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A small proportion of physicians were unscrupulous, doling out opioids without adequate regard for medical need. These factors are widely believed to have caused the steady rise in opioid analgesic consumption over the past three decades, while rates of overdose and addiction increased in tandem. Around 2010, the second phase started, marked by concern over intertwining opioid analgesic and heroin use. After remaining relatively stable for years, heroin overdose deaths spiked, tripling between 2010 and 2015. The vector model attributes this transformation to an expanded pool of susceptible individuals: with rising dependency and tolerance, some people who used prescription opioids transitioned to a more potent and cheaper alternative. This phase is contemporaneous with the reformulation of OxyContin that made it difficult to crush, although this reformulation’s contribution to the increase in heroin use is contested. More broadly during this time, clinicians and policymakers widely reassessed the effectiveness and safety of outpatient use of opioid analgesics.The third phase began in late 2013 and continues today. Increasingly efficient global supply chains and a sharp intensification in interdiction efforts created the conditions for the emergence of potent and less bulky products, for example, illicitly manufactured fentanyl and its analogs, which are increasingly present in counterfeit pills and heroin. Between 2013 and 2016, deaths attributed to fentanyl analogs spiked by a shocking 540% nationally, with pronounced regional increases. The rapid acceleration of the crisis has led to its designation as a national public health emergency. The roots of the opioid crisis are deeper than popular narrative suggests. In 1980, acute pain was so frequently treated with opioids that propoxyphene was the second-most dispensed drug in the United States.6 The Carter White House stated, “Diversion, misuse, and abuse of legal drugs may be involved in as many as seven out of ten reports of drug-related injury or death.” A decade later, US medicine was shaken by revelations of undertreated chronic pain, motivating normative practice and policy shifts. Previously, chronic pain was managed largely with cognitive behavioral therapy, even hypnosis. An Institute of Medicine report attributed the rise in chronic pain prevalence during the 1990s to the following: 1. greater patient expectations for pain relief, 2. musculoskeletal disorders of an aging population, 3. obesity, 4. increased survivorship after injury and cancer, and 5. increasing frequency and complexity of surgery. As insurers limited coverage of behavioral pain therapy, biopharmaceutical manufacturers sensed an opportunity. Pharmaceutical innovation propagated extended-release formulations, transdermal patches, nasal sprays, and oral dissolving strips. Medical device manufacturers drove a proliferation of novel painmodulating implants.1. Madras BK. The surge of opioid use, addiction, and overdoses: responsibility and response of the US health care system. JAMA Psychiatry. 2017; 74(5):441–442. 2. Dasgupta N, Kramer ED, Zalman MA, et al. Association between non-medical and prescriptive usage of opioids. Drug Alcohol Depend. 2006;82(2):135–142. 3. Meldrum ML. The ongoing opioid prescription epidemic: historical context. Am J Public Health. 2016;106(8):1365– 1366. 4. Jenkins P. THE OPIOID CRISIS AND ECONOMIC OPPORTUNITY: GEOGRAPHIC AND ECONOMIC TRENDS By Robin Ghertner and Lincoln Groves, Ph.D. INTRODUCTION Opioid use disorder has reached epidemic levels in the United States, with a 200 percent increase in overdose deaths from opioid and heroin use between 2000 and 2014.1 The Centers for Disease Control and Prevention (CDC) estimated that over 60,000 drug overdose deaths occurred in 2016, with overdose death rates three times the rate of 1999.2 Overdose death rates involving opioids have risen dramatically, with deaths due to synthetic opioids other than methadone doubling from 2015 to 2016.2 Lower-income individuals, including those on Medicaid and the uninsured, are more likely to misuse opioidsi and have opioid use disorder than the general U.S. population. 3–5 As shown in Figure 1, in 2016, individuals under the poverty line were 2.1 percentage points more likely to have misused opioids in the past twelve months than individuals above 200 i Throughout this brief the terms opioids, opioid misuse, and opioid use disorder include the use of prescription opioids as well as heroin and synthetic opioids. percent of the poverty level. They were over twice as likely to have has an opioid use disorder. In fact, even as rates of nonmedical use of opioids among the lowincome population decreased from the 2003-2005 period to the 2012-2014 period, rates of dependency rose by over 50 percent.3 In 2012, the CDC issued a report stating that “Medicaid recipients and other lowincome populations are at high risk for prescription drug overdose.”6 While the individual-level relationship is clear, the relationship between community prevalence of opioid use disorder and economic conditions has not been fully studied. This relationship is important for decision-makers at the federal, state, and local levels to understand as they consider policy and budgetary proposals to address the crisis. The opioid crisis has not affected the nation uniformly. The extent to which it may be concentrated in areas with higher poverty and fewer employment opportunities may exacerbate This study examines relationships between indicators of economic opportunity and the prevalence of prescription opioids and substance use in the United States. Overall, areas with lower economic opportunity are disproportionately affected by the opioid crisis. However, the extent of that relationship varies regionally. (1) The prevalence of drug overdose deaths and opioid prescriptions has risen unevenly across the county, with rural areas more heavily affected. Specific geographic areas, such as Appalachia, parts of the West and the Midwest, and New England, have seen higher prevalence than other areas. (2) Poverty, unemployment rates, and the employment-to-population ratio are highly correlated with the prevalence of prescription opioids and with substance use measures. On average, counties with worse economic prospects are more likely to have higher rates of opioid prescriptions, opioid-related hospitalizations, and drug overdose deaths. (3) Some high-poverty regions of the country were relatively isolated from the opioid epidemic, as shown by our substance use measures, as of 2016. 2 disparities in access to health care and treatment options in such communities. Figure 1. Past Year Opioid Misuse and Use Disorder by Poverty Status, 2016 Source: 2016 National Survey on Drug Use and Health. Note: Includes nonmedical use of prescription painkillers or use of heroin. N = 56,897. All differences across poverty status within each category are statistically significant at p < 0.001. One recent study found that increases in county unemployment rates predict increases in opioid death rates and that macroeconomic shocks drive the overall drug death rate.7 Another study found that per capita opioid-related hospital stays and emergency department visits are higher, and have increased at higher rates, in low-income communities than in higher income communities. 8 In addition, labor force participation has fallen by a greater percentage in areas where relatively more opioid pain medication is