk of opioid use disorder associated with oxycodone.[102] In 2010, Purdue Pharma reformulated OxyContin, using a polymer to make the pills extremely difficult to crush or dissolve in water to reduce non-medical use of OxyContin. The FDA approved relabeling the reformulated version as abuse-resistant.[103] OxyContin use following the 2010 reformulation declined slightly while no changes were observed in the use of other opioids.[104]
In June 2017, the FDA asked the manufacturer to remove its long-acting form of oxymorphone (Opana ER) from the US market, because the drug's benefits may no longer outweigh its risks, this being the first time the agency has asked to remove a currently marketed opioid pain medication from sale due to public health consequences of non-medical use.[105]
Hydrocodone
Hydrocodone is second among the list of top prescribed opioid painkillers, but it is also high on the list of most frequently used for recreational use. In 2011, the non-medical use of hydrocodone was responsible for more than 97,000 visits to the emergency room. In 2012, the Food and Drug Administration (FDA) rescheduled it from a Schedule III drug to a Schedule II drug, recognizing its high potential for non-medical use and addiction.[106]
Hydrocodone can be prescribed under a different brand name. These brand names include Norco, Lortab, and Vicodin.[107] Hydrocodone can also exist in other formulations where it is combined with another non-opioid pain reliever such as acetaminophen, or even a cough suppressant.[106]
When opioids like hydrocodone are taken as prescribed, for the indication prescribed, and for a short period of time, then the risk of non-medical use and addiction is small. Problems have surfaced over the last decade however, due to its wide overuse and misuse in the setting of chronic pain.[107]
The elderly are at an increased risk for opioid related overdose because several different classes of medications can interact with opioids and older patients are often taking multiple prescribed medications at a single time. One class of drug that is commonly prescribed in this patient population is benzodiazepines. Benzodiazepines by themselves put older people at risk for falls and fractures due to associated side effects related to dizziness and sedation. Opioids by themselves put older people at risk of respiratory depression and impaired ability to operate vehicles and other machinery. Combining these two drugs together not only increases a person's risk of the aforementioned adverse effects, but can increase a person's risk of overdose and death.[108] Benzodiazepines is also the second leading cause of teen overdose death after fentanyl. It killed 152 people in 2021, less than a fifth of fentanyl's death toll.[109]
Hydrocodone was declared the most widely prescribed opioid between 2007 and 2016, and in 2015 the International Narcotics Control Board reported that greater than 98% of the hydrocodone consumed in the entire world was consumed by Americans.[110]
Codeine
Codeine is a prescription opiate used to treat mild to moderate pain. It is available as a tablet and cough syrup. A 2013 study on the concoction of codeine with alcohol or soda, also known as "purple drank," reported that codeine is most widely used in a recreational way by men, Native Americans and Hispanics, urban students, and LGBT persons.[111] The study also noted that all people who used "purple drank" reported using alcohol within the past month, and roughly 10 percent of cannabis users reported abusing "purple drank".[111]
2010s to present (increase in fentanyl)
As of 2021, America's drug epidemic was the deadliest it had ever been, according to federal data. More than 100,000 people died of drug overdoses in the United States during the 12-month period ending April 2021, according to provisional data published November 17, 2021, by the US Centers for Disease Control and Prevention.[113] Overdose deaths increased 28.5% from the same period a year earlier and nearly doubled over the previous five years. Opioids continued to be the primary cause of drug overdose deaths. Additionally, the drug is increasingly affecting younger populations. A 2018 study found that fentanyl is involved in the majority of opioid-related deaths and that deaths involving fentanyl were more likely to occur in younger age groups and among non-Hispanic white individuals.[114] Furthermore, young adults are increasingly affected by nonfatal fentanyl overdoses in recent time periods along with these other deadly occurrences.[115] Many sources point to fentanyl as the leading cause of teen overdose death. According to a 2022 study in the Journal of the American Medical Association, between 2010 and 2021, the number of teenage deaths caused by black-market fentanyl and related synthetic substances increased more than twentyfold, from 38 to 884.[116] The drug is 50 to 100 times stronger than morphine and often cut with other drugs, meaning the user does not know they are taking fentanyl. The Drug Enforcement Administration (DEA) says 2.2 pounds represents half a million lethal doses.[117] Synthetic opioids, primarily fentanyl, caused nearly two-thirds (64%) of all drug overdose deaths in the 12-month period ending April 2021, up 49% from the year before, the CDC's 's National Center for Health Statistics found.
