The opioid painkiller and heroin epidemic, explained

In 2014, more Americans died of drug overdoses than any other year on record: more than 47,000 deaths in just one year, according to new federal data. That's far more than the nearly 34,000 who died in car crashes, the almost 34,000 who died due to gun violence, and the nearly 42,000 who died due to HIV/AIDS during that epidemic's peak in 1995.

But this latest drug epidemic is not driven primarily by illicit drugs. It began with a legal drug: opioid painkillers.

Back in the 1990s, doctors agreed — and many still do — that America has a serious pain problem: Tens of millions of Americans experienced debilitating pain, and it was left untreated. So they looked for a solution — and, fueled by a misleading marketing push from pharmaceutical companies, landed on opioid-based painkillers, widely known by brand names such as OxyContin, Percocet, and Vicodin. The drugs proliferated.

But this led to unintended, devastating results. Prescription painkiller abuse went up, and overdose deaths linked to the drugs did as well. Then, as policymakers and doctors took notice of widespread painkiller abuse, they pulled back access to the drugs. But federal data now shows many of these addicts didn't just quit the drugs altogether — some instead moved to a lower-cost, more potent opioid, heroin, and some are reportedly moving to the even cheaper, stronger opioid, fentanyl.

As a result, nearly 29,000 deadly drug overdoses in 2014 — more than half of all overdose deaths that year — involved some type of opioid.

It's a big public health crisis. And, surprisingly, many policymakers are treating it as a public health crisis: Whereas previous drug epidemics invited harsh tactics typical of the war on drugs (like increased prison sentences for drug possession), the current crisis is by and large fueling calls for more access to treatment programs. That reflects not just the opioid epidemic's unique circumstances, but a general shift in how the country views the decades-old drug war.

The desire to treat pain and marketing from drug companies led to a devastating epidemic

America has a pain problem. About 100 million Americans suffer from chronic pain, according to a 2011 report from the Institute of Medicine. This might seem like an excessive number — roughly one-third of all Americans — but it includes everyone in the chronic pain spectrum, from the silent sufferer who deals with constant back pain to the patient who can no longer move because the pain all over her body is just too much.

There isn't a single medication that will relieve all pain for all patients. But there was a huge push in the 1990s and 2000s — from drug companies in particular, the federal government's flawed "Pain as the Fifth Vital Sign" campaign, and pharmaceutical-backed advocacy efforts — that doctors do something about pain.

As Keith Humphreys, drug policy expert at Stanford University, explained, the evidenceon whether opioid painkillers can even treat chronic pain is weak at best, but it's clear that prolonged use can result in very bad risks and complications. But pharmaceutical companies saw an opportunity for profit, and they marketed opioids to doctors as a safer way to treat pain than other medications.

The result: Drug companies made a lot of money as people got addicted and died.

Pharmaceutical companies' claims of safety and efficacy were, of course, inaccurate, and Purdue Pharma, producer of the opioid OxyContin, later paid hundreds of millions of dollars in fines for its false claims. Opioid painkillers carry a significant risk of addiction and overdose, especially for long-term users who build up a tolerance of the high and use more and more of the drug without building as much resistance for the respiratory effects that lead to overdose.

But many doctors, under pressure to treat pain more seriously, bought into the messaging from those decades and prescribed a ridiculous amount of painkillers to patients. In 2012, US physicians wrote 259 million prescriptions for opioid painkillers — enough to give a bottle of pills to every adult in the country. And these pills don't just end up in patients' hands, instead proliferating to black markets, landing in the hands of teens who rummaged through parents' medicine cabinets, and so on.

As state and federal governments became aware of the problem, they began going after doctors and pharmacists who provided painkillers too leniently, threatening them with incarceration and the loss of their medical licenses. In 2014, the Drug Enforcement Administration reclassified some opioid painkillers from Schedule 3 to the more restrictive Schedule 2, limiting access for both patients and doctors.

Ideally, doctors should still be able to provide painkillers to patients who really need them — after, for example, evaluating whether the patient has a history of drug abuse. But doctors who weren't conducting even such basic checks are being told — not just through the crackdown, but by health care organizations and public education campaigns — to give more thought to their prescriptions.

Doctors don't always have to resort to opioids to treat pain as a serious medical issue. There are alternatives, such as special exercises, physical therapy, surgeries, and lifestyle changes. There's even some evidence for medical marijuana, which studies have shown to be effective at treating chronic pain and averting opioid deaths.

Despite increased awareness and the crackdown, there are still signs of some doctors doing a lot of overprescribing. A Centers for Disease Control and Prevention report found that a small minority of prescribers are responsible for most opioid prescriptions, although there's a lot of variation from state to state. For example, the top 1 percent of prescribers wrote one in four opioid prescriptions in Delaware in 2013, while the top 1 percent of prescribers wrote one in eight such prescriptions in Maine.

