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The American Opioid Crisis, which started in the late 1990s, has been called an epidemic by multiple media sources, both online and in print. In this essay, I will evaluate the extent to which the Crisis can be considered an epidemic by making comparisons to other epidemics from the past century. This topic interested me because the Opioid Crisis originated in a highly different way to other contemporary epidemics. Whilst opioid addiction is a disease, it cannot spread from person to person in the same way as Ebola, for example. Furthermore, the topic looks at addiction as a disease and raises the question ‘Can widespread addiction be classed as an epidemic?' There are various definitions of an epidemic; Merriam Webster defines it as ‘affecting or tending to affect a disproportionately large number of individuals within a population, community or region at the same time.' It can be ‘characterised by very widespread growth or extent.' To an extent, the Oxford Dictionary describes an epidemic in a very similar way, however, they suggest that the onset of an epidemic is ‘sudden,' and they are an ‘undesirable phenomenon.' The word ‘epidemic' has its roots in ancient Greek, being derived from epidemios (meaning prevalent). It was used in its current form for the first time in the early 17th century. By defining an epidemic, we are able to see that the Opioid Crisis matches some of the criteria set out by Merriam Webster, in that it affects a large number of individuals in the United States. However, in order to reach a definite conclusion, it is also necessary to evaluate some of the characteristics of epidemics as set out by epidemiologists. Epidemics tend to display certain behaviours, but these depend upon geographical and environmental conditions, as well as the host population (Nadu, 2012)1. According to Nadu, there are several main characteristics that are displayed in epidemics. Firstly, there are ‘an unexpected number of cases… affecting a large segment of the population.' There are three main types of medical epidemic: point source, continuous source and person-to-person (Giesecke, 2017)2. A point source epidemic is caused by single source or infection or exposure causing all cases to originate at the same time. For example, if a group of people contracted food poisoning at an event, this would be classed as a point source outbreak. The number of cases quickly reaches a peak, before starting to fall gradually.3 A continuous source epidemic happens when a single cause is responsible for infecting people who are in contact with it over a long period of time. An example of this would be a source of polluted water in a village. Person-to-person or propagated epidemics happen when a causal agent is passed from person to person, allowing the epidemic to spread. An example of this would be an outbreak of measles. By comparing the Opioid Crisis to the criteria above, I will be able to fully evaluate the extent to which it can be considered an ‘epidemic.'

Opioid use first became common in the United States in the nineteenth century, when thousands of Chinese people emigrated to America to work on gold fields during the 1849 California Gold Rush.4 Immigrants opened opium dens throughout the country and between the 1870s and 1880s, America's per capita consumption of opiates had tripled.5 Richard Heimer, a professor at Yale University said that following the Civil War, there were “an estimated two million people who abused opiates.” The Union Army issued ten million opium pills to its soldiers, as well as 2.8 million ounces of opium powders. However, historians believe that veterans were only a small percentage of this number. The popularisation of hypodermically injected morphine as a treatment for a wide range of ailments including asthma, headaches and gastrointestinal diseases, caused a widespread epidemic. By 1895, there was an addiction epidemic affecting 0.5% of Americans (Trickey, 2018).6 By the late 1800s, women made up more than 60% of opioid addicts, partly due to male doctors overprescribing morphine to relieve female patients' menstrual cramps. It was only when the crisis peaked in 1895 that doctors began working to end the epidemic. With the introduction of vaccines and x-rays, fewer physicians sought to inject morphine and instead, they used newer pain relievers such as aspirin (the drug was first sold in 1899). With the advent of better sanitation, fewer people caught waterborne diseases such as dysentery and cholera. This in turn led to fewer patients needing to use opiates for pain relief. Furthermore, the education of doctors through textbooks and educators helped to decrease the number of doctors prescribing morphine as a cure for all ailments. Over the next twenty-five years, several