The New Painkiller Epidemic

On average, 78 people a day die from heroin or painkiller overdoses in the USA. The two belong to a class of drugs known as opioids or opiates, and right now, the USA is in the midst of an opioid epidemic. In 2014, heroin and painkiller overdoses were responsible for 28,647 deaths. These numbers are comparable to HIV related deaths during the AIDS epidemic of the late 1980s and 1990s. There is no getting around the problem.

Opioids/opiates are a class of drugs that bind to opioid receptors in the brain and throughout the body. Opiates are drugs derived from the opium poppy plant, and opioids are drugs synthetically created to produce the same effect. The effect of drugs attaching to opioid receptors is simple; it dulls a person’s perception of pain. However, because these receptors also play a role in the brain’s pleasure system, they can produce an additional euphoric effect.

Back in 2000, Congress declared the upcoming decade to be the “Decade of Pain Control and Research,” opening new paths of funding for research on chronic pain. However, by 2014, deaths from heroin overdoses in the USA had increased six-fold. In a short time, our quest to better treat chronic pain went horribly wrong as overprescription combined with rural economic disaster to create a crisis.

Until roughly 30 years ago, chronic pain was largely considered something that patients, especially older patients, simply had to endure. Both doctors and patients saw pain as a part of aging and of life, albeit a rather unfortunate part. Opioids, most notably morphine, were occasionally used as pain medicine, but only in the most extreme circumstances. War veterans with amputated limbs and cancer patients in their last months of life received short doses of narcotics. The circumstances, for these patients, were considered dire enough to warrant the risk of addiction. Arthritis patients, or those complaining of back pain, were not considered. Doctors thought that risk of addiction in those cases was simply too high.  

But in the 1980s, both the public and doctors’ thinking began to change. Doctors began to argue in medical journals that all forms of chronic pain should be treated more aggressively, and that opioids were not addictive when prescribed for pain. Because doctors began to offer solutions, patients grew less tolerant of enduring their chronic pain. The change in thinking continued through the 1990s as both doctors and patients became more and more eager to search for ways to relieve chronic pain symptoms.

Drug companies were not only quick to capitalize on the excitement — they actively helped to create it. Pharmaceutical companies funded non-profits, like the American Academy of Pain Management and the American Pain Society which, in turn, published studies on eliminating chronic pain through opioid painkillers. In order to incentivize prescriptions for their specific opioid painkillers, pharmaceutical companies actively marketed towards physicians and pharmacists. In 1996, Purdue Pharma sent thousands of physicians and pharmacists on all-expenses-paid junkets to resorts across the southwestern United States to learn all about their opioid pain medicine: OxyContin. According to US Government Accounting Office (GAO) reports, Purdue Pharma distributed promotional material to doctors during this trip, including branded OxyContin fishing hats, stuffed plush toys, and even a CD titled "Swing in the Right Direction with OxyContin."

And it worked. The same US GAO reports found that by 2002, doctors were prescribing 10 times more OxyContin than in 1997. The sales of that single drug alone made up 80 to 90% of Purdue’s revenues. In 2007, Purdue Pharma pled guilty in federal court to misleading the public about the risk of addiction to their drug and paid $634.5 million in fines.

The outlandish marketing practices used for OxyContin have somewhat died down since then. Companies are no longer allowed to market so intensely and directly to doctors. However, the practice continues indirectly, and the effects from the original marketing campaigns are still being felt. Despite our best efforts, pharmaceutical companies still heavily incentivize doctors to overprescribe what once were considered highly dangerous drugs.

One of the most confusing things about the opioid epidemic is how easily it could have potentially been avoided. It is not unreasonable for patients to ask and expect doctors to help alleviate their chronic pain. Chronic pain can be debilitating and severely depress your quality of life. What is unreasonable is expecting highly addictive drugs to treat pain without addicting patients. 

Pharmaceutical companies worked to advance the idea that narcotics were the only answer to chronic pain. They aren’t. Other softer and less addictive methods exist, ranging from massage to prescription of less physically addictive drugs. Some experts argue that one of those drugs could be medical marijuana, but federal policies have largely blocked research. A study from researchers at Washington University in St. Louis, published in the journal Drug and Alcohol Dependence, found that even the NFL prefers players to treat pain with opioids over alternative methods. Health insurance companies often refuse to cover softer methods, such as massage or acupuncture. Right now, the United States relies on prescribing opioids as the only way to deal with pain, due to a lack of research towards exploring alternative methods. Despite the claims that some pharmaceutical companies and doctors make, significant numbers of people find themselves addicted to opioids when following the current treatment plan. And when the prescription pills run out, addicts take to the streets to find a cheaper substitute: heroin.

Heroin usage has spiked among young people in both rural and suburban areas in the past five years. This is partly due to the prescription problem. But there are other factors at play. The Great Recession drained many suburban and rural areas of their populations and their resources. There are fewer people, fewer jobs, fewer movie theaters and small shops than there used to be. But the people who live there, especially the young people, are still energized. Youths in rural areas explain that they began smoking heroin as a way to alleviate boredom. They complain that there is nothing engaging for them to do — no jobs, no transportation, nothing going on. Boredom can feel oppressive and even lead to chronic boredom. The need for an escape from that boredom can be overwhelming. A bag of heroin, enough for a weekend’s worth of use, goes for about $20 - $40. It’s not an expensive escape.

Painkiller overprescription has collided forcefully with recent economic downturn. Overprescription made narcotics like OxyContin widely available. As health experts and people in the field of medicine began to realize the problems this had created, the Great Recession hit and tightened everyone’s purse strings. Many people could no longer afford the drugs they had unwittingly become physically dependent on and turned to heroin to avoid withdrawal. Others, who had never been able to afford costly prescriptions but still felt the pain of unemployment and ennui, chose to alleviate their boredom with a powerful heroin high. The result is an epidemic that stretches across the country and across class divides.