Still, the crackdown appeared to slow down the rise in painkiller overdose deaths for a few years, but it also likely led to an increase in heroin abuse and deaths.

Painkiller-linked deaths stabilized for a few years, but heroin-related deaths skyrocketed

When opioid addicts couldn't fulfill their cravings with painkillers, many turned to an opioid that is, despite its status as an illegal substance, cheaper and more accessible than the legal medicine: heroin.

So as painkiller overdose deaths leveled off at around 16,000 to 17,000 for a few years, but later reached 19,000 in 2014, heroin deaths skyrocketed from just over 3,000 in 2010 to nearly 11,000 in 2014, according to CDC data. Though all heroin users didn't necessarily start with painkillers, it's the transition from painkillers to heroin, experts say, that led to the recent dramatic spike in heroin abuse.

WHEN OPIOID ADDICTS COULDN'T FULFILL THEIR CRAVINGS WITH PAINKILLERS, MANY TURNED TO HEROIN

Heroin is even deadlier than opioid painkillers — it's far more potent, and far more addictive. So even if a small number of painkiller users moved on to heroin, it would still, on a per-person basis, lead to far more deaths.

What's worse, painkiller and heroin users tend to mix opioids with other substances — like alcohol and cocaine — that exacerbate the risk of an overdose. A 2003 study found roughly half of heroin-related deaths involved alcohol, and the CDC found that 31 percent of prescription painkiller-linked overdose deaths in 2011 were also linked to benzodiazepines, a legal anti-anxiety drug.

There are also a growing number of reports of people using — and dying from — the very potent opioid fentanyl while using it by itself, with painkillers, or with heroin.

So as people used painkillers and moved on to heroin, they continued using all these other substances that made their risk of overdose much, much higher — and it's showing in the numbers.

That doesn't mean cracking down on painkillers was a mistake. It appeared to slow the rising number of painkiller deaths, and may have prevented doctors from prescribing the drugs to new generations of potential addicts. So the crackdown did lead to more heroin deaths, but it will hopefully prevent future populations of drug abusers, which could have suffered even more overdose deaths.

That's why, though they knew it could lead to a temporary spike in heroin use, state and federal agencies came down on painkillers.

The rise in heroin deaths wasn't unexpected

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The results of a government crackdown on opioid painkiller prescriptions were long a concern in medical circles and among drug policy experts, who warned it could lead to a rise in heroin abuse.

But it's only recently that research granted legitimacy to the concerns. A study in JAMA Psychiatry found many painkiller users were moving on to heroin, and a 2015 CDCanalysis found people who are addicted to prescription painkillers are 40 times more likely to be addicted to heroin.

"We always were concerned about heroin," Kevin Sabet, a former senior drug policy official for the Obama administration, told the Huffington Post in 2015. "We were always cognizant of the push-down, pop-up problem. But we weren't about to let these pill mills flourish in the name of worrying about something that hadn't happened yet. … When crooks are putting on white coats and handing out pills like candy, how could we expect a responsible administration not to act?"

The unintended consequence is a very typical result of governments' anti-drug efforts. It's called the balloon effect: When the government cracks down on one source of supply for drugs, people don't just stop using. Instead, they find another source — and the cycle continues.

The balloon effect has been observed not just with the crackdown on opioid painkillers, but with anti-drug efforts in Latin American countries. After the governments there cracked down on the illicit drug trade in the 1990s and 2000s, it simply shifted to other parts of Central and South America. This effect is one of the primary reasons the war on drugs has failed to significantly curtail drug trafficking.

But in the case of opioid painkillers, the consequence was new heroin users and deaths in sometimes unexpected places. Unlike the heroin epidemic of the 1960s and 1970s and the crack cocaine epidemic of the 1980s, the current epidemic isn't a mostly urban problem: The places reporting the biggest struggles with painkillers and heroin — like West Virginia and New Hampshire — tend to be very rural and very white.

As Sabet acknowledged, the government knew this was a possibility — but the feds still thought it was worth cutting off the supply of painkillers to prevent doctors and pharmacists from creating even more generations of painkiller addicts.

This didn't quite deal with all existing opioid users, who are now dying by the tens of thousands each year. To deal with that, officials and lawmakers are increasingly turning to public health policies — drawing a strong contrast with the tough-on-crime approach that followed other drug epidemics in the past few decades.

Unlike previous crises, the opioid epidemic is inspiring a stronger public health response

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Federal and state governments have, particularly since the 1970s, tended to respond to drug epidemics with tough-on-crime measures.

