Along with their ability to numb pain, the opium-derived drugs known as opiates and opioids come with an outsize capacity to cause it.
For millennia, human beings have been aware of the opium poppy’s potential for good and harm. The Sumerians of Mesopotamia, the first people known to have cultivated the flower, recognized its properties as early as 3400 BCE when they named it Hul Gil, or “joy plant.” The Romans saw the poppy as a symbol of sleep – or death.
The very effects that make these drugs valuable in a therapeutic setting – their ability to reduce pain, relieve tension and create a sense of well-being – have contributed to widespread addiction. The soaring rate of deaths from overdose has visited unprecedented suffering on individuals and American society as a whole. Opioid overdose is now the leading cause of injury deaths in the U.S.
Erin Fisher, a public health educator with the City of Evanston, said, “Although Evanston has not seen the high number of opioid overdoses experienced by some other communities, emergency responders have indicated that overdoses in Evanston continue to grow on a yearly basis.” Around 84 times a year, Evanston Fire Department paramedics have been called to revive someone who has overdosed by administering naloxone, a drug that blocks or reverses the effects of opioid overdose.
What are opioids?
While “opioid” and “opiate” are often used interchangeably in common speech, there are technical differences between the two. Opiate refers to certain alkaloids that occur naturally in the opium poppy plant. Semi-synthetic and synthetic opioids are drugs that are partially or completely manmade.
Nowadays – and in this article – the term “opioid” refers to any agent that binds to opioid receptors (molecules located on the membranes of some nerve cells) and causes the brain to release larger amounts of dopamine than the body would normally produce. Dopamine triggers the brain’s pleasure receptors and blocks pain messages. This makes opioids effective at killing pain but also highly addictive.
Opioids are good at producing feelings of comfort and joy, but taken in larger amounts, they slow breathing and heart rate, eventually to the point of death.
Figures from the Centers for Disease Control and Prevention illustrate the extent of the crisis by charting the steep climb of overdose deaths from opioids. From 1999 to 2016, more than 350,000 people died from an overdose involving any opioid, including prescription and illicit opioids. In 2016, the number of overdose deaths involving opioids (including prescription opioids as well as illegal opioids like heroin and illicitly manufactured fentanyl) was five times higher than in 1999.
On average, CDC data show that 115 Americans die every day from an opioid overdose. While there were some 18,000 HIV-related deaths per year at the peak of the AIDS crisis, nationally there are 50-60,000 deaths each year from opioid overdoses.
Evanston resident Dr. Keith Sarpolis is a primary care physician who last year gave up his practice with Presence to work at the Gateway Foundation. In a presentation for Evanston’s Lighthouse Rotary Club, he discussed the opioid epidemic and brought it closer to home. From 2002 till 2015, he said, Illinois saw a 70% increase in overdose deaths.
“From 8 to 12% of people who are prescribed opioids become addicted,” Dr. Sarpolis said. The clinical term for opioid addiction or abuse is “opioid use disorder.” Dr. Sarpolis noted that addiction is a disease for which “there is a significant genetic predisposition.” One explanation for the predisposition is that the density of D2 receptor cells in the brain varies widely from one individual to another.
Most patients get their first opioids from one doctor, Dr. Sarpolis said – some from two. Some 83% of opioids are prescribed for pain.
In the first step toward addiction, opioid users develop a “tolerance” for the drugs, meaning they need more and more to get the same effects. Many patients seek to continue taking opioids for pain or to get high. But 56% of opioid users keep taking them mainly to avoid the very painful symptoms of withdrawal, the doctor said. The relapse rate for opioids is very high, he added.
The First Wave of Opioid Overdose Deaths: Prescription Drugs
The current saga and the phenomenon the Centers for Disease Control calls a “wave” of overdose deaths began in the 1990s.
Dr. John Jay Shannon, Cook County Health CEO, identified one contributor to the overdose epidemic. The ‘90s, he said, saw a strong new emphasis on patient gratification. He explained, “…There was a significant pressure on providers to treat pain in the 1980s and 1990s … .” For example, Dr. Sarpolis said, “Medicare bases payments on high patient satisfaction.”
More important is the fact that doctors, who had previously been wary of prescribing opioids because of their known addictive character, fell prey to marketing tactics that emphasized the safety of the new medicines.
