Are You Aware? A Convergence of Crises — The Opioid Epidemic
This is part V in our “Rural America” Awareness Wednesday series. Read the other posts in the series here.
Somewhere in the neighborhood of 841,000 people in the U.S. have died of drug overdose since 1999. Drugs are the leading cause of death from injury in the U.S., by a significant margin. In 2019, 29% of injury-related deaths were caused by drug poisoning. The next closest causes of death by injury were falls, firearms, and motor vehicle-related deaths, at around 15-16% each. That same year, about 70% of all drug overdose deaths were caused by opioids.
Opioids, opiates, and opiums — what are they?
An opiate is a derivative of the poppy plant. They chemically bond with opiate receptors in the body to relieve pain and other symptoms and are often associated with a sense of euphoria. Opium, morphine, and codeine are all natural opiates. Related substances, opioids, are lab created and typically have synthetic elements but act just like opiates in the human body. Common opioids are OxyContin, hydrocodone, and fentanyl. Heroin can be an opiate or an opioid, depending on how it is made. Currently, many organizations use the term “opioid” to refer to all opium-like substances. For simplicity’s sake, we will refer to them as such.
In the late 1800s and early 1900s, opioids like morphine and heroin were marketed as over-the-counter remedies for coughs and headaches. Many of these remedies were even marketed for teething babies. After several children died, these products began to be regulated. By the mid-1910s, their dangers were widely recognized. Opioids became used mainly for severe pain and end-of-life care and were not widely prescribed, because the dangers of addiction were well known.
Beginning in the 1980s, our outlook on opioids shifted. Pain specialists and advocacy groups brought attention to inadequate pain management. The American Pain Society (APS) began a campaign that resulted in the establishment of the “fifth vital sign” and the monitoring and management of severe pain. This resulted in a sharp increase in the use of opioids and in opioid-related deaths. Widespread marketing campaigns and attention to pain management continued. In 2012 there was a peak in opioid prescribing rates — 255 million prescriptions in that year alone. This meant there were 81.3 prescriptions per 100 persons that year.
The first efforts to decrease opioid prescriptions
This prompted the beginning of efforts to decrease opioid prescriptions. As opioid prescriptions decreased, the illegal market took over, finding heroin to be a cheap but potent substitute. Most users admitted to misusing prescription opioids before starting heroin. The increase in heroin use resulted in a 286% increase in opioid deaths from 2002 to 2013. In 2013 a new wave of opioid-related deaths began as illegally manufactured fentanyl and other synthetic opioids were introduced.
The opioid crisis has taken different forms in rural and urban areas. While there has been an increase across the board in overdose deaths throughout the U.S. from 1999 to today, the details have varied by community. In 1999, urban America led in rates of overdose death. However, the opioid epidemic began around that time, primarily in rural areas, with prescription drugs. Around 2004, the rates for overdose death were similar in rural and urban areas. In 2006, rural America began trending higher. In the meantime, heroin and synthetic opioids began to take root in urban areas. Most recently, we have seen rates evening out, with a new trend that shows all three types of opioids affecting both urban and rural populations. Though fewer people report using drugs in rural areas, overall, the effects appear to be more severe in rural areas.
Why rural areas are hit hardest
A 2017 survey showed that about half of rural Americans and 74% of farmers and farm workers said they had been directly impacted by the opioid epidemic. The numbers were similar for people who said it would be easy to access opioids illegally. However, many of those surveyed thought it was an urban problem more than a rural problem, and only about a third of adults thought it would be easy to access effective, convenient, or affordable treatment if they had an opioid addiction.
The story of the opioid crisis in rural America has multiple components, with the Great Recession playing a role in worsening the situation. In the last two decades, deaths from opioids have climbed by more than 700% in rural areas, compared to less than 400% in urban areas. As we have discussed previously, rural communities were slower to recover from job loss during that period. Family-owned businesses disintegrated and were replaced, in part, by lower-paying jobs in the service sector. Uncertainty and financial insecurity have likely played a role in creating fertile grounds for an epidemic.
Another factor that has contributed to the opioid crisis is that many people in rural areas work in labor-intensive jobs, which often lead to chronic pain and injury. To treat the pain and avoid taking time off work, many have turned to pain medication to keep functioning. With increasingly limited access to proper healthcare and therapy, many overworked rural doctors have relied heavily on prescribing opioids to help their patients manage their pain. The CDC found that in 2019, patients in the most rural communities of our country were 87% more likely to receive an opioid prescription than their urban counterparts.