There have always been drug addicts in need of help, but the scale of the present wave of heroin and opioid abuse is unprecedented. In Maryland, the first six months of 2015 saw 121 fentanyl deaths. In the first six months of 2016, the figure rose to 446.
Christopher Caldwell,
senior editor The Weekly Standard[61]
Fentanyl, a synthetic opioid painkiller, is 50 to 100 times more potent than morphine and 30 to 50 times more potent than heroin,[61] with only 2 mg becoming a lethal dose. As of 2023, one dose costs $8 for users in San Francisco.[118] It is pure white, odorless and flavorless. The potency of fentanyl has led to the mistaken belief [119] that exposure to fentanyl by touch can cause an overdose, a myth that has been repeated by media outlets[120] and even government publications.[121][122] As a result, the Drug Enforcement Administration has recommended that officers not field test drugs if fentanyl is suspected, but instead collect and send samples to a laboratory for analysis. "Exposure via inhalation or skin absorption can be deadly," they state.[123] However, the American College of Medical Toxicity and the American Academy of Clinical Toxicology stated that, as of 2017, they were not aware of "emergency responders developing signs or symptoms consistent with opioid toxicity from incidental contact with opioids.".[124] A 2021 article in the journal Health & Justice reported that "many of the reported fentanyl exposure incidents among police share the symptoms of a panic attack rather an opioid overdose,"[119] and a 2020 article from the Journal of Medical Toxicology stated that "the consensus of the scientific community remains that illness from unintentional exposures is extremely unlikely, because opioids are not efficiently absorbed through the skin and are unlikely to be carried in the air."[120]
According to the United States Drug Enforcement Agency in 2023, China continued to be the primary source of fentanyl being imported into the United States, killing over 100 Americans every day.[125] Over a two-year period, close to $800 million worth of fentanyl pills were illegally sold online to the US by Chinese distributors.[126][127] The drug is usually manufactured in China, then shipped to Mexico, where it is processed and packaged, which is then smuggled into the US by drug cartels.[128] A large amount is also purchased online and shipped through the US Postal Service.[129] It can also be purchased directly from China, which has become a major manufacturer of various synthetic drugs illegal in the US.[130] AP reporters found multiple sellers in China willing to ship carfentanyl, an elephant tranquilizer that is so potent it has been considered a chemical weapon. The sellers also offered advice on how to evade screening by US authorities.[131] According to Assistant US Attorney, Matt Cronin:
It is a fact that the People's Republic of China is the source for the vast majority of synthetic opioids that are flooding the streets of the United States and Western democracies. It is a fact that these synthetic opioids are responsible for the overwhelming increase in overdose deaths in the United States. It is a fact that if the People's Republic of China wanted to shut down the synthetic opioids industry, they could do so in a day.[132]
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According to the United States House Select Committee on Strategic Competition between the United States and the Chinese Communist Party, the Chinese government directly subsidizes producers of fentanyl precursors and analogues through tax rebates and other incentives.[133][134] Since 2019, the Chinese government has removed online records of subsidies for fentanyl-related producers.[135]
Deaths from fentanyl in 2016 increased by 540 percent across the United States since 2015.[136] This accounts for almost "all the increase in drug overdose deaths from 2015 to 2016", according to a study published in the Journal of the American Medical Association.[73] Readily available fentanyl killed 70,000 people in 2021 alone.[18]
Fentanyl-laced heroin has become a big problem for major cities, including Philadelphia, Detroit and Chicago.[137] Its use has caused a spike in deaths among users of heroin and prescription painkillers, while becoming easier to obtain and conceal. Some arrested or hospitalized users are surprised to find that what they thought was heroin was actually fentanyl.[61] According to former CDC director Tom Frieden:
