Running Head: OPIOID ADDICTION EPIDEMIC IN AMERICA

The Opioid Addiction Epidemic in America

Sarah Armenio

HCIN 541

University of San Diego

OPIOID ADDICTION EPIDEMIC IN AMERICA 2

Abstract

Recent statistics show a year over year increase in the number of opioid-related deaths across the

United States. This paper aims to discover the causes of the opioid epidemic, its impact on

society, and what efforts are being taken to combat this public health problem. A literature

review reveals that the epidemic stems from a focus on pain management in the 1990s leading to

increased prescriptions for opioid painkillers coupled with pharmaceutical companies and

anecdotal evidence advocating that opioid prescriptions do not lead to addition. However, more

recent scientific research has shown otherwise. The current use of prescriptions opioids and

subsequent heroin use has led to significant costs on communities both economically and

socially. Health care costs are accrued for treating overdose patients, businesses have struggled

to find reliable employees, and overdose deaths and addiction have led to fragmented families

caring for the young. In response, several government programs, such as Ohio’s project DAWN

(Deaths Avoided with Naloxone), are using new tactics to combat opioid addiction with

medication assisted treatment. These tactics along with an overhaul of the treatment for addition

to ensure that all individuals receive the treatment that they needs regardless of their insurance

coverage may improve the crisis.

OPIOID ADDICTION EPIDEMIC IN AMERICA 3

A recent report from the Agency for Healthcare Research and Quality reported a dramatic

increase in the number of hospitalizations in recent years due to opioid use (Weiss et al., 2017).

The report shows opioid-related inpatient stays increased 64 percent between 2005 and 2014.

During that same time, emergency department visits nearly doubled. These increases occurred

regardless of sex and in virtually every state. In 2015 in Ohio alone, 2,590 deaths were opioid

related and accounted for 84.9% of all unintentional overdoes in the state that year (Ohio

Department of Health, 2015). By comparison, in 2003 there were only 296 opioid related deaths

in Ohio.

These alarming increases in such a relatively short time frame are indicative of a larger

problem across the United States. When a person becomes addicted to opioids, he or she is often

unable to remain or become employed. The subsequent financial and health struggles can be

harmful not only to the individual but those around them and the community that he or she

belongs to.

In the wake of these sobering statistics and trends, healthcare providers, law enforcement,

public health officials, and the government are scrambling to address the problem. Alternatives

to pain management, stricter regulations and scrutiny for prescription drugs, and initiatives to

improve access to treatment have been proposed and enacted in recent years. While the opioid

epidemic may get worse before it gets better, this paper will investigate its background, social

and economic impact, emerging trends in its management, and the federal and state programs

aimed to curb opioid use and treat addicts.

Background

Opioid are a class of drugs that interact with the opioid receptors in the body (NIDA,

2017b). They include both legally prescribed drugs such as oxycodone, hydrocodone, and
OPIOID ADDICTION EPIDEMIC IN AMERICA 4

morphine, and the illegal drug heroin. The number of prescriptions for opioids, usually

prescribed to treat pain, rose from 76 million in 1991 to 207 million in 2013 (NIDA, 2014).

However, they can often become misused or abused. To understand what caused a significant

increase in prescription opioids it is helpful to understand the history and trends of pain

management.

In 1980, in a letter published in the New England Journal of Medicine titled “Addition

Rare in Patients Treated with Narcotics,” Jane Porter and Hershel Jick described an anecdotal

review of patient records who were treated with narcotics for pain (Porter & Jick, 1980). This

single paragraph of a letter was not a scientific study and only focused on opioids used during

hospitalization with no mention of opioid prescribed for long-term use. Yet, it may have

contributed significantly to how physicians were taught to prescribe opioids. Primary care

physician instructors used this letter and other studies around opioid addiction since their

publication to reduce the stigma associated with prescription opioids (Kolodny, 2011).

This instruction was part of broader movement to change the thinking for pain

management. Indeed a research article by Portenoy and Foley published in the journal Pain in

1986 described the use of opioids to treat pain in 38 individuals with the conclusion that opioid

drugs can be used safely and effectively for long-term treatment with no risk of addiction as long

as the patient has no prior history of drug abuse (Portenoy & Foley, 1986). Furthermore,

guidelines released by the American Pain Society in 1996 encouraged providers to assess pain as

“the 5th vital sign” during encounters with patients (Morone & Weiner, 2013).

