No matter who you talk to, it seems like everyone in the country has some connection to the opioid epidemic. The impact of opioids has touched states from coast to coast, and while it may be more severe in certain areas than others, it is, in fact, classified by the Centers for Disease Control and Prevention (CDC) as a nationwide epidemic.
Approximately 130 people die every day in the United States from an opioid-related overdose, according to data from the CDC. From 2016 to 2017, the rate of opioid-related deaths increased in 23 states, including Alabama, California, Maine, and Wisconsin. According to a study from the American Psychiatric Association, about one-third of Americans personally know someone with an opioid use disorder. It's a problem that is clearly affecting so many lives, and yet it still seems there's so much that people don't know about it.
As part of Bustle's WTFAQ series, we aim to close that information gap by answering some of the common questions people often have about opioids, the problem in the United States, and what's being done about it.
What are opioids & how do they work?
Opioids are a class of drugs that provide pain relief, and there are many different painkillers that are classified as opioids. Some opioids are naturally made and derived from the opium poppy plant. The drugs that are naturally derived from opium are technically known as opiates, but people most often use the term opioids to describe the entire class of drug.
Opioids can be a crucial tool for people experiencing pain from cancer, severe acute pain, and sometimes, chronic pain. Your brain has opioid receptors, and when you take opioids, they bind to those receptors. Upon binding, opioids produce euphoric effects, pain relief, and sedation.
What prescription drugs are opioids?
Natural opioids (opiates) include morphine and codeine.
There are also semi-synthetic opioids in which the drug's base is a naturally derived opioid, like morphine or codeine, that is then chemically changed and synthesized to create a new drug. Semi-synthetic opioids include well-known painkillers like OxyContin and Percoset (oxycodone); Vicodin and Lortab (hydrocodone); Dilaudid (hydromorphone); and Suboxone and Subutex (buprenorphine). Heroin is also a semi-synthetic opioid.
Synthetic opioids are made entirely from chemicals and include Demerol (meperidine/pethidine); Ultram (tramadol); Ultiva (remifentanil); Alfenta (alfentanil); and Dolophine and Methadose (methadone). The most well-known synthetic opioid is fentanyl.
What makes opioids addictive?
Anyone can develop an opioid use disorder, says Dr. Hillary Kunins, the acting executive deputy health commissioner of the New York City Department of Health and Mental Hygiene.
"There are risk factors, including personal or family history of addiction, history of trauma, and mental health conditions," she points out. "But we do not know how to predict who will and will not develop an addiction."
"It’s important to note that dependence and addiction are not the same things," Kunins adds. According to a report from the nonprofit Center for Addiction, dependence happens when people begin to develop both a tolerance for and a physical reliance on a drug. Dependence can still occur when a person uses prescribed opioids as directed by their doctor, if their daily functioning relies on use of the drug.
Addiction, on the other hand, has more to do with misuse of a drug, whether that means taking more of a prescription than a person is directed to, for longer than they're meant to, or taking a drug for non-medical purposes. Unlike dependence, addiction "interferes with, rather than maintains" a person's daily functioning, as the Center for Addiction notes.
How did the opioid epidemic start?
The CDC outlines the rise of opioids in the United States in three "waves."
The first wave was in the 1990s, when providers began increasingly prescribing opioids for chronic, non-cancer pain. Before this time period, opioids were generally prescribed for cancer pain or for shorter-term, acute pain, like from an injury. Around 1999, overdose deaths related to prescription opioids began markedly rising.
The second wave started in 2010, when heroin overdose deaths began to rise. Prescription opioids and heroin provide a similar high, but heroin is less expensive and easier to access, according to the National Institute on Drug Abuse (NIDA). A study published by the Substance Abuse and Mental Health Services Administration (SAMHSA) in 2013 found that of people who used heroin for the first time, almost 80% had previously used prescription opioids for non-medical purposes.
The third wave started in 2013, when deaths involving synthetic opioids — mostly illegally manufactured fentanyl — spiked significantly. Fentanyl can be laced into heroin and other drugs, and it's impossible for an average person to tell if a drug has fentanyl in it, unless you test it with fentanyl testing strips. The rate of fentanyl-related deaths continues to rise today.
Who is affected by the opioid crisis?
In 2017, which is the most recent year for which data is available, white, non-Hispanic people made up 78 percent of opioid overdose deaths; Black people made up 12 percent; and Hispanic people made up 8 percent, according to the Kaiser Family Foundation. While white people have made up the majority of opioid overdose deaths since at least 1999, death rates are surging among Black and Latinx communities.
West Virginia, Ohio, Pennsylvania, Washington, D.C., and Kentucky, respectively, saw the highest rates of opioid deaths in 2017. But opioids can affect anyone at all, Kunins says.
"After caring for patients with opioid addiction for more than 15 years, I can say that people’s experiences are as varied as there are people," she says. Kunins has cared for people who began using painkillers "as part of experimenting during adolescence," as she puts it; people who were introduced directly to heroin by a partner or a friend; and people who had been in recovery but relapsed after an injury.
What role does heroin play in all this?
Heroin is an opioid, which is a class of drug, whereas heroin is a drug itself.
Heroin is a semi-synthetic opioid technically called diamorphine, and some countries, such as Canada, the United Kingdom, and Switzerland, still prescribe it for severe pain. In the United States, however, the Drug Enforcement Administration (DEA) considers heroin a Schedule 1 controlled substance, meaning a drug "with no currently accepted medical use and a high potential for abuse."