As overdose deaths involving heroin more than quadrupled since 2010, what was a slow stream of illicit fentanyl, a synthetic opioid 50 to 100 times stronger than morphine, is now a flood, with the amount of the powerful drug seized by law enforcement increasing dramatically. America is awash in opioids; urgent action is critical.[138]
According to the Centers for Disease Control and Prevention (CDC), death rates from synthetic opioids, including fentanyl, increased over 72% from 2014 to 2015.[17] In addition, the CDC reports that the total deaths from opioid overdoses may be under-counted, since they do not include deaths that are associated with synthetic opioids which are used as pain relievers. The CDC presumes that a large proportion of the increase in deaths is due to illegally-made fentanyl; as the statistics on overdose deaths (as of 2015) do not distinguish pharmaceutical fentanyl from illegally-made fentanyl, the actual death rate could, therefore, be much higher than reported.[139]
Those taking fentanyl-laced heroin are more likely to overdose because they do not know they also are ingesting the more powerful drug. The most high-profile death involving an accidental overdose of fentanyl was singer Prince.[140][141][142]
Fentanyl has surpassed heroin as a killer in several locales: in all of 2014 the CDC identified 998 fatal fentanyl overdoses in Ohio, which is the same number of deaths recorded in just the first five months of 2015. The US Attorney for the Northern District of Ohio stated:
One of the truly terrifying things is the pills are pressed and dyed to look like oxycodone. If you are using oxycodone and take fentanyl not knowing it is fentanyl, that is an overdose waiting to happen. Each of those pills is a potential overdose death.[143]
In 2016, the medical news site STAT reported that while Mexican cartels are the main source of heroin smuggled into the US, Chinese suppliers provide both raw fentanyl and the machinery necessary for its production.[143] In Southern California, a home-operated drug lab with six pill presses was uncovered by federal agents; each machine was capable of producing thousands of pills an hour.[143]
Overdoses involving fentanyl have greatly contributed to the havoc caused by the opioid epidemic. In New Hampshire, two thirds of the fatal drug overdoses involved fentanyl, and most do not know that they are taking fentanyl. In 2017, a cluster of fentanyl overdoses in Florida was found to be caused by street sales of fentanyl pills sold as Xanax. According to the DEA, one kilogram (2.2 lb) of fentanyl can be bought in China for $3,000 to $5,000, and then smuggled into the United States by mail or Mexican drug cartels to generate over $1.5 million in revenue. The profitability of this drug has led dealers to adulterate other drugs with fentanyl without the knowledge of the drug user.[144]
In 2022, the FDA warned, that xylazine, an animal tranquilizer, is increasingly being detected in heroin and illicit fentanyl.[145][146]
One study found that, although relatively uncommon, "the presence of fentanyl in the stimulant supply increased significantly between 2011 and 2016, with the greatest increases occurring between 2015-2016; the presence of these products was concentrated in the U.S. Northeast."[147]
Demographics
In 2016, opioid overdoses took the lives of approximately 91 Americans each day. Roughly half of these deaths were caused by prescribed opioids.[52] Given the complexity of the topic and the difficulty of controlling factors while researching, there is much speculation the differences between demographics.
In 2015, Anne Case and Angus Deaton's theory of the deaths of despair identified the root causes of the increase in opioid deaths as high levels of poverty, income inequality, and unemployment due to deteriorating labor markets, a lack of access to social capital, a lack of access to healthcare, and high social isolation.[148] They reported that opioid overdose deaths were disproportionately affecting white, middle-aged, and less-educated Americans, particularly those living in rural areas.
