Confronting America’s Opioid Epidemic

The Opioid Problem: History in the Making

Over the past two decades in the United States, the use of opioids— group of drugs that includes heroin and prescription painkillers—has escalated dramatically, with enormous human and financial costs to individuals, families and communities.

The CDC has described the opioid crisis as the worst drug addiction epidemic in US history.

According to the CDC, deaths related to prescription pain pills have more than quintupled, from 4,030 in 1999 to 20,101 in 2015, while heroin overdose deaths have increased even more, from 1,960 in 1999 to 12,990 in 2015 (33,091 total). All told, during those 17 years, opioid overdoses claimed almost 300,000 lives, including an average of 91 per day (55 to prescription opioids and 36 to heroin) in 2015 alone.

Driven by the rise in opioid deaths, drug overdose has become the leading cause of accidental death in America, with a record 52,404 overdose deaths in 2015 (144 per day). Car accidents, now a distant second, resulted in 38,300 deaths in 2015.

A New York Times analysis published on June 5, 2017, estimated that drug overdose deaths rose an additional 19 percent from 2015 to 2016, possibly the largest annual jump in overdose deaths in U.S. history, and reported that drug overdoses are now the leading cause of death among Americans under the age of 50. Overdose and other substance use-related deaths are also now contributing to reduced life expectancy for many Americans, reversing a decades-long trend toward longer lives.

Indeed, more than 625,000 American lives have been lost to drug overdose since 1999—a staggering total akin to losing the entire city of Portland, Oregon, and roughly the same number of people killed in all battles in the United States’ 240-year history.

Rates of drug overdose death increased for all age groups in 2015; with the largest percentage increase seen for adults ages 55–64. This age group had a fivefold increase in the rates of drug overdose deaths, from 4.2 per 100,000 in 1999 to 21.8 in 2015. Since 2005, rates have been highest for adults ages 45–54.

More than 60 percent of all drug overdose deaths involved an opioid in 2015. And the most common drugs involved in prescription opioid overdose deaths are methadone, oxycodone and hydrocodone.

We’ve also seen a troubling rise in the number of babies born dependent on the opioids their mothers took during pregnancy. At birth, these babies suffer from opioid withdrawal, a condition known as neonatal abstinence syndrome (NAS). From 2000 to 2012, almost 22,000 babies were born with NAS, a five-fold increase since 2000. Sadly, that means one baby is born every 25 minutes suffering from opioid withdrawal.

Not surprisingly, opioid use disorders have also increased dramatically. Of the 20.5 million Americans age 12 or older who had a substance use disorder in 2015, 2 million involved prescription pain relievers and 591,000 involved heroin. Within the Hazelden Betty Ford Foundation’s national system of care, nearly a quarter of our patients are admitted with an opioid use disorder, up 250 percent since 2001. Similarly, Blue Cross and Blue Shield said the number of its members diagnosed with opioid use disorder skyrocketed 493 percent from 2010 to 2016. In yet another barometer of the crisis, Medicaid spending on medications to treat opioid use disorder and opioid overdoses increased from $394 million in 2011 to $928 million in 2016.

Also on the rise: emergency room visits and hospitalizations for opioid-related illnesses, which totaled 1.27 million across the country in 2014 (with women now just as likely as men to be affected), including a 99 percent increase in emergency room visits compared to 2005. In Pennsylvania alone, overdose hospitalizations cost public and private insurers $27 million in 2016.

The total economic burden, including health care costs, of prescription painkillers—never mind heroin and other illicitly sold opioids—has been estimated at $78.5 billion annually.

Costs would be much greater if not for the nationwide deficit in addiction treatment capacity and access. Recent studies estimate that more than 80 percent of people in need of treatment are unable to access needed services, while others resources estimate the gap is as high as 90 percent.

And it’s important to note that people who experience problems using prescription painkillers, heroin and other opioids tend to have other substance use issues as well, and that overdoses typically involve two or three drugs in combination. In addition, most opioid prescriptions go to patients with mental health disorders. All of this highlights the fact that treating opioid use disorders requires comprehensive care addressing addiction to all substances as well as to mental health conditions.

The alarming increases in use, misuse, addiction, overdose deaths and economic costs have closely followed, as one might suspect, a huge increase in the rate of opioid prescriptions and use. The CDC says the amount of prescription opioids sold nearly quadrupled in the U.S. from 1999 to 2014, despite no change in the amount of pain that Americans reported. According to one analysis, about 300 million pain pill prescriptions were written worldwide in 2015, amounting to a $24 billion market. And despite having only 4.6 percent of the world’s population, the U.S. consumes roughly 80 percent of the world’s supply of painkillers, including almost 100 percent of the world’s hydrocodone (e.g., Vicodin).

