There is an ongoing opioid epidemic (also known as the opioid crisis) in the United States, originating out of both medical prescriptions and illegal sources. It has been described by doctors and researchers as "one of the most devastating public health catastrophes of our time". The opioid epidemic unfolded in three waves. The first wave of the epidemic in the United States began in the late 1990s, according to the Centers for Disease Control and Prevention (CDC), when opioids were increasingly prescribed for pain management, resulting in a rise in overall opioid use throughout subsequent years. The second wave was from an expansion in the heroin market to supply already addicted people. The third wave, starting in 2013, was marked by a steep tenfold increase in the synthetic opioid-involved death rate as synthetic opioids flooded the US market.
In the United States, there were approximately 109,600 drug-overdose-related deaths in the 12-month period ending January 31, 2023, at a rate of 300 deaths per day.Products - Vital Statistics Rapid Release - Provisional Drug Overdose Data . Centers for Disease Control and Prevention. Hover cursor over the end of the graph in Figure 1A to get the latest number. Scroll down the page and click on the dropdown data table called "Data Table for Figure 1a. 12 Month-ending Provisional Counts of Drug Overdose Deaths". The number used is the "predicted value" for the 12 month period that is ending at the end of that month. That number changes as more info comes in. If there are problems use a different browser. From 1999 to 2020, nearly 841,000 people died from drug overdoses, with prescription and illicit opioids responsible for 500,000 of those deaths. Drug overdose deaths totaled 70,237 in 2017, with 47,600 involving an opioid. This surpassed deaths from car crashes (37,133) by 28%. A December 2017 report estimated that 130 people die every day in the United States due to opioid-related drug overdose. The great majority of Americans surveyed in 2015 who used prescription opioids did not believe that they were misusing them.Rachel N. Lipari, Ph.D., Matthew Williams, Ph.D., and Struther L. Van Horn, M.A. "Why Do Adults Misuse Prescription Drugs?" Substance Abuse and Mental Health Services Administration Short Report. July 27, 2017.
The problem is significantly worse in rural areas, where socioeconomic variables, health behaviors, and accessibility to healthcare are responsible for a higher death rate. Teen use of opioids has been noticeably increasing, with prescription drugs used more than any illicit drug except cannabis – more than cocaine, heroin, and methamphetamine combined.
Background Opioids are a diverse class of strong, addictive, and inexpensive drugs, which include opiates (i.e., morphine and codeine), oxycodone (OxyContin, Percocet), hydrocodone (Vicodin, Norco), and fentanyl. Traditionally, opioids have been prescribed for short-term pain management, as short-term use is supported by a body of evidence. The usefulness of opioids in chronic pain is dependent on the kind of pain being treated (e.g., visceral and central pain may be "especially unresponsive to long-term opioid therapy") and the patient. Clinical guidelines advise that opioids should only be used for chronic pain if safer alternatives are not feasible, as their risks often outweigh their benefits.
The potency and availability of opioids have made them popular as both medical treatments and recreational drugs. The Substance Abuse and Mental Health Services Administration (SAMHSA) estimated that over 10 million Americans abused prescription opioids in 2018; 47,600 Americans died from opioid overdoses in 2018. These substances have high risks of addiction and overdose, and long-term use can cause tolerance and physical dependence. SAMHSA allocated $7.5 billion between January 2016 and June 2020, as response to this opioid crisis. These resources aim to increase access to medications for treatment, reduce overdose deaths, and sustain prevention and recovery. When people continue to use opioid medications beyond what a doctor prescribes, whether to minimize pain or induce euphoric feelings, it can mark the beginning stages of an opioid addiction."Why opioid overdose deaths seem to happen in spurts" , CNN, February 8, 2017 More than 650,000 Americans have died of drug overdoses since the opioid epidemic began. The deaths attributable to opioid overdose increased from 16 deaths to 595 deaths per 100,000 population in the US.
Waves of the opioid epidemic
The Centers for Disease Control and Prevention described the U.S. opioid epidemic as having arrived in three waves. 2022 research indicates that since 2016, the United States has been experiencing the fourth wave of the opioid epidemic.
The epidemic began with the overprescription and abuse of prescription drugs. As prescription drugs became less accessible in 2016 in response to CDC opioid prescribing guidelines, there was an increase in demand and accessibility to cheaper, illicit alternatives to opioids, such as heroin and fentanyl.
First wave (1990–2010)
The first wave, which marked the start of the epidemic, began in the 1990s due to the push towards using opioid medications for chronic pain management and the increased promotion by pharmaceutical companies for medical professionals to use their opioid medications. During this time, around 100 million people in the United States were estimated to be affected by chronic pain. Opioids were only reserved for acute pain experienced secondary to cancer or terminal illnesses.