new laws were passed in order to reduce the number of patients using opioids. The Pure Food and Drug Act of 1906, for example, gave new regulatory powers to the government, as well as regulating the labelling of products containing cocaine and heroin. In 1914, the Harrison Narcotics Tax Act restricted the distribution and sale of heroin and opium. Within the next ten years, it became illegal to make, import or sell heroin, due to the 1924 Anti-Heroin Act. After Prohibition ended in 1933, many people that had profited from selling illegal alcohol turned to selling opioids such as heroin as their main source of income. It was not until 1970 that more major legislation was put into place surrounding the use of opioids. The Controlled Substances Act created groupings of drugs based on their potential for causing dependence and abuse.7 Heroin is classed as a Schedule I drug in the United States and a Class A drug in the United Kingdom, meaning it has a high potential for abuse. Other opiates, such as morphine and fentanyl, are classed as Schedule II in the USA, as they have a high potential for abuse and dependence but unlike heroin, they have a currently accepted medical use in the United States. During the 1970s, the pharmaceutical market discovered that by combining opioids with other drugs like hydrocodone, they were able to produce short-acting painkillers that would provide relief for between four and six hours. In 1978, the pharmaceutical company Knoll introduced Vicodin to the market, a combination of hydrocodone and acetaminophen. Percocet, another combination drug that works by binding to the brain's opioid receptors and creating analgesic effects, was approved by the Food and Drug Administration in 1976. Despite these developments in the pharmaceutical industry, the major turning point in medical opioid use came in 1980, when a letter entitled ‘Addiction Rare in Patients treated with Narcotics' was published in the New England Journal of Medicine. This one-paragraph letter was based on a Boston physician's database that recorded the impact of prescribed drugs on hospital patients. The database found that only a small percentage of those treated with opioids developed an addiction. The physician, Dr Hershel Jick, reported that ‘there were only four cases of reasonably well documented addiction' in the eleven thousand patients treated with ‘at least one narcotic preparation.8' The letter and database were based on an exploratory article that looked at addiction in a highly specific set of patients, not a scientific study. It only examined hospital patients that were closely monitored by medical professionals. Despite this, the pharmaceutical industry took this letter as proof that opioid drugs were safe for commercial consumption. In 1986, a study published in the medical journal Pain observing 38 patients concluded that ‘opioid maintenance therapy can be a safe, salutary and more humane alternative.' Pharmaceutical companies disregarded the small size and general nature of these studies and took them as evidence that new opioid painkillers could be mass-marketed as safe and non-addictive. Despite this evidence, from the 1970s to the mid-1990s, the number of people addicted to opioids remained fairly stable. In the late 1990s, pharmaceutical companies such as Purdue Pharma began an aggressive marketing campaign, with adverts reassuring both patients and the medical community that opioid drugs had a ‘minimised risk of addiction.9' Oxycontin, an oxycodone painkiller that lasts longer than Percocet, became available in 1995 for the relief of moderate to severe pain. Despite many medical professionals recognising the addictive nature of oxycodone, the FDA still approved it for prescription use. Furthermore, the agency also permitted Purdue Pharma to claim that its painkiller was less appealing to drug abusers when compared with shorter-acting painkillers. The pharmaceutical company used this decision as OxyContin's ‘principal selling tool,' with Purdue Pharma admitting in 2007 that they trained their representatives to tell medical professionals that the drug was less addictive and prone to abuse than other opioids10. These marketing tactics allowed OxyContin prescriptions to increase from 670,000 a year in 1996 to more than six million within six years. By 2002, prescription opioids such as OxyContin were killing five thousand people a year and in 2016, there were 42,249 American drug fatalities that involved opioids (two-thirds of the total number of lives lost through drug overdose). In comparison, 41,070 Americans die from breast cancer each year, which is just over a thousand less than opioid-related deaths. Increases in deaths caused by drug overdose have also contributed to a decrease in US life expectancy for the second year in a row.