Another contributing factor to the shift in pain management may be attributed to key

marketing pushes by Purdue Pharma and other pharmaceutical companies. As the makers of the
OPIOID ADDICTION EPIDEMIC IN AMERICA 5

opioid OxyContin, Purdue Pharma created a promotional video for physicians called “ I Got My

Life Back” that sought to show that opioids for the treatment of pain was safe and could be used

long term without risk of addiction (Moghe, 2016). In hindsight, the physician training and

opioid promotions were misguided and contributed to the crisis we see today as more patients

received opioid prescriptions to treat pain than ever before.

As opioid use rose, the death toll from overdose rose as well. The number of deaths from

prescription opioids rose more than 5 fold in 15 years from 4,400 in 2000 to 22,598 in 2015

(NIDA, 2017a). With such drastic increases, physicians and law makers started to take notice.

However, stricter prescriptions or limited refills have caused many people to progress to heroin

as a substitute due to the availability and lower cost of heroin (Ohio Substance Abuse

Monitoring Network, 2008). Research shows a strong association between the use of pain

medication and subsequent heroin use, with close to 80% of reported heroin users having used

prescription opioids previous to their heroin use (Muhuri, Gfroerer, & Davies, 2013). Although

the prescription of opioids started leveling off in 2012, heroin related overdoses has been rising

since 2007 (Rudd, Seth, David, & Scholl, 2016).

Social and Economic Impact

Perhaps the most serious impact of the opioid epidemic is the loss of human life due to

overdose. Loss of a family member disrupts the family life and the use of drugs in a home can

have devastating consequences on children. Communities in areas that are especially hard hit by

the epidemic struggle with how to deal with the issue and are shocked when use of the drug

overrides even basic care of children. Caretakers have even been discovered unconscious from

opioids in a vehicle while a child sits in the back seat (Park, 2017).
OPIOID ADDICTION EPIDEMIC IN AMERICA 6

While communities struggle with the social consequences, the economic impact of the

opioid epidemic has been grave with noted costs for employers, on the economy, and for

healthcare. While Purdue Pharma’s “I Got My Life Back” argues that management of pain using

opioids allows individuals to return to work, reports from the Federal Reserve suggest otherwise.

Recent reports cite manufacturing employers having issues finding employee candidates that can

pass a drug test (Federal Reserve Bank, 2017). Other anecdotal reports from potential employers

state that employees that abuse opioids or other drugs are often unreliable, make mistakes, and

sometimes simply stop showing up for work (Cutter, 2017).

With an unemployable and addicted workforce, the cost to the economy continues to

grow but is difficult to measure. However it is estimated that the total national economic burden

is $78.5 billion, with one-third of that amount attributed to increased health care and substance

abuse treatment costs (Florence, Zhou, Lou, & Xu, 2016). A task force created to evaluate the

epidemic in Ohio estimated that the total annual cost of unintentional drug overdose in Ohio

alone was $31.9 million when accounting for health care, work loss, and quality of life costs

(Ohio Prescription Drug Abuse Task Force, 2010). Other reports from the Coalition Against

Insurance Fraud in 2007 estimate that the nonmedical use of opioid pain relievers costs insurance

companies up to $72.5 billion annually.

Emerging Trends in Management

Current treatment options for opioid abuse include substance abuse programs with

notable success using Medication Assisted Treatment (MAT) (Mattick, Breen, Kimbler, &

Davoli, 2014). MAT programs combine behavioral therapy with medication to ease withdrawal

symptom. They have shown to decrease opioid use, related overdose deaths, criminal activity

and disease transmission (Schwartz et al., 2013).

OPIOID ADDICTION EPIDEMIC IN AMERICA 7

In cases of overdose, administering naloxone reverses the effects of opioids and can save

a person’s life. Community programs to equip opioid users with naloxone and teach them how to

administer the drug in cases of overdose began in the 1990’s and are now a leading intervention

method in the prevention of overdose death (Fairbairn, Coffin, & Walley, 2017). Education for

physicians and patients on proper pain management and the risks of opioid addiction due to

prescription drugs is also starting to take hold (Hahn, 2011).

Federal or State Programs

In response to the opioid epidemic, the Federal government has held several hearings on

the issue. The Comprehensive Addiction and Recovery Act was signed into law in 2016 with the

specific goal of addressing the opioid epidemic (CARA, 2016). Provisions in the law expand

prevention and education efforts, improve access to addiction treatment including MAT and

naloxone, and provide grants to allow states to better monitor prescription drugs.

