Data from the National Institutes of Health reveal that overdose deaths from all categories of opioid drugs -- legal and illegal -- soared from 10,000 in 1999 to 49,068 in 2017, with the numbers consistently higher for men. But heroin fatalities (15,958 in 2017) must be included in the mix because the use of that drug and of prescription opioids has become intertwined.
Although less than 5% of those who misuse opioid pain medications drift to heroin, nearly 80% of heroin users start by misusing opioids. In addition, both people hooked on such painkillers and recreational users often combine them with heroin to boost their highs.
Addicts tend to rely on heroin only when they can no longer afford to buy opioids but are still desperate to feed their habit and so stave off "dope sickness." (Its wrenching withdrawal symptoms include nausea, chills, and diarrhea, as well as extreme anxiety and panic attacks.) Heroin dealers charge a fraction per fix of what illicit suppliers of the popular oxycodone- and hydrocodone-based analgesics demand per pill.
Consider Oxycontin. An 80-milligram pill costs about $6.00 at a pharmacy, but as much as $80 on the street. Compare that to the $15-$20 that will get you a hit of heroin. The price difference matters. Many opioid addicts end up putting the bulk of their earnings into purchasing the pills illegally, depleting their savings accounts. As a result, some end up resorting to selling personal possessions or even stolen machinery parts, piping, and copper wiring (for which there's a large black market).
Unfortunately, even the 49,068 deaths in 2017 don't provide the full picture. Additional fatalities result from combining painkillers with cocaine (4,184) or benzodiazepines (roughly 9,000). Add those into the mix and the total number of lives lost to the epidemic in this country reached 62,252 in 2017, the last year for which we have complete data. That figure soars higher yet if you include the nearly 16,000 deaths resulting from heroin.
To put the total number of opioid-related fatalities in perspective consider this: vehicular accidents killed 40,100 people in 2017. The decade-long Vietnam War resulted in 58,220 American deaths. More than five times as many Americans died from opioid-powered painkillers in 2017 alone as in the 9/11 attacks and the wars in Iraq and Afghanistan combined.
As for the economic consequences, a 2017 report by the president's Council of Economic Advisors pegged the total costs of the crisis, including medical services, lost earnings and productivity, and law enforcement, at $504 billion in 2015.
In other words, unlike what's happening on the southern border, this isn't a faux emergency.
The Pathway to Crisis
In nineteenth-century America, opiates were widely prescribed to treat many afflictions: pain from wounds or injuries sustained by Civil War veterans, menstrual cramps, asthma, anxiety, even babies' teething pains. But as doctors became more aware of a growing wave of addiction, the federal government imposed restrictive regulations on such medicines, culminating in the 1914 Harrison Narcotics Act.
Though that legislation didn't fully stamp out opiate use, it did mark a turning point. Medical opinion would not revert to a favorable view of such drugs until the 1970s, after which numerous opioid painkillers hit the market. The Federal Drug Administration (FDA) approved Lortab in 1982, Vicodin in 1983, MS Contin in 1987, and Percocet in 1999. Fentanyl was first introduced in 1959 and its skin patch variant received official approval in 1990 for the treatment of acute pain.
The current epidemic didn't start revving up until Purdue Pharma, owned by the Sackler family, developed Oxycontin, an oxycodone-based painkiller. Following FDA approval in December 1996, it became available, in varying strengths ranging from 10 to 160 milligrams. Compared to previous opioid treatments, Oxycontin was in a league of its own when it came to its potency. Doctors quickly started prescribing it, not a few with stunning abandon: in one instance 335,000 prescriptions over eight years. Within five years of its appearance, prescriptions had skyrocketed from 670,000 to 6.2 million.
Purdue claimed that Oxy, as it came to be known, was special and better than its predecessors because it worked through an extended, 12-hour time release, which would effectively eliminate addiction: the drug would neither provide a quick high nor have to be taken as often. In fact, the drug's efficacy often petered out well short of the touted timespan. Purdue became aware of this but stuck to its claim.
By 2001, Oxycontin sales surpassed $1 billion a year. The boom was not spontaneous, but owed much to Purdue's zealous product promotion. An army of sales representatives, deployed after being trained to convince doctors of the drug's safety and efficacy, often offered those same doctors free meals, holiday gifts, trinkets, junkets, and more. Those sales agents did not lack for incentive; they received hefty bonuses pegged to their success. Top performers raked in more than their annual salaries in extra cash.
Purdue also trained thousands of doctors, nurses, and pharmacists at numerous conclaves in beautiful venues -- all organized and paid for by the company -- to spread the word that Oxy was effective and safe, not only against the extreme pain produced by surgery or terminal illness but also more mundane varieties of pain caused, for instance, by back injuries or arthritis.