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Public Affairs. "What Is the U.S. Opioid Epidemic?" HHS.gov. Accessed May 02, 2019. https://www.hhs.gov/opioids/about-the-epidemic/index.html.

Dasgupta, Nabarun et al. “Opioid Crisis: No Easy Fix to Its Social and Economic Determinants.” American journal of public health vol. 108,2 (2018): 182-186. doi:10.2105/AJPH.2017.304187

Hari, Johann. TED. June 2015. Accessed May 02, 2019. https://www.ted.com/talks/johann_hari_everything_you_think_you_know_about_addiction_is_wrong/transcript.

Rogers, Kara. "The U.S. Opioid Epidemic." Encyclopædia Britannica. Accessed May 02, 2019. https://www.britannica.com/story/the-us-opioid-epidemic.

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Most people think of addiction only as a chemical reaction of the body that creates a dependence on certain substances. Although there is some truth to this, there are other emotional factors related to addiction.

Johann Hari traveled around the world talking to different people and scholars about drugs and addiction and found evidence that showed the psychological and emotional causes of addiction. He found a rat study made by a university professor in Vancouver that analyzed the consumption of "drug water" in different environments. In one cage, there was one rat with no entertainment, and in this case the rat always chose the drug water over the regular water. Then, in another cage he created a "rat paradise" with many rat friends, tunnels, and cheese. In the second cage, not only did rats not choose the drug water over the regular water they actually stopped consuming the drug water. This proved that addictions are a way of humans to fill a void caused by loneliness and a lack of a support system.

"Human beings have a natural and innate need to bond, and when we're happy and healthy, we'll bond and connect with each other, but if you can't do that, because you're traumatized or isolated or beaten down by life, you will bond with something that will give you some sense of relief. Now, that might be gambling, that might be pornography, that might be cocaine, that might be cannabis, but you will bond and connect with something because that's our nature. That's what we want as human beings."

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Everything you think you know about addiction is wrong

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What really causes addiction -- to everything from cocaine to smart-phones? And how can we overcome it? Johann Hari has seen our current methods fail firsthand, as he has watched loved ones struggle to manage their addictions. He started to wonder why we treat addicts the way we do -- and if there might be a better way. As he shares in this deeply personal talk, his questions took him around the world, and unearthed some surprising and hopeful ways of thinking about an age-old problem.

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Social and economic determinants of opioid crisis

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Social and economic determinants of opioid crisis

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"The accepted wisdom about the US overdose crisis singles out prescribing as the causative vector. Although drug supply is a key factor, we posit that the crisis is fundamentally fueled by economic and social upheaval, its etiology closely linked to the role of opioids as a refuge from physical and psychological trauma, concentrated disadvantage, isolation, and hopelessness".

In order to fix the opioid crisis, solutions need to focus on real root causes and not only the prescriptions problem. Rates of drug use have not decreased as much as prescriptions, so there are greater issues that cause addiction.

"One powerful line of structural analysis focuses on “diseases of despair”[...] The trend is especially pronounced among middle-aged Whites without a college degree, who are now dying earlier on average than did their parents"

There is a vicious cycle of using drugs and then being introduced in an environment that makes people more prone to use them: "Having a public record because of a drug conviction limits one’s ability to obtain meaningful employment, reinforcing the penury that drove problematic drug use in the first place"

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Abstract

The accepted wisdom about the US overdose crisis singles out prescribing as the causative vector. Although drug supply is a key factor, we posit that the crisis is fundamentally fueled by economic and social upheaval, its etiology closely linked to the role of opioids as a refuge from physical and psychological trauma, concentrated disadvantage, isolation, and hopelessness.

Overreliance on opioid medications is emblematic of a health care system that incentivizes quick, simplistic answers to complex physical and mental health needs. In an analogous way, simplistic measures to cut access to opioids offer illusory solutions to this multidimensional societal challenge.

We trace the crisis' trajectory through the intertwined use of opioid analgesics, heroin, and fentanyl analogs, and we urge engaging the structural determinants lens to address this formidable public health emergency. A broad focus on suffering should guide both patient- and community-level interventions.

