Opioid Epidemic in United States

Abstract
Drug overdose has become the leading cause of death in the United States, and the majority of overdose fatalities involve opioids. Both legal (by doctor prescription) and illicit opioids are implicated in the current public health epidemic. The vast majority (80%) of heroin addicts started off using prescription opioids, showing that the healthcare and pharmaceutical industries are in large part culpable for fueling the crisis. Opioids do have a role to play in providing pain relief in extreme cases, but this powerful class of drugs needs to be pushed to the periphery of options available for patients in need of pain relief. Exploration of alternative options for pain relief is one of many strategies that can be used to address and mitigate the opioid epidemic. Other necessary interventions include the re-education of healthcare staff and the bringing to justice of the pharmaceutical industry.
Introduction
It is hard to believe that a pretty flower could be responsible for ruining so many lives, but in fact the opioid crisis can indirectly be traced to the story of the opium poppy. This magical plant provides one of the world’s most—in fact probably the most—effective pain reliever. The opium poppy has been used for therapeutic and recreational purposes for thousands of years, and has even led to major global wars like the Opium Wars. Since the advent of modern chemistry, scientists have been able to synthesize the compounds found in the opium plant and to develop other related compounds that can be used for pain relief. Those compounds are collectively referred to as opioids, to differentiate them from naturally derived opium. Opioids do, however, include the most notorious of all the opioids: heroin.
As many lives as heroin itself has destroyed, many more so have died from overdoses of other opioids. Unlike heroin, the opioids that are causing the recent epidemic are legal drugs. They are drugs that are prescribed each and every day by doctors around the country and around the world, without regard for the fact that opioids are narcotics. Narcotics are powerful drugs with tremendous benefits, for sure, but they are also among the most addictive substances on the planet. The story of heroin will seem a lot less sinister compared with the current opioid crisis, which involves deceit and hypocrisy. As more information surfaces about the ways pharmaceutical companies and doctors have liberally prescribed opioids, it is likely that major lawsuits and public policy initiatives will ensue along the lines of what happened with the tobacco industry. The current opioid crisis has been officially defined as a public health epidemic by major public health organizations like the National Institutes of Health and the Centers for Disease Control and Prevention. Pharmaceutical companies and the healthcare system shoulder the majority of the burden for the current crisis; drug-related overdoses are now the leading cause of death in the United States. Responding to the opioid crisis requires a multifaceted approach, and may need to follow a similar trajectory as the one used to reduce the prevalence of smoking-related illnesses. 
What Are Opioids?
Opioids refer to a class of drugs derived from the chemical compounds that were originally found in the opium poppy. Synthetic opioids include everything from illegal heroin to a slew of legal prescription medications. All opioids are effective for pain relief, although opiate compounds may be located in other prescription drugs like Immodium. Many compounds in opioids also happen to be endogenously manufactured by the human body, albeit in much lower quantities than would be consumed when taking prescription opioids (Case-Lo, 2017).
Some of the most commonly prescribed prescription opioids include codeine, Oxycodone, morphine, methadone, Vicodin (hydrocodone), fentanyl, and Demerol (Meperidine). Collectively, this class of drugs is also referred to as narcotics. Both heroin and fentanyl are frequently manufactured illegally, contributing to the opioid epidemic (CDC, 2019). Opioids are legal drugs, showing how the war on drugs is not at all effective for harm reduction. Because opioids are essential for treating severe short-term pain, they will remain legal. However, opioids cannot be used in situations in which the patient may experience chronic pain, or in situations in which the patient has a history or propensity for addiction. There are many other alternatives to opioids that can be used as part of a harm reduction strategy.
Causes of the Current Opioid Crisis
Addiction to opioids is far from a new phenomenon. Humans have consumed opioids in some form or another for millennia, but the ability to synthesize opioids has led to a proliferation of drugs in this category. Many, if not most, opioids do have some clinical benefits—most notably the alleviation of pain. The cause of the opioid crisis is not the drug itself—which remains necessary in many contexts. Rather, the cause of the current crisis can be traced to unethical practices in healthcare and pharmaceutical industry business practices.
According to the U.S. Department of Health and Human Services (2019), pharmaceutical companies need to take responsibility for creating the current opioid crisis. Especially since the 1990s, pharmaceutical companies “reassured the medical community that patients would not become addicted to opioid pain relievers and healthcare providers began to prescribe them at greater rates,” (U.S. Department of Health and Human Services, 2019, p. 1). Much in the same way that tobacco companies had knowingly lied about the dangers of tobacco use and abuse, the pharmaceutical companies have systematically avoided full disclosure about the potentially disastrous public health outcomes of the overuse of opioids. Physicians and other healthcare workers also need to shoulder some of the blame given that the addictive nature of opioids has been known for centuries.