In order to evaluate whether the Crisis meets the criteria of an epidemic, it must be compared to other epidemics, both in the United States as well as other countries. In the early 1980s, there was a sudden increase in the use of crack cocaine for recreational use in the United States, due to its affordability and high levels of profitability. Data on cocaine seizures during the 1980s shows that the amounts seized increased by more than 40% each year, suggesting that larger amounts of cocaine were being shipped to the United States throughout the decade. This led to a significant decrease in the cost of cocaine, with the price falling in some areas by as much as 80%. By dissolving cocaine hydrochloride into water with sodium bicarbonate, drug dealers were able to form solid masses of cocaine crystals, or crack. This form of cocaine was easier to develop, as well as more cost efficient to produce. The drug first appeared in Miami, before spreading to other large cities across the country, including New York City, Detroit and Los Angeles. The origins of the crack epidemic indicate a key difference between the epidemic and the Opioid Crisis. Despite both drugs being highly addictive, the Opioid Crisis began with doctors prescribing opiate painkillers that they believed to be safe. On the other hand, the crack epidemic was due to a combination of falling prices of cocaine and a sudden increase in the amount of cocaine being shipped to the US, mainly from South American countries such as Columbia. Between 1982 and 1985, the number of cocaine users increased by 1.6 million people and between 1984 and 1987, emergency room visits in the United States increased fourfold. By 1986, crack cocaine was available in 28 states and by the next year, the number had increased to 46 states as well as Washington D.C11. This data on the ‘spread' of the crack epidemic implies that it had an impact on the vast majority of states across the United States. In comparison, the Opioid Crisis has affected certain states far more than others. States in the north including West Virginia, New Hampshire and Ohio have suffered the most deaths12, with 108,000 deaths caused by opioid overdose in West Virginia in 2015. Furthermore, there is a slight difference in the ‘typical' user of each drug. Whilst there is no data from the peak of the crack epidemic, there are some statistics from the National Institute on Drug Abuse that indicate that 52% of people who admitted to using crack were white. This is corroborated by the US House of Representatives' data, which stated that the majority of users were ‘white middle/upper-class.' The Opioid Crisis has also had a greater impact on white Americans but unlike the crack epidemic, it tends to affect poorer and more rural areas the most. Dr Andrew Kolodny, a drug abuse expert, said that ‘racial stereotypes' were protecting minority ethnic groups from the ‘addiction epidemic.' This is because several studies have found that doctors are much more reluctant to prescribe painkillers to non-white patients, fearing that they are more likely to sell them or become addicted. Despite any differences in origin or demographic, both drugs cause a wide variety of medical problems. According to the United States House of Representatives, drug users are six and a half times more likely to suffer from a stroke that may result in death or disability13. Whilst this data is fairly outdated in comparison to other data on the topic, it gives an insight into the consequences of long-term drug abuse. More recently, the Stroke Association published a document on the risk factors of stroke, stating that ‘cocaine increases the risk of stroke in the 24 hours following use' due to the drug increasing blood pressure and thickness14. Opioid use also leads to an increased risk of stroke, although indirectly. Bacterial endocarditis, an infection of the inner lining of the heart, can be caused by intravenous drug use if contaminated needles are used. Repeated injections make the skin more vulnerable, which significantly increases the likelihood of developing an infection. Stroke is a complication of endocarditis; it occurs when clumps of bacteria and cell fragments occur at the site of infection in the heart. When these clumps break off and travel up to the brain, causing a blockage that leads to haemorrhagic stroke. Stroke is not the only neurological problem attributed to drug abuse as the House of Representatives also stated that cocaine causes ‘problems with sensory systems, such as motor and visual problems.' More specifically, use of crack cocaine has been linked to dystonia, which is typically presented through involuntary and rapid movement15. On the other hand, opiates have contrasting effects on the nervous system, partly due to cocaine being a stimulant and opiates being sedatives. Compressive nerve palsies are common, where affected nerves are unable to function properly. Whilst having similar symptoms is not a prerequisite for an epidemic, it indicates the scale of the Opioid Crisis, as well as the impact it has on the individual drug users. Furthermore, when comparing the Crisis to the crack epidemic, it is apparent that they share many of the same characteristics. Both had a trigger cause, which led to a large number of individuals being affected across the United States. On the other hand, despite both developing over several years, the Opioid Crisis has not yet reached its peak, with an increasing number of deaths each year, a trend that seems likely to continue.