Often, people who are prescribed opioids or who try prescription opioids that were not prescribed to them turn to heroin because it's cheaper and easier to find.
You can find out more about all the different terms on the CDC website.
Why do I hear so much about fentanyl lately?
Fentanyl has been prescribed to cancer patients suffering from severe pain, but in recent years, people have made and sold it illegally. It’s particularly dangerous because it can be 50 to 100 times stronger than morphine, according to the NIDA.
What's methadone, and how is it different from these other opioids?
Methadone is a long-lasting, slow-release opioid that is used to treat opioid use disorder. It curbs cravings and does not impair people’s ability to function, according to NIDA. Using methadone alongside other treatments, like counseling, can help people wean off opioids.
Wait, using an opioid to treat opioid misuse? How does that work?
Methadone and buprenorphine are opioids that prevent people from feeling much euphoria and makes them safe to prescribe. Both are used in medication-assisted treatment (MAT) for opioid use disorder. The medications are approved by the Food and Drug Administration (FDA) to treat opioid dependence, as they can relieve withdrawal symptoms and suppress cravings.
There's also a non-opioid medication option. Extended-release naltrexone (brand name Vivitrol) can be effective in preventing relapse once a person has completely detoxed from opioids. Unlike buprenorphine, for example, naltrexone can't be taken while a person is using opioids, as it will only block the effects of opioids if there aren't any already bound to your brain's opioid receptors.
I still am just not sure that treating drugs with drugs makes sense.
Methadone, buprenorphine, and naltrexone are all proven to treat opioid use disorder. But the stigma behind medication-assisted treatment can be a huge barrier in making it accessible to those who would benefit from it.
"The evidence base for all of these drugs is quite strong," Dr. Rebecca Haffajee, PhD, a professor of health management and policy at the University of Michigan, tells Bustle. She notes that studies have shown that "those medications increased retention into treatment, and the drugs themselves are highly efficacious."
And anecdotally, providers have seen how their patients improve when they're on a MAT plan. "If you're in a program and you're stable and taking methadone, you're more inclined to keep your appointments, to keep your counseling appointments, to take your prenatal vitamins," says says Dr. Mariely Fernandez, MD, the chief medical officer at the Center for Comprehensive Health Practice in New York City.
What is President Trump doing about this?
In October 2017, President Donald Trump officially declared opioids a national public health emergency and appointed an opioid commission. At the Justice Department, then-Attorney General Jeff Sessions made several changes that year to prosecute and more severely punish people involved in opioid cases.
In 2018, Trump revealed an Initiative to Stop Opioid Abuse, whose website lists its goals as:
- Reduce drug demand through education, awareness, and prevention efforts.
- Cut off the flow of illicit drugs across our borders and within communities.
- Save lives by expanding opportunities for evidence-based treatments for opioid use disorder.
In the year since, he's continued to talk about treatment funding and stopping drugs at the border.
Is all that working?
First, Trump declared opioids a national public health emergency under the Public Health Services Act, rather than a national emergency through the Stafford Disaster Relief and Emergency Assistance Act. By making that crucial distinction, instead of automatically funneling federal funding toward the goal of ending the opioid epidemic, federal agencies were directed to divert parts of their own budgets toward the problem, as CNN explained at the time.
Meanwhile, former Rep. Patrick Kennedy (D-MA), who was a member of the opioid commission, said that despite having come up with 56 recommendations, the presidential administration didn't implement many of them. He called the whole commission a "charade."
Experts also told The New York Times that while Trump seemed to get more funding for and talk more about opioids than former President Barack Obama did, it doesn't seem like Trump really has a concrete and comprehensive plan to tackle the problem.
Did Obama do anything about opioids?
President Obama remained mostly silent about opioids until near the end of his tenure, garnering him a lot of criticism. According to The Washington Post, health experts asked Obama to declare the surging fentanyl issue as a public health emergency, which he did not.
However, the Affordable Care Act did greatly increase access to substance use disorder treatment. "Any historical assessment of the public health legacy of the Obama administration will have to look favorably at the impact of the Affordable Care Act on the US response to the opioid epidemic, and its ability to incentivize and assist states in taking action to fight against the epidemic," researchers wrote in the American Journal of Public Health.
Can I do anything about the opioid epidemic?
There are a lot of things you can do: you can get trained to use naloxone, the overdose-reversal drug, if your state allows it. You can volunteer at or donate money to shelters or day centers in your community that provide services for people who are unhoused, or are experiencing drug misuse or dependence. You can contact your representative to let them know that you want funding to go toward prevention and treatment of opioid misuse.
Most of all, you can work to help end the stigma. "Our friends aren't trying to get high every day, they're just trying to get well," says Lisa Etter Carlson, who co-founded a "neighborhood living room" in Seattle to provide an indoor place for people who are opioid dependent or experiencing homelessness to hang out in during the day.
Being compassionate and non-judgmental — not isolating people who are struggling with opioid misuse and marking them as "othered" in society — is where ending the opioid epidemic begins, Etter Carlson says. That means pushing for treatment services to exist in your neighborhood, not judging people who are unhoused or misusing opioids, and getting to know your neighbors who might be struggling.
"It has to be community driven, otherwise we aren't doing the good hard work of being neighbors and what that means," she says. "It's not going to happen, unless it starts on our block, in our neighborhood."
If you or someone you know is seeking help for substance use, call the SAMHSA National Helpline at 1-800-662-HELP(4357).