Physicians avoided prescribing opioids for other medical conditions because of the lack of evidence supporting their use, the concern of opioids having addictive properties, and the fear of being investigated or disciplined for liberal opioid practices. A letter to the editor featured in a January 1980 issue of The New England Journal of Medicine (NEJM) was frequently cited to justify more liberal use of opioids in pain management, which the World Health Organization eventually supported.
In addition, medical organizations began to push for more attentive physician responses to pain, referring to pain as the "fifth vital sign". This was coupled with the promotion of opioids by pharmaceutical companies which insisted that patients could not become addicted. Opioids became an acceptable treatment for a wide variety of conditions, leading to a consistent increase in opioid prescriptions. From 1990 to 1999, the total number of opioid prescriptions grew from 76 million to approximately 116 million, making them the most prescribed class of medications in the United States.
Mirroring the upwards trend in the volume of opioid pain relievers prescribed was an increase in admissions for substance use disorder treatments and opioid-related deaths. This illustrates how legitimate clinical prescriptions of pain relievers were being diverted through an illegitimate market, leading to misuse, addiction, and death. With the increase in volume, the potency of opioids also increased. By 2002, one in six opioid users was prescribed drugs more powerful than morphine. By 2012, the ratio had doubled to one in three. The most commonly prescribed opioids were oxycodone and hydrocodone.
Second wave (2010–2013) The second wave of the opioid epidemic began around 2010 and is characterized by the surge in heroin use and overdose deaths. Between 2005 and 2012, the number of people who used heroin nearly doubled, growing from 380,000 to 670,000 individuals. In 2010, there were 2,789 fatal heroin overdoses, representing an almost 50% increase compared to previous years.
This sharp increase can be attributed to the availability of heroin in the United States and its decreasing prices, which enticed a significant portion of individuals already dependent on opioids to switch to a more potent and cost-effective alternative. During this same period, there was a reformulation of OxyContin that made it more difficult to crush and misuse, although the precise impact of this reformulation on the rise in heroin use remains uncertain.
Third wave (2013–2016) According to the CDC, the third wave of the opioid epidemic began in 2013, and concluded in 2016. This wave coincided with a significant increase in overdose deaths involving synthetic opioids, particularly illegally produced fentanyl. During this period, deaths related to prescription opioids increased marginally, while heroin-related deaths remained relatively stable. The demographic affected during this wave was younger, less frequently male, and more likely to be white and rural compared to the previous waves.
The third wave also witnessed an increase in opioid-related overdoses among Black and Hispanic individuals in urban areas who use drugs. The rise in fentanyl-related deaths is attributed to the fact that fentanyl is 50 to 100 times more potent than morphine, and it is often mixed into heroin or cocaine to increase potency at a low cost. Considering that Black Americans tend to consume cocaine more frequently than heroin or other prescription opioids compared to white populations, the increase in deaths is linked to the greater prevalence of fentanyl-laced cocaine.
Fourth wave (2016–present) The fourth wave, which began in 2016, is characterized by polysubstance use and increased use of stimulants like methamphetamines and cocaine. Additionally, this wave is characterized by the emergence of novel adulterants, such as xylazine and more recently medetomidine in the fentanyl supply. The availability and use of illicit fentanyl continue to be the leading cause of fatalities, but the recent rise of polysubstance use, defined as the practice of using multiple drugs at once or in succession, and stimulants, is linked to the increased fatality rate with the ongoing opioid epidemic.
Between 2012 and 2018, there was a threefold increase in mortality related to cocaine use, and a fivefold increase in mortality related to psychostimulants like methamphetamine. This increase has primarily been observed in male populations from non-Hispanic American Indian, non-Hispanic Black, and non-Hispanic White populations. Researchers attribute the increase in illicit drug use to the CDC's recommendations to reduce opioid use through measures like tapering opioid prescribing.
In 2023, opioid deaths began a sustained decline after peaking at 73,000 that year. Deaths declined by over 1/3 in 2024. The decline is attributed to the reduced availability of fentanyl precursors from China, as the quality of fentanyl decline along supply chains affecting production in both Mexico and China.
Causes In 2019, the epidemic was described by Rolling Stone as a "uniquely American problem". In 2017, prescription rates for opioids in the United States were 40 percent higher than the rate in other developed countries such as Germany or Canada. yet the FDA did not fully utilize its regulatory mechanisms to restrict the pharmaceutical industry.
The structure of the U.S. healthcare system, in which people not qualifying for government programs are required to obtain private insurance, favors prescribing drugs over more expensive therapies. According to Professor Judith Feinberg, "Most insurance, especially for poor people, won't pay for anything but a pill."
While the rates of opioid prescriptions increased between 2001 and 2010, the prescription of non-opioid pain relievers (aspirin, ibuprofen, etc.) decreased from 38% to 29% of ambulatory visits in the same period.