Opioids 101: Basic Outlines of a Public Health Crisis
Definition of Terms
Opioids: “Opioids are a class of drugs that include the illegal drug heroin as well as powerful pain relievers available legally by prescription, such as oxycodone (OxyContin®), hydrocodone (Vicodin®), codeine, morphine, fentanyl, and many others. These drugs are chemically related and interact with opioid receptors on nerve cells in the body and brain. Opioid pain relievers are generally safe when taken for a short time and as prescribed by a doctor, but they are frequently misused (taken in a different way or in a greater quantity than prescribed, or taken without a doctor’s prescription) because they produce euphoria in addition to pain relief.”[1]
Opiates: “The difference between opioids vs. opiates encompasses a range of factors that all work together. Drug type, drug effect, and the body’s response all play into differentiating between opioids vs. opiates.
Natural Opiates: “The opium poppy plant has given rise to an entire class of drugs known as opiates. Natural opiates represent the poppy plant in its purest forms. Some of the more commonly known natural opiates include:
- Morphine
- Codeine
- Thebaine
- Opium
“Opiates, as a group, encompass opioid drugs, many of which are derived from opium poppy plant alkaloid compounds. While opiates and opioids do encompass two separate classes of analgesics, opioids vs. opiates entails much more than the drugs themselves.
“According to the National Institute on Drug Abuse, most opiate drugs produce analgesic effects in terms of blocking pain sensations and alleviating pain symptoms. Opiates work by stimulating neurotransmitter production in the brain, central nervous system, and gastrointestinal tract. These effects not only account for the drug’s pain-relieving effects, but also set off a chain reaction within the brain’s chemical system. With continued drug use, this chain reaction paves the way for addiction.”[2]
Opium: “Opium is a highly addictive narcotic drug acquired in the dried latex form from the opium poppy (Papaver somniferum) seed pod. Traditionally the unripened pod is slit open and the sap seeps out and dries on the outer surface of the pod. The resulting yellow-brown latex, which is scraped off of the pod, is bitter in taste and contains varying amounts of alkaloids such as morphine, codeine, thebaine and papaverine.”[3]
Opium poppy seed leaking liquid opium latex
Fentanyl: “Fentanyl is a synthetic opioid pain reliever. It is many times more powerful than other opioids and is approved for treating severe pain, typically advanced cancer pain. Illegally made and distributed fentanyl has been on the rise in several states.”[4] “Fentanyl can be absorbed into the body via inhalation, oral exposure or ingestion, or skin contact. It is not known whether fentanyl can be absorbed systemically through the eye. Fentanyl can be administered intravenously (IV), intramuscularly (IM), or as a skin patch (transdermally).[5]
“Drugs users generally don’t know when their heroin is laced with fentanyl, so when they inject their usual quantity of heroin, they can inadvertently take a deadly dose of the substance. In addition, while dealers try to include fentanyl to improve potency, their measuring equipment usually isn’t fine-tuned enough to ensure they stay below the levels that could cause users to overdose. Plus, the fentanyl sold on the street is almost always made in a clandestine lab; it is less pure than the pharmaceutical version and thus its effect on the body can be more unpredictable.
“Heroin and fentanyl look identical, and with drugs purchased on the street, ‘you don’t know what you’re taking,’ Tim Pifer, the director of the New Hampshire State Police Forensic Laboratory, has said. ‘You’re injecting yourself with a loaded gun.’”[6]
“Most recent cases of fentanyl-related harm, overdose, and death in the U.S. are linked to illegally made fentanyl. It is sold through illegal drug markets for its heroin-like effect. It is often mixed with heroin and/or cocaine as a combination product—with or without the user’s knowledge—to increase its euphoric effects.”[7]
Fentanyl pictured in multiple forms
Heroin: “Heroin is an illegal opioid. Heroin use has increased across the U.S. among men and women, most age groups, and all income levels.”[8]
“Heroin is an illegal, highly addictive drug processed from morphine, a naturally occurring substance extracted from the seed pod of certain varieties of poppy plants. It is typically sold as a white or brownish powder that is “cut” with sugars, starch, powdered milk, or quinine. Pure heroin is a white powder with a bitter taste that predominantly originates in South America and, to a lesser extent, from Southeast Asia, and dominates U.S. markets east of the Mississippi River. Highly pure heroin can be snorted or smoked and may be more appealing to new users because it eliminates the stigma associated with injection drug use. “Black tar” heroin is sticky like roofing tar or hard like coal and is predominantly produced in Mexico and sold in U.S. areas west of the Mississippi River. The dark color associated with black tar heroin results from crude processing methods that leave behind impurities. Impure heroin is usually dissolved, diluted, and injected into veins, muscles, or under the skin.”[9]
Heroin pictured in multiple forms
Morphine: “Morphine is the most abundant analgesic opiate found in opium and is a potent pain reliever. The drug is used in clinical pain relief but is also used illicitly for recreational purposes among drug users. It is potentially highly addictive and can cause intense physical dependence that leads to abuse of the substance.
