America is in the midst of an unprecedented drug overdose epidemic. Nationally, overdose deaths have more than doubled over the past decade and a half, driven largely by opioids – initially prescription painkillers, but increasingly heroin.
Today, more Americans die from drug overdoses than car crashes or gun fatalities. In all, overdoses killed 47,000 people in the US in 2014, the latest year for which data is available. That’s 130 deaths per day, on average. The majority of those deaths – 29,000, or 80 per day – involved an opioid.
The current epidemic has affected whiter and wealthier communities than previous drug crises. Some point to this change in racial and economic demographics as one reason many politicians have re-evaluated the tough “war on drugs” rhetoric of the past 30 years.
In March, the Obama administration announced a plan to expand access to opioid abuse treatment and prevent overdose deaths. The US House of Representatives and Senate have both passed bills aimed at curbing the crisis, in a rare display of bipartisan cooperation. Many local legislators have also shifted strategies, advocating for treatment, rather than punishment.
Even so, experts warn that the overdose epidemic has not yet peaked.
To understand how we got here, the Guardian mapped 16 years of county-level data on drug overdose deaths, released earlier this year by the Centers for Disease Control and Prevention.
Between 1999 and 2014, the overdose epidemic spread from a few concentrated pockets in Appalachia and northern New Mexico to nearly every corner of America.
A deep-rooted crisis
The overdose crisis began early in central Appalachia, a region encompassing much of West Virginia and eastern Kentucky.
The largely rural area – dominated by physically taxing industries, including coal mining, agriculture and timbering – was susceptible to the pain-relief promise of prescription opioids such as OxyContin and Vicodin. These painkillers were aggressively marketed throughout the 1990s and early 2000s. As prescriptions proliferated, so did misuse and abuse.
“At the time, it wasn’t understood how addicting these prescription pain medications were,” said Michelle Lofwall, associate professor at the Center on Drug and Alcohol Research at the University of Kentucky School of Medicine. “But they really hurt people here and across the nation. These were not safe medications with no abuse potential.”
In central Appalachia, as in many parts of the country, the prescription painkiller epidemic also fuelled the influx of a cheap, alternative opioid: heroin. As painkiller-related deaths began to fall in the early 2010s following federal and state crackdowns on prescription opioids, heroin-related deaths began to rise.
In all, West Virginia’s overdose death rate rose nearly eightfold between 1999 and 2014, from four deaths per 100,000 residents to more than 35 – double the national average. During the same period, Kentucky experienced a fivefold increase in its own rate of overdose deaths.
Stigma and inadequate access to treatment are the biggest barriers to overcoming the ongoing crisis, said Lofwall, who maintains a drug abuse treatment center in Lexington, Kentucky.
“People have views still that being addicted is your own fault, that it’s a spiritual flaw, that you should be able to stop on your own,” she said. But opioid addiction often requires medical help.
Lofwall pointed to medication-assisted treatment, using drugs like methadone and buprenorphine, as a “life-saving” intervention, but added that there aren’t enough providers to meet demand in the Appalachian region, nor in Kentucky overall.
Prevention efforts cut short
In the west, New Mexico showed earliest signs of the looming overdose crisis, but Utah was not far behind.
The state’s overdose death rate climbed steadily during the early 2000s, driven by growing prescription opioid dependence. But Utah lawmakers took action early. In 2007, they established a two-year public health-based program to combat painkiller misuse.
Over the next three years, prescription opioid-related overdose deaths dropped more than 25%, but the success was short lived. After funding ran out in 2010, deaths began to climb again.
“We saw that when we weren’t educating the public and providers, awareness decreased and deaths increased,” said Angela Stander, prescription drug overdose prevention coordinator at the Utah department of public health.
Drug overdose deaths in Utah continue to be fuelled by prescription painkiller misuse, often in combination with other depressant drugs. Though heroin deaths have made a smaller impact in the state, they are also on the rise.
Now, six years after the Prescription Pain Medication Program program ended, the Utah house of representatives declared drug overdose deaths to be a public health emergency, and passed a slate of new public health measures, including the legalization of needle-exchange programs.
Fentanyl: a new, deadly threat
New England is grappling with a more recent scourge. Since 2013, New Hampshire, Massachusetts, and other north-eastern states have seen large spikes in overdose deaths attributed to increasing heroin use and the introduction of a new deadly drug: fentanyl.
Fentanyl, a synthetic opioid 50 times more potent than heroin, first appeared in the region around 2012, making its way down from Canada. Suppliers often cut the drug into heroin or other substances before selling it to users who may not know exactly what they’re buying. Because of its strength – and users’ unfamiliarity with it – fentanyl has proven particularly deadly.
New Hampshire reported a sharp rise in fentanyl-related deaths between 2013 and 2014. Since then, every New England state has reported its own fentanyl crisis. According to the Massachusetts department of public health, fentanyl was present in more than half of the 1,319 opioid-related deaths in the state last year.
“The simplistic idea was, ‘Oh, this is all about prescription opioids, and therefore that’s all we need to do: reduce the supply of prescription opioids and we’ll reduce all these deaths and people won’t become addicted,’” said Alexander Walley, a physician and director of addiction consultation services at Boston Medical Center.
“Well, what we’re seeing now is that even as you reduce access to prescription opioids, you’re seeing an explosion of heroin use and heroin overdoses – and then there’s also now this ultra-potent substance [fentanyl] sold as heroin.”
In the face of the growing problem, Massachusetts and other north-eastern states have begun to expand prevention efforts and access to treatment programs. Naloxone, a drug that can reverse opiate overdoses, has become more widely available throughout the region and local harm-reduction programs are being tested.
This March, Massachusetts’ governor signed into law a bill that puts strict limits on opioid painkiller prescribing and encourages opioid-abuse evaluations by emergency room doctors. How much impact these steps will have remains to be seen.
Meanwhile, fentanyl has surfaced in several more states, including Ohio and Florida.
Cracking down on supply, not demand
Florida was once known as the prescription drug capital of America. But, in the early 2010s, the state began cracking down on “pills mill” clinics, which dispensed huge quantities of opioid painkillers. Soon after, the state’s drug overdose death rate took a downward turn, declining through 2013.
But by 2014, deaths were inching back up in Florida too.
“Florida did a good job of cracking down on the supply side, but at the same time they actually cut treatment funding,” said epidemiologist Jim Hall of Nova Southeastern University. “Not addressing the demand side of the problem has contributed to the continuing of the epidemic.”
Though postponed for a few years, Florida’s overdose crisis has progressed along a familiar pattern: a wave of prescription opioid abuse followed by heroin and, soon after, fentanyl. The Florida department of law enforcement reported large increases in both heroin and fentanyl deaths between 2014 and 2015.
More recently, fentanyl has cropped up in a previously unseen form: fake Xanax pills. The “death pills”, as they have become known, have also been found in California, Indiana and beyond.
Last month, a congressional delegation from Florida convened a meeting on Capitol Hill to discuss the growing crisis, including the need for greater treatment capacity.
Representative Ted Deutch, a Democrat from south Florida, said that the state could help extend mental health and substance abuse treatment to hundreds of thousands of low-income residents by expanding Medicaid. But that scenario isn’t likely under a conservative local leadership.
Florida is currently one of 19 states not adopting Medicaid expansion. The state also ranks 49th out of 50 for funding mental health services.
