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The Modern Opioid Epidemic in My Words

We’ve heard it — opioid epidemic — plenty of times across news broadcasts, the radio, on billboards, in newspapers, posted by peers on social media, referenced in prose, and everywhere else imaginable. But what is the opioid crisis, exactly?

The opioid crisis is the collective body of issues stemming from opioid use that American society is facing right now. It was declared a public health emergency in 2017, though I’d argue that it dates back as early as 2010. The opioid crisis is still in effect today and isn’t showing any signs of stopping.

Let’s browse the basic timeline that follows to understand what caused this epidemic.

First, Look Back to the 1900s

From the early 1900s up until the mid-1980s, opioids were regarded as scary and highly dangerous. Around the end of this period, organizations in medicine began recognizing that opioids were widely underused and chronic pain wasn’t being appropriately managed.

The World Health Organization (WHO) is the public health agency of the United Nations. In 1986, the organization declared that post-operative and cancer-related pain weren’t being treated sufficiently via the Cancer Pain Monograph.

Physicians improved overall cancer pain treatment around the world. Easy fix, right?

This “easy fix” prompted a few publications that brought light to the undertreatment of pain.

Also, opioids, at the time, were largely reserved for cancer treatment and not lifelong, chronic pain. Cancer specialists applied ideologies common in cancer treatment to respond to non-cancer chronic pain. Soon thereafter, the leading way of treating pain — the leading modality, in other words — became opioid prescriptions.

An organization known as the American Pain Society called on the medical community to recognize pain as the fifth vital sign alongside temperature, heart rate, blood pressure, and respiratory rate. In the past, physicians had largely not quantified patients’ subjective reports of pain as they had quantified the four vital signs for many decades of operation.

The American Pain Society wanted pain to be quantified just like the other four vital signs to ultimately improve the management of Americans’ pain.

Here Came Purdue and Company

Purdue Pharma is a pharmaceutical company that was one of the first — among the initial stages of the current opioid epidemic, not one of the first in general — to create an opioid formulation with extended-release function, a larger dosage of opioids (oxycodone) per tablet as compared to traditional instant-released opioid tablets, and allegedly being unable to be abused, as well as being non-addictive.

Purdue’s creation was the infamous OxyContin, which came out in 1996. Leading up to its release, however, the company’s decision-makers paid for a Godzilla-sized marketing campaign that made pharmacists, physicians, patient advocates, politicians, and other figures of importance recognize OxyContin as a safe drug.

Other companies followed this same strategy in creating name-brand formulations of opioids that had been in use for the past several decades — they weren’t anything new, though they were marketed as such.

Back to the American Pain Society

A survey I can’t seem to find that was published in the late 1990s found that some one-third of Americans were suffering from chronic pain. This made the entire domestic healthcare system place greater emphasis on pain management.

In conjunction with the American Pain Society, as well as many other organizations, the Veteran’s Health Administration hopped on board the campaign trail in 1999 to get physicians across the United States to better treat symptoms of pain.

The Drug Enforcement Agency and the Federation of State Medical Boards issued official statements in line with one another that told doctors they could immediately begin prescribing opioids more liberally without having to face the intense scrutiny they were accustomed to.

All of these factors culminated in a series of new, improved pain management standards. Their speedy implementation yielded unwanted byproducts:

  • Physicians were soon forced to provide sufficient pain control or risk getting in trouble.
  • Hospitals’ decision-makers began to believe that if they didn’t go big on opioids to adhere to these standards, they would lose tons of grant funding.
  • Pharmaceutical companies sent physicians as paid consultants around the United States to promote opioid prescribing to physicians through the ideas of opioids having high margins of safety and offering great benefits.
  • Medical trainees of all sorts were taught to start relying much more on opioids than ever before around this time.

Prescriptions Go Up, and Up, and Up

The number of opioid prescriptions, as well as the total amount of opioids consumed in general, increased substantially from at least 1999 to the mid-2010s.

The first wave of overdoses in the modern opioid crisis began in 1999 due to this increase in opioid prescriptions.

Physicians largely weren’t informing patients of the potential dangers of taking these opioids. Since patients trust doctors, they blindly accepted such opioid prescriptions for pain management.

These opioids, whether they were used by people for recreational or self-medication use, were generally safe for opioid users because they came straight from pharmacies and users confidently knew what they contained. Although they were still capable of causing opioid overdoses, at least users knew what they were getting.

2010 Rolls Around and Big Changes Are Made

Purdue Pharma’s OxyContin had been on the market for 14 years at this point.

The original form of OxyContin could readily be crushed to be snorted, readily dissolved in water for users to inject them or rectally administer them, or inhaled by smoking them on foil. More tame OxyContain users could simply chew the tablets or break them into powder before stalling them for a faster onset.

As everybody who’s consumed an “old school 80,” as they’re so endearingly referred to, will tell you, they’re super fucking easy to prepare for recreational use.

