The Opioid Crisis: An ‘Epidemic Within the Pandemic’
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Before the COVID crisis, there was the opioid crisis. Though the pandemic has grabbed the headlines, Americans continue to die of opioids at alarming rates: 136 Americans die every day from an opioid overdose. In all, more than 840,000 Americans have died of opioid-related causes since 1999.
This surge has been more than 20 years in the making, revealing underlying inequities in terms of who is afflicted, healthcare access and use, and treatments, among others. A fraying social safety net, the growing availability of a more dangerous synthetic opioid called fentanyl, the push by pharmaceutical companies to aggressively market opioids, and the COVID-19 pandemic, among others, have contributed to the growing complexities of addressing the opioid crisis.
Six IPR experts share their research-based insights around how this devastating crisis began and offer their insights on policies to address various aspects of the crisis, including addiction and treatment.
- What Exactly Is Addiction?
- Structural Causes and Policy Implications
- What Caused the Opioid Crisis?
- How Did the Pandemic Impact Opioid Use?
- Who Has Been Hit Hardest by the Opioid Crisis?
- Better Measurements Needed to Address the Crisis
- What Can Policymakers Do to Stem the Opioid Crisis?
What Exactly Is Addiction?
“Addiction is any behavior that somebody engages in that has negative consequences, but they can't stop,” IPR psychologist Robin Nusslock explained. As a neuroscientist as well as a psychologist, he studies the brain systems involved in addiction, using 21st-century tools like functional magnetic resonance imaging (fMRI) scanners.
Dependence on the substance is a defining characteristic of addiction and one that is especially evident in opioid addiction. When dependent, a person receives less pleasure from the drug and simply needs it to be functional—to “get up and do the day,” as Nusslock said.
Nusslock outlined how opioids work: We all have opioid receptors in our brain and throughout the body. The opioid system in our brain is a gating mechanism that releases the opioids our body manufactures, such as endorphins, to reduce pain we feel. Taking opioids makes us feel good because it binds to receptors in our biology that, by design, give us pleasure. The opioids also lead to the release of a molecule called dopamine, which motivates us and gives us energy.
“All drugs … eventually hijack the dopamine circuit in the brain,” he explained. “The person becomes hyper-focused on getting the drug at the expense of other rewards in the environment.”
Taking the drug goes from producing pleasure to a powerfully habitual necessity.
Additionally, stress triggers our brain’s reward circuits. For example, we may crave donuts when we are stressed. For someone who is addicted to opioids, stress increases the brain’s need for rewards and its craving for the drug.
Structural Causes and Policy Implications
In his work with IPR health psychologist Greg Miller, Nusslock focuses on how structural social stressors, such as poverty, prejudice, and maltreatment embed themselves in the brain’s reward circuit early in life, which elevates people’s risk for addictive behaviors, among other threats to health.
“I think approaching something like addiction, whether it's opioids, alcohol, or other substances, really requires a multi-systems perspective,” he said.
Nusslock and Miller show that adversity early in life increases inflammation that alters the brain’s reward system and leaves it less sensitive to reward. This can lead to depression that people may self-medicate by smoking, drinking, or addictive drug misuse.
In a study forthcoming in the Journal of Abnormal Psychology, Nusslock and his co-authors found more evidence that decreased reward functioning in the brain is a risk factor for increased drug use.
Given his understanding of the brain chemistry behind opioid addiction, Nusslock stresses a rehabilitation model rather than a punishment model of treatment. Addiction is complex, and someone struggling with addiction is not a “bad” person. Rehabilitation may take a long time but can work.
“There's compelling evidence that the act of going through a treatment program changes the brain back to a healthier state,” Nusslock said.
He emphasized that to overcome the powerful habit of addiction, we need to solve the stressors that drove the person to opioid use in the first place. Programs and policies that mitigate trauma and early adversity would help address the addiction prevalent in poverty-stricken communities.
Nusslock also notes that the biggest risk factor for becoming addicted to a substance is taking that substance. A significant minority of people are especially biologically vulnerable to opioids and respond immediately to their dose by loving how it makes them feel, although others dislike it. Since we cannot predict, at least as things stand now, how different people will respond, he urges more precision in prescribing opioid pain medications.
What Caused the Opioid Crisis?