The Opioid Crisis is largely an American problem, with the United States consuming more opioid painkillers than any other country. In 2012, American physicians wrote 259 million prescriptions for opioid painkillers12, which has been widely stated to be enough to give a bottle of pills to every adult in the country. Estimates vary, but the United Nations have found that Americans are prescribed six times as many opioids per capita as residents of France and Portugal16. Furthermore, the UN also found that the United States consumes more than 99% of the world's supply of hydrocodone, a powerful painkiller with high potential for abuse. Humphreys, the author of the article and a professor at Stanford university, believes that ‘economics, politics and culture' are most likely to be the causes of the imbalance of opioid consumption. Unlike the European Union, the United States has very few regulations on pharmaceutical advertising, a key factor in the early stages of the Opioid Crisis. In October 2002, Members of the European Parliament voted against relaxing the ban on all pharmaceutical advertising, as the vast majority thought that companies could not provide impartial information17. As of October 2018, direct to consumer (DTC) advertising is legal in only two countries: the USA and New Zealand. Whilst advertising is cited by many sources as the main cause of the Opioid Crisis, it cannot be solely responsible as many European countries have also had issues with prescription opioid misuse and addiction. A study published in the British Journal of General Practice aimed ‘to assess the amount of type of opioids prescribed in primary care in England' (Mordecai, 2018)18. The doctors involved found that there has been a significant increase in long-term prescriptions of opioids for pain management, despite the fact that other studies have shown the drugs to be inefficient for long-term pain management. In 2016, there were 16 million prescriptions for opioid painkillers issued, at a cost to the NHS of £200 million. Both the BJGP and the British Medical Journal suggest that this is due to an increase in people suffering from chronic pain, with estimates that 35-50% of people in the UK affected. Whilst the trend of increasing opioid prescriptions has been a concern to British medical professionals, many believe that the difference in our healthcare systems may prevent us from facing a similar crisis. Firstly, the American problem of ‘doctor shopping' has not had an impact in the UK, as the NHS has made pain management services universally accessible. ‘Doctor shopping' allows the patient to receive multiple prescriptions for the same highly addictive drug from multiple doctors without their knowledge. This lack of coordination in patient care allows patients to become and remain addicted, as well as sell on the drugs to others in their community. An investigation by the US Inspector General found that 22,308 people insured under Medicare appeared to be ‘doctor shopping,' with one patient in Washington D.C. receiving opioid prescriptions from 42 different prescribing doctors19. This patient received 2,330 pills from a single prescriber in just one month. These findings indicate that the problem is widespread within the United States. Furthermore, this also suggests that patients are not solely to blame for the prescription-based crisis. The Inspector General found that roughly 400 prescribers had ‘questionable prescribing patterns' for ‘serious risk' patients. Within the United Kingdom, there have been isolated incidences of ‘doctor shopping,' however, not to the extent of the United States. Another key difference between the USA and the UK in terms of chronic pain management is the approach to pain itself. In the 1990s, the American Pain Society deemed pain to be the fifth vital sign, alongside pulse rate, temperature, respiratory rate and blood pressure. Unlike pain, these signs can be measured accurately by medical professionals. Whilst pain can be measured on a numeric scale, it is highly subjective and requires the patient to make an assessment20. In 1998, the Federation of American Medical Boards encouraged medical societies to punish doctors for the under-treatment of pain. This placed enormous pressure on American hospitals to quickly find ways of managing chronic pain, with many turning to opioids as the solution. The adoption of pain as the fifth vital sign has led to American citizens believing that pain is always avoidable, leading to unrealistic expectations and a significant increase in opioid prescriptions. On the other hand, European doctors are under less pressure to accept pain as a vital sign, which leads to fewer opioid prescriptions. Despite this, European countries have still felt the effect of opioid painkillers, especially fentanyl. The drug depresses the nervous system, which decreases the rate at which messages travel between the brain and the body. Estimates vary, but on average fentanyl is thought to be between fifty and one hundred times stronger than heroin, making it far easier to overdose on the drug. In 2017, fatalities involving fentanyl increased by 29% in the UK21. The drug is used in hospitals for patients with chronic pain after surgery. Fentanyl targets receptors in the brain that control breathing rate, leading to respiratory arrest if a high dose is taken. Furthermore, fentanyl sold illegally is often mixed with heroin and cocaine which amplify the effects felt by the user. Whilst the overall rate of death from drug overdose remains constant in the UK, the sudden change in fentanyl deaths indicates that the drug may lead to an epidemic within the next few years. Furthermore, there is a large divide between overdose deaths regionally. The majority of heroin deaths are concentrated in the north of England, with the highest rate being 14 per 100,000 in Blackpool. Six of the top ten hotspots in the UK are coastal locations, with the majority of these situated in the north. In conclusion, despite the normal trend of American drug crises spreading to the UK, the British healthcare system seems to have prevented opioids causing as much damage as they have in the United States. In addition to this, the fact that the Opioid Crisis is mainly limited to the US provides further evidence that it is an epidemic, as a more global spread would indicate pandemic status.