Race
In the US, addiction and overdoses affect mostly non-Hispanic Whites from the working class.[81] The prevalence of opioid overdose deaths per 100,000 within the USA was highest for non-Hispanic White, followed by Black, Hispanic, and Asian/Pacific Islander individuals.[149] During the first and second wave of the opioid epidemic, White American people were most affected by opioid overdose.[150] While all groups were affected in the third and fourth wave of the epidemic, White Americans and non-Hispanic Black individuals saw the greatest rise in deaths.[151]
Native Americans and Alaska Natives experienced a five-fold increase in opioid-overdose deaths between 1999 and 2015, with Native Americans having the highest increase of any demographic group.[152] With the belief that there would be a low risk of addiction, Indian Health Service physicians, like doctors nationwide, readily prescribed opioids.[153] In addition, structural health care deficiencies from the provider and cultural beliefs against receiving care from the patient, as well as inadequate community support structures for substance misuse, contributed to high mortality rates.[153] In 2015, American Indians/Alaska Natives had the greatest drug overdose mortality rates of any U.S. population, comparable to White Americans.[153] In 2018, the opioid crisis continued to disproportionately affect non-Hispanic Whites and Native Americans with the National Institutes of Health (NIH) reporting a rise in opioid morbidity and opioid related fatalities.[154]
During 2019–2020, non-Hispanic American Indian/Alaska Native and non-Hispanic Black individuals experienced the greatest increases in drug overdose mortality rates.[151] Additionally, when accounting for the age-adjusted death rate, non-Hispanic American Indian/Alaska Native and non-Hispanic Black individuals in 2020 and 2021.[155] The percentage of individuals with documentation of prior treatment for substance use disorders was low, especially among Black individuals, at 8.3%.[156] Overall, Hispanic, non-Hispanic Native Hawaiians, and non-Hispanic Asians experienced the lowest rate of overdose deaths.[155]
Though previous statistics show that non-Hispanic White Americans have been affected by the opioid epidemic more than other racial/ethnic groups in the United States, recent statistics show that non-Hispanic Black Americans are experiencing a sharper increase in opioid-overdose deaths.[157] The annual percentage change of opioid overdose deaths among Black Americans increased to 26.16 from 2012 to 2018 while White Americans only experienced an 18.96 increase from 2013 to 2016 and even had an annual percentage change decrease to 5.07 from 2016 to 2018.[157] The challenges that non-Hispanic Black Americans face have a disparate impact on the rates of opioid-overdose related deaths when compared to non-Hispanic White Americans who have not dealt with the challenges of structural racism.[158] Recent research has linked the rise in opioid-overdose deaths among Black Americans to the lack of safety, security, stability, and survival in their communities.[159] Those missing pieces in these communities can be linked to a host of things including exposure to structural racism, lack of access to resources, and widespread mistrust in the healthcare system.[159][158]
Structural racism continues to have a lasting impact on predominantly Black communities in the United States.[159] Racial segregation is one of the main forms of structural racism that has been linked to the increase in opioid-overdose related deaths among non-Hispanic Black Americans.[158] Racial segregation does not only impact access to social and economic resources.[160] It also has an impact on public health and disrupts access to health care.[160] The impact that racial segregation has health care spills over to the access of substance use services.[160] This leads to Black Americans having a more difficult time when seeking treatment for opioid use.[160] Structural racism has also led to the consistent misdirection of funds and the over-funding of criminal legal systems within predominantly non-Hispanic Black communities.[159] Instead of funding being used to improve substance abuse treatment and prevention, funds have been used to criminalize drugs and impose harsh penalties on Black community members.[159] The policies put in place years ago have led to stereotyping and fear within Black communities that prevents Black Americans from seeking substance abuse treatment.[161] In America there are continual concerns regarding racial biases against non-Hispanic Black Americans when it comes to drug enforcement. Black Americas have historically been more criminalized for opioid related offenses, and despite calls for change there are still lasting impacts of this today.[157]
