A Google search for ‘opioid epidemic’ reveals sobering statistics from the US Centers for Disease Control and Prevention (CDC) that indicate 33,000 people died from opioid-related overdoses in 2015, which is quadruple the rate of such deaths that occurred in 1999. Today, opioids are the leading cause of mortality from overdose, accounting for 91 deaths every day. Between 2000 and 2015, opioid-related overdose deaths have amounted to approximately 180,000 fatalities, which is more than three times the number of American lives lost during the Vietnam War. The opioid epidemic has also seen a significant spike in deaths due to overdoses of heroin and fentanyl, which have become easier and cheaper to acquire than prescription opioids.

The opioid epidemic has been cited as credible reason to oppose the passage of the Senate’s most recently proposed health care bill that made cuts to Medicaid, which provides crucial coverage for opioid addiction treatment. The bill also proposed a $2 billion fund to help cover costs associated with substance and opioid use disorders, which critics of the bill said was not nearly enough and would instead exacerbate this public health problem. More recently President Trump has turned his attention to the opioid crisis, asserting a need for more law enforcement and drug abstinence programming. However, missing from this discussion is a greater focus on the context and key players that created and contributed to the opioid epidemic. These contributing factors must be brought into sharp focus if we are to have any hope of stemming the tide of this public health crisis.

In 1996, Purdue Pharma released OxyContin and marketed the opioid as long-lasting and non-addictive, pushing the message that more patients with pain issues should be prescribed the drug. Purdue Pharma’s marketing campaign continuously downplayed the risk of addiction (for which three of Purdue Pharma’s executives would be charged and plead guilty to in 2007). Pharmaceutical sales representatives persuaded doctors to prescribe opiate drugs and downplayed the risks of addiction, marketing ploys that were not substantiated by credible science. Around the same time, popular medical opinion was rallying around the practice of prescribing opioids for various types of pain and patients, citing studies that reportedly found opiates to be non-addictive. Consequently, many doctors prescribed opioids inappropriately and excessively coupled with the growing machinery (“pill mills”) put in place by unscrupulous pharmaceutical firms to meet the demand.

One of the contributing factors to the misconception that opioids were non-addictive was a one-paragraph letter written in 1980 by Dr. Hershel Jick and Jane Porter and published in the New England Journal of Medicine with the title “Addiction Rare in Patients Treated with Narcotics.” The letter described an analysis of approximately 12,000 hospitalized patients who received at least one dose of a narcotic painkiller. Jick and Porter reported only four cases of opioid addiction in patients without history of addiction and concluded that addiction among hospital patients was rare. According to Dr. David Juurlink and his colleagues in an article published this year in the same journal, pharmaceutical companies’ misrepresentation of this letter led to a huge increase in the rate of opioid prescriptions. Most of the companies who cited the findings to support sales did not bother to report that patients in the study were prescribed opioids for short hospital stays and that Jick and Porter made no assertion about the risks of long-term opioid use. Jick has recently reported he regrets writing the letter due to its contribution to pharmaceutical companies’ misleading if not patently false marketing campaigns.

Interestingly, pharmaceutical companies have made some attempts to address opioid misuse and addiction, yet some of these efforts have actually led to a worsening of the problem. In 2012, Endo Pharmaceuticals reformulated its opioid pain medication Opana ER with a coating to make the drug more difficult to crush and snort. However, the reformulation actually led to more injections of the drug because the coating was easy to separate when it was cooked. Increased injections of Opana ER were linked to outbreaks of hepatitis C, HIV, and serious blood disorder cases in multiple states. Following an FDA review that found that the “benefits of [Opana ER] may no longer outweigh its risks,” the FDA requested that Endo Pharmaceuticals remove Opana ER from the market, which Endo Pharmaceuticals has since agreed to do.

Last year, an episode of the podcast Embedded poignantly gave a voice to the people in Indiana at the epicenter of an HIV outbreak tied to prescription opioid addiction in the state. The podcast chronicles several individuals’ tragic stories and experiences injecting Opana ER, sharing needles, and being diagnosed with HIV. One of those interviewed includes a veteran named Jeff who was prescribed Percocet for a back injury, after which he was prescribed Opana and became addicted. He discusses the debilitating experience of withdrawal and the difficulty in obtaining the drug since the crackdowns on prescribers. Following Opana’s reformulation, he began injecting the drug.

The opioid crisis is put in perspective when Jeff says he no longer takes Opana to get high, but rather to avoid pain and the sickness that comes with withdrawal. As the host of the podcast continues talking to the individuals who have agreed to be part of the podcast, including watching them cook and inject Opana and hearing about their struggles with recovery, the everyday listener is led to the conclusion that complex systemic forces helped create and sustain the opioid crisis. Thus, any reasonable response to this problem must include a multi-systemic approach to solve this burgeoning health crisis.

In an effort to have the pharmaceutical industry pay the financial cost of their contribution to the opioid epidemic, various states, cities, and counties have filed lawsuits against several pharmaceutical companies. With a strategy similar to legal efforts against tobacco companies in the 1990s, many of these groups allege that pharmaceutical companies deliberately misrepresented the addictive potential of prescription opioids to encourage doctors to prescribe and consumers to take more opioids. However, representatives of some pharmaceutical companies have denied these allegations, instead insisting they have promoted efforts to keep prescription opioids out of the black market.

In an effort to address physicians who might excessively or inappropriately prescribe opioids, FDA Commissioner Scott Gottlieb recently announced plans to require manufacturers of immediate-release opioids, which account for 90% of opioid prescriptions, to provide more educational training for prescribers, something that is not currently required. Paradoxically, manufacturers of extended-release opioids, which account for only 10% of opioid prescriptions, are, in fact, required to provide prescriber educational training. This effort also includes broader information about pain management and non-medication treatments along with drug therapies. States have also taken up legislative efforts to limit the number of days doctors can prescribe opioids. Seeking to limit lengthy opioid prescriptions that may lead to opioid addiction, with exemptions for individuals like cancer and hospice patients, the aim of such laws is to have doctors consider the appropriateness of opioid prescriptions on a patient-by-patient basis.

However, a combination of efforts on multiple systemic levels is needed to address the opioid epidemic and its related problems. In his book Dreamland, Sam Quinones aptly points out that players at many different levels contributed to the opioid crisis, from money-motivated pharmaceutical companies and doctors to well-intentioned researchers looking for a non-addictive drug that reduced pain, individuals trying to cope with pain, and American towns responding to changing economic and social pressures. Through it all, the importance of focusing on accessibility of effective opioid addiction treatment stands out as perhaps the most important factor in combating the opioid epidemic. Quinones discusses drug courts who mandate treatment as opposed to prison sentences as a cheaper and better option in considering states’ budgets and citizens’ well-being.

Quinones also discusses efforts to address the opioid epidemic in Portsmouth, Ohio, which he cites as ground zero of the opioid epidemic. Portsmouth’s residents mobilized their community, creating needle exchange programs, pursuing drug and addiction research, and expanding access to treatment as major steps in reducing opioid and opiate misuse. Those he describes who are now in recovery include a woman now employed at a treatment center. She was prescribed Vicodin following a car accident, shortly after graduating from high school. The woman spent 14 years addicted to opioids, shooting up OxyContin and doctor-shopping for more opioid painkillers.

Effectively addressing the opioid epidemic must involve higher-level regulation of prescriber practices and pharmaceutical companies’ marketing behavior, comprehensive research into effective pain management in the form of non-addictive medicines or other therapies, and widespread access to effective and sustained treatment for people who suffer from opioid addiction. A failure to address the opioid crisis through a multi-pronged, systemic approach will simply lead to more of the same.