The consequences of the Crisis have had a colossal impact on all aspects of American society, leading to President Trump declaring it a public health emergency in October 2017. This declaration was renewed twice in both January and April 2018, providing a clear indication that the American government are aware of the seriousness of the opioid problem within the United States and are actively seeking to end the socioeconomic burden it has created. Complications arising from long-term intravenous drug use are highly expensive to treat, with hepatitis C costing between $20,000 and $90,000 to treat per patient. Bacterial endocarditis, another complication of opioid use, often requires open-heart surgery as treatment, which can cost up to $200,000 for a single patient. The US government has stated that they believe $45 billion is required to end the Crisis, but experts have said the actual price may be up to four times that22. In February 2018, Congress pledged an extra $6 billion to fund treatment for opioid abuse and mental health treatment. Whilst this is a large amount of money, it is only 3.75% of the additional budget allocated to the US military (they have been granted a boost of $160 billion of top of their current $549 billion baseline). This suggests that the US government has the available funds to pay for the necessary treatments, however, they do not see the Opioid Crisis as a serious issue. In the past, several Presidents have called for a ‘war on drugs,' with the first being President Nixon in 1971. During the crack epidemic, President Reagan's intolerance of illicit drug use led to a dramatic increase in incarceration rates; the number of people imprisoned for non-violent drugs offences increased from 50,000 in 1980 to just over 400,000 by 199723. The United States Sentencing Commission also introduced the 100-to-one rule, where possession of fifty grams of crack would lead to a ten-year prison sentence. In order to receive the same sentence for possession of powder cocaine, you would need to be found with five thousand grams of the substance. This harsher sentencing was due to a widespread belief that crack was far more dangerous than powdered cocaine, despite the drugs being chemically identical. Law changes such as this meant that very few large-scale drug dealers were caught and punished and instead, individual users were heavily punished. Furthermore, these harsh penalties prevented users from having access to needle exchange programmes, which helped to increase the rapid spread of HIV and AIDS in the United States. By 1988, the number of AIDS cases within the US reached 100,000, partially due to intravenous drug users contracting the disease from contaminated needles24. The statistics arising from the US government's response to the crack epidemic highlight that a punitive outlook will cause more harm than good, and that the public's opinion of drug users has a colossal impact on the way they seek help. Portugal's approach to drug epidemics heavily contrasts with past US policy and has seen far more positive results. In the 1980s, the country was affected by a heroin epidemic that led to one in one hundred people having an addiction to the drug. Within several years, Portugal had the highest rates of HIV infection in the European Union, causing a sudden increase in deaths caused by drugs25. In 2001, the Portuguese government decriminalised possession and consumption of illegal drugs, an unprecedented step in a largely conservative country. Nicholas Kristof, a writer for the New York Times, accurately summarises the difference between US and Portuguese drug policy by stating ‘drug addiction has been treated more as a medical challenge than as a criminal justice issue.'26 Instead of lengthy prison sentences, Portugal provides support and information about harm reduction and treatments available to them. These methods have been highly effective in reducing deaths from overdose: in 2015, Portugal had 3 overdose deaths per million citizens, far lower than the EU average of 17.3 per million. Furthermore, HIV infection rates have decreased from 104.2 cases per million in 2000 to 4.2 cases per million in 201527. However, these changes cannot be wholly attributed to a change in the law. Without first changing the attitudes in Portugal towards drug users, the laws would have had a much smaller impact. By recognising that addiction is a health problem rather than a crime, Portugal has been able to support those suffering and address the causes. Whilst the ‘Portuguese model' is