The photos of smiling young men and women look out of place in the obituaries in the local newspapers.
Accidental overdose, heroin, struggle with addiction — those words follow the loving remembrances by families to describe their sons and daughters, brothers and sisters. They plead that others don’t suffer the same fate.
A man who battled addiction for a decade died of an accidental overdose last year at the age of 26.
“Is it true everything happens for a reason?” his family asked, suggesting mourners donate to addiction recovery in their son’s name.
A 24-year-old, wearing a T-shirt and khakis, beams at the camera as he leans forward, perched on the edge of a leather sofa chair in a family living room. He is described as quick-witted and fun, a loving person, but he hid his struggle with addiction. He died of a heroin overdose.
A week before Christmas last year, a 23-year-old girl, affectionately referred to as “Peanut” and who enjoyed fishing and Dr Pepper, also died of a heroin overdose.
They are just a few of the 47,600 Americans who died last year from opioid overdoses. Opioid addiction has become a nationwide epidemic that President Trump has called a “national health emergency.”
“Nobody has seen anything like what’s going on now,” he said when making the declaration in October 2017.
The surge in overdoses of prescription painkillers, heroin and synthetics such as fentanyl has been so big that U.S. life expectancy has dropped in the past three years, the first time that has happened since the 1960s.
It is affecting the country in a variety of ways, beyond addicts and their families and friends.
Congress and the Trump administration are devoting billions of dollars to battling the epidemic. Both houses of Congress have approved dozens of bills, including some to force the U.S. Postal Service to better track packages coming into the U.S. and to expand access to treatment for pregnant, addicted women and babies who are born suffering from heroin withdrawal. First lady Melania Trump has visited several hospitals and treatment centers to learn about babies with neonatal abstinence syndrome, and she has spoken about the scourge on American society.
Police and law enforcement have been forced to change the way they do their jobs, as have health care professionals and community activists.
Pharmaceutical manufacturers and distributors are under fire for their role in the epidemic. States, cities and counties have filed hundreds of lawsuits to hold the pharmaceutical industry accountable.
More than 400,000 Americans have died from opioid abuse since 1999. The death toll is climbing, with an estimated 167 people dying each day in the U.S., up from 115 in 2016.
That is nearly seven times the number of U.S. service members who died in Vietnam and 100,000 fewer people than have died from HIV/AIDS over nearly three decades.
No part of the country has gone unscathed, with about 2.1 million Americans addicted to opioids.
From 2016 to 2017, emergency room visits for opioid overdoses increased across all demographics, by 21 percent in the most rural areas to 54 percent in big cities, according to the Centers for Disease Control and Prevention.
Nearly every state has reported an increase in the number of drug deaths, driven mainly by opioids. The national average of fatal drug overdoses is 21.7 per 100,000 people. West Virginia has the highest death rate, at 57.8 per 100,000 residents.
The scourge also is hurting America’s youngest. The number of pregnant women addicted to opioids quadrupled from 1999 to 2014, from 1.5 to 6.5 women per 1,000. That has led to a jump in the number of babies suffering from neonatal abstinence syndrome. Every 25 minutes, a baby is born suffering from opioid withdrawal, according to the National Institute on Drug Abuse.
A study released in August found that 1 in 7 children born with opioid-related symptoms have learning disabilities and require special education, compared with about 1 in 10 not exposed to opioids in the womb.
Preliminary data for 2018 showed modest gains in curbing overdose deaths, a decline of about 2.7 percent across the U.S., but health officials warn that the battle to keep addicts alive is far from over.
Scrambling for solutions
The nation has had to re-evaluate how it handles drug use as it tries to stop the growing number of deaths.
The powerful allure of euphoric drugs has long been a problem. The human brain is naturally equipped to send out pleasure chemicals when a person enjoys sensations such as a touch, music or food.
Opioids open the floodgates for those feel-good chemicals, and the brain becomes desperate to keep up production. The part of the mind that controls reason is disrupted. Eventually, users need the drugs to sustain themselves. Opioids essentially change the part of the brain that can help a person stop using.
Opioid addiction increasingly is being viewed as a sickness instead of a crime. The Trump administration in September called for a “culture shift” in how addiction is handled and discussed.
Drug users are being handled with more care, and courts are referring them to treatment programs instead of sending them to jail.
Instead of lecturing users on the dangers of intravenous drug use, community organizations are providing clean syringes to try to prevent deadly and infectious diseases and to connect them to the health care system in the hope that they will return to society.
Even safe-injection sites are being considered to provide sterile and secure environments for drug users and give them immediate assistance if they overdose.
Getting people into recovery and on medication-assisted treatment is a priority. Although the Food and Drug Administration has approved three drugs to curb cravings and block opioid effects, they are unpopular and underused by physicians and patients.
Health researchers are scrambling for alternatives, and the FDA is pushing drug manufacturers to develop painkillers that don’t include opioids.
How did we get here?
The opioid epidemic can be linked to many unchecked forces going back decades.
Marcia L. Meldrum, an associate professor at the University of California, Los Angeles, has documented the history of the problem.
“It took a number of years,” starting with a push by oncologists in the 1970s who were desperate to ease the suffering of terminal patients, she told The Washington Times.
“It was a change in medical thinking that was generational on the one hand, sort of pushed by specific leaders in the pain field from above — but the physicians were being pushed from the other side by patients with chronic pain who were coming into their offices and were deeply unhappy.”