In 2010, Purdue faced outside scrutiny for the true abuse potential of OxyContin. Working with the Food and Drug Administration to get a new, less-abusable form of OxyContin on the market, Purdue replaced its original formulation — which bore “OC” on one side and the dosage in milligrams on the other — with the new one — instead of “OC,” new tablets bore “OP.”

These OPs, as many drug users call them, including me, were made with new technology. OCs could be crushed within a few seconds, whereas OPs could not be crushed into powder — only small chunks at best. Whenever water touched OPs, they gelled up and could not then be broken down further.

The only way, as we drug users have found out, to reliably defeat this time-release mechanism is through leaving OPs in some Coca-Cola or another acidic drink for a few hours, which can be made faster by stirring. Although it can only be abused orally this way, it shouldn’t be a big deal to drug users, as oxycodone as a high oral bioavailability.

Another way is known as “crisping” and consists of breaking down OPs to a fine powder through steel files or Dremel tools. Next, a heat source is introduced to the powder, usually via a microwave or toaster oven, though it’s easier to spread the powder out on top of a piece of aluminum foil and then evenly, carefully run the foil’s contents over a flame — candles work the best, in my experience.

What’s important to remember is that OPs are frustrating as all hell and turned opioid users elsewhere to find opioids to stave off withdrawal and, in the case of legitimate chronic pain sufferers, keep pain at bay.

Immediately after OPs hit the market to replace OCs, users began turning to heroin to get their fix. Used to sourcing highly-regulated opioid pills that always contained the same amounts of oxycodone and other active ingredients, people used heroin irresponsibly and began overdosing like crazy.

Statistics show that, in total, the rate of opioid overdose deaths in the United States rose by a factor of four after OPs came around. Hepatitis C transmission also spiked following OxyContin’s reformulation in 2010.

The second wave of overdoses in the modern opioid epidemic began here.

Here Comes the Decline in Opioid Prescriptions

Great! That’s great news, right — to have fewer opioids pumped into the United States by physicians, correct?

Wrong!

In terms of creating future addicts and dependent opioid users, the reduction in opioid prescriptions ultimately helped out society. However, this forced people who were only using pharmaceutically-produced opioid tablets that were diverted from people who held legitimate opioid prescriptions or from people’s own prescriptions to seek out opioids somewhere else.

This further led to opioid users turning to heroin.

Around this time — in 2013, to be specific — heroin began being adulterated en masse by fentanyl known by researchers as illicitly manufactured fentanyl (IMF).

Fentanyl is super strong. IV fentanyl is about 20 to 25 times stronger than heroin, roughly 30 times stronger than IV morphine, and about 100 times stronger than oral morphine, per Wikipedia’s handy-dandy equianalgesic chart that is my favorite for comparing opioid potencies — opioid equianalgesic calculations are helpful for both recreational and medical opioid users, by the way.

This unfortunate condition plagued the illicit heroin market in the United States and set off the third major wave of overdoses from opioids in the modern opioid crisis.

When Will Overdoses Go Back to Normal?

The current opioid overdose rate isn’t slowing down in the near future, according to official U.S. government number-crunching.

Look at things this way — the opioid epidemic got several pain patients hooked on these drugs, many of whom ended up turning to the streets just to deal with pain and avoid withdrawal symptoms. Since a lot of opioids were diverted to self-medicating or recreational users, they, too, began hitting the illicit opioid market to keep having fun, medicating themselves, stop withdrawals, or all three of these things.

These two groups of people have died off en masse. The total population of these two types of people — those directly affected by the opioid crisis — throughout the United States will continue to shrink. Eventually, this class of opioid users will collectively end their involvement in the game through death, long-term incarceration, or ultimately quitting opioid use.

Only then will the domestic overdose rate return to a relatively normal level.

Here’s Another Potential Form of Fixing This Issue

Another way of reducing this overdose rate is to regulate the opioid market so that opioid users know what they’re getting. If they want to purchase heroin, they’ll always get heroin with absolutely no traces of fentanyl. People who use prescription opioids won’t have to face the risk of getting duped in terms of receiving counterfeit opioid tablets filled with fentanyl.

I think this solution is at least halfway reasonable. I couldn’t even begin to fool myself into thinking that the United States government would legalize and regulate opioids, even just for those who have been suffering from opioid use disorder for a long time and proven unable to see long-term positive outcomes through traditional forms of addiction treatment like buprenorphine or methadone substitution programs — at least not anytime soon.

Just because it’s not on our doorstep doesn’t mean we shouldn’t go out and get it (holy shit, a triple negative).

By Daniel Garrett

I'm a self-employed writer, long-term drug user, and resident of rural Tennessee. Find me on Twitter at @DanielGarrettHR or email me at danpgarr@ut.utm.edu.

4 replies on “The Modern Opioid Epidemic in My Words”

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