Only recently has the culpability of major pharmaceutical companies surfaced. An Oklahoma judge ruled in 2019 that Johnson & Johnson “has blood on its hands for driving America’s opioid epidemic,” (McGreal, 2019, p. 1). Johnson & Johnson of course defers responsibility for the opioid crisis, casting blame wherever it could: including on “Mexicans, doctors, and inevitably, the victims themselves,” (McGreal, 2019, p. 1). Granted, physicians do bear some of the burden given it is their responsibility to review the science, the published papers, and all the evidence surrounding the perils of any substance they prescribe to patients. Both doctors and the pharmaceutical industry are primarily responsible for the current crisis. During the 2000s, there has been a “surge” in the “prescribing of narcotic painkillers as a long-term treatment for even minor pain,” (McGreal, 2019, p. 1). There is clearly no logic in prescribing a powerful narcotic to treat minor pain, instead of offering the patient low-cost and non-addictive alternatives. Given that prescription drugs, manufactured legally and prescribed by doctors who know better, are the leading cause of drug-related problems in the United States, the situation seriously undermines the credibility of the war on drugs. In other words, legal drugs have become the leading drug-related public health issue.
Opioid Deaths and Recent Statistics
Instances of opioid-related overdoses have risen sharply over the past two decades. As a result, the Trump administration has been forced to declare the opioid epidemic a public health emergency. The Centers for Disease Control and Prevention (CDC, 2019) show that the public health emergency started in the 1990s, when the number of prescriptions for opioids skyrocketed—directly due to the pharmaceutical companies and doctors negligently ignoring the risk for widespread addiction. After patients get addicted to their prescribed opioids, they may turn to heroin. In fact, the CDC (2019) points out that around 2010, the number of overdoses from heroin started to rise dramatically. The “third wave” of the opioid epidemic started around 2013 as large amounts of illegal fentanyl started to flood the black market. Therefore, the crisis began with negligent prescription of opioids and led progressively to both legal and illegal opioids. 
Drug overdose is now the leading cause of death in the United States, surpassing other common culprits like cancer, accidents, and heart disease (Saloner, McGinty, Beletsky, et al., 2018). Almost seventy percent of all drug overdoses are from opioids (CDC, 2019). Therefore, the extent of the crisis cannot be underestimated. According to the Human Resources and Services Administration (2019), more than 130 people per day die from opioid-related drug overdoses. These are preventable deaths.
Of those patients who have been prescribed opioids by their physicians, an astonishingly high percentage will become addicted. The National Institute on Drug Abuse (which is part of the National Institutes of Health) reports that up to thirty percent of patients will misuse the opioids that have been prescribed to them. Upwards of ten percent will seek treatment for their opioid use disorder, and between four and six percent will shift from prescription opioids to heroin (National Institute on Drug Abuse, 2019). Perhaps most remarkable are the statistics about heroin. According to the National Institute on Drug Abuse (2019), eighty percent of people who use heroin had first misused prescription opioids. It would appear that pharmaceutical companies are even more dangerous than drug dealers, particularly given their tremendous political and economic clout.
Withdrawal
One of the proximate causes of the opioid crisis is the severity of opioid-related withdrawal. The withdrawal symptoms are always uncomfortable, usually painful, and often severe. Withdrawal has exacerbated the opioid crisis because the person is much less likely to stop using the drug if the withdrawal symptoms are even worse than the original pain that precipitated their use. The severity of the withdrawal symptoms prevents many people from going off the drugs; it is much easier to take more of the drug than it is to suffer through the withdrawal.
Withdrawal symptoms vary from person to person but may include diarrhea, nausea, cramping, sweating, anxiety, and elevated heart rate lasting for several days. There are some scales healthcare workers use to determine the severity of a withdrawal experience. Ranging from mild to severe, the opioid withdrawal scale factors in issues like family and case history of addiction (Case-Lo, 2017). After all, some individuals have a genetic predisposition to opioid addiction based on a multitude of factors such as the sensitivity of the body’s endogenous opioid receptors. Even after the acute stage of withdrawal passes after several days, the person may still be addicted to the drug and withdrawal symptoms can last for months (Case-Lo, 2017). Therefore, one of the most important ways of reducing the severity of the opioid crisis is to provide patients with access to effective withdrawal relief medications and interventions. Patients will invariably need access to powerful narcotics for acute pain—pain related to major accidents or surgeries for which no other class of drugs would be suitable. In these situations, the healthcare team needs to carefully monitor the patient, regulating the pain medication dosages and gradually substituting non-opioid pain relievers to reduce the severity of the withdrawal symptoms.
How To Respond to An Overdose
One of the ways opioids act on the human body is by reducing the rates of respiration and heart rate. Therefore, too much opioid can actually slow the breathing so much it becomes what is known as respiratory depression—which ultimately leads to death as the body is not receiving enough oxygen (WHO, 2018). If a person’s breathing has slowed to a near stop, the person may have overdosed. The person may go unconscious and have no pupil dilation.
