Why is the Opioid Epidemic happening in Maine and the United States?

(15-minute read) – This info-brief begins by providing data regarding opioid overdose deaths including the substances involved as well as trends over time. It then moves to a contextual discussion of exactly what are opioids, how the opioid epidemic began in the United States, why the “Rust Belt” is the epicenter of this epidemic, and finally what is substance use disorder and what are some of the bio-psycho-social-environmental risk factors for developing an opioid addiction.

The opioid epidemic: A State tragedy driven by national trends

The three waves of the opioid epidemic

A fourth wave of the opioid epidemic? Fentanyl adulteration

Fentanyl: Fueling drug overdoses

What are opioids?

Opioids: An American Epidemic

Addressing the Prescription Opioid Epidemic

The Rust Belt: Epicenter of the epidemic

Why do people develop substance use disorder?

How is the State of Maine responding to the overdose crisis?

From the year 2000 to 2019 more than 500,000 American’s lost their lives due to a fatal opioid overdose. Recently, the CDC estimated that in the twelve-month period from April 2020 to March 2021 over 100,000 Americans died of a drug overdose. In Maine, from 1997 to 2021 an estimated 5,432 Mainers died of fatal drug overdoses. From 2019 to 2020 there was a 36% increase in fatal overdoses from 380 to 515. It is estimated that from 2020 to 2021 the number of fatal overdoses increased 23% from 515 to 636. Although attention has been drawn away from the opioid epidemic due to global covid-19 pandemic, the fatal overdose crisis in Maine and in the United States is not only still ongoing, it is becoming more prevalent.

Source: Maine Drug Data Hub, Monthly Overdose ReportDrug overdose deaths in the United States, 1999–2020. NCHS Data Brief, no 428.

The causes of the opioid epidemic are complex and multi-layered, with political, social, and economic origins. The opioid epidemic is also a dynamic issue that has changed dramatically overtime both in regards to the number of victims experiencing a fatal overdose each year but also in the substances involved and the bio-psycho-social-environmental circumstances that increase a person’s risk of developing a substance use disorder.

The three waves of the opioid epidemic

The opioid epidemic is commonly thought to have unfolded—or evolved—in three distinct waves. Each of these waves saw unprecedented and rapid increases in the number of fatal drug overdoses at both the national and state levels.

  1. Prescription opioid medication wave: is characterized by increases in drug overdoses due to prescription opioids. This wave began in the late 1990s and continued through the first decade of the 2000s.
  2. Heroin wave: is characterized with an increase in the amount of deaths attributed to heroin. As seen in the graphs below, this wave began in 2010 and peaked in both Maine and the United States in 2016.
  3. Nonpharamceutical fentanyl wave: is indicated by several factors. The first is a precipitous rise in both fatal overdose deaths and deaths due to nonpharmaceutical fentanyl/synthetic opioids. The second factor is a stabilization and then decrease in deaths due to heroin beginning in 2016 both in Maine and nationally.

Source: Maine Drug Data Hub, Monthly Overdose ReportDrug overdose deaths in the United States, 1999–2020. NCHS Data Brief, no 428.

Note: Natural and semi-synthetic opioids include pharmaceutical drugs such as morphine, oxycodone, and hydrocodone. Synthetic opioids do not include methadone. Synthetic opioids include drugs such as fentanyl, fentanyl analogs, and nonpharmaceutical tramadol.

A fourth wave of the opioid epidemic? Fentanyl adulterations

The dramatic surge in overdose deaths since 2019 has prompted speculation by State and national behavioral health personnel that we are entering a fourth wave of the opioid epidemic. Although nonpharmaceutical fentanyl is involved in the majority of drug deaths, in Maine, the average number of drugs causing a fatal overdose is three. This characterizes the potential 4th wave of the opioid epidemic as being an epidemic of polysubstance misuse and the adulteration of the non-opioid illicit drug supply with nonpharmaceutical fentanyl and other dangerous cointoxicants.

In the following chart you can see that fentanyl overdose deaths involving heroin (an opioid) have been decreasing since 2016 while fentanyl overdose deaths involving stimulants such as cocaine and methamphetamine began increasing greatly during the same year. As with major metropolitan areas such as Philadelphia and New York, Maine is also seeing an increase of xylazine (tranquilizer) involved in fatal drug overdoses.

Fentanyl: Fueling drug overdoses

This rise of fentanyl and questions surrounding it are as complex as the opioid epidemic itself. As such there is an info-brief dedicated to fentanyl titled,

“Fentanyl: Fueling Drug Overdoses in Maine and Across the United States.”

To summarize, nonpharmaceutical fentanyl is an extremely potent synthetic opioid that is made in China and shipped to drug cartels in Mexico for distribution throughout the United States. Depending on purity and concentrations, fentanyl can be 100 times more potent than heroin and morphine. Some fentanyl analogs, such as carfentanil, are 100 times as potent as nonpharmaceutical fentanyl. This makes it desirable because it is easier to smuggle as an illicit product as it is much less bulky than heroin, adding a little bit to a distributor’s or dealer’s drug supply makes it more profitable, and adding small amounts to substances such as cocaine, methamphetamine, marijuana, and ecstasy produces novel effects. Further, nonpharmaceutical fentanyl is often used in the creation of counterfeit pharmaceutical drugs such as opioids (oxycodone), stimulants (adderall), and sedative pharmaceuticals (Xanax).

