The US President has finally declared a state of emergency on the US national opioid epidemic, the biggest killer of Americans under 50. We have to ask: Why has the US developed such a problem with fatal drug overdoses?

The numbers are shocking, but behind the facts and figures, of course, there are real lives. According to the UN’s 2017 World Drug Report the US has four per cent of the world’s population but 27 per cent of the world’s drug deaths. To put this in context, four people per million die of drug overdose in neighbouring Mexico, whereas that number rises to a staggering 245 deaths per million for Americans between 15 and 64. First estimates for 2016 put the number of overdoses at around 59,000 – 65,000, which means drug deaths now outnumber peak deaths from traffic accidents, or AIDS, and totals more than the number of US combat fatalities in the Vietnam War. 

The relationship between the US and drugs is a complex one. The root causes of what’s been labelled the opioid epidemic date back to the 1990s and the calls made then declare the under-treatment of chronic pain a public health problem. At the time, there were around 100million Americans in chronic and serious pain. Opioid painkillers, of course, have legitimate use and help many people in their pain management.  

Opioids is a loose term that categorises drugs related to the opium family, such as morphine, heroin, and oxycodone. They are often potent drugs which bind themselves to the receptors in the nervous system and block pain messages to the brain. In the 1990s, there was an emerging call for doctors to prescribe opioid painkillers more liberally owing to their efficiency and ‘safety’ in comparison to other drugs. As such, year upon year, legal use of these drugs went up.

The US is fairly unique in that it is one of the few countries in the world which allows public marketing and advertising of prescription drugs. What many would see as strange and damaging, the US has primetime television adverts, firmly aimed at the consumer, to ‘ask your doctor for…’ specific brands. By 2012, US doctors wrote 259 million prescriptions for opioid painkillers. The combination of commercial incentives and addictive qualities of prescription painkillers led to a state of dependency among many Americans.

With addictive qualities, many Americans began to become dependent on opioid drugs, but addiction is an equally complex issue in its own right. Those who are in long-term ill health, whether that’s emotional or physical, are going to be more likely to become dependent on drugs than those who are in good health. The pathways into addiction are both complex and equally matched with common-sense: Where there is suffering, a way to alleviate that pain is needed or sought after. 

An interim report released by The White House Commission on Combating Drug Addiction and the Opioid Crisis made it clear:

“We have an enormous problem that is often not beginning on street corners; it is starting in doctor’s offices and hospitals in every state in our nation.”

The report also highlights that, “over forty percent of people with a substance use disorder also have a mental health problem, but less than half of these people receive treatment for either issue.”

Due to the increased awareness of over-prescribing, there’s been a reactionary a cutback in patients’ supply to painkillers. Many of those who lost access to painkillers were still addicted and subsequently turned to cheaper, yet far more potent alternatives like heroin and fentanyl. This reinforced the expansion of the illegal market of these drugs. It’s believed that someone who is dependent on prescription painkillers is now 40 times as likely to be addicted to heroin. The US now has a thriving culture around drugs such as heroin, and stronger opioids such as fentanyl which is around 50 times stronger than heroin. Causing even greater concern is the advent of carfentanil, a tranquilizer that can be used on elephants and is reported to be 10,000 times stronger than heroin. Carfentanil is so potent and dangerous that first responders and medical teams have been reported to overdose on the drug simply through residual contact.

The general consensus is that fear, stigma or a general lack of understanding often resides with those who may want to seek help for their dependency. These are all driving forces as to why patients seek out their own opioids and turn to the Darknet or street dealers. 

The White House interim report does make some recommendations which are aligned with the wider calls for drug policy reform many NGOs have advocated for quite some time, such as the wider distribution of the overdose reversal drug Naloxone. The interim report on the opioid crisis proposes that this life-saving drug should, “be in the hands of every law enforcement officer in the United States”.

If the US wants to lessen its drug overdoses, as the interim report highlights, then punitive drug laws need to be addressed. ‘Good Samaritan’ laws are a broad recommendation in the pursuit of saving lives - their basic premise is to prevent civil or criminal prosecution for anyone attending the scene of an overdose, offering protection so that the only focus is saving a life. 

The US is not alone in this conversation - Canada and the UK also face their own problems with rising drug deaths and overdoses, highlighting the need for greater openness and to treat addiction with the care that we’d like to be available to their loved ones to be treated with. As the White House opioid commission points out: “It would also awaken every American to this simple fact: if this scourge has not found you or your family yet, without bold action by everyone, it soon will.”

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