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More Americans die from drug overdoses than HIV/AIDS did at its peak!

The deadliest drug crisis in America is happening right now.

With all the additional news going on, it can be easy to lose track of this reality. But it’s true: In 2015, more than 52,000 people died of drug overdoses, nearly two-thirds of which were linked to opioids like Percocet, OxyContin, heroin, and fentanyl. That’s more drug overdose deaths than any other duration in US history– even more than previous heroin epidemics, the crack epidemic, or the recent meth epidemic. And the initial data we have from 2016, 2017, and 2018 proposes that the epidemic may have gotten worse since 2015.

This scenario did not develop right away, but it has swiftly become one of the most significant public health crises facing America. To recognize how and why, I’ve put together a series of maps and charts that show the key elements of the epidemic– from its start through legal painkillers prescribed in droves by doctors to the latest rise of the highly powerful opioid fentanyl.

1) More people die from drug overdoses than gun homicides and car crashes combined

To comprehend just how bad the opioid epidemic has become, think about these statistics: Drug overdoses in 2015 were linked to more fatalities than car crashes or guns, and in fact killed more people than car crashes and gun homicides put together. Drug overdoses in 2015 also killed more people in the US than HIV/AIDS did during its pinnacle in 1995. So just as HIV/AIDS lives in the American mind as a horrible epidemic, the current opioid epidemic should too.

2) Drug, painkiller, heroin, and other opioid overdose deaths are still on the rise

It took years of increasing deaths to get to this point, but the opioid epidemic has only gotten worse over time. The result is horrifying: Between 1999 and 2015, more than 560,000 people in the US died to drug overdoses — a death toll larger than the entire population of Atlanta.

The epidemic has by and large been caused by the rise in opioid overdose deaths. First, opioid painkiller overdoses began to rise, as doctors began to fill out a record number of prescriptions for the drugs in an attempt to treat patients’ pain conditions. Then, people hooked on painkillers began to move over to heroin as they or their sources of drugs lost their prescriptions. And recently, more people have begun moving to fentanyl, an opioid that’s even more potent and cheaper than heroin. The result is a deadly epidemic that so far shows no signs of slowing down.

3) Opioid overdoses are one reason US life expectancy declined for the first time in decades

In 2015, US life expectancy fell for the first time in decades. There is an uncertain amount of causes behind the drop, including rising rates of diabetes, obesity, and suicide. But a big reason for the decrease was the rise in alcohol poisonings and drug overdoses.

4) The epidemic is much worse in some states than others

Not every single state in America has been evenly affected by the opioid epidemic. States such as West Virginia, New Hampshire, Rhode Island, and Ohio have been hit especially hard, suffering far more fatalities than even their neighbors on an annual basis. And the epidemic has typically been focused along the Rust Belt and New England– due in large part, it seems, to the vast number of painkiller prescriptions that doctors doled out in those areas.

5) By and large, the drug overdose epidemic has hit white Americans the hardest

The drug overdose epidemic hasn’t hit individuals of all racial clusters similarly either, with white Americans suffering far more overdose fatalities than their black and Latino peers. As the chart mentioned above shows, this is a switch from before the 2000s, when previous drug crises tended to hit black, urban communities much faster.

One reason for the disparity may be racism against nonwhite Americans. Reports show that doctors are more reluctant to prescribe painkillers to minorities, because doctors erroneously believe that minority individuals feel less pain or are more likely to abuse and sell the drugs. In a perverse way, this safeguarded minority victims from the tsunami of opioid painkiller prescriptions that got white Americans hooked on opioids and led to a wave of deadly overdoses.

6) Americans consume more opioids than any other country

This is perhaps the most important chart to understand why America in particular is suffering from the epidemic: Simply put, the US consumes far more opioid painkillers than any other country in the world. When a country collectively consumes more of a deadly, addictive drug, it’s obviously going to have more deaths as a result of those drugs.

7) In some states, doctors have filled out more painkiller prescriptions than there are people

So why do Americans use so many opioids? In short, it’s because doctors have prescribed a lot of them. Starting in the 1980s and ’90s, doctors were under pressure to take pain more critically. There was some excellent reason for that: About 100 million Americans suffer from chronic pain, according to a 2011 report from the Institute of Medicine. Some doctors under pressure from drug companies, medical organizations, government agencies, and pain patient advocates resorted to opioids.