In the mid-‘90s, the Sackler family, billionaire American philanthropists, developed the prescription painkiller OxyContin with their pharmaceutical company, Purdue Pharma. The main ingredient of OxyContin is oxycodone, a semi-synthetic drug twice as powerful as morphine. Purdue branded the drug as a breakthrough that would revolutionize pain management without worries of addiction.
The Food and Drug Administration handed Purdue a stamp of approval and a powerful marketing tool when they approved OxyContin in 1995. The FDA based its approval not on clinical trials but on a theory that drug users would not find OxyContin attractive because they preferred shorter-acting painkillers that deliver a quicker hit.
In fact, the likelihood of addiction to OxyContin increased because the drug, which had been promoted as lasting 12 hours, wore off much sooner. As its efficacy waned, not only did pain return but also, patients began suffering some of the agonies of withdrawal.
Purdue trained its sales force in persuading doctors that OxyContin was less addictive and less prone to abuse than competing opioids. Many doctors, having long searched for a safer way to ease their patients’ pain, succumbed to the claims. Prescriptions for OxyContin had taken off by 1996.
Experts trace the beginning of the opioid crisis to the jump in the number of prescriptions spurred by the misinformation disseminated to doctors by Purdue.
Purdue misrepresented, downplayed or hid early reports that OxyContin was being abused and was commanding the highest price of any prescription opioid on the street. In 2007, the federal government brought criminal charges against Purdue Pharma for misleading advertising that portrayed OxyContin as safer and less addictive than other opioids. The company and three executives were charged and pled guilty to criminal misdemeanor charges. They paid $734.5 million in criminal and civil fines. Later, they were sentenced to probation, while many patients who had taken OxyContin out of naiveté were locked in a prison of addiction.
Studies show, Ms. Fisher said, that the majority of abused prescription drugs are obtained from family and friends, including from the home medicine cabinet. A 2016 Illinois Youth Survey showed that 6% of Evanston Township High School students had used a prescription drug that was not prescribed for them in the previous 30 days. Some 3% of ETHS students had used a prescription painkiller like OxyContin to get high in the previous year.
The Second Wave of Opioid Overdose Deaths: Heroin
As doctors began to see the growing rate of addiction, they became less likely to prescribe opioids or to extend prescriptions. Patients already hooked on these prescription drugs had to look around for substitutes. Many turned to heroin, which is cheaper on the street than prescription drugs – and easier to get.
The CDC dates the second wave of opioid overdose deaths to 2010, when they saw rapid increases in overdose deaths involving heroin. Research shows that some 80% of current heroin users first misused opioid painkillers before switching to heroin, Ms. Fisher said. The number of overdose deaths related to heroin increased 533% between 2002 and 2016, from an estimated 2,089 in 2002 to 13,219 in 2016.
The Third Wave: Significant Increases in Overdose Deaths Involving Synthetic Opioids Such as Illicitly Manufactured Fentanyl (IMF)
The CDC dates this phase of the opioid epidemic to 2013 and a spike in overdose deaths linked to manmade opioids like fentanyl. Fentanyl is a synthetic pain reliever developed and approved for treating severe pain – typically, advanced cancer pain. It is 50 to 100 times more potent than morphine. In the U.S., most recent overdoses and deaths are linked to illegally made fentanyl 2, which is sold through illegal drug markets. It is often mixed with heroin and/or cocaine, with or without the user’s knowledge to increase its euphoric effects.
Treating Opioid Disorder
Treating opioid addiction is notoriously difficult, with relapse common. There is hope that a maintenance program centered on the drug buprenorphine can succeed. But a policy of using a drug to treat addiction is still a hard sell.
Dr. Sarpolis traces the widespread bias against addiction treatment to the passage of the Harrison Act in 1914. Earlier in the 20th century, he said, drugs had been regularly available. After the Act was passed, addiction was viewed as a criminal activity rather than a disease.
There was a push for treatment centers when many veterans came home from the Vietnam War addicted. But the momentum disappeared, while the prejudice about addiction remains. Dr. Sarpolis cited some strong evidence that treatment using buprenorphine results in a substantial drop in the number of deaths, in crimes committed by addicts to support their habit and in the acquisition of blood-borne disease.