What Caused the Opioid Crisis?

Medical practitioners have been recommending opioid pain meds to patients for hundreds of years, but the opioid crisis only began rearing its ugly head in the late 1990s. What happened?

As it turned out, a whole host of factors set in motion a crisis that would grow to take the lives of more than 200,000 people since 1999, including actions by pharmaceutical companies, physicians, Congress, and a changing economy.

opioid pills
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Key Players in the Opioid Crisis

Who played a role in causing the opioid crisis? These are the key players. 

Pharmaceutical Companies

In the story of how prescription pain meds grew out of control, it’s hard not to begin with the very companies that made them. For decades many doctors were reluctant to prescribe prescription painkillers because they were concerned about addiction, but in the 1990s, drug makers started courting doctors through targeted and aggressive marketing campaigns in hopes that they would prescribe more painkillers to their patients.

These strategies downplayed the potentially addictive properties of opioids and other risks, in an effort to ameliorate the concerns of doctors who were jumpy about prescribing the drugs. The information they put out was (as we now know) largely misleading, and either grossly misrepresented research related to opioid addiction or ignored it entirely.

One of the biggest players in these efforts was Purdue Pharma, the maker of OxyContin. The company reportedly spent $200 million in 2001 alone to promote its prescription pain relievers. It hosted all-expenses-paid conferences, established a lucrative bonus system of sales representatives and handed out tons of branded swag, including fishing hats and plush toys. It worked. Sales for prescription painkillers quadrupled between 1999 and 2014.

In the wake of the opioid crisis, Purdue has since backed off its aggressive marketing tactics, but they weren’t the only ones employing them. Pharmaceutical companies spend billions of dollars every year to promote their various products to doctors. In fact, drug makers gave more than $8 billion to physicians and hospitals, benefiting some 630,000 medical professionals. While many doctors swear these tactics don’t sway them, research suggests otherwise.

Patients and Advocacy Groups

At the same time pharmaceutical companies were attempting to win over doctors, they were also trying to reach out to patients. The 2017 research shows that U.S. doctors consider patient expectations and preferences as key factors in whether to formally recommend pain meds.

Physicians care about what patients want, and drug makers know this. That’s why pharmaceutical companies spend billions of dollars a year on advertising their drugs on television and other popular media.

The United States and New Zealand are the only countries in the world that allow drug makers to market their products in this way, and some doctors are concerned that the advertising has had a dangerous influence on prescribing practices for all kinds of drugs (not just opioids)—so much so that the American Medical Association, one of the largest professional organizations for physicians in the United States, called for a total ban on these kinds of commercials in 2015. The group was unsuccessful.

In addition to marketing to individual patients, drug makers also developed relationships with patient advocacy groups working to raise awareness about health issues, such as challenges related to chronic pain. These organizations have lobbied lawmakers, as well as the medical community, to expand access to pain medications for patients. 

An investigation by the U.S. Senate found that these advocacy groups have received at least $8 million so far from opioid manufacturers who stood to gain from these groups’ activities. It’s not clear whether the advocacy groups promoted opioids because they received funds from the drug makers (the groups’ financial records and policies aren’t publicly available), but the relationship between these two groups is certainly noteworthy.

As all of this unfolded, the number of opioid prescriptions started to grow sharply, and along with them, deaths from opioid overdoses. It’s impossible to know to what extent these activities contributed, but one thing’s clear: If pharmaceutical companies were the ones to jump-start the crisis, they weren’t the only reasons it kept rolling.

Physicians and Medical Professionals

Drug companies’ efforts to promote and market their pain meds likely wouldn’t have gotten very far if they hadn’t won the support of doctors across the country. As physicians were hit with reassuring messages and calls from pain patients to alleviate their suffering, they began to warm to the idea of prescribing opioids. And they did so, with gusto.

The number of prescriptions for pain meds climbed year after year until they seemingly peaked with a whopping 255 million opioid prescriptions in 2012 alone—enough for every adult in the United States to have their very own bottle of pills. As more and more people became aware of the crisis, health officials urged physicians to rein in their prescribing practices and exhaust all non-opioid pain relief options (such as physical therapy or over-the-counter meds like ibuprofen) before turning to prescription painkillers.

Things have calmed a little since 2012, but prescribing rates aren’t back to where they were before the crisis. Doctors in the United States still are way more likely than medical professionals in other countries to recommend opioids, and millions of people have since developed addictions to the pain meds possibly because of it.

Opportunistic Activities and “Pill Mills”

Coinciding with a rise in legitimate prescriptions came an explosion of questionable ones. Medical centers and pharmacies known as “pill mills” set up shop around the country, offering written and filled opioid prescriptions with little to no medical supervision.

The U.S. Drug Enforcement Agency caught on to these practices fairly early in the epidemic, but when they shut one operation down, another would pop up like a game of whack-a-mole. So instead, the DEA shifted its sights to drug companies.

