native americans has increased at similar rates. deaths by overdose among white, black, and native americans increased by 200–300% from 2010 to 2014. during this time period, overdoses among hispanics increased 140%, and the data available on overdoses by asians was not comprehensive enough to draw a conclusion. in august 2014, the website annals of emergency medicine collaborated with the academic life in emergency medicine (aliem) and posted a discussion board about the opioid epidemic. the discussion acquired a little over 1000 readers and lasted roughly 14 days. there were four questions posted on the discussion that encouraged readers to share their opinions on how opioids should be prescribed and used. dea data in july 2019 the washington post and the charleston (wv) gazette-mail gained a court order after a year-long battle with the drug enforcement administration (dea). the order allowed the post access to the dea automation of reports and consolidated orders system (arcos), a system that traces the manufacture, distribution and retail sale of every pain pill in the us. the post's analysis of the data indicated 76 billion oxycodone and hydrocodone pain pills were distributed throughout the us 2006–2012. 57 billion (75%) of these pain pills were distributed by these companies: mckesson corp., walgreens, cardinal health, amerisourcebergen, cvs and walmart. nearly 67 billion (88%) of the drugs were manufactured by specgx, a subsidiary of mallinckrodt; actavis pharma; and par pharmaceutical, a subsidiary of endo pharmaceuticals. the greatest number of pills/person were found in west virginia – 66.5; kentucky – 63.3; tennessee – 57.7; and nevada – 54.7. the highest opioid overdose rate 2006-2012 was in west virginia. rural communities were hit particularly hard. 306 pills/person/year were shipped to norton va; 242 to martinsville va; 203 the mingo county wv; and 175 to perry county ky. treatment the opioid epidemic is often discussed in terms of prevention, but helping those who are already addicted is addressed less frequently. opioid dependence can lead to a number of consequences like contraction of hiv and overdose. for addicted persons who wish to treat their addiction, there are two classes of treatment options available: medical and behavioral. neither is guaranteed to successfully treat opioid addiction. which treatment, or combination of treatments, is most effective varies from person to person. these treatments are doctor-prescribed and -regulated, but differ in their treatment mechanism. popular treatments include kratom, naloxone, methadone, and buprenorphine, which are more effective when combined with a form of behavioral treatment. accessing treatment, however, can be difficult. the strict regulation of opioid treatment programs dates back to the early 20th century. before 1919, physicians prescribed milder forms of opiates to help wean patients off opium. in webb v. united states, the supreme court ruled that doctors could no longer prescribe narcotics to aid in treating a narcotic use disorder. thus, morphine dispensaries emerged in communities to fill the treatment gap and were the early precedents to modern methadone clinics. it is still difficult for providers to prescribe opioids for medication-assisted treatment despite the data that show individuals addicted to opioids have better outcomes with that than abstinence-based treatment programs. programs are required to be accredited by samhsa or the drug enforcement administration which is a lengthy, time- and resource-consuming process including intensive training and site visit reviews. to stay in operation, they must submit to re-accreditation every 1–3 years. accredited programs are also able to administer buprenorphine, provided that those prescribing and administering the drug have completed the 8–24 hours of samhsa training. office-based physicians who wish to prescribe buprenorphine for the treatment of opioid use disorder must also complete the required training, as well as apply for and receive a waiver from samhsa. under regulation, physicians may not have more than 30 buprenorphine patients in their first year of prescribing the drug. they may apply to have this limit increased to 100 patients by year two and 275 patients by year three. in december 2015, the us government accountability office began a survey of the laws and regulations around opioid treatment programs and medication-assisted treatment and found that they were barriers to getting people with opioid use disorders the treatment they need. despite the fact that there is a shortage of opioid treatment programs across the united states, many clinicians do not want to start their own because the time and effort required to comply with the regulations is prohibitive. individual-level barriers to accessing medication-assisted treatment also exist. the federal regulations regarding program admission into treatment programs are considered "high-threshold." individuals seeking treatment must meet several criteria to be eligible for treatment. these criteria require potential patients to: have a diagnosable opioid use disorder, according to the dsm-5, be actively addicted to opioids at the time of intake, and have been addicted to opioids for at least one year before beginning treatment. in addition to these federal criteria, each state may have its own criteria individuals must meet. the us gao also cited the cost of treatment and lack of health insurance coverage for mat as barriers for many addicted to opioids. while methadone treatments are covered by medicaid for low-income individuals, the extent of coverage depends on which state they are in and if the state has opted into medicaid expansion under the affordable care act. buprenorphine, on the other hand, is not covered by medicaid or, often, even by private health insurers. because buprenorphine must typically be paid for out-of-pocket, lower-income individuals are often priced out of the lower-risk mat. in some areas this creates major disparities along racial lines with the higher-risk treatment utilized by lower-income individuals - disproportionately represented by people of color - and the lower-risk treatment only accessible to higher-income individuals - disproportionately represented by whites. other individual-level barriers may include transportation, especially for those who live in rural areas. the nearest opioid treatment program (otp) could be up to an hour away, and when daily methadone doses are required for treatment, this may interfere with the success of the mat or the client's compliance in the program. in rural vermont, 48% of respondents in treatment reported they had missed an appointment due to travel