THREE PHASES OF AN INTERTWINED EPIDEMIC

The roots of the opioid crisis are deeper than popular narrative suggests.4,5 In 1980, acute pain was so frequently treated with opioids that propoxyphene was the second-most dispensed drug in the United States.⁶ The Carter White House stated, "Diversion, misuse, and abuse of legal drugs may be involved in as many as seven out of ten reports of drug-related injury or death."⁷(p301) A decade later, US medicine was shaken by revelations of undertreated chronic pain, motivating normative practice and policy shifts.⁸ Previously, chronic pain was managed largely with cognitive behavioral therapy, even hypnosis.

An Institute of Medicine report⁹ attributed the rise in chronic pain prevalence during the 1990s to the following:

1. greater patient expectations for pain relief,

2. musculoskeletal disorders of an aging population,

3. increased survivorship after injury and cancer, and

4. increasing frequency and complexity of surgery.

As insurers limited coverage of behavioral pain therapy, biopharmaceutical manufacturers sensed an opportunity. Pharmaceutical innovation propagated extended-release formulations, transdermal patches, nasal sprays, and oral dissolving strips. Medical device manufacturers drove a proliferation of novel pain-modulating implants. By 2000, chronic pain was big business. Withdrawals from the market of popular nonopioid analgesics because of cardiovascular risk and acetaminophen toxicity raised concerns about nonopioid alternatives.¹⁰ Short lived but indelible, some pharmaceutical marketing improperly minimized addiction potential (OxyContin)¹¹ and promoted off-label use (Actiq),¹² later giving rise to physician kickback schemes (Subsys),¹³ lucrative speaking fees,¹⁴ and lobbying.¹⁵ In addition, a small proportion of physicians were unscrupulous, doling out opioids without adequate regard for medical need.16,17 These factors are widely believed to have caused the steady rise in opioid analgesic consumption over the past three decades, while rates of overdose and addiction increased in tandem.

Around 2010, the second phase started, marked by concern over intertwining opioid analgesic and heroin use.¹⁸ After remaining relatively stable for years, heroin overdose deaths spiked, tripling between 2010 and 2015.¹⁹ The vector model attributes this transformation to an expanded pool of susceptible individuals: with rising dependency and tolerance, some people who used prescription opioids transitioned to a more potent and cheaper alternative.²⁰ This phase is contemporaneous with the reformulation of OxyContin that made it difficult to crush, although this reformulation's contribution to the increase in heroin use is contested.²¹ More broadly during this time, clinicians and policymakers widely reassessed the effectiveness and safety of outpatient use of opioid analgesics.²²

The third phase began in late 2013 and continues today.²³ Increasingly efficient global supply chains and a sharp intensification in interdiction efforts created the conditions for the emergence of potent and less bulky products, for example, illicitly manufactured fentanyl and its analogs,²⁴ which are increasingly present in counterfeit pills and heroin.²⁵ Between 2013 and 2016, deaths attributed to fentanyl analogs spiked by a shocking 540% nationally,²⁶ with pronounced regional increases.19,25 The rapid acceleration of the crisis has led to its designation as a national public health emergency. Contradicting the singular blame on health care as the gateway to addiction, individuals entering drug treatment are now more likely to report having started opioid use with heroin, not a specific prescription analgesic.²⁷

In the vector model, the blame for this trajectory of opioid analgesic to heroin to synthetic opioid use rests with the drugs themselves and those who make them available. Although increased availability of prescription opioids fueled the overdose crisis, we have not adequately explored the source of the demand for these medicines.

ROOT CAUSES

The vector argument must grapple with contradictory data. Prescription opioid overdose death rates have not yet dropped following declining opioid prescribing: the number of outpatient opioid analgesic prescriptions dropped 13% nationally between 2012 and 2015²⁸ (with sharper regional declines). Yet, the national overdose death rate surged 38% during those years.²⁹ Overdose deaths attributable to prescription opioids have not decreased proportionally to dispensing. Although there is a strong historic linear association between dispensed volume and overdose nationally,² these associations are less pronounced at the county level.³⁰ Alternative explanations include misclassification of synthetic opioid deaths,³¹ evolving autopsy protocols, time lag effects,³² and unused medication.

