cabinets, especially as 12- to 17-year-old girls were one-third of all new users of prescription drugs in 2006. teens used prescription drugs more than any illicit drug except cannabis, more than cocaine, heroin, and methamphetamine combined. in 2014, roughly 6 percent of teenagers between the ages of 12 and 17 reported abusing prescribed opioids. deaths from overdose of heroin affect younger people more than deaths from other opiates. economic status prescription opioids are considered a better financial choice for treating pain than surgery. this resulted in an increased use of prescription opioids by individuals living in communities that were underserved medically or did not have health insurance. overdose death rates increased across most racial and ethnic groups due to county-level income inequality, particularly among black and hispanic individuals. in 2020, overdose rates were more than twice as high in counties with greater inequality compared to counties with lower inequality. geography in the united states, those living in rural areas of the country have been the hardest hit. according to rita noonan from the cdc, in rural areas, the overall death rate for accidental injuries is 50% higher than in urban areas. differences in a multitude of factors, such as income, social supports, and accessibility to health care resources, have led to rural communities majorly exceeding urban areas when it comes to the rate of opioid-involved overdose deaths. between 1999 to 2017, non-hispanic black populations in medium-small metropolitan regions saw a growth of opioid overdoses at 12.3%, while non-hispanic whites in non-metropolitan areas had an increase of 13.6% annually. urban black americans had the largest rise in overdose rates between 2013 and 2017, with younger (aged 55 years) and older adults seeing increases of 178% and 87%, respectively. however, black individuals living in urban areas had the largest rise in fentanyl-related fatalities during the same time period. prescription rates for opioids vary widely across states. in 2012, healthcare providers in the highest-prescribing state wrote almost three times as many opioid prescriptions per person as those in the lowest-prescribing state. health issues that cause people pain do not vary much from place to place and do not explain this variability in prescribing. researchers suspect that the variation results from a lack of consensus among elected officials in different states about how much pain medication to prescribe. a higher rate of prescription drug use does not lead to better health outcomes or patient satisfaction, according to studies. in palm beach county, florida, overdose deaths went from 149 in 2012 to 588 in 2016. in middletown, ohio, overdose deaths quadrupled in the 15 years since 2000. in british columbia, 967 people died of an opiate overdose in 2016, and the canadian medical association expected over 1,500 deaths in 2017. in pennsylvania, the number of opioid deaths increased 44 percent from 2016 to 2017, with 5,200 deaths in 2017. governor tom wolf declared a state of emergency in response to the crisis. table: opioid prescriptions per 100 persons in 2012. stateopioid prescriptions writtenrank alabama142.91 alaska65.146 arizona82.426 arkansas115.88 california5750 colorado71.240 connecticut72.438 delaware90.817 district of columbia85.723 florida72.737 georgia90.718 hawaii5251 idaho85.624 illinois67.943 indiana109.19 iowa72.836 kansas93.816 kentucky128.44 louisiana1187 maine85.125 maryland74.333 massachusetts70.841 michigan10710 minnesota61.648 mississippi120.36 missouri94.814 montana8227 nebraska79.428 nevada94.115 new hampshire71.739 new jersey62.947 new mexico73.835 new york59.549 north carolina96.613 north dakota74.732 ohio100.112 oklahoma127.85 oregon89.220 pennsylvania88.221 rhode island89.619 south carolina101.811 south dakota66.545 tennessee142.82 texas74.334 utah85.822 vermont67.444 virginia77.529 washington77.330 west virginia137.63 wisconsin76.131 wyoming69.642 impact the high death rate by overdose, the spread of communicable diseases, and the economic burden are major issues caused by the epidemic, which has emerged as one of the worst drug crises in american history. more than 33,000 people died from overdoses in 2015, nearly equal to the number of deaths from car crashes, with the deaths from heroin alone outnumbering gun homicides. it has also left thousands of children suddenly in need of foster care after their parents have died from an overdose. addiction does not only affect the people taking the drug but the people around them, like families and relationships. conflict is usually the number one problem between family members and the people abusing heroin, the fighting becomes an everyday routine. in jeff schonberg and philippe bourgois's ethnography, righteous dopefiend, they did a participant observation from 1994 to 2006, and they focused on the lives of the homeless heroin addicts in san francisco, california. they found that for example, sonny is still in contact with his family, but he doesn't live with them, and he vowed to himself that he will never let his family see him at his worst, but he goes to his family usually for holidays and important dates, and when he is with them he is sober. this kind of relationship isn't always the case though. they observed another example with tina whose parents have completely cut off contact with her, and she is left on the streets with nobody except the family she has created in the homeless society. a 2016 study showed the cost of prescription opioid overdoses, non-medical use, and dependence in the united states in 2013 was approximately $78.5 billion, most of which was attributed to health care and criminal justice spending, along with lost productivity. by 2015 the epidemic had worsened with overdose and with deaths doubling in the past decade. the white house stated on november 20, 2017, that in 2015 alone the opioid epidemic cost the united states an estimated $504 billion. two employees of the university of notre dame were killed in a murder-suicide over the refusal of dr. todd graham, 56, to renew the opioid prescription for the wife of mike jarvis, 48. united states representative jackie walorski sponsored a bill in the memory of the doctor who would not over-prescribe; the dr. todd graham pain management improvement act is intended to address the opioid epidemic. the national safety council calculated that the lifetime odds of dying from an opioid overdose (1 in 96) in 2017 were greater than the lifetime odds of dying in an automobile accident (1 in 103) in the united states. the opioid epidemic, combined with the patient protection and affordable care act, has led to a situation called the florida shuffle, where a drug user moves between drug rehabilitation