challenges. because of issues like these, it is estimated that, nationwide, only 10% of individuals who would be eligible to receive mat actually receive the treatment. the price of opioid treatment may vary due to different factors, but the cost of treatment can range from $6,000 to $15,000 a year. based on the research, most addicts come from lagging economic environment which multiple addicts do not have the support or funding to complete alternative medication for the addictions. methadone methadone has been used for opioid dependence since 1964, and is the most-studied of the pharmacological treatment options. it is a synthetic long-acting opioid, so it can replace multiple heroin uses by being taken once daily. it works by binding to the opioid receptors in the brain and spinal cord, activating them, reducing withdrawal symptoms and cravings while suppressing the "high" that other opioids can elicit. the decrease in withdrawal symptoms and cravings allow the user to slowly taper off the drug in a controlled manner, decreasing the likelihood of relapse. it is not accessible to all addicts. it is a regulated substance, and requires that each dose be picked up from a methadone clinic daily. this can be inconvenient as some patients are unable to travel to a clinic, or wish to avoid the stigma associated with drug addiction. buprenorphine buprenorphine is used similarly to methadone, with some doctors recommending it as the best solution for medication-assisted treatment to help people reduce or quit their use of heroin or other opiates. it is claimed to be safer and less regulated than methadone, with month-long prescriptions allowed. it is also said to eliminate opiate withdrawal symptoms and cravings in many patients without inducing euphoria. probuphine is an implantable form of buprenorphine lasting six months. rates of buprenorphine use increased between 2003 and 2011, with sales increasing, on average, by 40%. unlike methadone treatment, which must be performed in a highly structured clinic, buprenorphine, according to samhsa, can be prescribed or dispensed in physician offices. patients can thereby receive a full year of treatment for a fraction of the cost of detox programs. buprenorphine/naloxone is a combination medication that has been approved by the fda in 2002 for treatment of opioid dependence. it is a combination medication that contains two separate drugs: buprenorphine and naloxone. buprenorphine works as a partial opioid agonist. it is given in combination with naloxone because naloxone works as an opioid antagonist, meaning it will block the effects of the opioid medication. this combination medication can reduce a person's opioid withdrawal symptoms while they are discontinuing opioids after a period of long-term use. while buprenorphine/naloxone is indicated for the treatment of opioid use disorder, it does contain an opioid which means a person may be at risk of developing dependence to it as well. behavioral treatment behavioral treatment is less effective without medical treatment during the initial detoxification. it has similarly been shown that medical treatments tend to get better results when accompanied by behavioral treatment. for opioid dependence, popular non-pharmacological treatment options include cognitive behavioral therapy (cbt), group or individual therapy, residential treatment centers, and twelve-step programs such as narcotics anonymous. since addictive behavior is a learned behavior in opioid dependence, cognitive behavioral therapy aims to promote positive motivation to change that behavior. studies such as the rat park series indicate that a greater focus on improving the environments of those with opioid use disorders could also be beneficial. harm reduction harm reduction programs operate under the understanding that certain levels of drug use are inevitable and focus on minimizing adverse effects associated with drug use. in the context of the opioid epidemic, harm reduction strategies are designed to improve health outcomes and reduce overdose deaths. because many pain sufferers are also depressed, a challenge of harm reduction is that some applications, such as the use of drugs to reverse or avoid opioid overdose can nullify the effects of antidepressant medications which depend on the natural human opioid system. one of the first serious efforts to spread the harm reduction practices to combat heroin overdoses in american and beyond occurred in a conference in seattle in january 2001 called "preventing heroin overdose: pragmatic approaches." the conference was co-sponsored by the alcohol and drug abuse institute at the university of washington and the lindesmith center (later known as the drug policy alliance), which was led by ethan nadelmann, financed by george soros, and aimed to end the war on drugs and promote harm reduction. the conference brought "scholars, researchers, doctors and other health care providers, drug-treatment providers and a handful of police officials" from across north america and europe together to discuss approaches in combatting heroin overdoses. while some strategies endorsed in the program, including needle-exchange programs and good samaritan laws, became mainstream in american drug policy, other approaches that were advocated at the conference, including safe injection sites, have yet to be widely endorsed in the united states. nadelmann said at the time of the conference, "we could cut heroin overdoses in half if the information from this conference was widely disseminated." increasing bystander intervention there are currently two types of laws in place to reduce opioid overdoses through increased bystander intervention: good samaritan laws (gsls) and naloxone access laws (nals). gsls allow a bystander to not face civil damages when acting in good faith to provide emergency care in the event of an overdose, and nals increase the distribution and accessibility of naloxone. research suggests that increasing naloxone access will be the second most effective intervention for reducing overdoses. most states have the following three or varying degrees of naloxone access: third party distribution, pharmacist prescribing power, and standing orders. the standing order for naloxone allows for its distribution to a patient if they meet a certain criterion, which is most often the prescription of an opioid. the effectiveness of this legislation has been disputed since it's success depends on the change in behavior of people who are present during an overdose and the accessibility of naloxone. in 2001, new mexico was the first state to create a nal, which granted third-party prescribing and criminal immunity to prescribers. by 2017, all states had a