opioid epidemic in the united states opioid epidemic in the united states in the united states, the opioid epidemic (also known as the opioid crisis) is an extensive ongoing overuse of opioid medications, both from medical prescriptions and illegal sources. the epidemic began in the united states in the late 1990s, according to the centers for disease control and prevention (cdc), when opioids were increasingly prescribed for pain management, resulting in a rise in overall opioid use throughout subsequent years. the great majority of americans who use prescription opioids do not believe that they are misusing them. for the situation in other countries, see opioid epidemic. number of yearly u.s. opioid overdose deaths from all opioid drugs.u.s. overdose deaths involving opioids. deaths per 100,000 population by year.total drug overdose deaths in the united states.u.s. yearly overdose deaths, and the drugs involved. among the 106,000 deaths in 2021, the largest share was related to fentanyl and other synthetic opioids (70,601 deaths). in the united states, there were approximately 100,300 drug-overdose-related deaths in 12 months ending april 30, 2021. from 1999 to 2020, nearly 841,000 people died from drug overdoses, with prescription and illicit opioids responsible for 500,000 of those deaths. in 2017 alone, there were 70,237 recorded drug overdose deaths; of those deaths, 47,600 involved an opioid. a report from december 2017 estimated 130 people die everyday in the united states due to opioid-related drug overdose. those addicted to opioids, both legal and illegal, are increasingly young, white, and female, with about 1.2 million women addicted compared to about 0.9 million men in 2015. the problem is significantly worse in rural areas, where socioeconomic variables, health behaviors, and accessibility to healthcare are responsible for a higher death rate. teen use of opioids has been noticeably increasing, with prescription drugs used more than any illicit drug except cannabis, more than cocaine, heroin, and methamphetamine combined. background opioids are a diverse class of strong, addictive, and inexpensive drugs, which include opiates (i.e., morphine and codeine), oxycodone (oxycontin, percocet), hydrocodone (vicodin, norco), and fentanyl. traditionally, opioids have been prescribed for pain management, as they are effective for treating acute pain but are less effective for treating chronic pain. clinical guidelines advise that opioids should only be used for chronic pain if safer alternatives are not feasible, as their risks often outweigh their benefits. the potency and availability of opioids have made them popular as both medical treatments and recreational drugs. in 2018, the u.s. opioid prescription rate was 51.4 prescriptions per 100 people, equivalent to more than 168 million total opioid prescriptions. however, these substances also have high risks of addiction and overdose, and long-term use can cause tolerance and physical dependence. when people continue to use opioid medications beyond what a doctor prescribes, whether to minimize pain or induce euphoric feelings, it can mark the beginning stages of an opioid addiction. also, in 2018, after being prescribed an opioid medication, about 10.3 million people ended up misusing it, and 47,600 people died from an overdose. more than 650,000 americans have died of drug overdoses since the opioid epidemic began. waves of the opioid epidemic the centers for disease control and prevention describe the u.s. opioid epidemic as having arrived in three waves. although research more recently states that since 2016, the united states has been experiencing the fourth wave of the opioid epidemic. the epidemic began with the over prescription and abuse of prescription drugs. however, as prescription drugs began to become less accessible in 2016 in response to cdc opioid prescribing guidelines, there was an increase in accessibility to cheaper, illicit alternatives to opioids such as heroin and fentanyl. first wave the first wave, which marked the start of the epidemic, began in the 1990s due to the push towards using opioid medications for chronic pain management and the increased promotion by pharmaceutical companies for medical professionals to use their opioid medications. during this time, around 100 million people in the united states were estimated to be affected by chronic pain; however, opioids were only reserved for acute pain experienced secondary to cancer or terminal illnesses. physicians avoided prescribing opioids for other medical conditions because of the lack of evidence supporting their use, the concern of opioids having addictive properties, and the fear of being investigated or disciplined for liberal opioid practices. however, in 1980, a letter to the editor featured in the new england journal of medicine (nejm) challenged these notions. the letter advocated for more liberal use of opioids in pain management, which the world health organization eventually supported. in addition, medical organizations began to push for more attentive physician responses to pain, referring to pain as the "fifth vital sign." this was coupled with the promotion of opioids by pharmaceutical companies who insisted that patients could not become addicted. opioids became an acceptable treatment for a wide variety of conditions, leading to a consistent increase in opioid prescriptions. from 1990 to 1999, the total number of opioid prescriptions grew from 76 million to approximately 116 million, which led to them becoming the most prescribed class of medications in the united states. mirroring the positive trend in the volume of opioid pain relievers prescribed is an increase in the admissions for substance use disorder treatments and an increase in opioid-related deaths. this illustrates how legitimate clinical prescriptions of pain relievers are being diverted through an illegitimate market, leading to misuse, addiction, and death. with the increase in volume, the potency of opioids also increased. by 2002, one in six drug users was prescribed drugs more powerful than morphine; by 2012, the ratio had doubled to one in three. the most commonly prescribed opioids have been oxycodone and hydrocodone. second wave the second wave of the opioid epidemic started around 2010 and is characterized by the rise in heroin use and overdose deaths. between 2005 and 2012, the number of people who used heroin almost doubled from 380,000 to 670,000. in 2010, there were 2,789 fatal heroin overdoses, almost a 50% increase from the years prior. this spike reflects the increase in heroin