“Morphine is obtained from the seedpod extract or opium found in the poppy plant, Papaver somniferum.
“Morphine is widely used in clinical pain management, especially for terminal cancer pain and post-surgery pain. In the body, morphine has several effects including reduction of pain, loss of hunger, and suppression of cough.”[10]
Methadone: “Methadone is an opioid medication . . . Methadone reduces withdrawal symptoms in people addicted to heroin or other narcotic drugs without causing the ‘high’ associated with the drug addiction.
“Methadone is used as a pain reliever and as part of drug addiction detoxification and maintenance programs and is only available from certified pharmacies.
“Methadone can slow or stop your breathing, especially when you start using this medicine or whenever your dose is changed.”[11]
Oxycodone: “Oxycodone is a pain relieving medication that has recently become a very popular drug of choice for illicit users. In the medical sense, Oyxcodone is one powerful and amazing pain-relieving drug for those who really need it. It is most commonly prescribed to patients to manage pain after surgery. Oxycodone has very similar qualities to morphine. However, it is unique in the way that it is a 24 hour time released drug. This time release attribute allows those who are in pain to feel constant relief throughout the day.
“The name Oxycodone is generic; there are in fact many different forms of this drug that are prescribed by doctors for pain, but are also abused nationwide. Oxycodone is produced in two different ways. It is made into tablets that just contain Oxycodone; the most popular brand names for this form of the drug are Oxycontin and Roxycodone. It is also made into tablets that contain Oxycodone mixed with Acetaminophen; the most popular brand names for this form are Percocet, Percodan, and Tylox. For people who abuse Oxycodone, they will abuse the form that just contains the Oxycodone. Therefore, the most commonly abused forms of Oxycodone are Oxycontin and Roxycodone.”[12]
Hydrocodone: “Hydrocodone is an opioid pain medication. Zohydro ER and Hysingla ER are extended-release forms of hydrocodone that are used for around-the-clock treatment of severe pain. Extended-release hydrocodone is not for use on an as-needed basis for pain.
“Hydrocodone can slow or stop your breathing. Never use this medicine in larger amounts, or for longer than prescribed.”[13]
Naloxone: “Naloxone, marketed under the brand name Narcan, among others, is a medication designed to rapidly reverse opioid overdose. It is an opioid antagonist—meaning that it binds to opioid receptors and can reverse and block the effects of other opioids. It can very quickly restore normal respiration to a person whose breathing has slowed or stopped as a result of overdosing with heroin or prescription opioid pain medications.”[14]
The Scale of the Crisis Part I: Opioids In General
“More people died from drug overdoses in 2014 than in any year on record, and the majority of drug overdose deaths (more than six out of ten) involved an opioid.” – HHS
An average of 91 people fatally overdose on opioids (legal and illegal) every day. – CDC.
“Opioids—prescription and illicit—are the main driver of drug overdose deaths. Opioids were involved in 33,091 deaths in 2015, and opioid overdoses have quadrupled since 1999. The vast majority of these deaths, some 68%, are from illegal drugs.”[15] “As the CDC recently reported, “[T]he increase in opioid overdose death rates is driven in large part by illicit opioids, like heroin and illicitly manufactured fentanyl.”[16]
“In 2015, the five states with the highest rates of death due to drug overdose were West Virginia (41.5 per 100,000), New Hampshire (34.3 per 100,000), Kentucky (29.9 per 100,000), Ohio (29.9 per 100,000), and Rhode Island (28.2 per 100,000).” – CDC (“2015” Tab)
– CDC (“Natural and Semi-Synthetic Map” Tab)
When it comes to prescription opioid abuse, the most common drugs include:
- Methadone
- Oxycodone (such as OxyContin®)
- Hydrocodone (such as Vicodin®)
– CDC
“Most people who abuse prescription opioids get them for free from a friend or relative. However, those who are at highest risk of overdose (using prescription opioids non-medically 200 or more days a year) get them in ways that are different from those who use them less frequently. These people get opioids using their own prescriptions (27%), from friends or relatives for free (26%), buying from friends or relatives (23%), or buying from a drug dealer (15%). Those at highest risk of overdose are about four times more likely than the average user to buy the drugs from a dealer or other stranger.” – CDC
The Scale of the Crisis Part II: Heroin
“Heroin-related overdose deaths have more than quadrupled since 2010.
