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America’s opioid addiction crisis

Opioid overdoses killed more people in the US in 2017 than were killed during the whole of the Vietnam War. Meanwhile, prescriptions are on the rise in Britain too. Simon Wilson reports.

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What's happening?

The most recent full-year official figures on America's opioid epidemic show that drug overdoses killed more than 70,000 Americans in 2017, a record high. That's more than car crashes or gun violence (both around 39,000); more than HIV-Aids at its peak (42,000); and more than all the US soldiers killed during the whole of the Vietnam War (58,000). Of the 70,000, some 47,600 people were killed by opioid overdoses a five-fold increase since 2000 of which 32% were killed by prescription pills and 68% by illegal opioids (including heroin and fentanyl).

Perhaps most worrying of all, the number of people killed by fentanyl and similar synthetic opioids has rocketed: up from 3,000 in 2013 to more than 28,000 in 2017. The epidemic is so severe it has contributed to falling life expectancy in the US for the past three years a pattern not seen since World War II and drug overdoses are now the leading cause of death for people aged under 55.

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What exactly is an opioid?

It's the name for any drug (whether legal or illegal) that acts on opioid receptors in the brain and spinal cord to produce morphine-like effects that block out pain. These receptors get their name from opium, the narcotic derived from poppies that has been used by humans for millennia and is the original opiate.

From opium we have derived a range of other drugs with similar painkilling properties: morphine, heroin, then (in recent decades) prescription painkillers such as codeine, Vicodin, Percocet, OxyContin (oxycodone) and tramadol. All these drugs are opiates. And together with a class of opiate-like synthetic drugs chiefly methadone and fentanyl they are collectively known as opioids. These are powerful painkillers with important uses in modern medicine, but they are highly addictive and their suitability for the treatment of chronic pain is highly controversial.

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How did America get hooked?

Humans have been getting hooked on opiates for centuries. But the current crisis has its roots in doctors' massive overprescription of opioid painkillers, in particular the Purdue Pharma-produced OxyContin, amid a massive and heavily incentivised lobbying and marketing campaign in the 1990s. That led to the first wave of overdose deaths, as people both patients and those who stole or bought opioids from them misused and got addicted to the drugs.What then caused the crisis to grow was an influx of cheap heroin in the 2000s. Dealers preyed on a fast-growing cohort of people (disproportionately poor whites in the east, northeast and midwest of the US) who were addicted to opioids, but found it hard to get hold of them, or simply now wanted a cheaper, better high. According to US government figures, more than three-quarters of current heroin users first got addicted to prescription pills.

What's the situation now?

The US is in the grip of an even more deadly third wave of the crisis, due to the emergence of fentanyl, a synthetic opioid (used legitimately as a surgical anaesthetic) that is made mostly in China and is 50 times stronger than heroin. Since 2011, overdose deaths from prescription opioids have levelled off and are falling. But deaths are still going up due to synthetic drugs (such as fentanyl) that are far more deadly than prescription pills or heroin. That's because they are more potent, meaning they're more dangerous and that small errors in measurement can lead to an overdose. But it's also because the blends of illegal synthetic drugs sold on the streets (or via the internet) change frequently, meaning that users are prone to underestimate the strength of the drug they are injecting leading to more fatalities.

What's the economic cost of all this?

A report by the White House Council of Economic Advisers estimated the total social cost of the opioid crisis to the US at up to $504bn, or 2.8% of GDP. Other analyses focusing on the healthcare costs (and lost productivity costs) have come up with lower figures: a 2017 study in the academic journal Medical Care, for example, put those direct costs at $78.5bn. Either way, for big pharma, the financial pain could be just beginning with a major trial involving a total of 1,500 lawsuits against drugmakers and distributors due to begin next autumn. Back in 2006, Purdue's parent company paid $600m in fines over charges of "misbranding".

"Britain is in danger of sleepwalking into aUS-style opioid epidemic"

But the eventual liability of pharma companies is likely to make that sum look tiny (while probably not being in the same league as the $206bn paid in a master settlement by tobacco companies 20 years ago). Analysts at Berenberg believe the total compensation bill could be around $50bn. Purdue accounts for $27bn of that; Endo Intl a further $10bn, with Johnson & Johnson, Teva and Insys being among the other firms with significant exposure.

Could it happen here?

Some fear it already is, albeit on a smaller scale. According to figures collated byThe Sunday Times, a jump in prescriptions for opioid painkillers since 2007 has been mirrored by a (much bigger) jump in overdoses and deaths to some 2,000 opioid fatalities a year, including heroin. In Britain, the most prescribed opioid drugs are co-codamol, tramadol, codeine, co-drydramol, dihydrocodeine, oxycodone and fentanyl. There has been a 30% rise in prescriptions for these drugs since 2007 (though a flattening since 2014) and an 89% jump in overdoses (including of heroin).

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As in the US, the death rate from opioid overdoses is far higher in poorer areas. The problem is far worse in northern England and Wales than it is in the south (6.2 per 100,000 people in the northeast; 1.8 in London). The state is "facilitating the prescribing of potentially dangerous opioids at increasing levels", says former health minister Norman Lamb. As such, he warns, we're in danger of "sleepwalking" into a US-style epidemic.

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