What factors have contributed to the opioid epidemic?

Posted: October 28th, 2022

A description of the known explanations or causes of the opioid epidemic in the United States.

     The contributing factors of how opioid use disorder evolved into an epidemic have their “roots” in improving pain management.  According to a 2019 journal article in Nature, the opioid epidemic evolved from a confluence of sources, including doctors seeking better methods for controlling pain, aggressive and fraudulent marketing efforts by pharmaceutical companies, and oversights/corruption within the U.S. healthcare system (Deweerdt, 2019, p.8).  In the 1980s, states began passing legislation that would protect doctors from being prosecuted for aggressively treating a patient’s pain with a controlled substance.  Consequently, in 1995, the American Pain Society, run exclusively by physicians, now labeled pain as the “fifth vital sign,” meaning it should be checked as standard protocol in a doctor’s visit like a patient’s blood pressure (Deweerdt, 2019 p.10).  The combination of “pain” becoming part of a standard check-up with a physician, along with no legal threat of aggressively treating pain, now set the stage for pharmaceutical companies to take full advantage of.

Purdue Pharma, along with others, already had multiple strategies to take advantage/exploit the medical community and the public.  Lawmakers were lobbied, education courses of their own making were presented, along with an aggressive salesforce that solicited patient organizations and doctors directly (Deweerdt, 2019 p.10).  

As opioid use increased from the 1980s into the 1990s, the watershed moment occurred when new opioid-based products were introduced to the medical community, namely Oxycontin.  Oxycontin was manufactured and marketed by Purdue Pharma and was touted as having only a 1% addiction rate.  (Liu, 2018, p.2) The fact that physicians, according to Dr. Stephen Bernard, a specialist in palliative care at the University of North Carolina at Chapel Hill, “don’t get a lot of good training in pain management” gave the advantage to the pharmaceutical companies by using their “in-house” education programs to convince doctors of its effectiveness and safety in dealing with pain.  (Deweerdt, 2019, p.11).

In the public setting, the hardest-hit communities in the U.S. all had high rates of poverty and underemployment.  Ohio, West Virginia, Kentucky, and Massachusetts were the first states where pharmaceutical opioid abuse would negatively affect the poor and disenfranchised.  This, however, was only the “first wave” of the epidemic.

The National Capital Poison Center describes the opioid crisis as having “come” in three separate “waves” or times, with a progression to more and more potent opiates.  The NCPC describes the first wave as beginning in the early 1990s with prescription opiates.  Since the disease of addiction is progressive by nature, (CDC, 2021), more potent opioids would be sought by those with OUD.  The second wave began around 2010 with heroin, an illegal and much more potent/deadly opioid.  Finally, the third wave came by 2013 with the introduction of synthetic opioids like fentanyl which is 30-50 times more potent than heroin.  (Liu, 2018, p. 2-3).  

What was not making the news or considered an epidemic was that poor, inner-city communities, primarily minority populations, were being decimated by heroin in the 1960s and 70s.  The parallels/correlations between the communities targeted by pharmaceutical companies (poor, under-employed, and white) and the inner-city communities have overlapping socioeconomic/employment statistics.  Yet, the heroin epidemic among inner-city minorities was met with little to no attention.  The commonalities, however, are the same with regards to education, poverty, and underemployment, but the racism, discrimination, and disregard for people of color is appalling.

A description of the theoretical explanations and approaches scholars and policy analysts used to discuss this issue. 

One approach by the University of Tennessee reviewed 14 studies that all focused on the most effective treatments for people with OUD, assessing medically assisted treatment (MAT) compared with psychosocial interventions.  The methods in all 14 studies reviewed were with OUD patients in the early and “maintenance” stages of their recovery (Brown, 2017, p. 249).  There was no evidence of any adverse effects in any of the 14 studies, which included psychosocial interventions and proved to be as/more effective than the studies done that did not use them.  However, the overall findings, MAT treatment was shown to be the most effective treatment in the early/maintenance stages of OUD recovery.

