The History of the Opiate Epidemic in America

Unless you’ve been trapped on a desert island with nothing but a volleyball named Wilson to keep you company, you’re probably well aware that we’ve been dealing with a major opiate epidemic here in the U.S. In the biggest of cities and the smallest of towns, countless people — many of them good people with goals and ambitions and families — have fallen prey to what’s arguably the most destructive disease we’ve ever faced.

What makes addiction — not just opiate addiction but all forms of addiction — so devastating is that its influence is profound at both the micro and macro levels. This is a disease that originates in individuals, but its effects tear through the lives of each addict’s spouse, family members, close friends, and colleagues. Particularly with opiate addiction, the effects of this disease has ravaged entire communities, which is why it’s a top priority of lawmakers and law enforcement to find ways of alleviating this problem. Meantime, the epidemic continues rotting our society from the inside like gangrene.

With opiate addiction having reached this all-time high, it’s natural to wonder what it was that put us on this self-destructive path. Where did it all begin? How did it get to this? That’s exactly what we’re going to discuss.

IT STARTED WITH A SINGLE PILL

Although our history with opiate substances — or substances that are similar in their molecular structure and in their effects to the opium obtained from the opium poppy — goes back several thousand years, most experts trace the current opiate addiction epidemic to a more recent source. In fact, it’s often said that the source of the epidemic, the moment that the allowed the opiate epidemic to occur, was the release of OxyContin.

OxyContin, which is technically an opioid rather than an opiate, was the first prescription painkiller to become extremely popular in the mainstream and very widely used; however, it wasn’t the first time that a substance containing oxycodone — the active, opioid ingredient in OxyContin — was available. Oxycodone is a semi-synthetic substance that was first developed in 1916 in an effort to develop medications that were effective in treating pain while being less addictive than opiates, or the substances that are more directly derived from opium such as morphine, codeine, and heroin. While it made its way to America in 1939, it wasn’t until 1950 with the release of Percodan that oxycodone would be prescribed in America for the first time.

Initially, oxycodone was believed to be much safer than the drugs it was intended to replace, but over the years more and more research was conducted and it painted a very different picture. In 1963, the governor of California declared that Percodan was to blame for more than one-third of all the addiction that occurred throughout the state. In response, the Drug Enforcement Administration classified oxycodone as a Schedule II controlled substance in 1970.

Percocet made its first appearance in 1976 and remains in use today as one of the most well-known prescription painkillers. While Percodan contained a mixture of aspirin with a small amount of oxycodone, Percocet was a mixture of oxycodone and acetaminophen in a similar ratio. In other words, since both Percodan and Percocet contained small amounts of oxycodone, a patient prescribed one of these drugs had access to only so much oxycodone at a given time. While this didn’t prevent its abuse or oxycodone dependence from developing, it kept oxycodone addiction from quickly escalating, which is what occurred when a more powerful version of oxycodone would be released two decades later.

It was 1996 when Purdue Pharma first released OxyCodone after getting approval from the Food and Drug Administration the previous year. One of the main reasons for the release of such a powerful painkiller was the suggestion that people who suffered from chronic pain weren’t receiving sufficient treatment that would allow them a certain quality of life. And since OxyContin was intended to be a timed-release drug — which meant that instead of all the oxycodone contained in a dose being released at once, the drug would release smaller amounts of oxycodone into the body continuously over a period of time — it was believed that OxyCodone couldn’t be abused in the same way that previous painkillers. This was, in fact, the case as long as the pill wasn’t chewed or crushed; it was only if the pill was swallowed whole that the timed-release mechanisms worked appropriately.

After its release, OxyContin became wildly popular. Part of this popularity is attributed to the aggressive marketing and advertising campaign that Purdue Pharma had implemented so as to enhance the profitability of OxyContin. It’s even said that Purdue Pharma executives took physicians and the directors of medical facilities out to elaborate meals and coordinated events for them. In essence, the pharmaceutical company was “courting” as many high-profile and influential medical professionals — after creating a database of detailed profiles and carefully choosing the right ones — as they could in the hope that this would bolster OxyContin sales.

Of course, much of this took place behind-the-scenes despite the numerous articles and evidence cited in support of Purdue’s very unconventional marketing strategy. However, there are some who assert that the blame for the current opiate epidemic lies squarely on the shoulders of Purdue Pharma. While putting sole blame on the company is sensationalist and extreme, there’s no denying that they seem to have played their part.

It didn’t take long for OxyContin prescription rates to go through the roof. In its first year on the market, OxyContin sales reached $45 million. By the early 2000s, that figure breached the $1 billion mark. Ten years after its release, annual OxyContin sales were at $3.1 billion, representing more than 30 percent of the painkiller market. During this time, OxyContin was being heavily marketed in the media and there were a number of incentives offered to providers, encouraging them to prescribe OxyContin in lieu of alternatives. Expectedly, other pharmaceutical companies wanted to capitalize on the growing popularity of painkillers by releasing their own, resulting in an increasingly saturated market.

THE OXYCONTIN EXPRESS

More and more patients were receiving the drug, many of whom were prescribed far more opiates than they needed. These individuals soon realized that they could sell the excess on the street. So not only were patients becoming dependent on these drugs, but these substances were increasingly available even without a prescription. Rates of opiate addiction began to soar.