IPR economist Molly Schnell explains that there are two different narratives about the cause of the opioid crisis—a supply story and a demand story. The supply story says healthcare providers began prescribing more opioids, which led people to become addicted. The demand story says economic distress caused individuals to seek out opioids as a coping mechanism.
“Most of the evidence points to the opioid crisis being driven by the supply side,” Schnell said. “If you look across the U.S., areas with the greatest increases in prescribing also saw the greatest increases in opioid-related mortality. And these increases in prescribing are largely unrelated to underlying economic conditions.”
In the 1980s, a few studies suggested that opioids might not be as addictive as previously thought, Schnell says. Pharmaceutical companies took this information and began telling healthcare providers that they could safely prescribe these medications for a growing list of conditions.
At the same time, attitudes in the medical community were changing, and monitoring and treating patients’ pain became an important component of clinical practice, which led doctors to begin prescribing more opioid medications. Since 1999, overdose deaths have increased over six times to a total of more than 840,000, according to the CDC.
Prescribing practices differ dramatically across clinicians. Schnell’s research finds that physicians who attended lower-ranked medical schools prescribe nearly three times as many opioids per year compared to those who attended higher-ranked schools. These differences in prescribing are apparent even conditional on differences in the types of patients that these doctors see, suggesting that differences in medical training cause certain doctors to prescribe more opioids.
IPR economist Hannes Schwandt’s work also suggests the demand story, or the narrative that opioid overdoses are ‘deaths of despair’ caused by poor economic conditions, is not the main cause of the crisis. In a working paper, he shows that there is not a connection between unemployment rates and opioid overdose deaths in 2018. Schnell’s work further shows no simple causal relationship between local employment rates and opioid prescribing between 2006 and 2014. In fact, most people taking opioids were working and their prescriptions were paid by employer-provided private health insurance. Despair from poor economic conditions may factor into the mix of complex reasons behind the crisis, they said, but it doesn’t seem to be the primary driver.
“The notion that economic despair started the epidemic is still very strong, and I think that hinders people from understanding the role of providers,” Schwandt said.
How the Opioid Crisis Began to Evolve
As states began passing legislation to limit opioid prescriptions, it led many already addicted to opioids to turn to illegal substances. Between 2006 and 2017, annual prescribing rates fell more than 19% nationally, though, in 2015, they still remained three times as they were in 1999 and continued to be part of the problem, according to Schnell.
Sociologist and IPR associate Maryann Mason notes the shift to illegal substances is pronounced in Illinois, according to her research. When she looks at the fatal overdoses in Illinois from January 2019 to June 2020, only 15% of cases have prescription drugs at the time of death.
“Certainly, early in this crisis, overprescribing played a huge role,” she said. “The role of illicit drugs and the illicit drug market has grown as the crisis evolved.”
She noted the reasons for illicit drug use are multifaceted, so she credits drug supply and the despair that arises from poverty as contributing factors to the current state of the opioid crisis.
How Did the Pandemic Impact Opioid Use?
When Mason started to examine opioid overdoses in Cook County during the pandemic, she anticipated increased deaths. But she was surprised to see how closely the fatalities aligned with the stay-at-home order.
She and community health scholar and IPR associate Joe Feinglass found more than 35 deaths per week from December 2019 to March 2020, with weekly deaths rising to 44 during the first stay-at-home order that lasted 11 weeks in spring 2020. After the governor lifted the order in Illinois, the researchers saw opioid overdoses drop to nearly 33 deaths per week.
“However, they did not drop to pre-pandemic levels,” Mason said. Before the pandemic, she and Feinglass reported 23 deaths per week between January 5, 2018, and December 3, 2019, in Cook County.
Both Mason and Feinglass agree that the unprecedented economic instability, such as the sudden job loss in low-paying service jobs, and disruptions to drug supplies caused by the pandemic may explain why some people relapsed and opioid overdoses surged. Many social services paused during that time, too.
“The COVID lockdown triggered a major crisis for many including those in recovery who suddenly lost their in-person support groups and often their service sector jobs and livelihoods,” Feinglass said.
People who are relapsing are at higher risk of fatal overdose because they lose tolerance to the drug. If they resume using it at prior levels, they will likely overdose, Mason and Feinglass say.
