The trips to resorts in the sun traps of Florida, Arizona and California were a great chance for medics to network, take a break from patients and learn about new treatments. There were even freebies – fishing hats, cuddly toys to take back for the kids, music CDs. And the visits were all expenses paid.

But such events laid the groundwork for a national crisis.

From 1996 to 2001, American drug giant Purdue Pharma held more than 40 national “pain management symposia” at picturesque locations, hosting thousands of American doctors, nurses and pharmacists.

Q&A Why is there an opioid crisis in America? Show Almost 100 people are dying every day across America from opioid overdoses – more than car crashes and shootings combined. The majority of these fatalities reveal widespread addiction to powerful prescription painkillers. The crisis unfolded in the mid-90s when the US pharmaceutical industry began marketing legal narcotics, particularly OxyContin, to treat everyday pain. This slow-release opioid was vigorously promoted to doctors and, amid lax regulation and slick sales tactics, people were assured it was safe. But the drug was akin to luxury morphine, doled out like super aspirin, and highly addictive. What resulted was a commercial triumph and a public health tragedy. Belated efforts to rein in distribution fueled a resurgence of heroin and the emergence of a deadly, black market version of the synthetic opioid fentanyl. The crisis is so deep because it affects all races, regions and incomes

The healthcare professionals had been specially invited, whisked to the conferences to be drilled on promotional material about the firm’s new star drug, OxyContin, and recruited as advocates, the US government later documented.

But OxyContin was to become ground zero in an opioid crisis that has now engulfed the United States.

The pill comprises oxycodone, a semi-synthetic opioid loosely related to morphine and originally based on elements of the opium poppy. Such strong painkillers were traditionally used to ease cancer pain, but beginning in the mid-1990s, pills based on oxycodone and the similar compound hydrocodone began being branded and aggressively marketed for chronic pain instead – a nagging back injury from manual labor or a car accident, for example.

Literature on display at an overdose prevention organisation in Hamilton, New Jersey. Photograph: Bastiaan Slabbers/The Guardian

From 1996 to 2002, Purdue more than doubled its sales force and distributed coupons so doctors could let patients try a 30-day free supply of these highly addictive drugs.

Prescriptions issued for OxyContin in the US increased tenfold over those six years, from 670,000 a year to more than six million. A bulletin from the American Public Health Association in 2009, reviewing the rise of prescription opioids, is titled “The promotion and marketing of OxyContin: commercial triumph, public health tragedy”. The document also asserted that Purdue had played down the risks of addiction. In a landmark case, the company was fined more than $600m in 2007 for misleading the public, but it was making billions – at the time the only company making this kind of money from high-strength opioids.

By 2002 prescription opioids were killing 5,000 people a year in America and that number tripled over the following decade.



Coast to coast

One of the key regions of the US affected early in the crisis was central Appalachia, an area covering much of West Virginia and eastern Kentucky known for small towns, rolling hills and physically taxing industries, including coalmining, agriculture and lumber production. Here, the proliferation of opioids encouraged abuse and the pills came to be known as “hillbilly heroin”.

Even taken exactly as prescribed, they were addictive, blocking pain (without treating its cause) and reducing stress. But people also began grinding them up to snort or inject for a potent high.

“At the time, it wasn’t understood how addicting these prescription pain medications were,” Michelle Lofwall, associate professor at the Center on Drug and Alcohol Research at the University of Kentucky School of Medicine told the Guardian in a 2014 report. “But they really hurt people here and across the nation.”

In the new millennium, addiction spread coast to coast.

And as use of the drugs spread, the distribution of pills spilled out from primary-care doctors’ offices and hospitals to illegal deals on street corners. They were also sold in vast quantities through barely regulated “pain treatment centers” in places such as Florida, which became known as “pill mills”. People with spurious pain complaints flocked to feed their own dependency or sell the pills on.

Shoes of those who died of an opioid overdose on the steps of the West Virginia Capitol in Charleston. Photograph: Chris McGreal/The Guardian

In 2003, rightwing media blowhard Rush Limbaugh admitted he was hooked on opioids. Actor Heath Ledger had prescription opioids in his system, along with a cocktail of sedatives, when he was found dead in New York in 2008 at 28.