This, in my opinion, shows the power of OUD and why so many have died in this epidemic.  From 1999 to 2019, the number of OUD deaths has steadily increased from 12k to over 80k a year across the country.  (CDC, 2021) In early and maintenance periods of opioid withdrawal, MAT alleviates the pain and suffering that comes with “coming off” the use of opiates.  The Tennessee study, however, stated, “If psychosocial interventions (CBT) can help individuals detoxify from replacement therapies and achieve complete abstinence with long-term relapse prevention, then they would be a way to move from management to complete remission (Brown, 2017, p. 265).  Finally, the article recognizes that social workers are uniquely qualified to help the OUD population in preventing relapses and bolstering other protective factors (Brown, 2017, p. 265).

For me, what is critical to understand is that social workers play an essential role in helping meet the needs of a client with OUD, especially regarding long-term recovery.  In its review of the 14 studies, this article gave credence to the role of the social worker as a valuable resource in facing this epidemic head-on.

A description of the policies that have resulted from these discussions and an explanation of whether they are effective at resolving the issue.

One of the responses/results that came from discussions regarding the OUD epidemic was presented in a “policy mapping” article by Buffalo-State University in 2020.  This study focused on trauma-informed care rather than evidence-based practice.  The correlation between trauma and SUD guided the study.  

Given that psychological trauma is often linked with substance misuse, this study investigated the extent to which U.S. federal legislation responding to the recent opioid crisis was trauma informed.  Approximately 11% of opiate-related bills or resolutions introduced in Congress between 2009 and 2017 mentioned the term “trauma,” and 55% were aligned with at least one principle of trauma-informed care, such as safety, choice, or empowerment.  Stakeholders can use these findings as a basis for advocating for continued inclusion and expansion of trauma-informed principles in opioid policy in particular contexts, such as addressing pathways between incarceration, trauma, and opioid misuse.

This clinical impact statement is well in line with understanding SUD/OUD as more of a “symptom” to the deeper truth/realities in the world of addiction (CDC, 2021).  The coping skills, or lack thereof, are growing exponentially, especially with the Millennial generation and younger.  Suicidal ideation, suicides, depression, SUD, along with the two-year isolation component that Covid has now imposed, is wreaking havoc among all ages, but especially prevalent in younger generations (Bowen & Irish, 2020, p. 2-4).  Therefore, trauma-informed policy, in my opinion, is critical.  An example of this would be the Campaign for Trauma-Informed Policy and Practice (CTIPP), which strives to mobilize communities for trauma-informed policy change.  For instance, in 2016, Congress passed the Comprehensive and Addictive Recovery Act (CARA), signed by President Obama.  In CARA, the word “trauma” is mentioned in three sections of this piece of legislation regarding services, veterans, and chronic pain/opioid protocols/guidelines.

The opioid epidemic has proven/caused death and devastation/trauma, financial loss, etc., on micro, mezzo, and macro levels.  It is a disorder that affects everyone, either directly or indirectly.  Policies already in place, and many more that are needed, as mentioned above, are to the benefit of everyone.  OUD crosses all socioeconomic, gender, and ethnic populations.  It does not discriminate.  Our response, given the circumstances we now face, calls for a continuing monumental effort from all members of society, and social workers, as always, will be on the “front lines.”


Bowen, E. A & Irish, A. (2020). Trauma and principles of trauma-informed care in the U.S. federal legislative response to the opioid epidemic: A policy mapping analysis. Psychological Trauma: Theory, Research, Practice, and Policy.


Brown, A. R., (2017). A systematic review of psychological interventions in treatment of opioid addiction. Journal of Social Work Practice in the Addictions, 18:249-269. Routledge

            DOI: https://doi.org/10.1080/1533256X.2018.1485574

Center for Disease Control and Prevention (2020). Retrieved from:


Deweerdt, S., (2019). The natural history of an endemic. Nature Vol. 573, 8-12.

            https://media.nature.com/original/magazine-assets/d41586-019-02686/d441586-019-     02686-2.pdf

Liu, L., Pei, D. N., Soto, P., (2018). History of the opioid epidemic: How did we get here? National Capital Poison Center Retrieved from