In addition to the spike in fatal opioid overdoses during the pandemic, Mason and Feinglass found an increasing presence of fentanyl in opioid overdoses. Fentanyl, a lab-produced compound, is lethal in tiny quantities and replacing heroin, Feinglass adds. There is an increasing presence of fentanyl in the drug market and knock-off, or fake, drugs resembling prescription drugs. Mason says fentanyl could lead to rapid overdosing as well. In those cases, there is not enough time to call emergency medical services (EMS) to reverse an overdose.
“People who weren’t even intending to use opioids are dying by opioid overdoses just because of the mix in with fentanyl,” Mason said. “[Fentanyl] is very cheap, and it could be mixed into a drug supply of cocaine or knock-off drugs like Xanax.”
During the pandemic, the rate of fatal opioid overdoses among people of color increased dramatically, while the rates of fatal overdoses among White people declined, Mason says. She also notes that people of color who die of opioid overdoses tend to be older than White people.
The opioid overdose spike and presence of fentanyl during the pandemic are not unique to Illinois. Across the country, Mason, Feinglass, and Lori Ann Post, who is the Buehler Center for Health Policy and Economics director and an IPR associate, note a rise in opioid overdoses before the pandemic. In the last quarter of 2019, opioid overdoses were climbing back up after a slight decline from 2017 to 2019.
“I fear that the social isolation and despair created by the pandemic will have a long tail of deaths from drug and alcohol use, suicide, and other ‘diseases of despair’ among Americans, especially the growing numbers of formerly incarcerated, homeless, and traumatized young adults,” Feinglass said.
Schnell and Schwandt’s research reveals a similar trend in Ohio. During the state’s first lockdown between April–June 2020, overdose deaths spiked. At its peak, the state saw 145 overdose deaths during the week of May 31–June 6, a 70% increase from before the lockdowns. By August, overdose deaths had returned to pre-pandemic levels.
“During the months of the first pandemic wave, overdose rates were really at the highest that we have ever seen,” Schwandt said, calling it an “epidemic within the pandemic.”
Analyzing nearly half a billion prescriptions, Schnell and Schwandt find that initiation of buprenorphine, a drug commonly used for medication-assisted treatment of opioid use disorder, declined during the first wave of the pandemic.
“Limited access to treatment may have played a key role in driving increased opioid deaths,” Schnell said.
Who Has Been Hit Hardest by the Opioid Crisis?
White male Americans have died from opioid overdoses at the highest rate of any demographic throughout the crisis, but death rates have been increasing for Black Americans since 2016.
Schwandt says one of the reasons opioid use is concentrated among White Americans is because early in the opioid crisis, doctors were hesitant to prescribe opioids to Black patients.
“When doctors started to increase their prescribing of opioids early on in the crisis, communities of color were less affected because they were discriminated against,” Schwandt said. “This emphasizes once more the central role of providers.”
But racial differences have shrunk in recent years.
“The opioid epidemic, or what many now call the ‘opioid crisis ‘since there is no end in sight, has taken a large and growing toll of people of color,” Feinglass said. “African Americans have, by far, the largest recent rate of increase in overdose deaths nationally.”
In Illinois, he and Mason discover that most overdose deaths are among Whites, but Black overdose deaths are twice as high per capita. Specifically, they find a high hospital death rate in Cook County along Chicago’s South and West sides, which Mason says may signal more rapid overdoses.
Feinglass also points to variation in opioid use and deaths across U.S. cities, reflecting the strength of illegal drug markets, how established the drug cartels are in certain places, and other factors like the history of legal opioid prescribing over the years. Regardless of geography, fentanyl-related overdose deaths are becoming widespread throughout the country, he says.
Rural America Is Also Hard Hit
Post has compared the impact of opioids on rural mining towns and rural farming towns, finding that rural mining areas have higher death rates in the opioid epidemic. Additionally, her research shows the death rate is positively related to opioid prescription rate, mining dependence, percent of the area that is White, and age.
“Rural counties have lower death rates than in urban counties, but they have significant spatial heterogeneity,” Post said.
Better Measurements Needed to Address the Crisis
Looking at the distribution of deaths across counties can help policymakers identify which areas need the most resources. But Post argues the measurements need to be improved to predict early signs of an outbreak in the population.
“If you have a rate of opioid overdose deaths or just a rate of opioid overdoses that are non-fatal overdoses, we want to know if that rate is accelerating,” she said.