supplies in the united states and the decrease in prices, which encouraged a large proportion of individuals with an established dependency and tolerance on opioids to transition towards a more concentrated and cheaper alternative. during this same period, there was also a reformulation of oxycontin that made it more difficult to crush and use it; however, the effect of this formulation on the rise in heroin use is still unclear. third wave according to the cdc, the third wave of the opioid epidemic began in 2013; and the third wave ended in 2016. this wave coincides with the steep rise in overdose deaths that involved synthetic opioids, particularly illegally produced fentanyl. during this time, prescription opioid deaths increased marginally, while heroin deaths remained stable. the affected population was younger, less frequently male, and more likely to be white and rural compared to previous waves. however, the third wave also saw increases in opioid-related overdoses among black and hispanic individuals that use drugs in urban areas. the rise in fentanyl deaths is attributed to the fact that it is 50 to 100 times more potent than morphine, and fentanyl is often mixed into heroin or cocaine to increase the potency at a low cost. considering that compared to white populations, black americans tend to consume cocaine more often than heroin or other prescription opioids, this increase in deaths is linked to the increased prevalence of fentanyl laced cocaine. fourth wave the fourth wave, which is reported to have begun in 2016, is characterized by polysubstance use and increased use of stimulants like methamphetamines and cocaine. the availability and use of illicit fentanyl continue to be the leading cause of fatalities, but the recent rise of polysubstance use, which is the practice of using multiple drugs at once or in succession, and stimulants is linked to the increased fatality rate with the ongoing opioid epidemic. between 2012 and 2018, there was a threefold increase in mortality related to cocaine use and a fivefold increase in mortality related to psychostimulants like methamphetamine. this increase has primarily been observed in male populations from non-hispanic american indian, non-hispanic black, and non-hispanic white populations. researchers attribute the increase in illicit drug use to the cdc's recommendations to reduce opioid use through measures like tapering opioid prescribing. causes the epidemic has been described as a "uniquely american problem." the structure of the u.s. healthcare system, in which people not qualifying for government programs are required to obtain private insurance, favors prescribing drugs over more expensive therapies. according to professor judith feinberg, "most insurance, especially for poor people, won't pay for anything but a pill." prescription rates for opioids in the united states are 40 percent higher than the rate in other developed countries such as germany or canada. while the rates of opioid prescriptions increased between 2001 and 2010, the prescription of non-opioid pain relievers (aspirin, ibuprofen, etc.) decreased from 38% to 29% of ambulatory visits in the same period, and there has been no change in the amount of pain reported in the united states. this has led to differing medical opinions, with some noting that there is little evidence that opioids are effective for chronic pain not caused by cancer. the annual opioid prescribing rates have been slowly decreasing since 2012, but the number is still high. there were about 58 opioid prescriptions per 100 americans in 2017. characteristics of jurisdictions with a greater number of opioid prescriptions per resident include small cities or large towns, cities with more dentists and primary care doctors per capita, cities with a higher percentage of white residents, cities with a higher uninsured/unemployment rate, and cities with more residents who have diabetes, arthritis, or a disability.. several studies have been conducted to find out how opioids were primarily acquired, with varying findings. a 2013 national survey indicated that 74% of people who recreationally use opioids acquired their opioids directly from a single doctor, friend, or relative who received their opioids from a clinician. among pharmacies, the most prolific distributor was walgreens, which bought 13 billion oxycodone and hydrocodone pills from 2006 through 2012 (about twenty percent of all such pills in us pharmacies). though aggressive opioid prescription practices played the biggest role in creating the epidemic, the popularity of illegal substances such as potent heroin and illicit fentanyl has become an increasingly large factor. it has been suggested that decreased supply of prescription opioids caused by opioid prescribing reforms directed people who were already addicted to opioids to illegal substances. in 2015, approximately 50% of drug overdoses were not the result of an opioid product from a prescription, though most recreational users' first exposure had still been by lawful prescription. by 2018, another study suggested that 75% of people who use opioids recreationally started their opioid use by taking drugs obtained in a way other than by legitimate prescription. the top line represents the yearly number of benzodiazepine deaths that involved opioids in the united states. the bottom line represents benzodiazepine deaths that did not involve opioids. opioid involvement in cocaine overdose deaths. yellow line is cocaine and any opioid. light green line is cocaine without any opioids. yellow line is cocaine and other synthetic opioids. 2 mg of fentanyl. this is a lethal dose to most people. diameter of a us penny is 19.05 mm, or 0.75 inches. u.s. yearly deaths involving other synthetic opioids, predominately fentanyl. history there were fewer than 3,000 overdose deaths in 1979, when a heroin epidemic was raging in u.s. cities. there were fewer than 5,000 recorded in 1988, around the height of the crack epidemic. more than 64,000 americans died from drug overdoses last year , according to the u.s. centers for disease control and prevention. mike strobe, ap medical writer external audio treating america's opioid addiction part 1: the narcotic farm and the promise of salvation part 2: synanon and the tunnel back to the human race part 3: searching for meaning in kensington, science history institute opiates such as morphine have been used for pain relief in the united states since the 1800s, and were used during the american civil war. opiates soon became known as a wonder drug and were prescribed for a wide array