Photo: Jae C. Hong/AP Photo

From New England to coal country, the U.S. is in the throes of its worst drug crisis ever. How did we get here?

What’s going on?

Let’s start with a grim statistic. According to the Centers for Disease Control and Prevention, between 2000 and 2015, drug overdoses killed more than half a million people in the U.S. That’s like the entire population of Kansas City just dropping dead on a sunny day. In 2014, overdose deaths reached a record high. Then in 2015, we beat it—handily. A whopping 52,404 people died from drug overdoses that year, more than deaths from gun homicides and auto accidents combined.

Nearly two thirds of those overdoses involved an opioid, including illegal drugs like heroin and prescription painkillers like OxyContin and fentanyl. That’s 91 people dead from an opioid overdose every single day.

Numbers aren’t in for 2016 yet, but it’s already looking like a banner year. During one particularly gruesome six-day stretch in August, Cincinnati tallied 174 heroin overdoses. About a week earlier, 27 people overdosed in just five hours in Huntington, West Virginia. From prim New England towns to coal country, the U.S. is in the throes of its worst drug crisis ever.

What is an opioid?

Opioids are powerful drugs that interact with receptors in the brain and body to reduce pain and produce euphoria. The class of drugs includes illegal narcotics like heroin and prescription painkillers like oxycodone (OxyContin), hydrocodone (Vicodin) and fentanyl, which can be up to 100 times more powerful than morphine. The side effects associated with popping those Vicodin or fentanyl include tolerance to the drugs, physical dependence and increased pain sensitivity.

Why are opioids so dangerous?

Opioids slow breathing, and taking a high dosage or the wrong combination of drugs can stop breathing altogether, causing respiratory arrest and eventually death. Overdoses often occur when heroin or cocaine is laced with illegally produced fentanyl, a potent opioid used to treat late-stage cancer patients, or carfentanil, a drug 10,000 times stronger than morphine intended to tranquilize elephants. Yes, elephants.

And since black market drugs don’t come with ingredient labels, users often don’t realize that they’re getting a more dangerous cocktail or a different drug altogether. Counterfeit fentanyl is sometimes sold as heroin, oxycodone or even Xanax. The drug’s most famous victim? Prince, who died of an overdose of counterfeit fentanyl, which he may not have realized he was taking.

Prince, seen here performing at the 2007 Super Bowl in Miami, died April 21, 2016 due to an overdose of opioids. Chris O'Meara/AP Photo

Why did opioid prescriptions grow so dramatically?

Opioids have a long history of use for acute pain and end-of-life care, after surgery or for terminal cancer. (Heroin was actually a legal medication until the 1920s, when we realized it was maybe not the best pill to be popping.) However, changing attitudes towards chronic pain have meant that doctors are under increased pressure to relieve any and all discomfort. During the 1980s, pharmaceutical companies began pushing opioids to treat chronic pain, assuring doctors that the drugs were non-addictive and harmless over long periods of time. “That was patently false,” says Dr. Anna Lembke, who literally wrote the book on the prescription opioid crisis, Drug Dealer, MD.

In 2007, the state of Kentucky even sued Purdue Pharma, makers of OxyContin, alleging the company misled doctors about the safety and addictive nature of its star drug. Today, the CDC says prescription opioids are a “driving factor in the 15-year increase in opioid overdose deaths.”

What’s being done to fight the opioid epidemic?

Two main strategies are being used to combat the rise in deadly opioid overdoses. The first has been rethinking how doctors use opioid painkillers. In 2016, the CDC published new guidelines for treating chronic pain with opioids that included suggestions like seeking alternative therapies and medications first and limiting opioid prescriptions to the lowest effective dosage. While some medical groups have protested, individual states have passed legislation that restricts the length of first-time opioid prescriptions to as little as five days in an effort to curb the surplus pills spilling out of American pharmacies. So far, those efforts seem to be working. Opioid prescriptions have dropped in the past few years, after decades of unchecked growth.

All 50 states and the District of Columbia have also established prescription drug monitoring programs, electronic databases that document patient medical history, track prescriptions of opioids and other medications and help doctors and pharmacists identify people who may be abusing medication or diverting pain pills onto the black market.

The second strategy focuses on making overdose treatment more available. Naloxone (commonly known as NarCan) has been dubbed a “miracle drug” for its effectiveness in reversing early overdose symptoms and saving lives, but until recently it was only available via paramedics or the hospital. Now, first responders like police officers are being trained to carry and administer the drug, and even school nurses are stocking naloxone in places like Pennsylvania and New Jersey. Adapt Pharma, which makes a NarCan nasal spray, has offered a free carton to every high school in the U.S.

Many states now allow third-party naloxone prescriptions, so a friend or family member of a opioid addict can receive the life-saving drug, and some 35 states allow the overdose medication to be sold over the counter at places like CVS and Walgreens. In 2015, Baltimore Commissioner of Health Dr. Leana S. Wen issued a standing order that prescribed naloxone to all of the city’s 620,000 residents, so anyone who wants the drug can get it.

In Seattle, city officials are following Europe’s lead with the approval of safe injection sites where users can find clean needles and inject drugs under the supervision of medical workers trained to administer overdose treatment.

“The real goal is not to open a day spa where people can come in and have a good time and use drugs, but to engage them in treatment,” Seattle and King County health officer Jeff Duchin told the Washington Post. “They inject in a place where there’s a health-care worker who can save their lives if they overdose.”

Massachusetts, Vermont, San Francisco and Buffalo are also looking into opening safe injection sites.

How is the Trump administration addressing the overdose crisis?

In March, President Donald Trump signed an executive order establishing a new national opioid commission tasked with reporting on the current state of the opioid epidemic and suggesting a strategy of attack, including ways to fund treatment.

Led by New Jersey governor Chris Christie, the commission was well received as a positive step in combating the national opioid crisis. However, in May, a draft budget for the Office of National Drug Control Policy, the federal agency that guides drug policy, proposed cutting its funding by 95%, effectively dismantling the 30-year-old office, according to a memo sent by its acting director.

“It sends a terrible message,” Barry McCaffrey, a retired U.S. Army general who served as “drug czar” under President Bill Clinton, told the Washington Post. “Why send this bizarre political signal in the middle of what is without question a major healthcare crisis in America? It’s very strange.”

Are other countries dealing with their own opioid crises?

According to the United Nations, the U.S. consumes vastly more opioids than any other country, including more than 99% of world’s hydrocodone supply. Compared to France, where healthcare is far more accessible, Americans are prescribed six times as many opioids per capita.

However, prescription drug abuse has been on the rise in the European Union, and according to a report in the LA Times, the makers of OxyContin are responding to falling sales at home by looking for new markets abroad: “A network of international companies owned by the family is moving rapidly into Latin America, Asia, the Middle East, Africa and other regions, and pushing for broad use of painkillers in places ill-prepared to deal with the ravages of opioid abuse and addiction.”

“I would urge them to be very cautious about the marketing of these medications,” said former U.S. Surgeon General Dr. Vivek Murthy. “Now, in retrospect, we realize that for many the benefits did not outweigh the risks.”

Know someone struggling with opioid addiction?

The Center for Substance Abuse Treatment has an online directory of opioid treatment programs and operates a 24-hour hotline for people seeking information and referrals at 1-800-662-HELP.

Learn to recognize the symptoms of an opioid overdose and the proper procedure to follow if you suspect an overdose is occurring. For more information on finding and administering naloxone, visit the National Institute on Drug Abuse.