The "reversal of fortunes"37,39 in life expectancy saw rapid diffusion, going from largely limited to Appalachia and the Southwest in 2000 to nationwide by 2015.³⁴ The unprecedented 20-year difference in life expectancy between the healthiest and least healthy counties is largely explained by socioeconomic factors correlated with race/ethnicity, behavioral and metabolic risk, and health care access.⁴⁰ These indicators are the most recent evidence of a long-term process of decline: a multidecade rise in income inequality and economic shocks stemming from deindustrialization and social safety net cuts. The 2008 financial crisis along with austerity measures and other neoliberal policies have further eroded physical and mental well-being.⁴¹

Poverty and substance use problems operate synergistically, at the extreme reinforced by psychiatric disorders and unstable housing. The most lucrative employment in poorer communities is dominated by manufacturing and service jobs with elevated physical hazards, including military service. When sustained over years, on-the-job injuries can give rise to chronically painful conditions, potentially resulting in a downward spiral of disability and poverty. Although opioid analgesics may allow those with otherwise debilitating injuries to maintain employment, individuals in manual labor occupations appear to be at increased risk for nonmedical use.⁴² In much of the country, the counties with the lowest levels of social capital have the highest overdose rates.⁴³ The interplay between social and genetic factors, too, is being elucidated. Individuals living in low socioeconomic neighborhoods were more likely to develop chronic pain after car crashes, a process mediated by stress response genes.⁴⁴ Interactions between environment and genetic polymorphisms may in part explain substance use early in life.⁴⁵

In recasting pain as a broader condition that includes economic and social disadvantage, we urge an alternative explanation for the rising demand for opioids. It has been observed that people somaticize social disasters into physical pain. Subjective economic hardship was associated with new onset low back pain following the Great East Japan Earthquake.⁴⁸ Intensifying substance use may be a normal societal response to mass traumatic events, especially when experienced by people in lower socioeconomic strata. Increased alcohol use and binge drinking were noted after Hurricanes Katrina and Rita, with the greatest compensatory drinking among those with lower lifetime income trajectories.⁴⁹ Women experiencing work stressors after September 11, 2001, were more likely to have increased alcohol use.⁵⁰ Longitudinal housing relocation studies suggest that drug use improves when people move to neighborhoods with less economic disadvantage.⁵¹ Adverse childhood experiences have been strongly linked to subsequent substance use; likewise, childhood trauma, is associated with increased opioid use years later.⁵² People who use heroin in a deindustrialized steel production area of Pennsylvania cited economic hardship, social isolation, and hopelessness as reasons for drug use, explicitly calling for jobs and community reinvestment to stem overdoses.⁵³ Yet, some communities' protective family⁵⁴ and social structures generate resilience that mitigates negative impacts from the collision of economic hardship, substance use, and depression.⁵⁵

Collectively, these observations challenge us to expand our conceptualizations of the opioid crisis beyond the vector model. A seminal National Academy of Sciences report provides this summary:

overprescribing was not the sole cause of the problem. While increased opioid prescribing for chronic pain has been a vector of the opioid epidemic, researchers agree that such structural factors as lack of economic opportunity, poor working conditions, and eroded social capital in depressed communities, accompanied by hopelessness and despair, are root causes of the misuse of opioids and other substances.⁵⁶(p1-9)

TO TURN THE TIDE, FOCUS ON SUFFERING

The observation that Canada and the United States have the highest per capita opioid analgesic consumption is central to the belief that these medicines are overprescribed, leading to the unrealistic expectation that curtailing dispensing will automatically reduce overdose. In practice, overprescribing is an amalgamation of prescribing behaviors encompassing starting dose, number of units in a prescription, dosing schedules, potency, and other factors. A rational approach would treat these as parallel but distinct issues. Yet, the legislative and clinical reaction has included efforts to bring dosage below arbitrary targets or abandon patients who do not conform to clinically arbitrary expectations.³⁰

This is not merely a story about disadvantage (in income, race, place, etc.). On the basis of epidemiological studies, structural advantages in health care access may have contributed to increased opioid prescribing⁶¹ and availability⁶² among White patients. However, reverse associations were observed in controlled clinic-based experiments in which Black patients ended up receiving more opioids, possibly mediated through interactions with patient assertiveness,⁶³ physician gender, and cognitive load.⁶⁴ Regardless, the experience of many seeking health care to manage long-term pain and substance use disorders is tinged with racial undertones. Diez Roux warns:

We should guard against the unintended consequence that the focus on the increase in death rates in some Whites (significant as they are) detract attention from the persistent health inequities by race and social class, which are so large that they dwarf the size of what is a very troublesome increase in some Whites.⁶⁵(p1566)

As with previous drug crises and the HIV epidemic, root causes are social and structural and are intertwined with genetic, behavioral, and individual factors. It is our duty to lend credence to these root causes and to advocate social change.

