Do You Know the History of the Opioid Epidemic?
Key Points
- In 2022, an estimated 110,000 people died from drug overdoses in the U.S., the highest number ever recorded in a calendar year. More than two-thirds of those deaths, or about 75,000, involved a synthetic opioid.
- Purdue Pharma mass promoted OxyContin intending to sell 205,000 prescriptions with a value of $25 million in 1996 alone. The company's goals tripled in 1997 and continued to rise, reaching $1.4 billion in 2001 and $1.2 billion in 2002.
- More than 150 people in the U.S. die every day from overdoses related to synthetic opioids such as fentanyl, per the CDC.
The opioid epidemic, one of the most severe and deadly public health crises in United States history, has affected the nation for more than 30 years.
People have used opiates—chemicals derived from the poppy plant—for millennia. But the development and mass production of opioids, also known as synthetic opiates, has made these powerful and addictive compounds more potent and accessible than ever before.
Opioids are a class of drugs that, like opiates, affect receptors in the brain to alleviate pain and induce euphoria and relaxation. Whereas opiates—codeine, opium, morphine—are created solely from the poppy plant, opioids can be wholly or partially manufactured in a laboratory.
They include illegal substances such as heroin and prescription medications such as morphine and hydrocodone. The World Health Organization (WHO) has deemed these as essential medicines, even though the long-term use of any of these drugs can cause dependence and permanent neurological changes.
In the U.S., more than 645,000 people died from opioid overdoses between 1999 and 2021, according to the Centers for Disease Control and Prevention (CDC).
Opioid use disorder (OUD) continues to claim tens of thousands of lives every year, and about 3 million people are living with the condition, according to the National Library of Medicine.
This chronic, life-threatening disease can decimate a person's life, career, relationships and health. One of the more common complications of OUD is opioid-induced endocrine deficiency.
Characterized by the depletion of hormones such as testosterone, estrogen and progesterone, OUD can cause erectile dysfunction (ED), menstrual irregularities, diminished fertility and low libido. Opioid use disorder also raises the risk of pregnancy complications.
Opioid use disorder is highly treatable, but overcoming it requires tremendous resources and support. Knowing the history of the opioid epidemic can be useful in better understanding OUD and helping those affected by it.
What is the opioid epidemic?
The opioid epidemic refers to the rapid escalation and widespread overprescription and misuse of prescription and nonprescription opioids in the United States and beyond.
About 110,000 people died from drug overdoses in 2022 in the U.S., the highest number ever recorded in a calendar year. More than two-thirds of those deaths, or about 75,000, involved a synthetic opioid.
The history of the opioid crisis
People have used opium for medicinal and recreational purposes since at least 3400 BCE, according to the Drug Enforcement Administration (DEA) Museum. In the 19th century, codeine and morphine were discovered and isolated, and the first syringe was developed to make morphine administration easier.
Since the beginning of their use, the powerful pain-relieving properties of opiates have been as well-known as well as their propensity to cause dependence and addiction.
In search of a better solution, scientists in the early 20th century investigated how to separate the drugs' medicinal properties from their addictive components, according to the National Institutes of Health (NIH).
In the 1960s, the first synthetic opiate or "opioid," pentazocine, emerged. The drug, which was made with both natural and synthetic chemicals, combined the effects of morphine with those of an opiate antidote, making it far less addictive than its predecessors.
Along with pain relief, it was used to help people addicted to heroin manage withdrawal symptoms. The drug didn't replace other more addictive opiates on a large scale, however, nor did it eradicate misuse, which was already prevalent.
In the 1970s, a severe opium shortage occurred, fueled by escalating demand and poor poppy crops, among other factors. This prompted scientists and pharmaceutical companies to race to find a way of making completely synthetic opioids, according to the NIH.
In 1979, Kenner Rice, Ph.D., determined how to produce the three critical chemical components of opium—thebaine, morphine and codeine—in a lab.
Although this finding was critical for legitimate medical purposes, it also unwittingly laid the groundwork for mass production of opioids, and the onset of an epidemic.
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The creation of oxycodone
The opioid crisis is composed of three "waves," according to the CDC. The first occurred in the 1990s.
This first opioid wave was characterized by a sudden spike in prescription opioids spurred by the release of oxycodone, a synthesized form of thebaine, the main ingredient in OxyContin.
"This prescription drug was distributed as a means of pain relief but soon became a catalyst for the opioid addiction epidemic when they began getting over-prescribed," said Olalekan Otulana, M.B.Ch.B., a general practitioner and addiction specialist in Stevenage, United Kingdom.
Purdue Pharma claimed the drug was not addictive except to some people with "addictive personalities." Purdue made the claim due primarily to the drug's extended-release properties, according to a report published in Missouri Medicine, the Journal of the Missouri State Medical Association.
The company aggressively mass promoted OxyContin intending to sell 205,000 prescriptions worth $25 million in 1996 alone, according to the Kaiser Family Foundation (KFF).
As part of the Purdue Pharma strategy, the company paid physicians to promote it, according to the Harvard T.H. Chan School of Public Health.
Purdue Pharma and its representatives also touted the drug as an effective, safe solution for chronic pain, such as that caused by arthritis, per KFF.
In the past, healthcare providers had almost exclusively used opioids and opiates to treat severe, acute pain, such as that caused by surgery or a broken bone. The change meant people were prescribed opioids for long-term use, raising the risk of misuse and addiction.