By law, drug makers and distributors are required to stop shipments and alert law enforcement if they see any suspicious orders coming in, such as very high quantities of pain meds or a lot in a low-population area. The DEA started cracking down on drug companies who were looking the other way, and, in turn, cut off the supply of opioids to pill mills.

But in 2016, Congress (after facing pressure from pharmaceutical companies and patient advocacy groups) passed a bill into law that made it virtually impossible for the DEA to continue these efforts. No one can say for sure how this might have affected the crisis, but it did take away a tool the DEA had been using to stop the flow of prescription painkillers into communities.

Pill mills weren’t the only illegal enterprises to sprout in the wake of the crisis. As physicians once again became cautious about prescribing opioids, now-addicted pain patients began to seek out relief with cheaper, more accessible—and far more deadly—street opioids like heroin.

Seeing an opportunity, illegal drug cartels began manufacturing illicit fentanyl, a type of opioid typically prescribed to cancer patients for “breakthrough” pain, or sporadic and intense pain that occurs even when taking other medications. The street version of the drug is often laced with other things like cocaine and has proved to be extremely dangerous. Since 2013, overdoses related to street fentanyl have skyrocketed to unprecedented levels. It’s now the single greatest cause of overdose deaths in the United States.

Medication Management

While both doctors and drug dealers are the primary sources for opioids, they aren’t the way most people who misuse pain meds get the drugs. Nearly 12 million people misuse prescription pain relievers in the United States—meaning they take them in a way that wasn’t prescribed, increasing chances of addiction and overdose. Only about 20 percent of those individuals get the meds because they were prescribed them by their doctor, and just 4 percent bought them from a drug dealer. The overwhelming majority of those who misuse opioids get them from a friend or relative, either for free (54 percent), for money (11 percent), or because they stole them (5 percent).

Prescriptions are required for opioids because taking them without medical supervision is dangerous. Take too many pills or for too long, and it can significantly increase your risks of getting addicted or dying from an overdose. 

How Lack of Treatment Plays a Role

Opioids work by manipulating the pain and pleasure centers of the brain, making them highly addictive. An estimated two million people have a substance use disorder related to pain meds, which often involves addiction. For these individuals, opioids can completely take over their lives, affecting not just their health, but also their relationships. As the brain gets used to the effects of painkillers, going without them can disrupt the entire body, resulting in withdrawal symptoms like nausea, anxiety, and tremors.

Once addicted to opioids, it can be extremely difficult to quit using them on your own. Safe and effective treatment options are available to help people overcome their opioid addictions, yet only about 18 percent of those with opioid use disorders received specialty treatment in 2016. 

One of the biggest barriers keeping people from seeking treatment is the fear of being in pain. The majority of opioid users take the drugs (including illegal versions) because they're in pain due to an injury or health condition, and some are reluctant to seek treatment because they're concerned stopping their opioid use will cause their pain to come back. Similarly, while opioid use is extremely common—more than 91 million people reported using them in 2016—many hesitate to ask for help with their opioid use because they're worried about the stigma associated with addiction.

Even when those with substance use disorders want to get treatment, many are unable to access it. Millions of adults in the United States still lack access to health insurance that cover the costs of treatment. Without it, low-income individuals often can't afford the price of the medications, clinic visits or counseling sessions. When people can afford to get help, many doctors and treatment centers refuse to adopt some of the most evidence-based strategies like medication-assisted treatment (MAT).

MAT combines the use of certain medications with behavioral therapy to treat both physical and psychological aspects of addiction. Patients who use MAT are more likely to stay in treatment compared to those who get counseling alone and are less likely to use opioids or engage in criminal activity—yet fewer than half of all privately funded treatment centers offer MAT-based programs. With so many patients failing to get the treatment they need, the number of people addicted to opioids continues to mount. 

Economic and Cultural Influences

All of these factors: marketing ploys, prescription practices, and barriers to treatment, were shaped by and in turn influenced the economic and cultural climate in the United States during the 2000s. The opioid crisis is a uniquely American phenomenon in part because of the ways the country differs from the rest of the world.

One notable difference is in how people in the United States experience pain. In one international study looking at differences in pain and happiness around the globe, more than a third of Americans reported experiencing pain “often” or “very often”—the highest in the 30 countries surveyed. Are people in the United States really in more pain than the rest of the world? Or do they simply report it more frequently? It's difficult to say. However, it should be noted that one side effect of prescription painkillers is increased sensitivity to pain, potentially contributing to both pain and opioid use in a perpetual spiral.

Another potential factor nudging the crisis along was the economy. Research shows that the use of pain meds increases during times of recession, as do substance use disorders related to them. Though the opioid crisis started prior to the Great Recession of 2008, median earnings had been stagnant and productivity slowed in various areas for decades prior. As companies move away from pension-based retirement and industries change and collapse, financial insecurity has weighed heavily on some communities, especially less educated, predominantly white areas where the opioid crisis has hit hardest. While it’s unclear what effect depressed labor force participation had on the opioid epidemic (or vice versa), the two forces appear to be very much intertwined.

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