Close-knit families and communities may also play a role in the problem. People who live and work together in rural communities are used to sharing resources. According to the National Institute of Drug Abuse, people often share or sell their unused pain medicine, unaware of the danger it presents. These same close-knit communities can sometimes foster stigma and judgment. About a third of adults surveyed in rural America said there was a huge stigma associated with addiction, which can help exacerbate the problem. Many of these areas also have a history of drug and alcohol abuse. Circumstance in these communities has created an environment ripe for these powerful drugs to take root.
When the government gets involved
The policies of the last administration produced a mixed bag of outcomes in regard to the opioid crisis. The year Donald Trump took office, more than 42,000 Americans died from overdoses linked to opioids. That same year, Trump declared a national public health emergency. He signed legislation boosting funding for evidence-based drug treatment and pressured China to decrease fentanyl exports (which were not meant to supply the medical community, but illicit drug dealers).
But there were also some serious missteps, including the sidelining of the Office of National Drug Control Policy, and turning over leadership of the crisis response to political appointees. There was a slight decline in opioid deaths in 2018 but a surge the following year: 2019 saw nearly 71,000 opioid-related deaths. And between May 2019 and May 2020, 81,000 deaths were recorded — the highest number ever in a single year. The Trump administration also fought to dismantle the Affordable Care Act, which funds about 40% of the opioid addiction treatment programs in the U.S.
The huge rise in opioid-related deaths is likely due, in part, to the pandemic. With many people left jobless, lonely, and stressed, and treatment programs and other support services temporarily closed, a perfect storm of compounding cause and effect emerged. People who are isolated are more likely to use drugs alone, with no one to call emergency medical services if they become incapacitated. Also, people who have been clean are at higher risk of overdosing during a relapse because of decreased tolerance.
With multiple crises facing our country, the Biden administration has yet to roll out any comprehensive strategy for combating the opioid crisis. The administration has been criticized for rescinding guidelines outlined in the final days of the Trump administration, which would make opioid treatment drugs more widely available to doctors. The new administration says it was a decision made too hastily, and they have legal concerns over implementation, including training and waivers for doctors.
Efforts toward change have also been indirectly opposed by the pharmaceutical industry through lobbying and advocacy groups. “Researchers from two universities found that the opposition to the CDC guidelines was significantly more common among organizations that received funding from opioid manufacturers.” Another investigation by the U.S. Senate Committee on Homeland Security and Governmental Affairs found millions of dollars were spent to promote messages and policies that favor the pharmaceutical companies instead of the CDC guidelines.
Local communities fight the crisis with education and awareness
In light of all these factors, some communities have taken matters into their own hands.
Education and awareness are important tools in confronting the opioid crisis, especially in rural America. For example, rural communities of South Dakota have developed the Strengthening the Heartland program. The program provides one-hour seminars with information about opioids and the services available to surrounding communities. These seminars go beyond the harmful effects of opioid addiction, addressing issues such as how to handle stress and depression, and how to take prescribed medicine correctly. In towns where mental health services are minimal, having information and learning how to recognize a drug dependency, or even what to do once a problem is detected, is paramount. “We are trying to bridge the gap between what professionals in the field know and the services and information that people who are actually dealing with addiction need,” said clinical coordinator Kristine Ramsay-Seaner.
When people have knowledge, they are better able to come together and figure out what works best for their community. Knowledge empowers and allows financial planning for programs like the one in Snohomish County, Washington, where a small town of 7,000 is responding to the opioid crisis as if it were a natural disaster: “The county’s program includes small steps, like making transportation easier for people in drug treatment. They train family members and others in the community on steps to reverse overdoses with medicine, and they send teams of police officers and social workers to help addicted homeless people.”
These programs take money and a great deal of cooperation to be successful, and sometimes the results are slow in coming. As the director of communications for the Snohomish Sheriff’s office, Shari Ireton wisely said success will not come if the goal is to just “end the opioid epidemic.” Education and awareness will help fuel the smaller goals that will ultimately affect this addiction battle. “It’s like eating an elephant. You just can eat one piece at a time. Breaking it down into a piece that you can actually digest.”
The National Safety Council has suggested steps each of us can take to fight the opioid epidemic:
- never mix your medications
- get rid of expired and unwanted prescriptions
- request an opioid Warn Me Label (which helps clarify if the prescription is an opioid, if there are other alternatives, and what the risks are)
- talk to your children about the fact that painkillers can be as dangerous as illegal drugs
For further information about responsible opioid use, or if you or someone you love is struggling with opioid dependence, call the Substance Abuse and Mental Health Services Administration help line, at 1-800-662-HELP (1-800-662-4357).
This post was a collaboration by the entire Awareness Wednesday Team: Charlotte Mountain, Debra Oaks Coe, Jenny Rogers Moody, and Molly Cannon Hadfield.