not perfect (the country has failed to make anti-overdose drug Naloxone readily available), it indicates that unconventional thinking and methods will be required to reduce the tens of thousands of overdose deaths in the US each year. Currently, access to treatment is one of the biggest problems for people with an opioid addiction in the United States. The Surgeon General's report in 2016 estimated that only 10% of people with a drug use disorder will get treatment, further implying that access is a barrier for many Americans with a drug addiction. There is a shortage of sustainable addiction treatment facilities in the US because treatment providers are heavily underpaid by large health insurers. To overcome this, Virginia used Medicaid, a federal program that covers mostly low-families, to boost funding for treatment providers. By doing this, the state has been able to create a ‘continuum of care,' according to the chief medical officer of Virginia Medicaid. The Addiction Recovery and Treatment Services (ARTS) program has increased the percentage of people receiving treatment in the state by 29% and the number of emergency department visits caused by opioids by 31%. Whilst ARTS has been highly expensive considering it is only a state-based program, these results suggest that it could be a possibility across the United States. It has become increasingly clear over the past thirty years that unprecedented methods and a lack of stigma are often required to combat an epidemic. The fact that the procedures used in the crack epidemic will not bring an end to the Opioid Crisis provide further evidence that it can be considered an epidemic. Furthermore, the cost of the Opioid Crisis, both in financial and human terms, indicate that it has more in common with more traditional epidemics than previously expected.

In conclusion, the US Opioid Crisis can be deemed an epidemic to a greater extent, as it meets the majority of the necessary criteria. At the outset of the project, it appeared that the Crisis was only referred to as an epidemic by various media outlets to generate interest in their articles. However, after extensive research I have found that there are a wide range of experts from both the United States and Europe that call the Opioid Crisis an epidemic. Furthermore, whilst opioid use is not spread from person to person in the same way as a contagious disease would spread, the majority of the US population has witnessed first-hand the impact of opioid addiction. The project has given me an in-depth insight into the impact of chronic pain and the reasons people seek out the drugs in the first place. Despite approximately 100 million Americans suffering from chronic pain28, the condition is still not fully understood by medical professionals. The lack of understanding can be attributed to the nature of pain, as it is often difficult for doctors to comprehend the level of pain experienced by a patient. Elliot Krane, a paediatric anaesthetist, stated in his 2011 TED talk that there is a ‘despondency, despair and depression that always accompanies severe chronic pain.' This helps to explain why so many Americans started to take prescription opioids in the early 1990s, as well as why doctors were so keen to prescribe them. Furthermore, the research behind this project has also indicated the importance of treating addiction as a disease and not a crime. The lack of support available for those in the United States suffering from an opioid addiction is an indication of the government's indifference towards the issue, despite the Crisis being declared a ‘public health emergency.' On the other hand, there are solutions available, if the necessary funding is made available. Firstly, there are other medications that have been proven to be equally effective but far less addictive. Non-steroidal anti-inflammatory drugs help to reduce swelling, one of the most common causes of long-term pain. A recent study published in the Journal of the American Medical Association provided evidence that a combination of non-opioids was just as effective at managing pain as a single opioid painkiller29. Furthermore, medication can be combined with therapies, such as physical therapy and acupuncture30. Surgery can also be used to correct physical abnormalities that may be responsible for causing the pain. Over the past twenty years, the Opioid Crisis has had a colossal impact on American society, and unless unprecedented action is taken, it looks set to continue.

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