Although OxyCodone was the instigator, it should also be said that hydrocodone added a lot of fuel to the flame. Vicodin, in particular, has been the most well-known, widely used, and most popular form of hydrocodone since its development and release in the late 1970s. OxyContin was certainly the more desirable substance, but Vicodin and other forms of hydrocodone have been much more widely available. Between the two semi-synthetic opioids, painkiller addiction grew to be a major epidemic throughout the 2000s. Expectedly, this meant a dramatic increase in rates of prescription drug overdose; while only one percent of all emergency room visits were the cause of painkiller abuse in 1997, no less than five percent of all emergency room visits in 2007 were the result of painkiller abuse. In short, the rate of painkiller overdose more than quadrupled over a ten-year period.

Over the course of the 2000’s, awareness of the painkiller problem grew. At a point, there was a slight crackdown on the rate at which painkillers were prescribed, but it wasn’t enough to curb how much painkiller abuse was happening. In fact, many of those who found it difficult to get more opiates from their own doctors in their own towns began making regular trips to Florida, which was referred to as the “OxyContin express” due to how easy it was for patients to get prescriptions for painkillers from Floridian physicians. In fact, an acclaimed documentary called The OxyContin Express detailed the painkiller pipeline that ran specifically from the Fort Lauderdale area of Florida to the Appalachian region of the mid-Atlantic U.S., one of the areas that had been hit particularly hard by the growing painkiller epidemic.

According to estimates, doctors in Florida prescribed at least ten times more painkillers than doctors in every other state combined. People would travel from all over the Southeastern U.S. — and in some cases from the far corners of the continental U.S. — to see doctors. In many cases, these individuals would make these trips each month and would oftentimes make appointments to see several doctors back-to-back in a single day; then they would fill their prescriptions and drive back to their home states with thousands of dollars in opiate painkillers. Even when many other states starting instituting statewide databases with which they could monitor the amount of opiate painkillers that were being given and to whom they were prescribed, Florida was one of the last remaining holdouts and was a major contributor to the longevity of the opiate epidemic.

By the late 2000s, a federal task force had made it their mission to stop the OxyContin express. Over just a one-year period, the task force sent undercover agents to a number of so-called “pill mills” located throughout Florida; during this time, their agents collected evidence against 300 facilities that were overprescribing painkillers and knowingly prescribing them to patients who did need them and who essentially would show up to pay cash for an opiate prescription.

The fact that Florida had been the painkiller capital of the U.S. complicated things for the droves of addicted who had been flocking to Florida for treatment. It was becoming difficult for anyone to get sober in Florida when opiates and other prescription drugs were so readily available. Fortunately, the state finally implemented a prescription drug monitoring database, coinciding with the closing of hundreds of illicitly operating facilities located throughout the state. Additionally, there were federal regulations being implemented nationwide with regard to controlled substances. Doctors and physicians were monitored more closely and had stricter guidelines by which to abide, resulting in a rather sharp decline in the amount of painkillers that were being prescribed.

These pain medications were still available to those who needed them, but the statewide databases and policy changes made it much more difficult for people to get duplicate prescriptions. Patients were being prescribed the bare minimum amount of these addictive drugs that they needed for quality of life, and that meant there were far fewer opiates being diverted and sold to substance abusers on the street. By 2011 we were beginning to see the first signs that the opiate epidemic was finally in decline. Unfortunately, it couldn’t have been foreseen that a new threat would immediately take its place like a proverbial passing of the baton.

THE NEW MENACE: HEROIN (THE CHEAPER ALTERNATIVE)

As painkillers became harder and harder to find, all the people who’d been addicted to those painkillers had to make a choice: They could either accept that it was time to get clean or they could find a replacement drug. Many people chose the latter.

If you refer to the beginning of our history of the opiate epidemic, you’ll recall how we explained that drugs like oxycodone and hydrocodone were developed in the hope of finding as safer alternative to morphine, codeine, and heroin. As it happened, heroin was the most powerful of these substances and was readily available. Not only was it powerful and available, but it was cheaper, too. So when it became difficult to find opiate painkillers, addicts quickly began using an opiate that’s several times worse than any of the painkillers they’d been abusing. Sure enough, the decline of the painkiller epidemic just so happened to cause an abrupt spike in heroin addiction.

It’s almost ironic that fighting one addiction inevitably led to the advent of another, but there’s no getting around it. Experts agree that it was the decline in availability of painkillers that caused many addicts to turn to heroin as a substitute. Heroin is extremely inexpensive compared to the painkillers that had previously been so popular and which often sold for over a dollar per milligram. By comparison, substance abusers found themselves able to buy much more heroin for the same amount of money, resulting not just in a major wave of heroin addiction, but in an addiction that spread and worsened at an astronomical rate. People were becoming hooked on heroin fast, which meant they’d have to increase their habit; in turn, this resulted in financial destitution, causing many heroin addicts to resort to stealing from their loved ones or committing crimes in their communities to support their habits.

While the current heroin epidemic may garner the most attention and concern, the unfortunate reality is that all opiates remain a major problem. There are significantly lower rates of painkiller addiction today than there were ten years ago, but it does still occur; meanwhile, the spike in heroin use and the subsequent epidemic has resulted in a situation that’s arguably worse than the painkiller problem ever was. Needless to say, this is a highly discouraging situation that never could have been foreseen.

On the other hand, there’s a silver lining. The fact that we were able to curb the painkiller epidemic is something to be commended. Even though it inadvertently triggered an even worse drug problem, we have every reason to believe that we’ll find a solution for the heroin epidemic, too. In the meantime, we continue developing better rehabilitation strategies and innovative, multidisciplinary addiction treatments while making recovery as accessible to those in need as possible.