It should be no surprise to anyone reading this newsletter that we are in the middle of the worst opioid epidemic to ever strike our country. Thanks to fentanyl (a powerful synthetic opioid), the 2016 mortality figures are even worse than 2015 – over 60,000 deaths. To put this in perspective, there were more overdose deaths in that one year than the entire Vietnam war! How did we possibly get here?

A powerful recent book outlines the history of the current opioid epidemic. The book is called Dreamland, and was written by Sam Quinones. He is an investigative journalist and tells the story in a very compelling and a very readable manner. I recommend it to everybody. In fact, it has become required reading for the incoming class at Virginia Commonwealth University. The author provides a lot of answers to the question of how we got into this terrible situation. Here are a couple of my observations on how we got here.

First, the disease of Chemical Dependency has been a constant over time. The disease has always been with us, affecting about 10% of the population. What does change over time is the drugs that people use. Alcohol has been a ever present, but other dugs come and go. What tends to happen a new drug comes on the scene and people don’t really know how dangerous or addictive it really is - so, the drug becomes widely used. Eventually, the truth comes out and people stop using it quite as much - but then, other drugs are there to replace it. We saw this happening with opiates at the turn of the 20th century. Around 1900, about 1-2% of the entire population was addicted to opiates. Opiates could be obtained without a prescription from any pharmacy. People didn’t know how addictive they were. But, over a short period of time, it became obvious, and so, in 1914, Congress passed the Harrison Act making opiates scheduled drug that could only be prescribed by doctors and dispensed by pharmacists. Other cycles happened with amphetamines in the 1950s, Valium in the 1960s, Xanax in the 1970s, and then, cocaine in the 1980s. Now we are seeing it happen again with opiates.

In the late 1990s, coinciding with this ignorance of how dangerous opiates really were, we started to see the appearance of high potency, powdered heroin. In the old days, heroin that came into the country was so impure that people had to use needles to try it and of course this turned a lot of people off from experimenting or trying it a few times. By the mid-1990s, very potent heroin started appearing from South America and other countries, and this allowed people to start to snort it. Many young people tried it because it was a powder that looked just like cocaine. It lasted about 12 hours and it was a lot cheaper than cocaine. They didn’t realize how addictive it was. A lot of young people had no fear of this new drug. They very quickly become physically dependent, and very quickly, they needed more and more.

The other development that was happening around this time was the medical community had started to prescribe huge amounts of opioids. Doctors became misled into thinking that opiates were not really very addictive and that opiates could be safely used for long-term pain treatment. Doctors were also led to believe that patients shouldn’t feel any pain, and so, if pain persisted, it was quite safe and appropriate to increase the dose. If patients were still in pain, they should just be prescribed more. Drug companies like Purdue Pharma made billions of dollars. Lots of other people made lots of money by obtaining these pills and selling them. The number of people being addicted and fatal overdoses skyrocketed.

Unfortunately, things have yet to really improve. It is true that physicians are now better educated and informed about effective ways to treat pain, and so, the number of new prescriptions for opiates is decreasing. But, drug importers and dealers have stepped in, and now, cheap heroin has become readily available all over the country. To make things worse, fentanyl is becoming readily available. Fentanyl is 50 times stronger and many times more dangerous than heroin. It is being mixed in with street heroin. Drug users have no idea what they are really using. Overdoses have skyrocketed.

There is some good news: Physicians are finally starting to prescribe less opiates. Everyone is now becoming more aware of dangers these drugs present. Community groups are organizing all over the country to educate and help people get into long-term recovery. The justice system is even recognizing that it is not helpful to just punish people who have the disease of addiction. Many jails are now offering drug rehabilitation and there are many drug courts providing a treatment structure to help people to truly recover and get into long-term recovery. There is hope that, over time, the number of people experimenting with opiates will decline, and those who have become ensnared in addiction will find long-term recovery.

Peter R. Coleman, MD