Opioids 101 – A Synopsis of the Crisis

As the nation’s health and policy leaders continue to address the opioid epidemic problem—“carnage” as some have put it—we believe it is important to ensure resources, time, and thought are best spent on the dominant problems driving the crisis.

Part of the problem in addressing the opioid crisis is the confusing and misleading terminology. People hear or read about “opioids,” “prescription opioids,” or “fentanyl” and begin to lump of all of these issues together and think the opioid crisis is a problem driven primarily by the use of prescribed drugs. No doubt, while they contribute to part of the problem, they are nowhere near the biggest part of it. According to the most reliable statistics available (taken from the Office of National Drug Control Policy and the CDC):

In 2015, there were 33, 091 opioid overdose deaths
Heroin deaths constitute 12, 990 of deaths
Synthetic opioids (mostly illegal fentanyl) account for 9, 580 deaths[1]

Because opioid deaths usually involve the use of more than one drug, percentages and raw numbers will not neatly add up to 100% or the 33,091 deaths. According to the White House, “A portion of the overdose deaths involved both illicit opioids and prescription opioids.” But what we see from the information above is that over 68% of the problem is from the use of illegal drugs. As the CDC clearly put it in December of 2016, “[T]he increase in opioid overdose death rates is driven in large part by illicit opioids, like heroin and illicitly manufactured fentanyl, a synthetic opioid.”[2]

As for deaths from prescription opioids, the majority come from the diversion and illegal use and distribution of them. As the CDC notes, “Most people who abuse prescription opioids get them for free from a friend or relative.”[3] Those at the highest risk of overdose “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%).”[4] Thus, for the population that overdoses from opioid prescriptions, 64% abuse them from a diverted or illegal source. In other words, the abuse of opioid prescriptions that leads to overdose deaths involving a patient acquiring a legal prescription and misusing that prescription himself is less than 30% of the prescription problem and about 15% of the overall opioid overdose problem.

This is confirmed by testimony from the Director of the National Center for Injury Prevention and Control at the CDC, Dr. Debra Houry. In March of 2017, she testified to Congress:

“Although prescription opioids were driving the increase in overdose deaths for many years, more recently, the large increase in overdose deaths has been due mainly to increases in heroin and synthetic opioid (other than methadone) overdose deaths, not prescription opioids. Importantly, the available data indicate these increases are largely due to illicitly manufactured fentanyl.”[5]

Again, the main driver of our current crisis is the use and abuse of illegal drugs, not legally prescribed drugs used in the manner they were prescribed and intended. Indeed, there is some common sense to this. Almost anyone who has had a surgical procedure was likely given a legal opioid like fentanyl. As one prominent anesthesiologist wrote, “To an anesthesiologist, fentanyl is as familiar as a Philips screwdriver is to a carpenter; it is an indispensable tool in my toolbox. It is the most commonly used painkiller during surgery. If you’ve had surgery, it is more likely than not that you have had fentanyl.”[6] And yet the vast majority of people who have had surgical procedures do not develop an opioid abuse problem.

Yes, there is a narrative involving a reverse gateway theory about heroin abuse, i.e., that high percentages of heroin users started by abusing prescription opioid drugs. But that is misleading and, indeed, looks at the problem from the wrong direction. As Dr. Robert DuPont from the Institute for Behavioral Health has put it, “[W]hile 80% of heroin users used a prescription opioid before they first used heroin, the vast majority, over 96%, of people who have used a prescription opioid non-medically [i.e., illegally] have not transitioned to using heroin. Five years after the initial nonmedical use of a prescription opioid, only 3.6% ever used any heroin. Among prescription opiate users, the people most vulnerable to switching to heroin are those who are also abusers of other drugs including alcohol.”[7]

In other words, the vast majority of prescription opioid patients do not transition to the use of an illegal drug like heroin. Other data bear this out, as well. For example, according to an important article in the January 2016 issue of The New England Journal of Medicine, “[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.”[8]

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 clearest picture of the problem. In our research, we have found there is a great deal of confusion on what is leading the epidemic and causing the majority of the problem. If we focus our time and effort tackling the least part of the problem, or misidentifying the majority of the problem, we will only aid and abet the exacerbation of the crisis. 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://obamawhitehouse.archives.gov/the-press-office/2016/12/08/continued-rise-opioid-overdose-deaths-2015-shows-urgent-need-treatment

[2] http://www.prnewswire.com/news-releases/new-data-show-continuing-opioid-epidemic-in-the-united-states-300379945.html

[3] https://www.cdc.gov/drugoverdose/data/prescribing.html

[4] Ibid.

[5] http://docs.house.gov/meetings/IF/IF02/20170321/105739/HHRG-115-IF02-Wstate-HouryD-20170321.pdf

[6] http://bigstory.ap.org/article/c0ee724af1324663a2d16bcde2371822/fentanyl-widely-used-deadly-when-abused

[7] https://www.ibhinc.org/reduce-prescription-drug-abuse/

[8] http://www.nejm.org/doi/full/10.1056/NEJMra1508490#t=article