The practice of medicine typically shifts as research evolves and consensus builds about better solutions. Yet looking back on the change about opioid use, Ms. Meldrum points out that a relatively small body of evidence was used to support a major shift in medical policy.
Two research papers published in the 1980s and a one-paragraph letter in a medical journal became the “rather fragile foundation of a 20-year campaign for the long-term use of opioids in chronic non-cancer pain,” Ms. Meldrum wrote in a 2016 article.
Patients suffering from chronic pain advocated for better treatment of their symptoms, and medical providers argued for pain to be a diagnosis, not merely a symptom.
A critical moment in 2000 shifted popular opinion toward opioids. The Joint Commission, which directs hospital and medical policy, issued a consensus declaring pain the “fifth vital sign,” as important to measure as blood pressure, heart rate, temperature and breathing.
“Excuses for inadequate pain control appear to have run their course and will no longer be accepted …,” Donald M. Phillips wrote in an article for the Journal of the American Medical Association. “Poor pain control is unethical, clinically unsound, and economically wasteful.”
With backing from the medical profession, pharmaceutical companies ramped up efforts to make people aware that their pain, whether from a dental procedure or a chronic condition, could be safely and effectively managed with opioids such as Percocet, Vicodin and OxyContin.
Purdue Pharma found a market primed for its promotion of OxyContin and presented it as a safe and nonaddictive painkiller.
Prescription rates rose. Providers wrote orders for dozens of pills so patients wouldn’t have to return for office visits.
In 1991, doctors wrote 76 million opioid prescriptions. That number tripled to 219 million 10 years later, according to the National Institute on Drug Abuse.
“Overstressed and well-intentioned general practitioners, and a number of unscrupulous ‘pill mill’ operators, wrote liberal prescriptions for the new analgesic,” Ms. Meldrum wrote.
Drugmakers rarely flagged large and questionable pill orders. Meanwhile, they courted physicians and handed out financial incentives such as speaking fees, free travel and meals that drove up prescribing rates.
Warning bells finally went off when data scientists started counting more deaths related to overdoses.
By 2004, drug overdoses were the second-leading cause of accidental deaths, behind car crashes.
A 2010 editorial in the journal Annals of Internal Medicine raised the alarm that doctors needed to re-evaluate their roles in the growing epidemic and that out-of-control prescribing rates were contributing to the rise in deaths.
Patients who were hooked on powerful opioids but no longer able to refill their prescriptions turned to cheap and accessible heroin.
“Just at that time, the Mexican black tar heroin peddlers were moving around the country,” Ms. Meldrum told The Times. “They’re coming into new cities where heroin has not been much of an issue, and they’re selling this stuff cheaply.”
Heroin, fentanyl move in
When OxyContin and other painkillers became too difficult to obtain, people turned to highly available and affordable heroin. Eighty percent of heroin users told the National Institute of Drug Abuse that they used prescription opioids first.
In a 2013 survey of drug users in San Francisco, researchers interviewed young men and women who described their move from pharmaceutical opioids to harder drugs.
“Many expressed surprise and dismay at their progression to sniffing and subsequently to injecting heroin,” the authors wrote.
That year, data from across the country revealed a frightening threat: Overdose rates were soaring from powerful synthetic opioids such as fentanyl.
Fifty to 100 times more potent than morphine, fentanyl is attractive to a dealer’s bottom line. It can cheaply multiply the heroin supply and cut the price.
From 2013 to 2016, overdose deaths attributed to fentanyl jumped from about 2,500 across the U.S. to more than 20,000. They included legendary musician Prince, who died after taking a fake Vicodin laced with fentanyl. More frequently, fentanyl relatives such as carfentanil — 100 times more powerful than fentanyl and used to tranquilize elephants — are showing up in toxicology reports.
Last year, 60 percent of opioid overdoses involved a synthetic, according to the CDC. Synthetics accounted for almost 30,000 deaths — more than all opioid overdose deaths in 2013.
A few milligrams of fentanyl, made in laboratories in China and Mexico, are potent enough to kill a person and can fit on the surface of a postage stamp. Traffickers mail envelopes to the U.S. with sheets of fentanyl, which is pressed into counterfeit pills and mixed with heroin. It is increasingly showing up in non-opioid drugs such as cocaine and methamphetamine.
In August, more than 70 people in a park outside Yale University in Connecticut overdosed on synthetic marijuana laced with fentanyl, although no one died.
The government has committed more than $13 billion since 2016 for prevention, treatment, recovery, law enforcement, criminal justice reform and overdose reversal.
The Trump administration and Congress are increasing those efforts by earmarking $3 billion in the fiscal 2018 budget for the opioid epidemic and pushing for $10 billion in 2019.
In October, Congress overwhelmingly passed, and the president signed, the Opioid Crisis Response Act of 2018, a package of about 60 bills designed to fight the epidemic. That includes the Synthetic Trafficking and Overdose Prevention (STOP) Act, designed to stop the shipment of fentanyl through the U.S. Postal Service by requiring more data-gathering on packages from overseas.
“To those I represent who are struggling with addiction, to those who have friends or loved ones who struggle or continue to struggle with addiction and to the millions of people in communities across this country who have been crippled by this crisis, this legislation is the turning point,” said Sen. Rob Portman, the Ohio Republican who sponsored the STOP Act.
“It is a glimmer of hope. It’s a glimmer of hope at the end of a dark tunnel.”