For much of the last decade, the United States has been in the grips of an opioid epidemic. Rather than improving, the crisis is steadily growing worse.
Opioids are a class of drugs that interact with opioid receptors to relieve pain and produce pleasurable effects. These include heroin, fentanyl, and prescription pain relivers such as oxycodone, hydrocodone, and codeine.
The earliest government report on 2016 drug overdose deaths indicates that roughly 64,000 people died from drug overdose in the United States last year, more than a 22% increase over 2015’s record numbers.
In just three years, overdose deaths involving synthetic opioids, particularly fentanyl, have risen from 3000 to over 20,000. Drug overdoses are the leading cause of death for Americans under 50, and the drug epidemic is killing people at a faster rate than the HIV epidemic at its peak.
In fact, the opioid epidemic has even negatively impacted Americans’ life expectancy.
There’s no denying that we have a true drug crisis on our hands, one that urgently needs to be addressed. But who is to blame for the United States’ rapidly mounting opioid crisis?
In partnership with SurveyMonkey, Fortune surveyed the public on their views of the opioid crisis. Of the 3,645 adults surveyed in May, 29% blamed users for the opioid epidemic. 19% blamed doctors, while 15% said pharmaceutical companies were responsible.
These poll results are cause for concern: Blaming the addicts themselves is a simplistic response that will do nothing to combat this public health crisis.
How Opioid Addiction Begins
In many cases, opioid addictions begin innocently. Someone is injured, and a doctor prescribes pain medications, following the directions of the drug manufacturers.
The individual initially takes the pills as prescribed, coming to rely on the pain relief and enjoy the feelings of contentment and relaxation produced by the opioids. Physical dependence can form within days, and tolerance develops over a period of weeks.
Once the highly addictive opioids no longer produce the same effect, patients may increase their dosage. Over time, the pills may entirely fail to produce the effect the user craves. At this point, many turn to heroin, which is more potent, less expensive, and often easier to obtain.
According to NIDA, in three recent studies of young people who inject heroin, nearly half reported that their addiction began with prescription pain medications.
Because they are prescribed so frequently, opioids are also easily accessible for teenagers or young people who raid their parents’ medicine cabinets or casually begin using prescription pills at parties.
The highly addictive nature of opioids means that “casual” use is never really casual, and a more serious problem can rapidly develop.
The Beginnings of The Opioid Epidemic
To understand why we can’t simply blame users for the opioid crisis, it’s helpful to understand how the epidemic got started.
In the 1990’s, doctors sought to address the burden of chronic pain experienced by many patients. “Big pharma,” or the pharmaceutical companies, saw an opportunity to capitalize. Companies marketed prescription opioids as effective and safe, downplaying the risks associated with these drugs.
Purdue Pharma, the makers of OxyContin, for instance, were forced to pay over $600 million in fines after pleading guilty to charges that they “misled regulators, doctors, and patients about the drug’s risk of addiction and its potential to be abused.” Other pharmaceutical companies are facing similar lawsuits.
Doctors began prescribing large quantities of opioids, partly as a result of the push from pharmaceutical companies. Doctors were also under pressure from government agencies, medical associations, and advocacy groups to manage pain more effectively, in addition to pressure to see more patients at a faster rate.
Instead of spending time and effort to treat complex pain problems, doctors could simply prescribe opioids, so pain prescriptions skyrocketed. Currently, approximately 80% of the global opioid supply is consumed in the United States.
Are Doctors to Blame?
Some doctors over-prescribed opioids, writing prescriptions for weeks’ worth of pills when a few days would have sufficed.
On some occasions, like wisdom tooth removal, doctors prescribed (and sometimes continue to prescribe) opioids when ibuprofen would suffice. Doctors wanted to prevent patients from returning with complaints that they hadn’t been prescribed enough medication.
Other doctors had malicious intentions, opening “pill mills” to generate massive profits. At these pill mills, patients could be prescribed opioids with little to no scrutiny, often paying in cash.
Is Big Pharma to Blame?
