Epidemiology of the US Opioid Crisis

Addiction to opioids has become a crisis in this country. Addiction is defined by the ICD

10 as a dependence syndrome, which can be characterized as “a cluster of physiological,

behavioral, and cognitive phenomena in which the use of a substance takes on a much higher

priority for a given individual than other behaviors that once had greater value” (WHO 2015).

Opioid addiction in the US has increased in recent years and has become a particularly serious

problem as it has been estimated that 1.7 million people may be addicted to opioid-based

painkillers (NIDA 2019). Due to the nature of addiction, the cost of using, and the illegal

activities required to support an opioid addiction, people addicted to opioids are at risk of losing

their families, their livelihoods, and even their lives.

Opioids are naturally or synthetically derived chemicals that mimic the natural

endorphins in the human body (Mayo Clinic 2018). Endorphins are the body’s natural pain

killers and they can also create a feeling of euphoria in the body and mind. Opioids have a

similar effect on the human body as endorphins. Over time, usage of opioids can lead to mental

and physical addiction as the body adjusts to the intake of these chemicals and reduces normal

production of endorphins. Use of opioids depresses respiration rates and can cause vital

systems in the body to shut down leading, if those systems are not reactivated, to death. The

shutdown of those systems, whether or not it results in death, is called an overdose. Natural

opioids, known as opiates, have been used throughout history but overall opioid use has

recently increased as 80% of current heroin users were previous abusers of prescription drugs

(NIDA 2019). Overdose rates have increased anywhere between 30% and 70% in affected

areas around the country (NIDA 2019).

The US Health and Human Services Department (HHS) declared the rise in opioid use

and overdose a public health crisis in 2017 (2019). According to the HHS, pharmaceutical

companies contributed heavily to the rise in opioid use when they convinced medical personnel

that opiate-derived painkillers were a non-addictive way to treat pain in patients (2019). This led
to an increase in opioid prescriptions across the country (HHS 2019). The increased rates of

prescribing increased the number of patients using legally prescribed opioids. Approximately

10% of prescription opioid users become addicted and addiction can lead to the use of a

cheaper substitute, heroin (NIDA 2019). The National Institute on Drug Abuse (NIDA) described

an increase in the rates of opioid overdose across the country and attributes this rise in

overdose deaths to the increase in availability, legal and illegal, of prescription painkillers as well

as an increase in the prevalence of fentanyl, a very potent synthetic opioid, used with or instead

of heroin as a cheap substitute (NIDA 2019). According to the Center for Disease Control

(CDC), “drug overdoses are the [current] leading cause of injury death in the United States”

(Mack et al. 2017). The intravenous use of heroin has led to a rise in the spread of other

infectious diseases among drug users, which compounds the seriousness of this epidemic

(NIDA 2019). In addition, future generations are affected as babies are born already addicted, if

their mothers had used opioids while pregnant (NIDA 2019).

The typical profile of a user of opioids has changed as the risk factors of opioid use have

shifted, due to the increase in prescribing opioids. The Mayo Clinic lists several populations at

risk for opioid addiction that includes those who are young, those with depression, and those

who live in poverty (2018). The Mayo Clinic goes on to state that extended use of prescription

drugs for pain relief is not safe and is linked to an increased risk of addiction (2018). This

inclusion of an additional section of the population, those prescribed opioid painkillers, indicates

that an increased percentage of the whole population is now at risk of opioid addiction.
Figure 1: Opioid deaths per 100,000 in the US from 1999 to 2017 for three types of opioid uses (CDC

2018)

Synthetic opioids, prescription painkillers, and heroin are all considered contributors to

the crisis in the United States. According to Figure 1, all three sources of opioids have seen an

increase in overdose death rates between 1999 and 2017 (HHS 2018). Each source has a

different rate of rise described in the graph that can help to determine its contribution to the

epidemic. Prescription overdose deaths were on a steady rise from about 2000 to 2016, but

heroin and synthetic opioid deaths don’t exhibit a distinct increase until 2010 and 2013,

respectively. Due to these events on the timeline, it could be deduced that the rise in heroin and

fentanyl overdose rates were affected in some way by the preceding rise in prescription drugs

overdoses, which could direct researchers to a line of questioning that would better examine this

issue. Studying the timeline of overdose rates allows researchers to determine likely origins of,

or sources contributing to, the epidemic.

months broken down by regions of the US (NIDA 2019).

Although this is considered a country-wide epidemic, it’s important to note that not all

areas of the country are affected equally by opioid use. Figure 2 shows an overall increase in

number of suspected opioid overdoses between the last half of 2016 and the first three quarters

of 2017, but the regional breakdown of the overdose rates allows researchers to better

determine which areas are most affected by this epidemic. Some regions, such as the Midwest

and West, appear to have been more heavily affected by this crisis than others. Knowing what

areas of the country are most and least affected could help researchers to understand what

policies and other regional systems are in place that may be influencing the rates of opioid use.

Researchers can then design and study comparable regions to determine the effect of the

policies and systems in question.

illicit drug use, by sex and residential area — National Survey of Drug Use and Health, United States,

2003–2014 (Mack et al. 2018)

The CDC’s October 20, 2017 Morbidity and Mortality Weekly Report (MMWR)

emphasizes the importance of examining the data on illicit drug use by breaking it down into

types of areas by population size in order to get a view of where these problems are occurring,

which can lead to a better understanding of the sources of these problems and how to manage

them (2017). According to Figure 3’s last time period, 2012-2014, there was a decrease in the

use of illicit drugs in large and small metropolitan areas but an increase in nonmetropolitan

areas. Shifts like this can provide important information about the epidemic that are not evident

when only presented with simple usage numbers of large or unspecified areas. For example,
this shift could indicate that a preventative measure implemented in cities is working and an

expanded reach is necessary.

As more data is accumulated by researchers, the sources of these problems will become

clearer. They will also be able to determine which measures are effective at reducing the

increased prevalence of opioid abuse and subsequent overdoses and which have little to no

effect. Recently, using some of the data already accumulated from highly affected areas,

authorities were able to determine that doctors and other medical personnel were abusing their

prescribing abilities and distributing prescription opioids illegally in those areas (Robertson

2019). As a result, the offenders have been charged with crimes and this source of the

potentially deadly drugs has been removed from the system.

[CDC] Opioid Overdose: Understanding the Epidemic. 2018. Atlanta (GA): Center for Disease

Control; [cited 2019 Apr 25]. Available from:

[Link]

[HHS] What is the US Opioid Epidemic? [Internet]. 2019. Washington (D.C.): US

Department of Health and Human Services; [cited 2019 Apr 25]. Available from:

[Link]

Mack KA, Jones CM, Ballesteros MF. 2017. Illicit drug use, illicit drug use disorders, and drug

overdose deaths in metropolitan and nonmetropolitan areas — United States. MMWR

Surveill Summ 2017;66(No. SS-19):1–12.

[Mayo Clinic] How Opioid Addiction Occurs [Internet]. 2018. Rochester (MN): Mayo Clinic;

[cited 2019 Apr 25]. Available from:

[Link] abuse/in depth/how-

opioid-addiction-occurs/art-20360372

[NIDA] Opioid Overdose Crisis [Internet]. 2019. Bethesda (MD): National

Institute on Drug Abuse; [cited 2019 Apr 25]. Available from:

[Link]

Robertson, C. 2019 April 17. Doctors accused of trading opioid prescriptions for sex and cash.

The New York Times. Sect. A:18.

[WHO] The ICD-10 Classification of Mental and Behavioral Disorders. 2015. Geneva

(Switzerland): World Health Organization.