centers so those centers may bill the user's insurance company. in one study, a decision analytical model of the us population aged 12 years or older found that "under the status quo, an estimated 484,429 individuals were projected to die of fatal opioid overdose" between 2020 and 2029. however, a combination of "reducing opioid prescribing, increasing naloxone distribution, and expanding treatment for opioid use disorder was associated with an estimated 179,151 lives saved when compared to the status quo." healthcare professionals are also among those heavily affected by this epidemic. studies have been done to determine how well nursing students, nurses, and even doctors are prepared to treat patients affected by opioid addictions. the studies have pointed to the fact that nurses and other healthcare professionals are highly undertrained in this area. as a result, many specific education programs have been proposed and implemented into nursing education institutions. treatment and effects during covid-19 pandemic after slight decreases in opioid fatalities 2017–2018, overdose deaths in the us increased in 2019, due largely to an increase in non-medical use of fentanyl. the covid-19 pandemic's interference with both social safety and health care delivery systems has intensified the opioid epidemic. us media, on national, state, and local levels, infer that overdose deaths are increasing. but there is no national reporting system on overdose mortality to confirm these reports. conclusions on the relationship between increasing overdose fatalities and the covid-19 pandemic will require more research. studies, such as those by wainwright et al. and ochalek et al. estimate that opioid use and overdose deaths may be increasing, just as reported by the media. but more study is needed. statistics reveal that during the covid-19 epidemic, drug overdoses increased. according to statistics from the centers for disease control and prevention, there were 91,799 overdose fatalities in the united states in 2020, a more than 30% rise from 2019. drug-related overdose fatalities increased to more over 106,000 in 2021, the greatest number of overdose deaths recorded in a 12-month period. most of these deaths were caused by synthetic opioids other than methadone (mostly fentanyl or analogues) and methamphetamine. during this time, non-hispanic black and non-hispanic american indian populations had the highest rate of overdose deaths, and non-hispanic american indian and white populations had the greatest increase in overdose rates. further, during the first year of the covid-19 pandemic, overdose disparities widened between black persons and white persons. for example, in 2020, overdose rates among black men 65 years or older (52.6 per 100 000) were nearly 7 times those of white men of the same age (7.7 per 100 000). during times of economic distress such as the covid-19 pandemic or the 2008 recession, harmful rates of drug use has been seen to increase in populations experiencing joblessness and disadvantaged populations; moreover, carpenter et al. found evidence that economic downturns lead to increases in the intensity of prescription pain reliever use as well as increases in clinically significant substance use disorders involving opioids. according to the us national institute on drug abuse, the coronavirus disease 2019 (covid-19) pandemic could hit certain populations, such as those suffering from substance use disorders and especially those with opioid use disorder, particularly hard. for opioid use disorder patients, covid-19's effects on respiratory and pulmonary health is a significant threat. in addition, the covid-19 pandemic has marked the start of health care policies that, should they be adopted permanently, could not only lessen the effects of the pandemic on overdoses, but also make overall treatment of opioid use disorder more effective by eliminating obstacles to previously proven therapies for these disorders. according to an april 2020 health affairs journal article "once the coronavirus pandemic subsides, the opioid epidemic will rage," recommended potential solutions include requiring doctors in large physician groups to get the federal waiver that would allow them to prescribe fda-approved medications to treat addiction. under the drug addiction treatment act of 2000, physicians can obtain an "x-waiver" to prescribe buprenorphine. other studies have looked at treatments for oud during the covid-19 pandemic. for example, one jama internal medicine research letter from december 2020 found that since the covid-19 national emergency declaration, "the number of individuals filling buprenorphine prescriptions has plateaued but has not decreased; however, filled prescriptions for all medications collectively have decreased considerably." 6.9–11 11.1–13.5 13.6–16.0 16.1–18.5 18.6–21.0 21.1–52.0 of the 64,070 overdose deaths in the us in 2016, opioids were involved in 42,249. in 2016, the five states with the highest rates of death due to drug overdose were west virginia (52.0 per 100,000), ohio (39.1 per 100,000), new hampshire (39.0 per 100,000), pennsylvania (37.9 per 100,000) and kentucky (33.5 per 100,000). drug overdose deaths in the us per 100,000 people by state. top third of us counties in per-capita opiate prescriptions top third of us counties in per-capita disability insurance claims top third of us counties in both per-capita opiate prescriptions and in per-capita disability insurance claims countermeasures us federal government in 2010, the us government began cracking down on pharmacists and doctors who were overprescribing opioid painkillers. an unintended consequence of this was that those addicted to prescription opiates turned to heroin, a significantly more potent but cheaper opioid, as a substitute. a 2017 survey in utah of heroin users found about 80 percent started with prescription drugs. in 2010, the controlled substances act was amended with the secure and responsible drug disposal act, which allows pharmacies to accept controlled substances from households or long-term care facilities in their drug disposal programs or "take-back" programs. in 2011, the federal government released a white paper describing the administration's plan to deal with the crisis. its concerns have been echoed by numerous medical and government advisory groups around the world. in july 2016, president barack obama signed into law the comprehensive addiction and recovery act, which expands opioid addiction treatment with buprenorphine and authorizes millions of dollars in funding for opioid research and treatment. in 2011, the obama administration began to deal with the crisis, and in 2016, president barack obama authorized millions of dollars in funding for opioid research and treatment, followed