“From 2014 to 2015, heroin overdose death rates increased by 20.6%, with nearly 13,000 people dying in 2015.
“In 2015, males aged 25-44 had the highest heroin death rate at 13.2 per 100,000, which was an increase of 22.2% from 2014.” – CDC
“According to the National Survey on Drug Use and Health (NSDUH), in 2012 about 669,000 Americans reported using heroin in the past year, a number that has been on the rise since 2007. This trend appears to be driven largely by young adults aged 18–25 among whom there have been the greatest increases. The number of people using heroin for the first time is unacceptably high, with 156,000 people starting heroin use in 2012.” – NIH
“[N]ew heroin users, approximately three out of four, report abusing prescription opioids prior to using heroin.” – CDC (“Overdose Prevention” Tab)
“But, the vast majority of opioid users—over 90%—do not engage in heroin use. As the New England Journal of Medicine reports, “[A]lthough the majority of current heroin users report having used prescription opioids non-medically before they initiated heroin use, heroin use among people who use prescription opioids for nonmedical reasons is rare, and the transition to heroin use appears to occur at a low rate.”[17]
“Heroin-related deaths more than tripled between 2010 and 2015, with 12,989 heroin deaths in 2015. The largest increase in overdose deaths from 2014 to 2015 was for those involving synthetic opioids (other than methadone), which rose from 5,544 deaths in 2014 to 9,580 deaths in 2015. One of these synthetic opioids, illegally made fentanyl, drove the increase. It was often mixed with heroin and/or cocaine as a combination product—with or without the user’s knowledge.” – CDC (“Heroin Use” Tab)
The Scale of the Crisis Part III: Fentanyl
“[M]ost recent cases of fentanyl-related harm, overdose, and death in the U.S. are linked to illegally made fentanyl.” – CDC
“[C]onfiscations, or seizures, of fentanyl increased by nearly 7X from 2012 to 2014. There were 4,585 fentanyl confiscations in 2014. This suggests that the sharp rise in fentanyl-related deaths may be due to increased availability of illegally made, non-pharmaceutical fentanyl, and not prescribed fentanyl.” – CDC (“The Problem” Tab)
“Much of the synthetic opioids that find their way into the United States — including fentanyl, which is 50 times more potent than heroin — originate in China but come through Mexico, where they are processed and packaged by drug cartels before being smuggled into the United States, federal officials say.
“But a significant amount is bought by American users on the so-called dark web, a term for Internet sites that sell illegal products and then ship them directly from overseas and through the U.S. mail, according to the experts.” – Boston Globe, “Synthetic opioids are getting into US by mail”
When it comes to the illegal sale of fentanyl, most of the attention has focused on Mexican cartels that are adding the drug to heroin smuggled into the United States. But Chinese suppliers are providing both raw fentanyl and the machinery necessary for the assembly-line production of the drug powering a terrifying and rapid rise of fatal overdoses across the United States and Canada, according to drug investigators and court documents.
‘We have seen an influx of fentanyl directly from China,’ said Carole Rendon, the acting US attorney for the northern district of Ohio in Cleveland. “It’s being shipped by carrier. It’s hugely concerning because fentanyl is so incredibly deadly.”
The China connection is allowing local drug dealers in North America to mass produce fentanyl in pill form, in some cases producing tablets that look identical to an oft-abused version of the prescription painkiller OxyContin. It also has been added to Xanax pills. And last week, fentanyl pills made to resemble the painkiller hydrocodone were blamed for a wave of overdoses in the Sacramento area, including nine deaths.
The fentanyl pills are often disguised as other painkillers because those drugs fetch a higher price on the street, even though they are less potent, according to police.
…
The emergence of decentralized drug labs using materials obtained from China — and often ordered over the Internet — makes it more difficult to combat the illicit use of the drug.
…
We have tracked the import from China,” Schiavetta said of fentanyl sold in the Canadian city. “The dealers ask for fentanyl powder and there are websites that guarantee delivery. If it is stopped at the border, they will send you a new one.” He said the packages are labeled as different products, such as car parts.
In Edmonton, Alberta, police inspector Dwayne Lakusta said fentanyl and pill presses are coming from China. “It is getting worse,” he said of that city’s fentanyl problem. “We will be battling this every day moving forward.”
Federal agents in Southern California became aware of the fentanyl operation there when a US Customs and Border Protection agent discovered a commercial pill press being sent from China to Gary Resnik, a Long Beach, Calif., man who has since been charged in the drug ring along with three other men.