An overdose does not need to lead to another drug-related death. Almost half of all opioid users experience nonfatal overdoses (WHO, 2018). Recognizing the warning signs or risk factors for overdose will help save lives, which is why a public health campaign should focus on specific techniques for responding to an overdose. Some of the warning signs include a history of drug use, having other family members in the household also have opioids (increased availability), using prescription opioids (which can contain high doses of the drug), and combining the opioids with other substances like alcohol (WHO, 2018).
If an overdose is suspected, people in the immediate vicinity need to know how to respond in order to save the person’s life. Besides calling 911, the public also needs to know about the available overdose reversal drugs. One of those overdose reversal drugs is Narcan, which is a nasal spray. The spray contains naxolone, which blocks the effect of the opioids. Naxolone is also the main ingredient in other overdose-reversal drug interventions that can be administered intravenously or subcutaneously (WHO, 2018). Unfortunately, naxolone is not available over the counter. By the time someone finds the person, calls 911, and rushes the person to the hospital for the naxolone, it could be too late.
What Can Be Done About the Crisis
Addressing the opioid crisis requires a multifaceted approach beginning simply with awareness and education. Knowing that there are ways of managing mild to moderate pain without the use of opioids is a first and most critical step towards preventing future cases of opioid abuse. Doctors should refrain from prescribing opioids in cases where they are not deemed necessary, or when the patient clearly has other options. Also, doctors need to take into account the patient’s history with addictive behaviors or family history thereof. Providing patients with access to information about their options for pain relief may also help. Pain can be dealt with in more sustainable ways.
Second, withdrawal needs to be made easier to tolerate using novel interventions or substitute drugs that can reduce the person’s chemical dependency. For patients who already become habituated to prescription opioids, due perhaps to the pain being too severe for any other intervention, should be given access to a wide range of resources for weaning off the drug including alternative pain relief procedures. Similarly, persons who struggle with withdrawal may be given substances that help reduce the signs and symptoms to ease their way off the opioids. Counseling and other mental health interventions also need to be immediately accessible, commonplace, and at little to no cost to the patient.
In addition to educating the general public about the dangers of opioid abuse and the many other alternative methods of pain relief, it is crucial to educate healthcare professionals. Healthcare professionals should be given specialized and up-to-date training related to the right use of opioids. Such professional education could even be made legally mandatory. More funding can also be diverted towards the discovery of non-addictive alternatives for pain relief.
Another necessary response to the opioid crisis is litigation. There have already been some success stories indicating that litigation may prevent the crisis from worsening or from recurring. For example, in 2007 Purdue Pharma pled guilty to criminal charges over how its brand of prescription opioid, OxyContin, was marketed (McGreal, 2019). According to the evidence presented in the case, OxyContin “played a major role in firing up the epidemic,” (McGreal, 2019, p. 1). While doctors should also be held accountable for their role in prescribing the drugs, there is some evidence that pharmaceutical industries pushed through public policy that “led hospitals and clinics to strong-arm doctors into prescribing narcotics,” (McGreal, 2019, p. 1). No one held a gun to the doctors’ heads, though. Blaming pharmaceutical company sales reps will not work because doctors are trained to know better; they are trained in medicine, not sales reps. Physicians have a legal and ethical responsibility to nonmaleficence—doing no harm. Doing no harm means refraining from haphazard and irresponsible prescribing of narcotics. Otherwise, the healthcare system is little more than a state-sanctioned drug dealer. 
Finally, responding to the opioid crisis will also involve sensible harm reduction strategies put into effect immediately to reduce the number of overdose deaths. For example, naxolone and other overdose reversal options should be available over the counter. Naxolone could even be provided to anyone who is currently taking prescription or illicit opioids, so that friends or family members can use it to save the person’s life. The WHO (2018) recommends that any person who knows someone at risk for overdose have access to naxolone.
Conclusion
The opioid epidemic represents a failure in the American healthcare system. It is largely a preventable problem, though, and can be addressed using effective public policy. Framed in crude financial terms, the opioid crisis is unsustainable. It drains valuable resources—human and financial resources. The opioid epidemic is also a humanitarian crisis. Responding to this crisis will take time. It is not enough to ban opioids, which remain critical to pain relief. The most effective response to the opioid crisis will be to restructure the healthcare system to place greater legal responsibility upon pharmaceutical companies and healthcare institutions.
The first step in reducing the number of opioid-related deaths is to thoroughly raise awareness and improve knowledge about how to identify early warning signs of addiction, how to wean people off opioids via the use of proven interventions, and how to respond to an overdose in order to prevent death. The second step would be to thoroughly re-educate healthcare professionals. Physicians and others who are legally allowed to prescribe opioids need to take responsibility for their complicity in the crisis. Physicians and nurses need to work together to screen patients for risk factors related to propensity for addiction. Likewise, the healthcare team can decide when opioids are necessary and when alternative methods of pain relief would serve just fine.