Chapter 9.0: Opioids

Ch. 9.2: Contributing Factors to the Opioid Epidemic

How the Opioid Epidemic Came to Be

The number of individuals using heroin, as well as the number with opioid use disorder, more than doubled in the years between 2002 and 2014 (NIDA, 2018).

Important milestones in the evolution of the opioid epidemic include (Quinones, 2015):

  • OxyContin (time-released oxycodone) becomes available and heavily marketed for treating chronic pain.
  • The first “pill mills” (as pain clinics) emerge on the scene.
  • Health care providers are urged to assess and manage pain as “the fifth vital sign.”
  • The development and marketing of new (lucrative) opioid formulations, combined with prescribers’ inadequate training about addiction, sincere wish to alleviate patients’ pain, and dependence on positive patient evaluation ratings contributed to opioid overprescribing practices, not to mention ethically questionable “pill mill” practices (NAS, 2017).
  • As the number of opioid prescriptions dispensed in the U.S. nearly tripled from 1991 to 2011, there was a parallel near-tripling in the number of opioid-related deaths (NIDA, 2018).
  • Concurrently, Mexican and Columbian heroin sources expanded dramatically across the U.S., making an easily injectable white powder form of heroin easily accessible and relatively low-cost: major factors in heroin use initiation by many individuals (NIDA, 2018). Fentanyl entering the country through Mexico and China are also major contributors to the crisis.
  • Concerns about overdose deaths began to be expressed in the early 2000s; while heroin addiction and overdose had historically been recognized as problems in urban, minority communities, the problem was emerging in new populations, new geographical areas, and explosively larger numbers.
  • In 2008 drug overdose surpassed auto fatalities as the leading cause of accidental death in the U.S (Quinones, 2015).
  • By 2014, concern about the addictive behavior pattern of shifting from pain pills to heroin was evident, too (Quinones, 2015).
  • It is possible that making opioid drugs (OxyContin in 2010, for example) more difficult to misuse—harder to dissolve or crush for injection or “snorting”—may have contributed to an increase in heroin use (Evans, Lieber, & Power, 2017).
    • Again in Ohio’s Franklin County, the number of persons infected with Hepatitis C (often associated with intravenous drug use) increased by 68% between 2012 and 2016 (
  • On the illegal drug market, fentanyl is a favored product because it is much less expensive than heroin, making it a far more lucrative product in which to traffic (NAS, 2017).
  • The intense (and apparently misleading) opioid marketing practices of various drug companies has led to a series of multi-billion dollar lawsuits against the companies by individuals surviving opioid addiction, family members of individuals who died from opioid use, and communities facing staggering costs from law enforcement, emergency response, and health/mental health/addiction care services required in response to increased opioid misuse.
  • While there was a dip in overdose deaths, the slight decrease has now reversed during the initial phase of the COVID-19 global pandemic with 12 month overdose deaths projected to approach 73,000 by January 2020 (

Strategies to address the opioid problem include  (NAS, 2017):

  1. create abuse-deterrent formulations (non-addictive forms)
  2. promote alternative pain management strategies that may include behavioral health interventions with or without medication;
  3. reduce supply/access/availability through efforts such as
    1. restricting lawful access through DEA scheduling,
    2. influencing prescribing practices
    3. imposing prescription drug monitoring programs,
    4. training healthcare practitioners about substance misuse and substance use disorders,
    5. preventing diversion from legal to illegal use (e.g., with easy to access, regular drug take-back programs to eliminate access to leftover drugs),
    6. addressing pharmaceutical company marketing practices;
  4. reduce demand through patient and public education campaigns,
  5. promote access to evidence-supported treatment for OUD,
  6. initiate treatment engagement efforts with individuals who experience overdose, need  emergency department care, or who have other health-related consequences; and,
  7. reduce harmful consequences associated with use, such as
    1. overdose prevention and response efforts (e.g., dissemination of opioid overdose reversal training and kits),
    2. supervised drug injection sites,
    3. disperse tools for checking “street” drugs for fentanyl,
    4. wound care education for individuals engaged in injection use,
    5. providing immunity from prosecution for possession of substances or paraphernalia when first responders treat an overdose event.

A combination of changes to supply, demand, practitioner and public education, and legal/policy actions continue to be necessary to help address the opioid epidemic.   


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Introduction to Substance Use Disorders by Patricia Stoddard Dare and Audrey Begun is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License, except where otherwise noted.