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Charting Two Decades of the Evolving Opioid Crisis
November 18, 2022:
In more than 20 years, the overdose crisis has shifted and grown from prescription opioids to a range of illicitly trafficked drugs |
Just over a decade after the U.S. Centers for Disease Control and Prevention (CDC) declared an “epidemic” of overdoses from prescription painkillers in 2011, the opioid crisis is worse than ever—yet it only vaguely resembles those earlier days. While people are still dying of overdoses tied to prescription opioids, the problem has largely shifted to illicitly trafficked opioids, such as fentanyl, and is now deeply intertwined with other non-opioid substances, such as methamphetamine and cocaine.
This blog examines the history and evolution of the opioid crisis through several charts based on data from SHADAC’s State Health Compare.
Changing attitudes in opioid prescribing
Today, it is broadly accepted that the over-prescribing of opioid painkillers—such as the blockbuster drug Oxycontin (a brand-name version of oxycodone produced by Purdue Pharma) and related semi-synthetic opioid hydrocodone—sparked what became an epidemic of overdoses and deaths. Over more than 10 years, deaths from overdoses involving those medications gradually crept upward until they finally capture widespread attention. When the toll of overdose deaths from prescription opioids was fully recognized and the U.S. healthcare system started to grapple with the problem, efforts to curb prescribing began.
In the first chart, data from the U.S. Drug Enforcement Agency show how legal sales of oxycodone and hydrocodone began the early days of the crisis at about 5 kilograms per 100,000 people in 2000. But within a decade, oxycodone sales roughly quadrupled and hydrocodone sales almost tripled (Figure 1). Following growing awareness of the problem, legal sales of both drugs—driven by prescriptions written by healthcare providers—have declined substantially. In 2021, hydrocodone sales had fallen to about 5 kilograms per 100,000 people, and oxycodone sales to less than 10 kilograms per 100,000 people.
Figure 1: Prescription opioid painkiller sales, 2000-2021
Source: SHADAC analysis of U.S. Drug Enforcement Agency's Automated Reports and Consolidated Ordering System (ARCOS) Retail Drug Summary Reports, obtained from statehealthcompare.shadac.org.
These data demonstrate that legal sales of prescription opioid painkillers are down dramatically from their heights when the CDC first rang alarm bells over the issue. However, some experts and advocates argue that the abrupt pivot in opioid prescribing practices was not done carefully enough, with many people who were already addicted to opioids suddenly cut off without sufficient screening for addiction or access to treatment. And data show that although deaths from prescription opioids have essentially plateaued since prescribing of opioid painkillers dropped, opioid overdose deaths have still continued to climb.
Persistently growing rates of opioid overdose deaths
Because overdose deaths were driven largely by prescription opioid painkillers in the early days of the epidemic, the hope and expectation was that death rates would drop as healthcare providers curtailed their prescribing of the risky medications. But this next set of charts shows that this hope was not fully realized.
In fact, the enhanced scrutiny on opioid prescribing and declining sales of prescription opioid painkillers appears to have marked a turning point in the epidemic. While deaths from prescription opioid painkillers have not declined dramatically, their growth trend leveled off and has remained relatively steady, around 4 deaths per 100,000 people, for almost a decade (Figure 2).
Figure 2: Prescription opioid painkiller death rates, 1999-2020
Source: SHADAC analysis of National Center for Health Statistics mortality files, obtained from statehealthcompare.shadac.org.
But to the shock and horror of many, overall overdose death rates—including prescription opioid painkillers as well as all other kinds of opioids—only continued to accelerate.
Figure 3: Death rates from all opioid types, 1999-2020
Source: SHADAC analysis of National Center for Health Statistics mortality files, obtained from statehealthcompare.shadac.org.
In less than a decade, the overdose death rate from all opioids roughly tripled, from 7.3 deaths per 100,000 people in 2011 to 21.4 deaths per 100,000 people in 2020 (Figure 3). But this time, the growth came from different types of opioids. First came heroin—an opioid that is without legal medical uses in the U.S. and is only available through the illicit drug trade. This was followed by fentanyl (and other closely related synthetic opioids), which does have legal medical uses but has been adopted by traffickers as a new drug of choice.
