From Epidemic to Crisis
The Most Preventable Public Health Crisis in U.S. History
Drug overdose is now the leading cause of accidental death in the United States, with opioids driving this epidemic. In 2017, there were 72,000 reported overdose deaths, and opioids contributed to at least two-thirds of these deaths. While the opioid epidemic may have been sparked by prescription drugs, the advent of highly potent synthetic opioids over the last few years—estimated to be 50-10,000X more potent than morphine—has spiraled the opioid epidemic into a much deadlier crisis.
Wave #1: Prescription Opioids (1999-2010)
The opioid crisis evolved in three distinct waves. The epidemic was born in 1991 following a sharp increase in the prescribing of opioid analgesics for the treatment of pain. The increase in opioid prescribing was influenced by assurances by pharmaceutical companies that prescription opioids were non-addictive and safe for the treatment of chronic pain. Deaths involving prescription opioids reached epidemic proportions in 1999, marking the first wave of the death toll.
Wave #2: Heroin (2010-2013)
As legislative efforts to reduce opioid prescribing took effect in the early-to-mid 2000s, prescription opioid use declined, and heroin emerged as a cheaper, more potent alternative. The rapid rise in heroin-related deaths became apparent in 2010, marking the second wave of the opioid epidemic.
Wave #3: Fentanyl & Co. (2013-)
Heroin-related deaths continued to dominate epidemic until 2013, when illicitly manufactured fentanyl (IMF) emerged. Fentanyl and its analogues are estimated to be between 50-10,000X more potent than morphine, and their entrance into the opioid ecosystem in 2013 transformed this deadly epidemic into an official crisis.
One of the largest contributors to the crisis is our criminal justice system. Despite the known dangers and ineffectiveness of forced abstinence, jails and prisons are notorious for imposing this approach on inmates with addiction. Forced abstinence precipitates physical withdrawal which often leads to severe and overwhelming cravings, while simultaneously reducing one’s physical tolerance for opioids. With the recent availability of adulterated of heroin containing highly toxic and deadly synthetic opioids, addicts are up to 40-129X more likely to suffer a fatal overdose in the first two weeks following incarceration.
Figure 1. Opioid overdose deaths in the U.S. between 1999-2017
Figure 2. Opioid overdose deaths in the U.S. (per opioid) between 1999-2017.
Figure 3. Drug overdoses in the United States in 2017, broken down by drug. Opioids accounted for 2/3 of all drug-related deaths in 2017.
The "War on Drugs"
The criminalization of drug addiction and the ongoing opioid crisis are inextricably intertwined. Since the advent of the infamous “War on Drugs” campaign in 1971, the number of people incarcerated for drug offenses in the United States has skyrocketed. According to the United States Bureau of Justice Statistics (BJS), there are nearly 2.3 million adults currently detained in federal or state correctional facilities—the highest number of any nation in the world, and sixty-five percent of these individuals meet the criteria for substance abuse or dependence. Today, there are more people behind bars for a drug offense than the number of people who were in prison or jail for any crime in 1980.
Opioid overdoses are the leading cause of premature mortality among recently incarcerated persons, accounting for one-quarter of all deaths among this population. The high mortality rates among prisoners with opioid use disorder (OUD) is a direct result of the institutional practice of forcing drug abstinence on inmates. Forced abstinence precipitates physical withdrawal, which often leads to severe and overwhelming cravings, while simultaneously reducing one’s tolerance for opioids. The body’s reduced tolerance for opioids, combined with potential exposure to highly potent synthetic opioids, makes opioid addicts particularly susceptible to suffering a fatal overdose in the first two weeks following incarceration.
The risk of overdose within the first few weeks of release cannot be emphasized enough. Experts in the field of addiction medicine have deemed incarceration as the most lethal and socially disruptive point of an opioid addiction. Incarceration usually leads to prolonged periods of abstinence, and though drug use ceases during these periods, the addiction itself does not. Incarceration addresses the drug offense, not the underlying illness contributing to the drug offense. The inadequacy of forced abstinence is reflected in the statistics alone: 95% return to drug use following incarceration, and 60-80% reoffend within one year. Given the significantly higher risk of overdosing upon release, it should come as no surprise that recently incarcerated populations comprise a substantial proportion of the death toll.
Medications like buprenorphine and methadone can counteract the disruptive effects of opioid addiction on the brain and reduce up to 75% of overdoses in the weeks following incarceration, Despite the life-saving potential of these medications, less than 1% of correctional facilities offer them to opioid addicts. The remaining 99% of jails and prisons force abstinence, which renews cycle of relapse and recidivism that predisposes opioid addicts to overdose and death. These post-release fatalities have fueled massive spikes in the death toll and is why the criminal justice system's role in this crisis cannot be overlooked.