In 2011 the US government reported that deaths from prescription opioid overdoses had overtaken combined fatalities from heroin and cocaine.



By 2012, sales of prescription opioids were grossing $11bn in the US annually and, with insufficient regulatory oversight, causing 15,000 fatal overdoses.

The street-drug epidemic of crack in the 80s and early 90s wrought particular havoc among low-income, urban African Americans, while the sordid blight of backyard-cooked methamphetamine was at its height among more rural, white populations in the 90s and early 21st century.

In contrast, the opioid crisis rippled out from neat pharmacy counters across broader income and geographical bands. The typical addict was most likely to be white, male and middle-aged, but the drug has a wide grip.

Gradually, the authorities began shutting down pill mills and warning health professionals and the public that opioids were far from a magic bullet.

But for many, the squeezing of supply, combined with a chronic lack of resources to treat addiction, didn’t help them quit, it made them desperate. A new, even darker chapter unfolded: the resurgence of street heroin and the emergence of a treacherous street-drug version of its synthetic cousin, fentanyl.

Fast forward to today and America is losing almost 1,000 people a week to drug overdoses. Two-thirds of those are opioid fatalities – with the pill problem still pervasive, but with a rising number of heroin and fentanyl deaths.

In 2015, a quarter of drug overdose deaths involved heroin, compared with 8% in 2010.

The death rates are highest in West Virginia, New Hampshire, Kentucky and Ohio, but the opioid epidemic has spread nationwide, as this map shows.

In 2014, renowned actor Philip Seymour Hoffman died of a heroin overdose in New York, after 23 years of sobriety. Last year Prince died when he overdosed on pills containing fentanyl – and the world suddenly became familiar with this synthetic narcotic being milled in Mexico from Chinese ingredients and rushed into the US illegal drug market.

On Thursday Donald Trump is expected to declare the opioid crisis to be a “national emergency”.

Other developed countries, including the UK, have been grappling with a rise in opioid addiction, too, although Britain’s public health system means the issue of massive over-prescription is less acute.

But the US is the epicentre and the origin of the crisis, consuming more than 80% of global opioid pills even though it has less than 5% of the world’s population and no monopoly on pain.

National data has stated that the volume of opioid pills prescribed in the US since 1999 has quadrupled, and so has the number of opioid overdoses.

But “there has not been an overall change in the amount of pain Americans have reported in that period”, the government reported.

142 fatal overdoses a day

Overdoses killed more people in the US in 2015 than car crashes and gun deaths combined. The daily death toll is 142 fatal overdoses, 91 of them from opioids, adding up to almost 52,000 drug overdose deaths in 2015.

Declaring a national state of emergency over opioids will focus fresh attention and increase government powers to cut red tape and release funding to expand treatment. Action such as providing all police departments and other first responders with the overdose antidote naloxone, which helps save lives, is being urged.

Tom Marino had to withdraw as Donald Trump’s choice as drug ‘czar’ amid controversy over his role in sponsoring legislation hindering attempts to tackle the opioid crisis. Photograph: Matt Rourke/AP

But if Trump succeeds in his determination to repeal the Obama administration’s Affordable Care Act, which brought health insurance to millions more Americans, it will hinder those seeking affordable treatment programs.

And in recent public pronouncements, the president appears to be stuck in the failed 80s mentality of “Just say No” to drugs, and in blaming individuals for becoming dependent on dangerous pills their doctors told them were safe.

He called for drug prosecutions to increase, and said: “The best way to prevent drug addiction and overdose is to prevent people from abusing drugs in the first place.” He emphasized the administration’s efforts to stop the flow of drugs over the Mexico-US border, but did not mention the pharmaceutical companies producing opioids within the US.

Although Trump said Congress was too beholden to the pharmaceutical companies, which shower Washington with donations and persuasive lobbyists, his declaration embarrassingly coincided with news that the man who was poised to be his new national drug policy “czar” had to withdraw from consideration because he had sponsored legislation that hindered attempts to crack down on opioids.

“In 2015, the amount of opioids prescribed in the US was enough for every American to be medicated around the clock for three weeks,” warned a recent draft report by a commission on the crisis led by the combative New Jersey governor, Chris Christie.

It concluded: “Our citizens are dying. We must act.”