The outcome: In 2012, US physicians composed 259 million prescriptions for opioid painkillers, enough to give a bottle of pills to every adult in the country. And these pills didn’t just end up in patients’ hands; they also multiplied to black markets, were shared among friends and family, landed in the hands of teens who rummaged through parents’ medicine cabinets, and so on.

8) Drug companies have made a lot of money from opioids

One of the indisputable factors to the opioid epidemic is drug companies. Observing the demand for doctors to take pain more seriously, drug companies launched newer products like OxyContin as the big medical solution. The marketing was extremely misleading, often showing these drugs as safer and more successful than other painkillers and opioids on the market when these drugs were in fact extremely addictive and dangerous.

Inevitably, some drug companies would pay for their misleading marketing. Purdue Pharma, producer of OxyContin, in 2007 paid hundreds of millions of dollars in fines for its false claims. And Purdue and other opioid producers linger in legal battles over the drugs to this day.

9) At the same time, Americans admit to higher levels of pain

Despite the boost in painkiller prescriptions, reports show that Americans typically report higher levels of chronic pain than they did prior to the epidemic started.

This gets to a crucial point in the opioid epidemic:

Regardless of drug companies’ marketing, opioid painkillers don’t seem to be an effective treatment for chronic pain. There’s simply no good scientific evidence that opioid painkillers can treat long-term chronic pain as patients grow tolerant of opioids’ effects, but there’s plenty of evidence that extended use can result in very bad complications, including a greater risk of addiction, overdose, and death.

Yet painkillers, due to how they function, can in fact trick patients into believing that the drugs are effective for chronic pain. As Stanford psychiatrist Anna Lembke, author of Drug Dealer, MD, recently clarified:

It’s absolutely that if you were to get opioids for your pain, it would be like a magical cure for about a month or maybe two. But after a while, there’s a very high likelihood that they would stop working. And then you would have two problems: You would have your pain, and you would be dependent on this drug and experience painful withdrawal if you try to get off [opioids]

After extended use, some patients who try to stop taking opioids will feel a sudden surge of pain. They’ll likely think the pain they’re feeling is their chronic pain coming back in full force now that the painkillers are gone. The opioids have likely stopped working on the initial chronic pain due to tolerance, and the surge of pain is an entirely new pain from drug dependence withdrawal. Only by slowly weaning themselves off opioids can they completely stop this new withdrawal-induced pain.

There’s also evidence that opioids can make pain even worse. Opioids might make people more sensitive to pain. They might compromise the bones.

And they might get people to behave in ways that expose them to greater injury, which of course would lead to far more pain. Lembke gave an example of someone popping extra pills to let them do more yard work: “If you take additional opioids, you can’t hear the signals from your body about what you shouldn’t be doing, and then maybe you’re going to do some long-term harm above what’s already been done.”

10) Painkillers are often prescribed for extended periods of time, even though there’s no evidence they effectively treat chronic pain

Despite the lack of evidence for opioids’ effectiveness in treating chronic pain, doctors have resorted to prescribing the opioids to patients for exorbitant periods of time. (I can’t even count the number of people, from friends to family to colleagues, who have told me that a doctor prescribed extra weeks of pills “just to be safe.”)

This, it turns out, is extremely dangerous: A recent study from the Centers for Disease Control and Prevention revealed that the risk of dependency increases dramatically for each day someone is prescribed opioids. Overly long prescriptions, then, contribute to the cycle of addiction, overdose, and death that’s spread across the US in the past few years.

Yet if opioids aren’t the answer to chronic pain, what is? There are alternative treatments, although these can involve more work (and money) than just taking a pill — such as physical therapy, massage, and acupuncture. More exotic but less tested ideas include medical marijuana and kratom.

But the reality is that, at some level, some patients struggling with chronic pain may just have to learn to live with the pain. This may sound cruel, but it’s something that’s asked of patients dealing with other chronic conditions when medicine just has no good answers. For example, a patient with heart disease might be told that she needs to eat less or adjust her activity level — potentially ruining her interests or hobbies — to avoid a heart attack as she becomes older.

“You can’t use the pills to extend your limits. You have to accept that there’s some things you just won’t be able to do anymore,” Lembke told me. “People are very resistant to that idea. I think that speaks to some of the core hope for at least Americans that they should really be able to keep doing what they were doing in their 20s, and that somehow a doctor should be able to fix them and make that happen, instead of accepting that maybe that’s something that they just can’t do anymore.”