Resnik allegedly set up a company called “Beyond Your Dreams” to order the machine, which was shipped through Los Angeles International Airport by a Chinese company called Capsulcn International, according to court records. Those records allege the Chinese company has a history of shipping pill presses to customers in the United States using fake shipping labels. Attempts to identify a specific location of the company and contact information were unsuccessful.
Federal agents eventually seized six pill presses they allege were used by the Southern California dealers. Each machine could produce thousands of pills an hour.” – STAT News, “‘Truly terrifying’: Chinese suppliers flood US and Canada with deadly fentanyl”
“The DEA estimates that drug traffickers can buy a kilogram of fentanyl powder for $3,300 and sell it on the streets for more than 300 times that, generating nearly a million dollars.
“Fentanyl is often trafficked through the cartels’ standard maze of routes through Mexico and into the U.S. But sometimes it’s simply ordered on the notorious dark web and shows up straight from China in the buyer’s mailbox.” – CNN
Opioid Crisis in the News
“Widespread abuse of powerful opioids has pushed U.S. overdose death rates to all-time highs. It has also traumatized tens of thousands of children. The number of youngsters in foster care in many states has soared, overwhelming social workers and courts. Hospitals that once saw few opioid-addicted newborns are now treating dozens a year.
“And many of the children who remain in the care of addicted parents are growing up in mayhem. They watch their mothers and fathers overdose and die on the bathroom floor. They live without electricity, food or heat when their parents can’t pay the bills. They stop going to school, and learn to steal and forage to meet their basic needs.
…
“Social workers say the scale of the trouble exceeds anything they saw during the crack-cocaine or methamphetamine crises of previous decades. Heroin and other opioids are so addictive they can overwhelm even the strongest parental instinct to care for a child, doctors and social workers say.
“The recent black-market arrival of synthetic opioids many times more potent than heroin, such as fentanyl and carfentanil, has only made the crisis worse.” – WSJ, “The Children of the Opioid Crisis”
“The rate of drug-related deaths among American Indian and Alaska Native people has almost quadrupled since 1999, according to the Indian Health Service. It’s now double the rate in the US as a whole. Oklahoma — home to the 120,000 citizens of Cherokee Nation — leads the country in prescription painkiller abuse.
Conclusion
The crisis is here and it is real. As the journalist Christopher Caldwell recently wrote, “In his inaugural address, President Trump referred to the drug epidemic (among other problems) as ‘carnage.’ Those who call the word an irresponsible exaggeration are wrong.”[18] After a full investigation into the roots and scope of the problem, Caldwell concludes, “It is true that we cannot arrest our way out of a drug problem. But we cannot medicate and counsel our way out of it, either, and that is what we have been trying to do for almost a decade.”[19]
We put the foregoing together to provide as comprehensible and comprehensive description of the problem we all now face. The numbers and factors we detail are not meant to diminish or emphasize any particular effort to address the variety of opioid issues contributing to the crisis, but, rather, to detail the full picture of the problem as best we can. A responsible drug education policy and successful series of messages and communications aimed at prevention should make every effort to ensure the right problems are understood and addressed.
[1] https://www.drugabuse.gov/drugs-abuse/opioids
[2] http://www.opium.org/opioids-vs-opiates-whats-the-difference.html
[3] https://www.drugs.com/illicit/opium.html
[4] https://www.cdc.gov/drugoverdose/opioids/index.html
[5] https://www.cdc.gov/niosh/ershdb/emergencyresponsecard_29750022.html
[6] http://www.pbs.org/newshour/rundown/fentanyl-deadlier-heroin-single-photo/
[7] https://www.cdc.gov/drugoverdose/opioids/fentanyl.html
[8] https://www.cdc.gov/drugoverdose/opioids/index.html
[9] https://www.drugabuse.gov/publications/research-reports/heroin/what-heroin
[10] http://www.news-medical.net/health/What-is-Morphine.aspx
[11] https://www.drugs.com/methadone.html
[12] http://www.nmshealth.com/blog/what-is-oxycodone/
[13] https://www.drugs.com/hydrocodone.html
[14] https://www.drugabuse.gov/related-topics/naloxone
[15] https://obamawhitehouse.archives.gov/the-press-office/2016/12/08/continued-rise-opioid-overdose-deaths-2015-shows-urgent-need-treatment
[16] http://www.prnewswire.com/news-releases/new-data-show-continuing-opioid-epidemic-in-the-united-states-300379945.html
[17] http://www.nejm.org/doi/full/10.1056/NEJMra1508490#t=article
[18] https://www.firstthings.com/article/2017/04/american-carnage
[19] Ibid.