Recent studies have shown a real need for equality when it comes to opioid abuse treatment and prevention.[157] Medication-assisted treatments like buprenorphine have been proven to help treat substance use.[160] The facilities that offer this treatment tend to be in communities with predominantly non-Hispanic White populations and they are rarely seen in predominantly non-Hispanic Black communities despite their proven effectiveness.[160] The national focus being on prescription of opioids for pain management is a leading cause for non-Hispanic Black Americans receiving unequal treatment opportunities.[158] Data has shown that this is not the main issue in every city/state, which shows the need for a more local data driven approach to opioid abuse intervention.[158]
Sex
This is especially concerning considering the epidemiology of opioid affliction among white women, who are at a greater risk because they receive more prescription medications than men.[162] According to the NIH (2018), "The opioid epidemic is increasingly young, white, and female" with 1.2 million women being diagnosed with an opioid use disorder compared to 0.9 million men in 2015.[154]
Age
In 2014, roughly 12 percent of young adults between the ages of 18 and 25 reported abusing prescribed opioids.[163] Non-medical prescription drug use rates have been increasing in teenagers with access to parents' medicine cabinets, especially as 12- to 17-year-old girls were one-third of all new users of prescription drugs in 2006. Teens used prescription drugs more than any illicit drug except cannabis, more than cocaine, heroin, and methamphetamine combined.[11] In 2014, roughly 6 percent of teenagers between the ages of 12 and 17 reported abusing prescribed opioids.[163] Deaths from overdose of heroin affect younger people more than deaths from other opiates.[81]
Economic status
Prescription opioids are considered a better financial choice for treating pain than surgery.[164] This resulted in an increased use of prescription opioids by individuals living in communities that were underserved medically or did not have health insurance.[164] Overdose death rates increased across most racial and ethnic groups due to county-level income inequality, particularly among Black and Hispanic individuals. In 2020, overdose rates were more than twice as high in counties with greater inequality compared to counties with lower inequality.[151]
Geography
In the United States, those living in rural areas of the country have been the hardest hit.[165] According to Rita Noonan from the CDC, in rural areas, the overall death rate for accidental injuries is 50% higher than in urban areas. Differences in a multitude of factors, such as income, social supports, and accessibility to health care resources, have led to rural communities majorly exceeding urban areas when it comes to the rate of opioid-involved overdose deaths.[10]
Between 1999 and 2017, Non-Hispanic Black populations in medium-small metropolitan regions saw a growth of opioid overdoses at 12.3%, while non-Hispanic whites in non-metropolitan areas had an increase of 13.6% annually.[166] Urban Black Americans had the largest rise in overdose rates between 2013 and 2017, with younger (aged 55 years) and older adults seeing increases of 178% and 87%, respectively.[166] However, Black individuals living in urban areas had the largest rise in fentanyl-related fatalities during the same time period.[167]
Prescription rates for opioids vary widely across states. In 2012, healthcare providers in the highest-prescribing state wrote almost three times as many opioid prescriptions per person as those in the lowest-prescribing state. Health issues that cause people pain do not vary much from place to place and do not explain this variability in prescribing.[51] Researchers suspect that the variation results from a lack of consensus among elected officials in different states about how much pain medication to prescribe. A higher rate of prescription drug use does not lead to better health outcomes or patient satisfaction, according to studies.[81]
In Palm Beach County, Florida, overdose deaths went from 149 in 2012 to 588 in 2016.[168] In Middletown, Ohio, overdose deaths quadrupled in the 15 years since 2000.[169] In British Columbia, 967 people died of an opiate overdose in 2016, and the Canadian Medical Association expected over 1,500 deaths in 2017.[170] In Pennsylvania, the number of opioid deaths increased 44 percent from 2016 to 2017, with 5,200 deaths in 2017. Governor Tom Wolf declared a state of emergency in response to the crisis.[171]