The Root of the Opioid Epidemic

What is the root of the opioid epidemic? Popular media from bestselling books to TV shows reveal the salacious story of how it all started due to the Sackler family’s greed and reckless pushing of Oxycontin onto innocent victims, but this narrative oversimplifies a complex phenomenon to a singular scapegoat.

To be clear, the way the Sacklers’ company Purdue Pharmaceuticals marketed Oxycontin caused substantial harm. It was heralded as a wonder drug that could and should be used to ease anyone’s pain. They taught physicians to monitor pain as constantly as blood pressure, temperature or heart rate. From doctor kickbacks to the unscientific claim that the medication carried no addictive risk, Purdue committed many wrongs. But to be the root of something suggests that is where it all began.

Unfortunately, this isn’t the first time America has faced an opioid epidemic. Two previous waves came in the aftermath of wars, when Civil War soldiers left the battlefield hooked on morphine and when GIs returned from Vietnam addicted to heroin. Both produced backlashes: after Vietnam came Reagan’s War on Drugs. In the decades following the Civil War, dangerous and misleading marketing of opioid products for cough, sore throat, and diarrhea lead to overdose deaths among infants and prompted the creation of the Food and Drug Administration. Heroin, mirroring Purdue’s claims a century later, was advertised as the “non-addictive” form of opium. 

Perhaps the literal root is the poppy plant itself. But it was human technology that extracted morphine and made the hypodermic needle and semi-synthetics like heroin, followed by synthetics like fentanyl. Don’t blame the flower. Humans have been cultivating poppy plants for thousands of years for medicinal purposes, most notably the treatment of pain.

What if pain is the root? Opioids are powerful analgesics that target pain pathways from peripheral nerves to the spinal cord to the brain. Countless individuals started using oxycontin to treat their chronic pain only to end up holding an empty bottle and turning to the streets for something that could keep life tolerable.

There is a tendency to go a step further and identify the root of the pain. Conservatives lament how globalization uprooted job prospects from the struggling rust belt and shipped them overseas while liberals point to growing inequality as the groundwork that allows epidemics to take root. But under further examination it becomes clear that the opioid crisis cuts across party lines, affecting people from rural and urban counties, rich and poor, of all races. Still, both sides agree America is in pain. Looking back at previous opioid epidemics it’s apparent whether it is war or economic hardship, these crises always seem to play out over the backdrop of sorrow. Can there be one root of pain?

Just like addiction, the root of all pain is the brain. Trying to find the root of a problem assumes an otherwise spotless garden that can be restored by pulling some weeds. With the exceptions of tumors and infections, brain disorders are not due to one bad actor that can be extracted. Addiction and pain are caused by connections of neurons tangled like roots. Modern problems may be acute sources, but pain is embedded in our existence as living beings. 

Perhaps then, rather than try to remove the pain, we should use this root as the foundation for growth. If we can’t destroy the root cause of the opioid epidemic, maybe the best approach is to recognize the pain common to all of us to strengthen our efforts towards a solution.

While there is much more biomedical research still to be done in the search for better cures, we do already have an arsenal of tools that can be better dispatched with more compassion. Methadone maintenance is a proven treatment for opioid addiction, but the fear of diversion to the black market has resulted in strict controls that force people to a special treatment center daily for their dose, which takes a toll on their personal and professional lives. The less burdensome buprenorphine can only be prescribed by physicians with a special license, leaving many unable to find help. Fortunately, in the emergency of the COVID-19 pandemic some restrictions were lifted, proving the feasibility and benefit of expanding access.

In addition to pain, addiction is often comorbid with other mental health disorders. Physicians often grapple with dual diagnoses: “Which one is at the root?” But mental health disorders don’t just stack on top of each other, rather they grow together, intertwined. Across the board there needs to be more access to mental healthcare services like psychotherapy and medications that have been proven to reduce disease burden and help people reclaim their lives.

A harm reduction approach is based on this root of our shared humanity and a belief that treating the individual is more important than treating the addiction. It meets people where they are and gives them what they need in that moment. Clean needle exchanges ensure that IV drug users don’t add HIV or hepatitis C to their list of worries. Fentanyl test strips allow users to screen the substances they buy for the most lethal of opioids. Fortunately, naloxone, a nasal spray that can reverse overdose, is now available over the counter. Safe use centers create a space for drug use with medical oversight to ensure no one dies from overdosing alone, but they remain officially illegal in much of the United States. Harm reduction always meets resistance from people who fear drugs more than they fear the potential dangers drugs pose for users.

Even methadone maintenance faced an uphill battle to approval because people thought it was appeasing the addiction rather than treating the person. Hopefully we can look at the history of opioid epidemics and see not just the continued shortcomings and villains like the Sacklers but also the progress that led to the approval of methadone and other interventions. These advances come from treating people as humans, because their suffering is the root of the opioid epidemic. If we remember this and go beyond assigning blame, we reduce stigma and spread the compassion necessary to bring help to those in need and save lives.

From the author: As someone who studies opioid addiction I am always forwarded news, books, and shows about the Sacklers. I wish we could change the narrative about the opioid crisis away from these villains and towards those who are suffering, and hope this piece putting the crisis into greater historical and neurobiological context can help.