Drug Abuse in America: The Unseen Side

From the lecture series: The Skeptic's Guide to Health, Medicine, and the Media

By Roy Benaroch, M.D., Emory University

Everyone has been blaming pharma companies and doctors for the rise in drug abuse, but people have not bothered to see the other side of it. How do users get these drugs in such quantities that they can misuse them? It is not through prescriptions alone. There is an unseen aspect of the whole issue.

Graph showing the drug overdose deaths involving cocaine in the US,  from 1999 to 2017.
The graph shows opioid involvement in cocaine overdose deaths. (Image: National Institute on Drug Abuse(NIDA) / Public domain)

The story of drug abuse is quite complicated. It is not only about drug companies pushing their pills through their salesforce. There is a lot more than that in it. Vice, a print magazine and website out of Canada, ran a long-form article under their Tonic brand in 2017 titled “Prescribed Painkillers Didn’t Cause the Opioid Crisis”.

The Vice article begins by summing up the problem: The idea is that the overdose epidemic was caused by evil drug companies pushing greedy doctors to prescribe unnecessary drugs, which turned innocent pain patients into people with heroin addiction, who are now overdosing on street fentanyl. That, however, is not exactly what happened.

The article says that drug companies irresponsibly marketed these medications, made inaccurate claims about addiction risk, and hired salespeople to pressure doctors into prescribing more.

But a physician is quoted as making a critical observation. He says, “The simple story is that addiction happens all the time when people get opioids for pain and that simple story is clearly wrong. The research actually shows that people who developed new addictions in recent years were overwhelmingly not pain patients.”

Instead, in recent years, addiction is much more commonly occurring in friends, relatives, and others to whom legitimate opioid prescriptions have been diverted. Less than 25% of the people indulging in drug abuse get them directly from a doctor. Most of them get them from their friends or relatives. So though the pills share blame, it’s not usually the doctors who are prescribing them, at least not directly.

This is a transcript from the video series The Skeptic’s Guide to Health, Medicine, and the Media. Watch it now, on The Great Courses Plus.

The Complexity Of Drug Abuse

Doctors are guilty of simply prescribing too many pills. The spare ones sit in medicine cabinets to be shared, borrowed, or stolen, and that’s an important contributor. Further in the article, the author cites research that two-thirds of surgical patients don’t take all of the opioid pills that were prescribed. This means a large number of extra pills.

Drug abuse or misuse means using them without the prescription of a doctor. But only 3.6% of people who abuse opioids ever even try heroin, and the percentage of people who turn to heroin after using opioids under a doctor’s care is even smaller.

Picture of raw opium.
Medical use of raw opium has unintentionally led to easy access to opioids. (Image: Unknown author/Public domain)

Therefore, the perception that the crisis has happened because of the patients who took the opioids under a doctor’s prescription and then got addicted to it is wrong. Medical use has unintentionally led to easy access to these pills, but it’s not the people taking the pills for pain that are the main problem.

Thus, efforts to curtail addiction by forcing doctors to prescribe fewer of them for pain patients may not work. In fact, the current crackdown on physician prescribing may be contributing to deaths. When people who are dependent can’t get those pills (which, at the very least, are pure and consistent), they sometimes turn to substitutes like heroin, or maybe unknowingly to heroin cut with fentanyl.

Another evidence of the pain pills not causing most of the damage comes from the health departments of different states. The department of health in Ohio, which has the highest number of deaths related to the opioids, said that as compared to 2010 when about 20% of deaths occurred due to heroin or fentanyl, the figure rose to 80% in 2015. Similar trends were reported from Florida and Massachusetts. So there is no disputing the fact that most of the deaths that occurred recently have not been due to pain pills but due to drug abuse like heroin and fentanyl.

Learn more about why health recommendations can suddenly change.

Fentanyl: The Deadly One

Fentanyl has caused the majority of opioid deaths recently. Fentanyl is 50 times more powerful than heroin, is cheap to make, and because it’s so concentrated, is much easier to smuggle to distributors in the US.

Picture shows fatal dosage of fentanyl next to a coin for size reference.
Fentanyl is 50 times more powerful than heroin. See how fatal dosage of fentanyl compares in size to a coin. (Image: United States Drug Enforcement Administration/Public domain)

Fentanyl is especially lethal not only because it’s so strong, but because it acts very quickly. It can trigger a deadly overdose and complete cessation of breathing in seconds. And being cheap, it is mixed with other drugs in different quantities so the users have no idea what amount they are consuming. It is believed that most of the people who died of fentanyl overdose did so unintentionally.

The United States has the dubious distinction of being a world leader in opioids consumption. For every one million Americans, almost 50,000 doses of opioids are taken every day. That’s four times the rate in the UK.

The article points out that in the US, most insurance companies cover a pill to treat pain, but they don’t often cover other modalities, like massage or physical therapy. And the US and New Zealand, alone in the world, allow prescription drugs to be advertised on television, driving up usage.

Learn more about life expectancy in the United States.

Possible Solutions for the Opioid Crisis.

So what can be done about it? Though reasonable steps to prescribe fewer opioids can help, it is known that the threat of addiction comes mostly from diversion—that is, opioids used by people other than the prescribed patient. Tackling that problem can start with prescribing fewer pills, and especially fewer pills to people who won’t need them. Plus, the pill-mills and the doctors who prescribe these pills beyond good medical care should be shut down.

In addition, mental illness that commonly contributes to pain, or makes pain very difficult to deal with, like depression, anxiety disorders, and alcoholism, needs to be identified and treated. Opioids are not the best treatment for conditions like anxiety, depression, and alcoholism. And addiction should be treated as addiction only. The use of medically prescribed and long-lasting opioids could be the best treatment for weaning off the effect of drug abuse and addiction. Additionally, Narcan should be made easily accessible in order to save lives. Narcan is naloxone, a drug that reverses the opioid overdose effect. 

Media is doing a good work of keeping the issue of the opioid crisis and drug abuse in focus. They’ve been helping to create pressure for policy changes, while educating families about warning signs and resources that can help. But, they can’t do it alone. People must work unitedly so that help can reach the pain sufferers and newer people don’t get into addictions.

Common Questions about Drug Abuse

Q: What is drug abuse?

Drug abuse is using prescription drugs for something other than their intended purpose, or the use of illegal drugs. The use of these drugs in large quantities also comes under drug abuse.

Q: Why is drug abuse done?

There are multiple reasons causing drug abuse. It may be due to a family history of addiction, or just peer pressure or mental health issues.

Q: What is the effect of drugs on the brain?

When drugs are taken, they hinder the normal procedure of neurons sending, taking, and processing the signals through neurotransmitters. So drug abuse interferes with the normal communication between neurons.

Q: How is someone identified as a drug addict?

When the drug taking or using becomes compulsive, and someone is not able to control it in spite of knowing about the dangerous consequences, then it can be said that the person has developed drug addiction.

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