Viewing The Opioid Crisis in Three Distinct Waves

A recent article in the International Journal of Drug Policy, written by Daniel Ciccarone, attempts to explain the supply and demand drivers of the opioid epidemic in the US. The author breaks the current crisis into three distinct waves each with different supply and demand characteristics. Download the full article here.

Wave 1: Prescription Pain Pills

From the early 1990s through 2011, prescription opioids tripled. The massive increase in supply exposed a huge swath of Americans to opioids. Many people who never would have experienced the euphoria associated with opioids found that not only did they like the experience, but when they tried to stop they experienced debilitating withdrawal symptoms. Doctors were often providing prescriptions for many months giving plenty of time for new opioid receptors to build tolerance of higher doses. This supply shock is often referred to as Iatrogenic, or caused by medical treatment.

The demand side of wave one is explained as the following:

The most compelling structural determinants include an aging population with rises in reported pain and disability, economic distress, declining social cohesion and rising psychological malaise that may have led an at-risk population to seek opioids in the first place.
— Ciccarone, D., International Journal of Drug Policy, https://doi.org/10.1016/j.drugpo.2019.01.010

Wave 2: Heroin

Since the middle of the 2000s, heroin use has been increasing dramatically. Up until that point the typical path was for people, as their tolerance grew to pain pills and their supply was shut off by the medical establishment, would turn first to buy illicit pain pills but would quickly find that heroin is much cheaper and just as effective. Since the mid-2000s there has been a growing cohort of people who start their opioid use with heroin. This correlates with a change in the quality and purity of the heroin imported into the US. Competition between Colombian and Mexican suppliers resulted in an upgrade in the quality from both countries.

Wave 3: Synthetic Opioids (e.g. Fentanyl)

In the last 5-10 years, heroin in the midwest and the northeast was boosted with synthetic fentanyl. Referred to as FASH, Fentanyl-adulterated and fentanyl-substituted heroin was “integrated into the illicit drug supply and sold as ‘heroin’ in powder form, or as counterfeit opioid or benzodiazepine pills”. The DEA reports that the new supply of fentanyl and its analogues is produced in China and comes through Canada in pill form or through Mexico in powder form. Fentanyl is much more concentrated than heroin, making it the perfect substitute for bulky heroin. Transport of the same equivalent dose is easier to conceal and deliver.

Fentanyl’s high potency allows shipment in small volumes. Considering a seizure to importation ratio of 1:4, a total of 2.6 metric tons of fentanyl may have been distributed in the US in 2016. This would fit into approximately 10 industrial drum barrels – a tiny volume that if divided up over the huge trade that occurs across the Pacific Rim constitutes a proverbial needle in a haystack.
— Ciccarone, D., International Journal of Drug Policy, https://doi.org/10.1016/j.drugpo.2019.01.010

This new supply of illicit fentanyl makes assessing demand challenging. Consumers can only guess as to the contents in the drugs they are buying now. Some consumers are wary of fentanyl boosted heroin, others see it as a premium product, but none of them know exactly what they are consuming. Much of the leap in overdoses and overdose deaths is explained by the introduction of FASH.

If you or a loved one is struggling with dependence on opioids, please reach out to MATClinics for more information about treatment.