ACKNOWLEDGMENTS

L. Beletsky acknowledges support from National Institutes of Health (NIH)/National Institute on Drug Abuse (NIDA) grants R01DA039073 and R37DA019829. D. Ciccarone acknowledges support from NIH/NIDA grant DA037820.

N. Dasgupta is a part-time employee of the RADARS System, which had no involvement in this commentary. The RADARS System is the property of Denver Health and Hospital Authority, a political subdivision of the State of Colorado. Many manufacturers of controlled substances (including prescription opioids or stimulants) as well as federal government agencies subscribe to the RADARS System. Subscribers receive information, but do not participate in developing the System, data collection, or analysis of the data. They do not have access to the raw data. Employees are prohibited from personal financial relationships with any biopharmaceutical company.

The authors thank the six peer reviewers for their insightful comments, which helped shape the final version of the commentary.

REFERENCES

32. Alexandridis AA, McCort A, Ringwalt CL et al. A statewide evaluation of seven strategies to reduce opioid overdose in North Carolina. Inj Prev. 2017 Epub ahead of print. [[ PMC free article] [ PubMed] Google Scholar]

39. Ezzati M, Friedman AB, Kulkarni SC, Murray CJ. The reversal of fortunes: trends in county mortality and cross-county mortality disparities in the United States. PLoS Med. 2008;5(4):e66. [Erratum in [[ PLoS Med. 2008;5(5):e66] PMC free article] [ PubMed] Google Scholar]

56. National Academies of Sciences, Engineering, and Medicine. Pain Management and the Opioid Epidemic: Balancing Societal and Individual Benefits and Risks of Prescription Opioid Use. Washington, DC: National Academies Press; 2017. [[ PubMed] Google Scholar]

Articles from American Journal of Public Health are provided here courtesy of American Public Health Association

# data[].attributes.attachment_link.title
Opioid Crisis: No Easy Fix to Its Social and Economic Determinants

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The accepted wisdom about the US overdose crisis singles out prescribing as the causative vector. Although drug supply is a key factor, we posit that the crisis is fundamentally fueled by economic and social upheaval, its etiology closely linked to the ...

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Overview of opioid epidemic // some government solutions

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Overview of opioid epidemic // some government solutions

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The death rate from opioid drug overdose in the US has nearly doubled between 2013 and 2014

"Together with heroin, synthetic opioids are the main substance of abuse behind the US epidemic. The drugs are highly addictive owing to their actions at opioid receptors in the brain"

In response to the epidemic, public health officials have restricted opioid prescribing due to the adverse health effects and later addictions of substances.

They also increased access to naloxone, a drug that reverses opioid overdose and implemented systems to facilitate identification of individuals at increased risk of opioid abuse.

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Deaths involving opioids have risen sharply in recent years, bringing the highly addictive drugs to the forefront of U.S. public health concerns.

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Government website - Prescription problem, statistics

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Government website - Prescription problem, statistics

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In the late 1990s pharmaceutical companies reassured medicine community that opioid pain relievers were not addictive so they began prescribing them at much higher rates.

From a national survey:

From 1999 to 2017, more than 700,000 people have died from a drug overdose.

Around 68% of the more than 70,200 drug overdose deaths in 2017 involved an opioid.

In 2017, the number of overdose deaths involving opioids (including prescription opioids and illegal opioids like heroin and illicitly manufactured fentanyl) was 6 times higher than in 1999.

On average, 130 Americans die every day from an opioid overdose

886,000 people use heroin

11.4 million people misused prescription opioids

2.1 million people had an opioid use disorder

"Increased prescription of opioid medications led to widespread misuse of both prescription and non-prescription opioids before it came clear that these medications could indeed be highly addictive"