Under assault from three opioids. Nine years after the World Health Organization (WHO) recommended increased opioid use to reduce pain in Cancer Pain Relief, the Food and Drug Administration (FDA) approved Purdue Pharma’s OxyContin. Aggressive marketing, an expanding sales force, and misleading promotional material led physicians—many of whom may not have been trained in pain management—to prescribe OxyContin for non-cancer pain. 

Addiction and overdose deaths, initially fueled by expanded use of opioid prescription painkillers, later were exacerbated by an increased supply of potent, low-cost Mexican heroin and Chinese fentanyl (see Figure 1).

Figure 1

Figure 2

Medical meetings and conferences that focused on pain treatment were hosted in Salt Lake City by groups interested in using opioids like MS Contin (released in 1984) and OxyContin (released in 1996) to treat chronic pain.

A lucrative black-market in OxyContin gave rise to “pill mills” where doctors would prescribe, and pharmacies would fill, numerous fraudulent prescriptions. OxyContin was particularly conducive to abuse because its controlled-release property could easily be bypassed by crushing the pills. Abuse reports in the media surfaced in 2000. Although several western states, in particular Utah, have high concentrations of communities where the use of illegal drugs is generally taboo, the path to addiction and overdose through prescription opioids has become more and more common. Data from 2014 show that the states in the west account for the majority of states with the highest level of opioid prescription rates.[3]

Figure 3

Black tar heroin. In 2010, OxyContin was reformulated to reduce abuse (see Figure 2). However, at about the same time, potent and inexpensive Mexican heroin became more prevalent in America. So-called black tar and brown powder heroin moved east across the country into new markets, and white powder heroin moved west into new markets. Starting in the 1990s, western cities like Salt Lake, Boise, Portland, and Denver saw heroin traffickers begin to focus on stable middle- and upper-class areas. Places without  much heroin use prior to the 1990s faced a growing presence of illegal opiates alongside the rise in prescription opioids.

Overdose deaths have been rising precipitously in the Appalachian region of Ohio, West Virginia, and Kentucky. Columbus, Ohio, became a major heroin market. In 2015, Ohio had the highest heroin death rate in America followed by West Virginia. Ohio ranked third and West Virginia first in overall opioid death rates (see Figure 3)

Fentanyl. A synthetic opioid, fentanyl, is diverted from legal markets and frequently used as a substitute ingredient in black market products without the customers' knowledge.  Manufactured in China, and possibly Mexico, it is 50 times stronger than heroin and sold as heroin, mixed with heroin, or used in the production of counterfeit prescription pills.[4] DEA-seized fentanyl evidence (called “exhibits”) has skyrocketed since 2013 (see Figure 4).

Carfentanil, also a synthetic opioid, is 100 times more potent than fentanyl and 10,000 times more potent than morphine. It is not approved for humans and can be absorbed through the skin or accidentally inhaled, if airborne, to deadly effect.

Figure 4