As mentioned above, pharmaceutical companies have been blamed for minimizing the risks associated with opioid use in order to maximize profits.
Senator Claire McCaskill, a Missouri senator, is investigating the business practices of the manufacturers of America’s top-five prescription opioids. In the investigation’s first report, Insys Therapeutics was found to have “systematically manipulated” authorization for its fentanyl drug Subsys.
The report includes excerpts from an audio tape that reveal a sales representative from Insys Therapeutics misrepresenting information about Subsys in order to obtain authorization for the drug.
McCaskill cited evidence that Insys had “aggressively pressured its employees and the entire medical system to increase the use of a fentanyl product during a national epidemic that was taking the lives of tens of thousands of Americans a year in order to make more money – it’s hard to imagine anything more despicable.”
Ohio’s Attorney General Mike DeWine has filed a lawsuit against pharmaceutical companies including Johnson & Johnson and Purdue Pharma. The lawsuit alleges that these companies spend millions on marketing campaigns designed to “trivialize the risks of opioids while overstating the benefits of using them for chronic pain.”
The lawsuit further accuses these pharmaceutical companies of lobbying doctors to influence their opinions about opioid safety, “borrowing a page from Big Tobacco.”
There is some evidence that big pharma has knowingly misrepresented information about opioids in order to gain profit. Purdue Pharma, for instance, was found to have marketed OxyContin as relieving pain for 12 hours, although the company was aware that the effects did not last this long. As a result, some users experienced withdrawal and became addicted.
Purdue Pharma has also been accused of knowing that their drugs were being funneled to the black market and doing nothing to stop this illegal activity.
Like Big Tobacco before them, pharmaceutical companies have downplayed the risks of their prescription opioids (and overstated the benefits) for the sake of generating profit.
Heroin and Street Opioids
Of course, prescription pain pills are not the only drugs involved in the opioid crisis. Heroin and other illegally manufactured opioids have dramatically exacerbated the problem.
Fentanyl, for instance, is a synthetic opioid that is 50 times more powerful than heroin. It can be prescribed, but it can also be cheaply manufactured. For this reason, fentanyl is often illegally manufactured and sold as heroin or used to make counterfeit prescription pills.
As users lose access to prescription pills or begin craving a stronger high, many turn to illicit drugs like heroin or illegally manufactured fentanyl. A 2014 study in JAMA Psychiatry reported that 75% of heroin users in treatment started with prescription pain medication.
Some opioid addicts, in an attempt to purchase heroin or prescription medication, unknowingly buy drugs laced with fentanyl. Not realizing that these drugs are far more potent than what they normally consume, they often fatally overdose.
In addition, attempts to crack down on illegal prescription of pain pills have only led to increased use of street opioids like heroin.
In Florida, for example, major pill mills were shut down beginning in 2010. From 2010-2015, deaths from oxycodone dropped by 69%. At the same time, heroin deaths more than doubled in 2014 alone.
It’s difficult to pinpoint one party to shoulder the blame for America’s opioid crisis.
In the ‘90s, drug manufacturers, medical associations, and government agencies pointed to an “untreated pain epidemic” in the United States. Patients paying large insurance premiums came to believe in the right to be pain free.
And pharmaceutical companies, seeking to capitalize, introduced highly addictive prescription pain medications.
In an effort to increase profits, the pharmaceutical companies overstated the benefits of these opioids while downplaying the risks. Looking to treat patients quickly and easily, and responding to pressure from Big Pharma, doctors overprescribed opioids to their patients.
Money from pharmaceutical lobbyists keeps Congress on the side of pharmaceutical companies, and drug companies can buy access (for up to $35,000) to invite-only meetings with officials from the United States Food and Drug Administration (FDA).
Drug cartels have pushed cheap, easy to obtain heroin and fentanyl into the United States, providing a powerful and inexpensive alternative to prescription pain pills.
Ultimately, the opioid crisis stems from greed, and from a focus on profits rather than health. But regardless of who’s responsible, it’s clear that the United States must take bold and immediate action to address this deadly epidemic.