On the face of it, it doesn’t seem to make much sense. Over the past few years, the number of opioid painkiller prescriptions dispensed in the United States has decreased significantly. But at the same time, the number of opioid-related overdose deaths has continued to climb at a dramatic rate.

How Bad Is the Opioid Crisis in America?

It has been called the “worst public health crisis in American history”, and that is not an exaggeration. For the last several years, EVERY year has set an unfortunate new record for the number of drug overdose deaths.

• 2013 – 43,982
• 2014 – 47,055 (+7%)
• 2015 – 52,404 (+11%)
• 2016 – 64,070 (+22%)
• 2017 – 71,600 (est.) (+11%)

During the last five years, the total number of overdose deaths in the American has jumped by 63%! To put those numbers in perspective, the “peak” of the HIV/AIDS crisis was in 1995, when “only” 43,000 Americans lost their lives. But it is called the “opioid epidemic” for good reason. Approximately 2 out of every 3 overdose deaths involve an opioid of some type – prescription pain-relieving medications, illicit heroin, or, increasingly, powerful synthetic opioids that can kill at tiny doses. The relief of pain is supposed to Be a GOOD thing, so how did it get this bad in the first place?

How the Opioid Epidemic Began

Back in 1980, large drug manufacturers began zealously – and misleadingly – began touting their opioid painkilling products as “safe” and non-addicting”. Overly-aggressive marketing targeted healthcare providers, who began treating pain as a “sixth sense”, prescribing opioid medications like OxyContin and Vicodin unconcernedly for both short-term and long-term pain relief. Unfortunately, these claims by “Big Pharma” were inaccurate. In reality, opioids have a HIGH potential for abuse, dependence, and addiction, even when taken precisely as prescribed. And when abused, opioids are anything but safe, because one of their major side effects is respiratory depression – at high enough doses, opioids cause the body to “forget” how to breathe normally. This effect is magnified to a deadly degree when the patient uses alcohol or tranquilizers.

The Official Response to the Prescribing Problem

After years of rising ascription opioid overdose deaths, both the government and the medical community enacted new laws and guidelines as to when and how painkilling drugs should be prescribed. For example:

• In 2016, the Food and Drug Administration passed new guidelines directing that physicians should only prescribe opioid painkillers as a “last resort”, when other pain management therapies have proven to be ineffective – diet, exercise, physical therapy, massage, etc. have proven to be ineffective.
• And, when an opioid painkiller absolutely MUST be prescribed, it should always be at the lowest dosage and for the shortest duration possible. Doctors are advised to hold frequent checkups to ensure the patient’s safety.
• Significantly, opioid drugs are no longer recommended for long-term, chronic pain. This is virtually the polar opposite of the policies of the past, when patients could receive refill after refill almost indefinitely.
• Prescription Monitoring Programs (PMPs) were implemented to improve communication between providers and to help prevent fraudulent “doctor shopping” to obtain multiple prescriptions.
• Authorities began cracking down on rogue doctors and “pill mills” that improperly overprescribed opioid drugs.
• Drug manufacturers have worked to create abuse-deterrent formulations of their painkiller medications.
• Even pharmacies are stepping in to curb prescription opioid abuse. For example, retail giant Walmart is limiting opioid prescriptions to just seven days’ worth.

These policies are having a decidedly positive effect. Before 2010, the average growth rate of prescription opioid deaths was over 13%. Since that time, the growth rate has slowed to just under 5%.

How Prescription Opioids Lead to Heroin Abuse

But there has been an unexpected negative side effect to these efforts aimed at curbing opioid over-prescribing and misuse. As legitimate opioid prescriptions became harder to obtain, that of course drove up the price of illicit medications purchased “on the street” from dealers. Faced with the limited availability and the high price of illicit prescription drugs, desperate opioid -dependent people looked for a simpler alternative. They found it with heroin. While black market OxyContin can run as high as $80 per pill, a single dose of heroin can be purchased for under five dollars. 80% of heroin addicts say that they started out by misusing prescription opioids. And 94% say that they made the switch because prescription opioid painkillers were “far more expensive and harder to obtain.” How is this the case? Now that marijuana is enjoying an increasingly-legal status in America – both medically and recreationally – the demand for Mexican marijuana has dropped sharply. In response, some cartels are switching from growing marijuana to cultivating the opium poppy, from which most opioid drugs – including heroin – are derived. Today, the Drug Enforcement Administration reports that 93% of the heroin seized in America is of Mexican origin. Additionally, 44% of law enforcement agencies responding to a DEA survey reported that heroin is the greatest drug threat in their area. All of this has led to an alarming spike in the number of heroin-related overdose deaths in America:

• 2017: There were an estimated 15,446 overdose deaths involving heroin.
• In 2015, there were “only” 12,990.
• Even more telling, in 2012, the number of heroin overdose deaths stood at 5925.
• 2012-2017: That represents a 261% increase.

