From 2014 to 2017,  life expectancy in the USA decreased for three consecutive years, a pattern unseen since World War Two. A major contributor: increasing deaths from opioid substance abuse. If the phrase ‘opioid crisis’ conjures up images of dark alleyways, scattered needles and emaciated heroin users, you wouldn’t be wrong. However, the reality is complicated, with legal prescription opioids (used as strong painkillers), illicit opioids like heroin, and more recently synthetics like fentanyl contributing to the rising death toll over the past 30 years.

 The origins of the crisis are attributed to the development and marketing of legal opioids in the -90s, like ‘OxyContin’ by Purdue Pharma, which were initially touted as less addictive and a necessity to battle the supposed under-treatment of chronic pain. Another similar case is that of Johnson & Johnson, currently being sued for distributing misleading promotional material and increasing pressure on medical professionals through financial incentives to prescribe its products. The net result: overprescription of strong opioids and the potential for abuse and overdose.

 The damage however, extends beyond this; the increase in opioid prescriptions has been followed by a surge in illicit opioid use, mainly heroin and fentanyl. The connection is straightforward; around 20-30% prescribed a long course of opioids end up misusing and/or developing addictions. Heroin is more potent, cheaper, and is the natural next step; according to the National Institute of Drug Abuse, over 80% of new heroin users started out by misusing prescription opioids. This, coupled with an independent increase in the supply and distribution of illicit opioids has led to an alarming increase in heroin related deaths and overdoses since 2010. This is often termed ‘the second wave’ of the opioid crisis. Since 2013, the prevalence of synthetic opioids has also begun to increase, the most common being fentanyl, which is now responsible for most opioid related deaths in the USA. This is referred to as the ‘third wave’.

 To combat the crisis, the USA has initially chosen to intensify its pre-exisisting ’War on Drugs’ campaign, focusing on incarcerating drug users and a crackdown on supply chains. Recently, there has also been attribution of responsibility to pharmaceutical companies, and a push to reduce prescribing. However, many western countries have taken a medical approach to deal with substance abuse, through ‘harm reduction’ strategies; methadone (a safer, less potent alternative to heroin) substitution, needle exchange programmes, safe spaces for injection, and prescription heroin, all designed to holistically mitigate the individual and societal effects of drug use. Apart from ensuring a better quality of living and reducing deaths, evidence shows that these strategies increase the likelihood of accessing treatment and cessation services and reduce overall drug abuse. Portugal, formerly the ‘heroin capital of the EU’ has gone as far as to decriminalise the use of heroin, the premise being that this allows regulation and removes stigma surrounding drug use and its treatment. Others like Norway and The Netherlands are also in the process of relaxing their drug laws.

 Surprisingly, the USA’s attitudes towards harm reduction have been skeptical at best, mainly arguing that, despite contrary evidence, the strategy normalises drug use. For example, until 2016, no federal funding was allowed to be used for needle exchange programmes, and even now their prevalence is limited. Methadone substitution is legal but difficult to access, and safe injecting spaces are illegal. It is not all bad news though; under the Trump Administration, the opioid crisis has been declared a national emergency and in 2018, the number of opioid deaths fell for the first time since 1990, mostly attributable to funds increasing access to treatment and more stringent prescribing policies. However, without concrete plans to pursue harm reduction strategies, mitigate stigma and provide holistic care, it is unclear how effective these changes will be. Nevertheless, it is a start.