"This marketing plan was a big player in the major roll-out of OxyContin, resulting in the continuous development of opioid abuse and, thus, addiction," Otulana said.
The company's sales goals tripled in 1997 and continued to rise, reaching $1.4 billion in 2001 and $1.2 billion in 2002. All the while, the company insisted the drug was safe. That changed in 2007 when Purdue pleaded guilty to felony charges. Executives admitted they knew the drug was addictive and falsely advertised it.
However, many people, including healthcare professionals, were initially unaware of the dangers, per KFF.
"Most providers didn't overprescribe intentionally," Otulana said. "Even knowing the risks, doctors may inadvertently prescribe more doses than a patient needs."
For example, they may prescribe one dose daily for 30 days, but the patient may feel better within 20 days, leaving 10 doses unused.
"This can result in there being doses left over, granting the opportunity for substance abuse," he said. "This is a hypothetical circumstance, but it can reflect how even a small overprescription can contribute to the gradual development of opioid abuse."
Turning to illegal sources
In the early 2000s, the opioid crisis took a turn. As crackdowns on prescription opioids began, people with OUD started turning to a cheaper and more potent alternative: heroin.
In 2010, the epidemic's second wave began, characterized by a rapid increase in heroin-related overdose deaths, according to the CDC.
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The emergence of fentanyl
In 2013, the third wave began, marked by the emergence of powerful opioids such as fentanyl, which is 50 to 100 times more potent than morphine. Not only is fentanyl cheaper and more addictive than its predecessors, but people taking it for the first time may have been unaware of its potency and taken too much, leading to overdose.
Illegally manufactured fentanyl is often mixed with other drugs—these can include heroin, cocaine or methamphetamine—or made to resemble prescription opioids. Users may not always realize this when purchasing it, further raising the likelihood of an overdose.
More than 150 people in the U.S. die every day from overdoses related to synthetic opioids such as fentanyl, per the CDC.
The impact of the COVID-19 pandemic
"COVID-19 significantly exacerbated the crisis for various reasons, with one of the most significant being the pandemic's effect on people's mental health and overall well-being," Otulana said. "The pandemic presented problems many people have never faced, ranging from overwhelming anxiety to housing loss or the death of a loved one.
"This deterioration of mental stability acts as one of the root causes of abuse and addiction."
Isolation and an overwhelmed healthcare system meant people in OUD recovery had to fight harder to combat addiction alone, greatly increasing their risk of relapse.
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Lawsuits and controversy
In the past decade, more details have come to light regarding the role of pharmaceutical manufacturers and distributors in the opioid crisis, prompting numerous individuals, local and state governments, and Native American tribes to file thousands of lawsuits nationwide.
The most significant case to date occurred in 2019, when Purdue Pharma settled with 23 states and attorneys representing about 2,000 local governments, according to the American Bar Association (ABA).
The deal required Purdue Pharma to file for bankruptcy and pay up to $12 billion over time, up to $4.5 billion of which comes from the company owners, the Sackler family.
Several states have also filed separate suits against the Sackler family, per the ABA. The company settled multiple other cases, including one in 2007 for $635 million and another in 2019 for $270 million.
"The suit was a huge victory for states seeking to recover funds to address the crisis," said Mitchel Ashley, owner of the Ashley Law Firm in New York City.
Additionally, in 2020, the company pleaded guilty to federal criminal charges and agreed to pay up to $8.3 billion, including $225 million in civil penalties, which will come from the Sackler family, according to the U.S. Department of Justice.
"Purdue Pharma is far from the only culprit," Ashley said.
In 2019, an Oklahoma court ordered Johnson & Johnson to pay more than $570 million for its role, per the ABA.
In 2022, four U.S. corporations agreed to pay about $26 billion to settle multiple lawsuits connected to their contributions, according to National Public Radio (NPR). The accused included Johnson & Johnson and three drug wholesalers: AmerisourceBergen, Cardinal Health and McKesson.
Several other large companies, including Walgreens and Rite Aid, have also faced lawsuits tied to their alleged misleading marketing practices and vast over-distribution, according to the ABA.
"There are also myriad civil suits against individual doctors who over-prescribed opioids, causing 'tremendous harm,'" Ashley said.
Overcoming the epidemic will require a multifaceted, holistic approach and the cooperation and investment of multiple local, state and federal entities, according to experts. The U.S. has already made significant strides on this journey.
"Besides helping communities, state governments and tribes recover funds to combat the epidemic, lawsuits and criminal investigations have contributed to positive outcomes such as more drug regulation and oversight in the healthcare and pharmaceutical industries," Ashley said
The federal government has also taken steps to combat the epidemic, including passing the Opioid Crisis Response Act of 2018. The bill establishes a series of programs and requirements related to opioid misuse, according to the official website of the U.S. federal legislature.
These programs and requirements include the following:
- Programs to support non-addictive pain management therapies
- Training for first responders and treatment and recovery centers
- Public education campaigns
- Controlled substance regulation
In 2022, the U.S. Department of Health and Human Services (HHS), through the Substance Abuse and Mental Health Services Administration (SAMHSA), awarded nearly $1.5 billion to all states, tribal lands and territories to address the crisis and support people in recovery, according to the White House.
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