The Opioid Crisis – Three Waves of Abuse

The Opioid Crisis – Three Waves of Abuse

First Wave – Over prescribing

In January 1980 a letter published in the New England Journal of Medicine mentioned a study in which 11,882 patients were treated with opioids for chronic pain and found that for those with no history of addiction, were not at risk of developing addiction. A half a dozen years later, an additional study investigating 38 opioid users concluded that opioid treatment was safe, non-addictive, and there were no potential risks for abuse if there was no prior drug abuse history.

Over time, pharmaceutical companies reassured doctors and those prescribing opioids that if a patient was legitimately suffering from chronic pain, they were not at risk for developing an addiction and should be prescribed opioids for pain management whenever possible. As healthcare providers felt comfortable prescribing more and more, the number of pain killer prescriptions tripled between 1991 and 2011, and with that came addiction, misuse, illegitimate markets, and death.

In 1996, Perdue Pharma released OxyContin, claiming no serious medical side effects were associated with the drug and urged physicians to prescribe the painkillers to anyone who was experiencing some form of chronic pain. Despite what pharmaceutical and health care companies were telling doctors, patients prescribed opioids became addicted and dependent on the pills. Patients began to misuse their prescription, taking higher dosages than prescribed as their tolerance and subsequent addiction grew.  In 2011 a new form of OxyContin was introduced that was supposed to be “abuse-deterrent.”  This new formula was intended to make OxyContin harder to crush, making it more difficult to use by inhalation or injection and subsequently abuse. A 2012 study published in the New England Journal of Medicine that compared the effects of this new formula to other opioids and found that the number of those abusing OxyContin had indeed dropped, but 66 percent of those addicted found other ways to feed their addiction.


Second Wave – A Move to Heroin

Early attempts to control over-prescribing resulted in addicted opioid users looking elsewhere to maintain their lifestyle and turned to the cheaper, stronger, and more available opioid: heroin. Heroin is a derivative or morphine, a semi-synthetic drug that is used recreationally and is illegal. More potent than a prescription opioid, heroin related deaths increased 286 percent between 2002 and 2013. Over 80 percent of those users admitted that their prescription painkillers led them to move on to heroin, and thus, the second wave of the opioid crisis was born. The National Institute on Drug Abuse noted that  in the 1960s, 80 percent of those in opioid abuse treatment programs began their addiction with heroin. By the 2000s, 75 percent of those who were addicted to opioids admitted that that addiction began with a prescription for the painkillers. The increase was directly linked to the initial over-prescribing from the 1990s and by 2008, the overdose death rate was nearly four times the rate in was in 1999.


Third Wave – Fentanyl

Drug overdose deaths continued to climb and in 2015 alone, over 33,000 people died in the United States– doubling the amount of people who had passed away from overdoses in the last decade. The dramatic increase in deaths, despite opioid prescription rates being down was because of fentanyl, a fully synthetic opioid that is up to 100x more potent that morphine.

Fentanyl is most often used for severe cancer pain and anesthesia. Effects are felt almost instantaneously. Fentanyl is much cheaper than heroin, and with the heroin shortage, its illicit use can be traced to illegal manufacturing in China and Mexico. However, even though there is a demand for fentanyl, many opioid users don’t want it since the likely-hood of overdosing is almost certain. Drug manufacturers and cartels began cutting their heroin with fentanyl to move their product and make a profit. Drug dealers typically don’t know their product is laced with fentanyl and neither does the consumer. A two-milligram dosage of fentanyl is lethal to even the most seasoned opioid user. From prescription pills to drug misuse and addiction, to heroin, to fentanyl laced-heroin, addiction and overdose death rates continued to climb to unforeseen numbers.

The National Forensic Laboratory Information System found that fentanyl confiscations increased nearly seven-fold in just two years – between 2012 and 2014. According the Center for Disease Control and Prevention, overdose deaths involving synthetic opioids increased 47 percent between 2016 and 2017. In 2017, the United States saw nearly 72,000 deaths from drug overdoses – nearly 200 per day – with two-thirds of those deaths linked to opioids. The opioid epidemic has actually decreased average life expectancy, dropping it to 78.6 years. The opioid crisis was eventually declared national public health emergency and with that came the new five-point opioid strategy: designed to prioritize prevention, treatment and recovery; distributors; research; public health data and reporting; and pain management alternatives.


Sonia Moghe, “Opioid History: From ‘Wonder Drug’ to Abuse Epidemic” CNN (October 14, 2016). [Link]
Georgetown Behavioral Health Institute, “The Origin and Causes of the Opioid Epidemic” (August 14, 2018). [Link]
Maggie Fox, “Why Would Anyone Cut Heroin with Fentanyl? It’s Cheap, These Researchers Say” NBC News (December 4, 2018). [Link]
Michael O’Brian, “Fentanyl Changed the Opioid Epidemic. Now It’s Getting Worse” Rolling Stone (August 31, 2018). [Link]


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