Documenti di Didattica
Documenti di Professioni
Documenti di Cultura
Sarah Armenio
HCIN 541
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
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
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
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
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
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
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
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
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)
and the proper use of naloxone with the goal of reducing deaths related to opioid overdose (Ohio
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
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
http://jamanetwork.com/journals/jamapsychiatry/fullarticle/1874575
Comprehensive Addiction and Recovery Act (CARA). (2016, July 22). Public Law 114-198.
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.
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.
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’
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
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.
Gladden, R. M., Martinez, P., & Seth, P. (2016, August 26). Fentanyl Law Enforcement
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-
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
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
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
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.
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
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.
to-congress/2016/americas-addiction-to-opioids-heroin-prescription-drug-abuse
https://www.drugabuse.gov/related-topics/trends-statistics/overdose-death-rates
on 2017, July 29
Ohio Department of Health. (2015). 2015 Ohio Drug Overdose Data: General Findings.
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
http://www.odh.ohio.gov/health/vipp/drug/ProjectDAWN.aspx
Ohio Prescription Drug Abuse Task Force (2010, October 1). Final Report Task Force
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
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.
Porter, J., & Jick H. (1980, January 10) Addiction Rare in Patients Treated with Narcotics. New
http://www.nejm.org/doi/10.1056/NEJM198001103020221
Portenoy, R. K., & Foley, K. M. (1986, May). Chronic use of Opioid Analgesics in Non-
Rudd, R.A., Seth, P., David, F., & Scholl, L. (2016, December 30). Increases in Drug and
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
https://www.ncbi.nlm.nih.gov/pubmed/23488511
Weiss, A. J., Bailey, M. K., O’Malley, L., Barrett, M. L., Elixhauser, A., & Steiner, C. A. (2017,
Department Visits Nationally and by State, 2014. Agency for Healthcare Research and
Characteristics-Opioid-Hospital-Stays-ED-Visits-by-State.pdf