If the acceleration increases, that informs researchers, public health organizations, and policymakers where a spike may occur.
“If I give you a graph generated this morning about the rates of opioid overdose deaths by race and ethnicity, it tells you what happened already,” Post said. “It doesn’t tell you that actually Latinos, African Americans, and Native Americans are accelerating at three times the rate of White people.”
What Can Policymakers Do to Stem the Opioid Crisis?
Schwandt says the continuing opioid crisis has gotten lost in the focus on stopping the spread of COVID-19 and dealing with the economic recession.
“It doesn’t seem to be at the top of policymakers’ priorities right now,” he said.
For policymakers set to move on addressing this crisis, IPR experts have the following recommendations.
Reduce Unnecessary Prescriptions
“We definitely want to stop unnecessary prescribing to prevent people from getting addicted in the first place,” Schnell said. “But growing evidence shows that some individuals switch to illicit opioids when the legal supply of prescription opioids is disrupted, and we cannot just leave them unsupported.”
Reducing prescriptions should be paired with policies that provide better access to treatment for populations already addicted to opioids, she says. For example, overprescribing is already starting to go down in part because programs like prescription drug monitoring programs allow doctors to see if a patient got medications from another provider before writing a prescription. But these initiatives should be paired with better access to drug treatment programs for individuals struggling with addiction.
She also points out that now more people are dying from overdoses due to illicit fentanyl rather than prescription opioids, which was not the case earlier in the opioid crisis. Some of these people started on prescriptions and switched to illicit drugs, but more people may start with illegal substances as they become more readily available.
“As the nature of the opioid crisis evolves, our policies to address it will also need to adapt,” Schnell said.
Funding Specific Treatment Options
Mason argues that medication-assisted treatment is the only effective treatment of opioid addiction, and it may reduce illicit opioid use. But it is not widely supported, especially among providers with “ideological opposition.”
“We know it’s more brain-based, it’s chemical-based, and it’s actually a medical condition, and why would you not treat a medical condition with medications that help it?” Mason asked.
Feinglass calls for an even more controversial idea: safe-consumption sites. The idea is that people can self-administer drugs at these facilities and receive sterile equipment, with the primary goal focusing on reducing overdose deaths and infections. Other harm reduction initiatives that can save lives are a greater distribution of naloxone, a drug that reverses overdoses, especially from hospital emergency rooms, and fentanyl test strips that check for lethal doses, he says.
Both medication-assisted treatment and safe consumption sites may be beneficial in reducing rapid overdoses, which spiked during the pandemic. Mason and Feinglass find that community deaths with no bystanders or timely EMS response were three times as many as deaths of people who made it to the hospital.
Improving Social Services and Reducing Stigma
More broadly, Feinglass says improving social services, like access to housing and jobs, could help increase the reach of harm-reduction strategies. Decriminalizing opioid use and illicit drug use is an important step, too.
“This has the potential to reduce stigma, reduce the role of drug cartel and street gang crime and violence, and increase medically assisted community treatment,” Feinglass said.
Post, who examines toxicology reports in her research, finds a mix of substances connected to opioid overdose deaths. To her, that shows a more significant substance abuse problem in America, which requires policymakers to address the hardships that push people to use drugs.
“We have incredible economic disparities, we have disparities in life expectancy, we have disparities and victims of crime,” Post said. “When your life is like that, you are living in despair.”
Mason, who also looks at toxicology reports, agrees the opioid crisis is part of a larger polysubstance issue. For older adults, for example, Mason said she is finding a mix of alcohol and opioids.
“If opioids went away tomorrow, I don’t think our problems will be solved because there are many substances out there,” Mason said.
Robin Nusslock is an associate professor of psychology and an IPR fellow. Molly Schnell is an assistant professor of economics and an IPR fellow. Hannes Schwandt is an assistant professor of human development and social policy and an IPR fellow. Joe Feinglass is a research professor of medicine and preventive medicine and an IPR associate. Maryann Mason is associate professor of emergency medicine and an IPR associate. Lori Ann Post is director of the Buehler Center for Health Policy and Economics, Buehler Professor of Geriatric Medicine, and an IPR associate.
Photo credit: iStock and Pexels
Published: June 28, 2021.