Several states have implemented programs to also curb the epidemic. In Ohio, which

ranks fifth for highest rate of drug overdose deaths in the US, guidelines have been issued for

hospitals on the appropriate and reasonable use of opioids for acute care facilities, chronic pain,

and acute pain. The guidelines instruct prescribers to first consider non-opioid therapies for the

treatment of pain and to check the state’s prescription drug monitoring program, (MacKinnon &

Penm, 2016). Additionally, Ohio has launched Project DAWN (Deaths Avoided with Naloxone)

to educate community members on overdose prevention techniques, recognizing an overdose,

and the proper use of naloxone with the goal of reducing deaths related to opioid overdose (Ohio

Department of Health, 2017).

Conclusion
OPIOID ADDICTION EPIDEMIC IN AMERICA 8

While originally hailed as an effective treatment for chronic pain, prescription opioids

have morphed into an abused substance that is the leading cause of accidental drug overdose

deaths in 2015, which is the latest year for which data is available (NIDA, 2017a). In 2015, there

were more deaths from prescription opioid pain relievers than heroin and cocaine combined. And

yet the alarming trend is that while abuse of prescription drugs is declining, other illicit opioids

are increasing in usage including heroin and fentanyl (Houry, 2017). Fentanyl is a powerful

synthetic opioid that can be illicitly manufactured and combined or sold as heroin without the

user knowing. It is fast-acting and thus it can be more difficult to reverse an overdose. Overdose

deaths from fentanyl more than doubled in one year from 2013 to 2014 (Gladden, Martinez, &

Seth, 2016).

As law enforcement and public officials have looked for an answer to this new

troublesome issue that affects the US socially and economically, some had attempted to hold

pharmaceutical companies responsible for the damage that has been caused. The State of Ohio is

suing five major pharmaceutical companies including Purdue Pharma, the makers of OxyContin

and the marketing push to increase prescriptions for opioid drugs, for their role in the opioid

epidemic (Dwyer, 2017). Education and stricter guidelines on opioid prescriptions may further

reduce the number of abusers of prescription opioids with the number of opioid doses dispensed

in Ohio dropping each year since 2012 which is when the state issued opioid prescription

guidelines to emergency departments (Ohio Department of Health, 2015). However, during that

same time heroin and fentanyl overdose deaths increased. While the correlation of the tighter

prescription drug control laws and guidelines with increased illicit opioid usage does not

implicitly imply causation, studies have shown evidence of such cause (Cicero, Ellis, Surratt, &
OPIOID ADDICTION EPIDEMIC IN AMERICA 9

Kurtz, 2014). However, other articles suggest otherwise and that no such relationship between

stricter prescription controls and increased heroin use exist (Compton, Jones, & Baldwin, 2016).

Perhaps America should look overseas for a potential alternative solution. Switzerland

dealt with a major opiate abuse problem for years dating back to the 1980s and 1990s

(Uchtenhagen, 2009). Crackdowns and tighter drug control only worsened the issue. It was not

until the early 2000s that a new approach of a heroin-assisted treatment program in which

medically supervised centers administered heroin to users while also providing support and

treatment options that the situation began to improve.

In conclusion, with the number of opioid drug overdoses on the rise in recent years, all

aspects of the situation must be evaluated if any solution is to be found. While pharmaceuticals

may have had a hand in the opioid epidemic, corrupt physicians, addicted users, and illicit drug

dealers have all shared responsibility and directing efforts to curbing any single entity has not

solved the issue. Perhaps the most important tool to combat the issue is to ensure that addicts

receive the treatment that they need and destigmatize addiction. Although there are many

avenues for treatment, those with limited or without health care insurance may find their options

for treatment limited or non-existent. Even those with insurance may find themselves forced

down a pre-determined treatment plan that views addition as a “disease” so that the treatment is

paid for. Yet many other successful treatment programs that do not consider it a disease are not

covered by health insurance and therefore must be paid out of pocket—ensuring that only the

wealthy have all treatment options available to them. To address such an opioid epidemic in

America we must not only evaluate the policies and social and economic impact, but also re-

think our health care insurance and the treatment options so that all possible solutions are

considered.
OPIOID ADDICTION EPIDEMIC IN AMERICA 10

References

Cicero, T. J., Ellis, M. S., Surratt, H. L., & Kurtz, S. P. (2014, July 1). The changing face of

heroin use in the United States: a retrospective analysis of the past 50 years. JAMA

Psychiatry 71, 821–826. Retrieved from

http://jamanetwork.com/journals/jamapsychiatry/fullarticle/1874575

Comprehensive Addiction and Recovery Act (CARA). (2016, July 22). Public Law 114-198.