Perhaps most significant of all, the Centers for Disease Control and Prevention thinks that the number of heroin deaths is actually underreported, and that the TRUE death toll is up to 30% higher. The Rise of Synthetic Opioids

“In terms of danger level, opioids are bad, heroin is worse, and fentanyl is the worst.” ~ San Diego DEA Agent Tom Lenox

But despite the rising threat coming from south of the border, there is another threat that has overtaken heroin as the most dangerous drug in America – powerful synthetic opioids like fentanyl and its chemical analogues. Fentanyl is a completely-synthetic opioid that is up to 50 times stronger than 100% pure, laboratory-great heroin. At that potency, a dosage as small as six grains of salt can kill a full-grown man. In the past three years, the number of fatal fentanyl poisonings has mushroomed by 540%. And while heroin production requires a tremendous commitment of resources – land, manpower, time, and facilities – synthetic opioids can be manufactured in a clandestine laboratory. This profitability makes it extremely popular to illicit drug manufacturers, especially those in Asia. Of special relevance, 90% of the illicit fentanyl-type drugs in the United States were made in illegal unauthorized laboratories in China. In fact, the problem of Chinese-made fentanyl reaching America is so bad that New York Senator Chuck Schumer is calling for fentanyl to be made part of the US-China trade discussion.

“I am demanding negotiators impose real pressure on China to stop the export of fentanyl. As the scourge spreads and addiction grows, China’s authorities continued to turn a blind eye. Negotiators must not leave the table without addressing the export of fentanyl. This issue must be a major priority, because too many lives have been lost, and too many others are at stake…” says Senator Schumer.

The Role of the Internet in the Opioid Crisis

“(The Dark Web) has become such an important source of distribution for this sort of deadly drug. It has enabled distribution channels that previously didn’t exist.” ~ Kathryn Haun, Digital Currency Coordinator for the Justice Department

There is an area of the Internet known as the “Dark Web”, where illegal purchases of every type can be made anonymously. Using special identity-concealing browsers, drug-seeking individuals can freely purchase illicit substance by using virtual currencies such Bitcoin. The Dark Web now brings the opioid threat closer to home than ever before – it is now in living rooms, bedrooms, and anywhere else with a high-speed Internet connection. A quick online query on one of the top Dark Web drug marketplaces produces more than 21,000 opioid listings and over 4100 listings for fentanyl and other analogous drugs. Once ordered, the drugs can be shipped through the US Post Office or through private mail carriers. Between 2016 and 2017, the amount of illicit fentanyl confiscated by US customs and border control more than doubled. 75% of those seizures were made at international mail facilities. An ordinary first-class envelope fits enough fentanyl for 50,000 doses. But not all Chinese fentanyl arrives in America via a direct route. Much of it is first shipped through Mexico, where it is used to make counterfeit drugs that are smuggled into the United States. In June 2017, the DEA seized almost 100 pounds of illicit fentanyl from a home in San Diego County. It was the largest fentanyl bust in US history. But more importantly, this one bust, in this one location, seized enough fentanyl to kill 14 million people.

Why Synthetics Are More Dangerous Than Other Opioids

There are several reasons why fentanyl-class synthetic opioids are particularly dangerous. FIRST, they are so much more potent that legal dosages are measured in micrograms instead of milligrams. Some fentanyl analogues are up to 10,000 times stronger than morphine. SECOND, drug cartels and dealers will often improve the potency of other low-grade products by mixing in – or even substituting entirely – fentanyl. THIRD, this inclusion or substitution of fentanyl for other drugs is usually done completely without the knowledge of the user. Then, when someone takes one of these counterfeit drugs at their accustomed-to dose, they rapidly experience a potentially-deadly fentanyl overdose. FOURTH, although all opioids cause respiratory depression, fentanyl does so to a greater degree and for a longer period of time. Significantly, however, fentanyl disrupts normal breathing while at the same time producing less sedation than other opioids. Because extreme sedation is one of the warning signs of opioid overdose, a user may mistakenly think that they are still within their “safety threshold” and take even more of the drug, with fatal consequences. FIFTH, fentanyl’s effects are so powerful that it may take multiple applications of the emergency anti-overdose drug Narcan to successfully revive the victim. While there is a nationwide push to make Narcan more widely available, it’s not likely that a bystander in that situation will have multiple doses on hand. SIXTH, counterfeit drugs interfere with the timely application of Narcan. For example, fentanyl mislabeled as “Xanax” will prevent first responders from administering the antidote, since Narcan is ineffective against benzodiazepines. In a fentanyl overdose emergency, even a brief delay of just a few minutes can mean the difference between life and death.

The Bottom Line about Preventing Opioid Deaths

Finding alternatives to dangerous opioid drugs and reducing the number of prescriptions are excellent early responses to the drug crisis. Unfortunately, these measures don’t go far enough, because they are treating the symptoms – abuse, overdose, etc. – rather than the disease – addiction. While policymakers definitely need to continue addressing improper prescribing practices and continue working at stopping the flow of illicit opioids into the country, there must also be increased focus on the prevention and treatment of substance abuse as a whole. In other words, focusing on the supply without addressing the dependent disorder always pushes desperate addicts into seeking and using other substances. The underlying issue that must always be addressed is the addiction itself. The best way to do THAT is with specialized professional addiction treatment.