Figure 4: Death rates from fentanyl and other synthetic opioids, 1999-2020
Source: SHADAC analysis of National Center for Health Statistics mortality files, obtained from statehealthcompare.shadac.org.
In just a few years, the opioid crisis had transformed. What began as a problem rooted in widespread availability of prescription opioid painkillers shifted to illicitly trafficked opioids as legal opioid sales started to fall. By 2020, heroin overdose death rates had more than tripled since the CDC declared an opioid epidemic. And overdose death rates from fentanyl and similar synthetic opioids had grown more than 20 times (Figure 4).
In some ways, those developments may not be surprising. Economics tells us that when a good becomes scarce—such as prescription opioids after recognition of the crisis—people tend to cut back their consumption. But when people can’t simply stop their consumption, as in the case of addiction, they often turn to substitutes. With opioids, that unfortunately left many people to seek out substances such as heroin on the illicit market, where the purity and potency is unreliable, making them even riskier than prescription opioids. And once drug traffickers embraced the potent opioid fentanyl, it pervaded the illegal drug trade and became entangled with non-opioid substances, such as cocaine and methamphetamine.
A metastatic phase of the crisis
The opioid crisis is complex, and definitive evidence of how the epidemic evolved is hard to find. That is particularly the case in understanding the role of the illicit drug trade. However, it is widely accepted that some people shifted to heroin as prescription opioid painkillers became harder to obtain. Afterward, drug traffickers incorporated fentanyl into their supplies, sometimes to cheaply boost the potency of their heroin or simply to pass fentanyl off as heroin. Another approach was manufacturing counterfeit prescription medications, such as fake Oxycontin pills that actually contained fentanyl rather than the less-potent opioid oxycodone.
Over time, fentanyl became ubiquitous in the U.S. illicit drug market. Non-opioid illicitly trafficked substances, particularly cocaine and methamphetamine, are now often contaminated with fentanyl and related powerful opioids. And various kinds of illicitly trafficked counterfeit medications are found to contain fentanyl. In some cases, those counterfeit pills may mimic prescription opioid painkillers, but other counterfeit pills may contain fentanyl, even if the legitimate version does not. For instance, law enforcement agencies have reported interdicting fake stimulants (e.g., Ritalin and Adderall pills) that are mixtures of methamphetamine and fentanyl, even though the genuine medications do not contain opioids.
Ultimately, the pernicious impact of fentanyl and related synthetic opioids have transformed the opioid crisis. The prescription opioid painkillers that sparked this epidemic now only account for a fraction of drug overdose deaths in the U.S. (Figure 5), dwarfed by the toll of synthetic opioids such as fentanyl. And largely because of the pervasiveness of fentanyl in the market for illicit substances, deaths involving non-opioids also have grown to historic levels.
Figure 5: National Death rates for opioid and non-opioid substances, 2020
Source: SHADAC analysis of National Center for Health Statistics mortality files, obtained from statehealthcompare.shadac.org.
Lessons from opioids data
More than two decades into the opioid crisis, the main consistency is that the problem is continually evolving. When the role of prescription opioids in overdose deaths led the health care system to curtail dangerously generous prescribing of those medications, some people seemingly transitioned to illicitly trafficked opioids. When drug traffickers saw an opportunity to enhance their profits on heroin sales by using fentanyl and by manufacturing counterfeit pills, the epidemic became even deadlier. And as fentanyl became more pervasive, it also became intertwined with non-opioid substances, such as cocaine and methamphetamine—further extending the deadly reach of opioids.
To better understand and address the opioid crisis, it is important to use data to identify evolving patterns and trends and to anticipate new developments before they snowball into larger public health threats. Examining the history of the opioid crisis may prove useful to avoid recurrences of similar situations in the future, but it is also important to recognize the limitations of retrospective data for designing solutions to a dynamic situation. For instance, an overemphasis on prescribing of opioid painkillers now, when the vast majority of drug overdose deaths are caused by illicitly trafficked substances, could be considered akin to driving down a busy interstate highway while fixed on the rearview mirror.
Related Reading:
Blog: 2020 U.S. alcohol-involved deaths climbed by 26.6%, and drug overdose deaths by 30.6%
Resource Page: The Opioid Epidemic in the United States