Retrieved from http://www.cadca.org/comprehensive-addiction-and-recovery-act-cara

Compton, W. M., Jones, C. M., & Baldwin, G. T. (2016, January 14). Relationship between

Nonmedical Prescription-Opioid Use and Heroin Use. New England Journal of Medicine.

374, 154-163. DOI: 10.1056/NEJMra1508490 Retrieved from

http://www.nejm.org/doi/full/10.1056/NEJMra1508490#t=article

Cutter, C. (2017, July 26). The opioid crisis is creating a fresh hell for America’s employers.

Retrieved from https://www.linkedin.com/pulse/opioid-crisis-creating-fresh-hell-

americas-employers-chip-cutter?trk=v-

feed&lipi=urn%3Ali%3Apage%3Ad_flagship3_search_srp_content%3BbTTH0c5y4x86

TSIwF86t6g%3D%3D

Dwyer, C. (2017, May 31). Ohio Sues 5 Major Drug Companies for ‘Fueling Opioid Epidemic’

NPR. Retrieved from http://www.npr.org/sections/thetwo-

way/2017/05/31/530929307/ohio-sues-5-major-drug-companies-for-fueling-opioid-

epidemic

Fairbairn, N., Coffin, P. O., & Walley, A. Y., (2017, July 4). Naloxone for heroin, prescription

opioid, and illicitly made fentanyl overdoses: Challenges and innovations responding to a
OPIOID ADDICTION EPIDEMIC IN AMERICA 11

dynamic epidemic. The International Journal of Drug Policy. DOI:

http://dx.doi.org/10.1016/j.drugpo.2017.06.005

Federal Reserve Bank. (2017, July 12). Beige Book - July 12, 2017. Retrieved from

https://www.federalreserve.gov/monetarypolicy/beigebook201707.htm

Florence, C. S., Zhou, C. Luo, F., & Xu, L. (2016, October). The Economic Burden of

Prescription Opioid Overdose, Abuse, and Dependence in the United States, 2013.

Medical Care. 54(10), 901-906. DOI: 10.1097/MLR.0000000000000625

Gladden, R. M., Martinez, P., & Seth, P. (2016, August 26). Fentanyl Law Enforcement

Submissions and Increases in Synthetic Opioid–Involved Overdose Deaths — 27 States,

2013–2014. MMWR Morb Mortal Wkly Rep 65, 837–843. DOI:

http://dx.doi.org/10.15585/mmwr.mm6533a2

Hahn, K. L. (2011, March). Strategies to Prevent Opioid Misuse, Abuse, and Diversion That

May Also Reduce the Associated Costs. American Health & Drug Benefits. 4 (2), 107-

114. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4106581/

Houry, D., (2017, March 21). Testimony of Dr. Debra Houry, Centers for Disease Control and

Prevention (CDC) before the Energy and Commerce Committee, Oversight and

Investigations Subcommittee Hearing titled, Fentanyl: The Next Wave of the Opioid

Crisis. Retrieved from http://docs.house.gov/meetings/IF/IF02/20170321/105739/HHRG-

115-IF02-Wstate-HouryD-20170321.pdf

Kolodny, A. (2011, October 30). Opioids for Chronic Pain: Addition is Not Rare. Retrieved from

https://www.youtube.com/watch?v=DgyuBWN9D4w
OPIOID ADDICTION EPIDEMIC IN AMERICA 12

MacKinnon, N. J., & Penm, J. (2016, December 12). Evaluation of the Implementation of the

Ohio Emergency and Acute Care Facility Opioids and Other Controlled Substances

(OOCS) Prescribing Guidelines. Final Report to the Ohio Department of Health.

Retrieved from https://www.odh.ohio.gov/-/media/ODH/ASSETS/Files/health/injury-

prevention/Evaluation-Reports/Evaluation-of-the-ED-Guidelines_121316_for-

distribution.pdf?la=en

Mattick, R. P., Breen, C., Kimbler, J., & Davoli, M. (2014, February 4). Buprenorphine

maintenance versus placebo or methadone maintenance for opioid dependence. Cochran

Database of Systematic Revivews. Doi: 10.1002/14651858.CD002207.pub4 Retrieved

from:

http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD002207.pub4/abstract;jsessionid

=FE6217D7D6C6C6CDB71DE0DF46439E33.f04t03

Moghe, S., (2016, October 14). Opioid History: From ‘Wonder Drug’ to Abuse Epidemic. CNN.