11) States are now cracking down on opioid prescriptions

As the issue with opioid painkillers goes on, various ranks of government and regulatory bodies have taken steps to limit their use. Some states, for example, have limited how long opioid painkillers can be prescribed. The idea is easy: After years of allowing these painkillers run haywire and wipe out tens of thousands of people, doctors need to be told to take a much more conventional approach to dangerous drugs.

12) Opioid users moved from painkillers to heroin, because heroin is so cheap

As governments and regulatory authorities cracked down on painkillers, however, many people addicted to the drugs didn’t just stop using. Many rather resorted to another opioid to fill their habit: heroin. A 2014 study in JAMA Psychiatry found many painkiller users were moving on to heroin, and a 2015 CDC analysis found people who are addicted to prescription painkillers are 40 times more likely to be addicted to heroin. Not all painkiller consumers went this way, and not all heroin users started with painkillers, but painkiller use played a crucial role in leading more people to heroin.

The main factor for this: Heroin is incredibly cheap in the black market, despite law enforcement efforts for decades to push up the price of drugs by cracking down on the illicit supply. In fact, over the past few decades, the price of heroin in the US has dramatically dropped– to the point that it’s not only cheaper than opioid painkillers sold in the black market, but often even candy bars.

But heroin is also more powerful and, therefore, deadlier than opioid painkillers. So even though not every painkiller user went to heroin, just enough did to cause the big spike in heroin overdose fatalities that America has observed over the past few years. So now more people die of overdoses linked to heroin than die of overdoses linked to typically prescribed painkillers.

That doesn’t mean cracking down on painkillers was an error. It appeared to slow the rising number of painkiller deaths, and may have stopped doctors from prescribing the drugs– or letting them breed– to new generations of people who ‘d develop drug use disorders. The crackdown did lead to more heroin loss of lives, but it will hopefully stop future populaces of drug users, who could have experienced even more overdose deaths.

13) Fentanyl has become a growing problem as well

As if the increase in heroin deaths wasn’t bad enough, over the past few years there has been proof of another opioid that’s even more potent than heroin leading to more drug overdose deaths: fentanyl. Sometimes drug users intentionally seek out this drug. But often it’s laced in other substances, like heroin and cocaine, without the users knowing it, leading to an overdose.

The fact that the attempts to crack down on the supply of opioid painkillers has only led people to even more dangerous drugs hints at one more lesson from the epidemic: Just reducing access to opioids isn’t enough. As long as people are addicted, they’re going to try to find ways to fulfill that addiction, even if it means using more dangerous drugs.

While lessening access to opioids might in the long term stop the development of new generations of people with drug use disorders, in the shorter term the country needs to devise remedies for how to get people to stop using drugs and how to make their drug use less deadly and dangerous. That’s where drug treatment, including medication-assisted treatment that substitutes dangerous opioid use with safer opioids like buprenorphine, and harm reduction efforts, such as clean needle exchanges, can help.

14) Anti-anxiety drugs are involved in more overdoses as well

Opioid painkillers aren’t the only legal drug that’s killing more people. Federal information shows that benzodiazepines, such as Xanax and Valium, are also considerably involved in overdose deaths.

The data speaks to this: Most benzodiazepine overdoses have consisted of opioids in the past few years, as the chart above shows. And the Centers for Disease Control and Prevention previously discovered that 31 percent of opioid painkiller overdose deaths in 2011 were also linked to benzodiazepines.

15) Most people who meet the interpretation for a drug use disorder don’t get treatment

While drug treatment may be the true option to the opioid epidemic, the reality is it remains unattainable to a lot of people. According to 2014 federal data, at least 89 percent of people who met the definition for having a drug use disorder didn’t get treatment. And that’s likely an underestimate: Federal household studies leave out incarcerated and homeless individuals, who are more likely to have serious, untreated drug problems.

The reasons why vary. People might not have insurance to pay for drug treatment. If they do have insurance, their plans may not fully cover drug treatment. And even if their plans do cover drug treatment, there might not be enough room in treatment facilities to take them, leading to weeks- or months-long waiting periods for care.

In general, all of this proposes that the country needs to put more resources toward making drug treatment choices more widespread, accessible, and affordable. So far, Congress has taken some steps to that end, including a recent $1 billion boost in drug treatment funding over two years. But as so many people with drug use disorders struggle to get into treatment and the opioid epidemic goes on, the call will likely increase for more action. Opioid painkillers aren’t the only legal drug that’s killing more people. Federal information shows that benzodiazepines, such as Xanax and Valium, are also significantly involved in overdose deaths.

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