Some positive news: IMS Health, whose data on prescribing is used widely in health care, found a 12 percent decline in opioid prescriptions nationally since a peak in 2012. IMS further reports that opioid prescriptions have fallen in 49 states since 2013.

Still, opioid prescriptions remain extraordinarily high. Michigan, for example, had more annual opioid prescriptions than people in 2015 and 2016, with 11 million such prescriptions written each year. Blue Cross Blue Shield reported that more than 20 percent of those it insures were prescribed an opioid at least once in 2015. And despite the beginning of a downward trend in prescriptions, opioid-related deaths continue to rise. Increased demand has led to a robust black market for heroin, fentanyl and other opioids that are often combined with each other and/or other drugs to create dangerous drug “cocktails.”

While most prescription opioid users do not go on to use heroin or other illicit opioids, those who are addicted to prescription opioids are 40 times more likely to become addicted to heroin. And multiple studies now indicate that almost 80 percent of new heroin users did previously use prescription opioids. That is consistent with what we hear anecdotally from our young patients who have an opioid use disorder. They often report a relatively swift path from medicine bottle to heroin needle. As prescription supplies dry up and doctor-shopping options run out, heroin becomes the cheaper and more available alternative. A 2014 survey of people in treatment for opioid addiction validated our experience, with 94 percent of respondents saying they used heroin “because prescription opioids were far more expensive and harder to obtain.”

The U.S. now has an estimated 1 million heroin users, and the number of young adult users—those ages 18-25—has more than doubled since 2002, while the number of heroin-related overdose deaths has more than quadrupled, with most of that increase occurring since 2010. Most recently, heroin death rates increased 26 percent from 2013 to 2014, with an additional 21 percent from 2014 to 2015. The rise of synthetic opioids such as fentanyl has exacerbated the crisis, with the death rate from synthetic opioids (other than methadone) increasing by 72 percent from 2014 to 2015.

Opioid problems are now affecting every area of the country, devastating an entire generation in some communities. Hardest hit have been Appalachia and the Rust Belt—including the states of West Virginia, Kentucky, Ohio and Pennsylvania.

The troubling trends of this crisis began to emerge in the late 1990s, after the U.S. Food and Drug Administration (FDA) approved OxyContin and allowed it to be promoted to family doctors for treatment of common aches and pains. Unfortunately, as education campaigns—funded in many ways by opioid manufacturers—exaggerated the benefits and minimized the risks, state policymakers loosened standards governing opioid prescribing. Then, in 2000, the Joint Commission on Accreditation of Healthcare Organizations implemented new pain management standards. Soon, more physicians and organizations began advocating for increased use of opioids to address what, at the time, was perceived to be a widespread problem of undertreated pain. Today, amid this unprecedented public health crisis of opioid addiction and overdose deaths, several states and counties are suing pharmaceutical companies that spent millions on marketing campaigns that “trivialize(d) the risks of opioids while overstating the benefits.”

When prescribed on a short-term basis to treat severe acute pain, opioids can be helpful. In fact, they are one of the best medicines we have. But when these highly addictive medications are taken around-the-clock, for weeks, months and years to treat relatively common conditions, they may actually produce more harm than help. An increasing body of research suggests that for many chronic pain patients, opioids may be neither safe nor effective. Over time, patients often develop tolerance, leading them to require higher and higher doses, which can ultimately lead to quality-of-life issues and functional decline, not to mention addiction. Indeed, the CDC says addiction struggles are experienced by as many as 25 percent of the people who are prescribed opioids long term for non-cancer pain in primary care settings. A more recent analysis, in late 2016, showed that one-third of Americans who had taken prescription opioids for at least two months say they became addicted to or physically dependent on them. And in some cases, opioids can even make pain worse, a phenomenon called hyperalgesia.

Many people associate prescription painkillers with older adults, and that certainly is a significant population affected by the current crisis, with 40 percent of rheumatoid arthritis patients, for example, using opioids regularly. But overdose rates have been highest among people in the middle stages of life (i.e., ages 25–54). Youth are at risk, too, especially with opioids available in the medicine cabinets of so many homes. Young brains are particularly vulnerable because they aren’t fully developed until the mid-20s. Teens may think the drugs are safe because a doctor prescribed them, unaware that pain pills can be as life-threatening as heroin.

