Andrew Kolodny is Co-Director of Opioid Policy Research at Brandeis University


Drug overdose deaths, once rare, are now the leading cause of accidental death in the U.S., surpassing peak annual deaths caused by motor vehicle accidents, guns and HIV infection.

As a former public health official, clinician and researcher, I've been engaged in efforts to control the opioid addiction epidemic for the past 15 years.

The data show that the situation is dire and getting worse. Until opioids are prescribed more cautiously and until effective opioid addiction treatment becomes easier to access, overdose deaths will likely remain at record high levels.

How the crisis started

Opioids are drugs that stimulate the brain's opiate receptors. Some are made from opium and some are completely synthetic. In the U.S., the most commonly prescribed opioids are hydrocodone and oxycodone, which are classified as semi-synthetic because they are synthesized from opium. Heroin is also a semi-synthetic opioid. The effects of hydrocodone and oxycodone on the brain are indistinguishable from the effects produced by heroin.

Opioids are essential medicines for palliative care. They are also helpful when used for a couple of days after major surgery or a serious accident. Unfortunately, the bulk of the opioid prescriptions in the U.S. are for common conditions, like back pain.

In these cases, opioids are more likely to harm patients than help them because the risks of long-term use, such as addiction, outweigh potential benefit. Opioids have not been proven effective for daily, long-term use. Evidence suggests that chronic use of opioids can even make pain worse, a phenomenon called hyperalgesia.

Over the last two decades, as prescriptions for opioids began to soar, rates of addiction and overdose deaths increased in parallel.

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The increase in opioid prescription was fueled by a multifaceted campaign underwritten by pharmaceutical companies. Doctors heard from their professional societies, their hospitals and even from state medical boards that patients were suffering needlessly because of an overblown fear of addiction.

The campaign minimized opioid risks and exaggerated the benefits of using opioids over the long term for chronic pain. Several states and counties have recently filed lawsuits against opioid manufacturers for the role they played in causing the opioid addiction epidemic by misleading the medical community.

The rise of heroin

Until 2011, most opioid overdose deaths involved prescription opioids. Then prescription opioid overdose deaths leveled off, while overdose deaths involving heroin began to soar.

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Why did this happen? A common misconception is that so-called "drug abusers" suddenly switched from prescription opioids to heroin due to a federal government "crackdown" on painkillers.

There is a kernel of truth in this narrative. It's true that the vast majority of people who started using heroin after 1995 switched from prescription opioids because heroin was easier to obtain. But heroin use among young whites has been increasing since before 2011. From the beginning of the opioid crisis, young adults who became addicted to prescription opioids would switch to heroin, a less expensive option.

Substance Abuse and Mental Health Services Administration

As young people switched to heroin, the heroin supply also became more dangerous. This caused the sharp increase in heroin overdose deaths in 2011. Increasingly, fentanyl, a potent and inexpensive synthetic opioid, was mixed with heroin or sold as heroin.

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Until 2013, medical examiners didn't routinely test heroin overdose victims for the presence of fentanyl, but once they did, an alarming trend appeared. Preliminary data indicate that, in 2016, deaths involving fentanyl surpassed deaths involving prescription opioids and heroin.

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