Retrieved from http://www.cnn.com/2016/05/12/health/opioid-addiction-

history/index.html

Morone, N. E., & Weiner, D. K. (2013, November). Pain as the fifth vital sign: exposing the vital

need for pain education. Clinical Therapeutics, 35 (11), 1728-1732. Retrieved from

http://dx.doi.org/10.1016/j.clinthera.2013.10.001

Muhuri, P. K., Gfroerer, J. C., & Davies, C. (2013, August). Associations of Nonmedical Pain

Reliever Use and Initiation of Heroin Use in the United States. Center for Behavior

Health Statistics and Quality. Retrieved from

OPIOID ADDICTION EPIDEMIC IN AMERICA 13

https://www.samhsa.gov/data/sites/default/files/DR006/DR006/nonmedical-pain-reliever-

use-2013.htm

NIDA. (2014, May 14). America’s Addiction to Opioids: Heroin and Prescription Drug Abuse.

Retrieved from https://www.drugabuse.gov/about-nida/legislative-activities/testimony-

to-congress/2016/americas-addiction-to-opioids-heroin-prescription-drug-abuse

NIDA. (2017a, January). Overdose Death Rates. Retrieved from

https://www.drugabuse.gov/related-topics/trends-statistics/overdose-death-rates

NIDA. (2017b, July 6). Opioids. Retrieved from https://www.drugabuse.gov/drugs-abuse/opioids

on 2017, July 29

Ohio Department of Health. (2015). 2015 Ohio Drug Overdose Data: General Findings.

Retrieved from https://www.odh.ohio.gov/-/media/ODH/ASSETS/Files/health/injury-

prevention/2015-Overdose-Data/2015-Ohio-Drug-Overdose-Data-Report-

FINAL.pdf?la=en

Ohio Department of Health. (2017, February 6). Project DAWN (Deaths Avoided with

Naloxone). Retrieved from

http://www.odh.ohio.gov/health/vipp/drug/ProjectDAWN.aspx

Ohio Prescription Drug Abuse Task Force (2010, October 1). Final Report Task Force

Recommendations. Retrieved from

https://www.odh.ohio.gov/health/vipp/drug/~/media/1F1DD52D1CA24ADBB98551AD

588114EC.ashx
OPIOID ADDICTION EPIDEMIC IN AMERICA 14

Ohio Substance Abuse Monitoring Network. (2008, June 18). Surveillance of Drug Abuse

Trends in the State of Ohio. Retrieved from

http://mha.ohio.gov/Portals/0/assets/Learning/Drug%20Trend%20Reports/Drug%20Abus

e%20Trends%20in%20the%20State%20of%20Ohio%20June%202008%20(3).pdf

Park, A. (2017, January 24). The Story Behind the Viral Photo of an Opioid Overdose. TIME.

Retrieved from http://time.com/4634809/photo-opioid-addiction/

Porter, J., & Jick H. (1980, January 10) Addiction Rare in Patients Treated with Narcotics. New

England Journal of Medicine 30, 123 Retrieved from

http://www.nejm.org/doi/10.1056/NEJM198001103020221

Portenoy, R. K., & Foley, K. M. (1986, May). Chronic use of Opioid Analgesics in Non-

Malignant Pain: Report of 38 Cases. Pain. doi: 10.1016/0304-39

Rudd, R.A., Seth, P., David, F., & Scholl, L. (2016, December 30). Increases in Drug and

Opioid-Involved Overdose Deaths — United States, 2010–2015. CDC Morbidity and

Mortality Weekly Report 65 (50-51), 1445–1452. doi:

http://dx.doi.org/10.15585/mmwr.mm655051e1

Schwartz, R. P., Gryczynski, J., O’Grady, K. E., Sharfstein, J. M., Warren, G., Olsen, Y., …

Jaffe, J. H. (2013, March 14). Opioid agonist treatments and heroin overdose deaths in

Baltimore, Maryland, 1995-2009. American Journal of Public Health. Retrieved from

https://www.ncbi.nlm.nih.gov/pubmed/23488511

Uchtenhagen, A. (2010), Heroin-assisted treatment in Switzerland: a case study in policy change.

Addiction. 105, 29–37. doi:10.1111/j.1360-0443.2009.02741.x

OPIOID ADDICTION EPIDEMIC IN AMERICA 15

Weiss, A. J., Bailey, M. K., O’Malley, L., Barrett, M. L., Elixhauser, A., & Steiner, C. A. (2017,

June). Patient Characteristics of Opioid-Related Inpatient Stays and Emergency

Department Visits Nationally and by State, 2014. Agency for Healthcare Research and

Quality. Retrieved from https://www.hcup-us.ahrq.gov/reports/statbriefs/sb224-Patient-

Characteristics-Opioid-Hospital-Stays-ED-Visits-by-State.pdf