President Richard Nixon launched the modern war on drugs in 1971 in part as a response to the heroin epidemic of the time, which Nixon characterized as a "deadly poison in the American life stream." And President Ronald Reagan massively increased drug penalties in the 1980s as part of a response to the crack cocaine epidemic, which helps explain why possession of crack received a prison sentence 100 times as harsh as possession of the pharmacologically similar cocaine.

But the opioid painkiller and heroin epidemic is resulting in a different type of response. Although some officials — particularly in conservative states, like Louisiana and Indiana— have reacted to their heroin crises with a tough law enforcement approach, many federal and state officials have encouraged treating the opioid epidemic as primarily a public health problem.

RACE AND CLASS MAY PLAY A ROLE IN THE SOFTER RHETORIC

Race and class may play a role in the softer rhetoric: While previous drug epidemics that inspired a tough-on-crime approach — such as the crack cocaine epidemic — predominantly hit poor black people in cities, the opioid epidemic is more likely to hit middle-class white people in more rural and suburban areas.

Budget concerns likely play a role, too. Faced with growing prison costs and the failure of the drug war to significantly curtail drug abuse, states have cut back on old tough-on-drugs tactics by, for example, pushing low-level offenders to specialized drug courts that attempt to put drug addicts in treatment and rehabilitation instead of jail and prison. (Although this approach has been heavily criticized.)

These are policy changes that should, at least in theory, benefit anyone with a drug problem, but opioid painkiller and heroin addicts will be among the first to claim the results of reform due to the ongoing epidemic.

Whatever the cause, the public health approach is in line with both public and expert opinion. Polls show that most Americans prefer treating drugs as a public health issue, not a criminal one. And many experts, including the International Narcotics Control Board, have asked for a greater focus on public health policies to curtail demand for drugs.

The public health responses emphasize treatment and prevention

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White House drug czar Michael Botticelli.

Practically all levels of government have reacted to the opioid epidemic in some way, usually with an emphasis on prevention and treatment for addiction.

Various state legislatures controlled by Democrats and Republicans have, for example, passed laws allowing police and even private individuals to carry naloxone, which reverses opioid overdoses.

Some police chiefs have gone as far as refusing to arrest heroin users, instead guiding them to rehabilitation and treatment. And governors from both parties, including New Jersey Gov. Chris Christie and West Virginia Gov. Earl Ray Tomblin, have characterized the epidemic as an urgent public health problem.

The Obama administration, too, has embraced the public health approach. It's stepped up general spending on treatment and prevention programs over the past few years. It dedicated $2.5 million in 2015 to fight heroin abuse. The Department of Health and Human Services also unlocked more than $100 million for drug abuse treatment in 2016. And the administration helped launch a combination of federal, state, local, and private efforts in 2015 to provide better prescriber training and improve access to addiction treatment.

"The main distinction with this plan is the general acknowledgment that substance use is a public health issue," White House drug czar Michael Botticelli told me in 2014, speaking to his office's budget. "We can't arrest our way out of the problem, and we really need to focus our attention on proven public health strategies to make a significant difference as it relates to drug use and consequences to that in the United States."

"WE CAN'T ARREST OUR WAY OUT OF THE PROBLEM, AND WE REALLY NEED TO FOCUS OUR ATTENTION ON PROVEN PUBLIC HEALTH STRATEGIES"

This is all trying to address a serious gap in health care: According to 2014 federal data, at least 89 percent of people who meet the definition for a drug abuse disorder don't get treatment. (That's likely an underestimate: Federal household surveys leave out incarcerated and homeless individuals, who are more likely to have serious, untreated drug problems.)

One big concern: boosting access to medication-assisted treatments for addiction like methadone and Suboxone, opioids that when taken as prescribed can supplant someone's painkiller or heroin use without a similar risk of overdose or addiction. Decades of research have deemed these drugs effective. The Centers for Disease Control and Prevention, National Institute on Drug Abuse, and World Health Organization acknowledge their medical value.

Still, even the most basic treatment remains out of access to many. There are many reasons for this gap, including stigma against drug addicts and addiction treatment. But one key factor is that there simply aren't enough treatment options and programs out there — during President Barack Obama's visit to West Virginia, one of the most common complaints from families was that they had to wait months to get a family member into treatment.

So the Obama administration has put more resources toward treatment and prevention programs. At the same time, the administration has been advocating for scaling back the war on drugs by calling for reducing criminal penalties on nonviolent drug offenders.

That doesn't mean that much of the old tough-on-crime approach is completely gone. Most of the Office of National Drug Control Policy's budget, for one, continues going to law enforcement and interdiction efforts that are typical of the drug war. Many states still impose long prison sentences for heroin-related crimes, including possession.

But the current government response is largely softer than previous responses to past drug epidemics — leading to an approach focused more on public health.