The good news is the 2016 Monitoring the Future survey shows that prescription opioid use among teens has declined in recent years. For example, past-year misuse of Vicodin among 12th graders had dropped from 7.5 percent in 2012 to 2.9 percent in 2016. And over those five years, misuse of all prescription opioids dropped 45 percent, from 8.7 to 4.8 percent.

Yet other troubling numbers continue to add up. According to the National Survey on Drug Use and Health, 969,000 adolescents age 12–17 misused prescription pain relievers in 2015, approximately 415,000 adolescents misused pain relievers for the first time in 2015 and an estimated 216,000 had a prescription drug use disorder.

Perhaps most concerning is the ready access that teens have to opioids. In the 2012 National Survey of American Attitudes on Substance Abuse, 34 percent of teenagers reported they could get prescription drugs within a day. And the National Institute on Drug Abuse said 70 percent of 12th graders who used prescription opioids non-medically in 2011 reported obtaining the drugs from a friend or relative, which is the number one source of opioids for non-medical users in most age groups. Our own 2015 survey of nearly 1,200 college-age youth from around the country substantiated these findings, with almost 16 percent of those surveyed reporting they had used pain pills not prescribed to them at some point in their life, while over a third said opioids were “easy to acquire” (most commonly from family and friends) and 37 percent said they did not know where to go for help in the event of an overdose.

Awareness is certainly increasing, partly because prescription drug addiction now affects nearly half of the public on a personal level. A 2016 Kaiser Family Foundation survey found that 44 percent of Americans personally know someone who has been addicted to prescription painkillers, with 26 percent saying the person they know is an acquaintance, 21 percent saying a close friend, 20 percent saying a family member and 2 percent saying themselves.

Doctors are also more aware of the problem although, when it comes to addiction, most are still undereducated through no fault of their own, but due instead to the longtime marginalization of the disease within medical education and mainstream medicine. To be sure, doctors didn’t start overprescribing opioids out of malicious intent but rather out of a desire to treat pain more compassionately. The top reason people visit a physician is pain. As mentioned, doctors were mistakenly informed beginning in the 1990s that treating pain with opioids was safe. Physician visits are now shorter. Non-prescription-related health support services for pain patients have been fragmented and underutilized. Pressure to make decisions and provide quick solutions add to the doctor’s dilemma. Often it is easier for a physician to write a second or third prescription than to ask the difficult question, “Should I change how I am treating this patient?”

We have a culture that now seeks opioid medication for pain relief, perhaps a natural outgrowth of pleasure seeking within a significant percentage of patients who take opiates for pain. In the absence of more holistic self-care approaches, it makes sense that some patients are at significant risk for the development of addiction in our culture, which promotes quick fixes, instant gratification and escapism. But the Hazelden Betty Ford Foundation has learned that recovery from pain conditions—and recovery from pain and addiction—requires far more than taking pills.

Some progress has been made to confront this crisis. Because of new policies to rapidly expand access to the overdose reversal agent naloxone, thousands of people are surviving overdoses and getting another chance to recover from their opioid addiction and reclaim their lives. Federal legislation such as the Comprehensive Addiction and Recovery Act, the 21st Century Cures Act, the Mental Health Parity and Addiction Equity Act, and the Affordable Care Act, have expanded prevention, treatment and law enforcement efforts. And a robust national conversation also has led to more doctors and patients becoming aware of the serious risks associated with opioid pain medications. We were especially enthused to support the new voluntary opioid prescription guidelines issued by the CDC in 2016. We believe the guidelines strike a common-sense balance that will help address overprescribing without stigmatizing pain. We were also pleased to support enhanced warning labels on opioids, which the FDA announced in 2016, about the risks of taking them in combination with other medications known as benzodiazepines.

Unfortunately, the problem is expanding faster than our solutions. Much more needs to be done. This is a crisis that demands our continued attention and commitment.

Joining Forces to Overcome the Opioid Epidemic

Together, We Can Overcome Addiction

In pursuit of our mission to be a force of healing and hope for individuals, families and communities affected by addiction, the Hazelden Betty Ford Foundation has mobilized our entire organization to comprehensively confront the national opioid epidemic—and to make our addiction treatment practices and knowledge available in ways that can be used in communities and health care organizations anywhere.

In addition to public education and policy efforts, our clinical teams have developed the field’s most innovative approach to treating opioid addiction. Hazelden Publishing is leading the way in bringing our knowledge, experience and solutions to communities, professionals and health care providers.