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The opioid painkiller and heroin epidemic, explained in fewer than 600 words

A brief guide to one of the biggest public health crises facing America today.

A bottle of prescription painkillers.

Education Images/UIG via Getty Images

In 2015, more Americans died of drug overdoses than any other year on record — more than 52,000 deaths in just one year. That's higher than the more than 38,000 who died in car crashes, the more than 36,000 who died from gun violence, and the more than 43,000 who died due to HIV/AIDS during that epidemic's peak in 1995.

This latest drug epidemic, however, is not solely about illegal drugs. It began, in fact, with a legal drug.

Back in the 1990s, doctors were persuaded to treat pain as a serious medical issue. There's a good reason for that: About 100 million US adults suffer from chronic pain, according to a 2011 report from the Institute of Medicine.

Pharmaceutical companies took advantage of this concern. Through a big marketing campaign, they got doctors to prescribe products like OxyContin and Percocet in droves — even though the evidence for opioids treating long-term, chronic pain is very weak (despite their effectiveness for short-term, acute pain), while the evidence that opioids cause harm in the long term is very strong.

Painkillers proliferated, landing in the hands of not just patients but also teens rummaging through their parents’ medicine cabinets, other family members and friends of patients, and the black market.

As a result, opioid overdose deaths trended up — sometimes involving opioids alone, other times involving drugs like alcohol and benzodiazepines (typically prescribed to relieve anxiety). By 2015, opioid overdose deaths totaled more than 33,000 — close to two-thirds of all drug overdose deaths.

Seeing the rise in opioid misuse and deaths, officials have cracked down on prescriptions painkillers. Law enforcement, for instance, threatened doctors with incarceration and the loss of their medical licenses if they prescribed the drugs unscrupulously.

Ideally, doctors should still be able to get painkillers to patients who truly need them (and they can work for some individual chronic pain patients) — after, for example, evaluating the patient's history of drug addiction. But doctors, who weren’t conducting even such basic checks, are now being told to give more thought to their prescriptions.

Yet many people who lost access to painkillers are still addicted. So some who could no longer obtain painkillers turned to cheaper, more potent opioids: heroin and fentanyl, a powerful synthetic opioid.

Not all painkiller users went this way, and not all opioid users started with painkillers. But statistics suggest many did: A 2014 study in JAMA Psychiatry found 75 percent of heroin users in treatment started with painkillers, and a 2015 analysis by the Centers for Disease Control and Prevention found that people who are addicted to painkillers are 40 times more likely to be addicted to heroin.

So other types of opioid overdoses, excluding painkillers, also rose.

That doesn't mean pulling back on the number of painkiller prescriptions was a mistake. It appeared to slow the rise in painkiller deaths, and likely prevented doctors from prescribing opioids to new generations of people with drug use disorders.

But it must be paired with more access to addiction treatment. According to a 2016 report by the surgeon general, just 10 percent of Americans with a drug use disorder obtain specialty treatment. The report found that the low rate was largely explained by a shortage of treatment options.

So federal and state officials have pushed for more treatment funding, including medication-assisted treatment like methadone and buprenorphine.

Some states, like Florida and Indiana, have taken a "tough on crime" approach that focuses on incarcerating drug traffickers. But the incarceration approach has been around for decades — and it hasn’t stopped massive drug epidemics like the current crisis.

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