One challenge in addressing the overdose epidemic is that people who are victims of fentanyl overdoses—even opioid users—do not realize that fentanyl is adulterating their drug supply. Another challenge is that overdose deaths are an indicator of the toxicity of the drug supply, international drug trafficking patterns, and possible bio-psycho-social-environmental determinants of health rather than a gauge to measure the efficacy of national and State prevention, harm reduction, treatment, and recovery policies.

As seen in the charts below, waves two and three of the opioid epidemic can be seen as a function of international drug trafficking by examining the drug seizures of Maine DEA and the federal Customs and Border Protection agency.

Source: Maine Drug Data Hub Prevention Metrics; U.S. Customers and Border Protection CBP Enforcement Statistics. Note, CBP fentanyl seizures listed as N/A prior to 2017.

Above, the same pattern of fatal drug overdoses by substance is seen in the grams of drugs seized by Maine DEA task forces and the pounds of drugs seized Customs and Border Protection. This indicates that fatal drug overdoses are related to the lethality and potency of substances in the illicit drug supply. MDEA heroin seizures peaked in 2019 dropping in 2020 and 2021. This same pattern is replicated in the CBP drug seizures nationally. Seizures of pharmaceutical drugs peaked in 2019 and also dramatically dropped in 2020 and 2021. Fentanyl seizures, much like drug deaths, peaked in 2017 dipped in 2018, and abruptly rose beginning in 2019 and continues through 2021. CBP drug seizures saw fentanyl sharply rise from 2017 to the present. In both MDEA and CBP data methamphetamine also began sharply rising in 2018.

What are opioids?

Opioids are a type of chemical that bind to the opioid receptors in the nervous system. This cause them to have a powerful analgesic effect but also side effects such as constipation and respiratory suppression.

image of poppy plants

People often conflate opiates and opioids though they are two separate categories. All opiates are opioids but not all opioids are opiates. Opiates are naturally derived from the poppy plant while non-opiate opioids are artificially synthesized. For example heroin is an opioid because it is synthesized from morphine an opiate. Laboratory derived opioids such oxycodone, fentanyl, and carfentanil are non-opiate opioids.

Opioids: An American epidemic

The United States contains 4% of the global population, however, it consumes more than 80% of the world’s oxycodone. This is one of the constellation of factors that fostered an environment ripe for creating the opioid crisis during the last two decades of the twentieth century.

Part of the reason Americans consume a disproportionate amount of opioid pain medication was the development of semi-synthetic opioid medications by major pharmaceutical companies. Doctors were encouraged to prescribe these new medications by pharmaceutical representatives that touted their formulations as being nonaddictive. Patients experiencing pain, and seeing a litany of drug advertisements, also began requesting the medications from physicians. Doctors also were provided guidance from their professional organizations that pain was the 5th vital sign and that providers should address the unmet pain treatment need of their patients.

Image of the pain scale, 0=no pain; 1-3 = mild pain; 4-6 = moderate to severe pain; 7-9 = very severe pain; 10 = worst pain possible.

As the number of opioid prescriptions increased, so too did the number of fatal opioid overdoses. The risks of taking opioid medications, especially for the long-term treatment of chronic pain, were poorly misunderstood and in some cases misrepresented as posing low or no risk to patients. In the modern era of prescribing opioids for the treatment of pain, the United States has far outpaced the rest of the world in its use of opioid pharmaceuticals. Today, more than 80% of all people who use illicit opioids report that they first misused them as prescription medications.

Addressing the prescription opioid epidemic

State and federal governments addressed the sharp increase in pharmaceutical overdoses through increased regulations and new insurance company policies to reduce both the number of opioid prescriptions as well as the amount of opioids being prescribed. In Maine, since 2015 the number of patients prescribed opioids dropped from 110,000 patients to 67,000 patients. The number of opioid prescriptions dropped from 268,000 to 160,000 and the amount of morphine milligram equivalents prescribed (a measure of drug potency) dropped from 307 million MMEs to 130 million MMEs.

Source: Office of Behavioral Health, Prescription Drug Monitoring Program.

The Rust Belt: The epicenter of the epidemic

Opioid addiction flourished in the epicenter of America’s late twentieth-century industrial decline. The region know as the “Rust Belt” includes the largely rural states from New England into Appalachia and the Mountain South, that had once prospered from the wealth generating capacity of American industry, but then saw rapid economic decline after American factory and natural resource extraction jobs disappeared.

Image of coal miners

Economic depression and social despair made for fertile ground where the opioid epidemic took root. Many began using pharmaceutical opioids prescribed by their doctors to treat workplace accidents or other causes of pain. Others, too, fell prey to provider and pharmacy based “pill-mills” that promised to end their physical and mental pain.

As pharmaceuticals became less available due to state and federal regulations, heroin smuggled from Mexico found a ready market for consumption in the “Rust Belt.” People who had become dependent on pharmaceutical opioids turned to heroin as a cheaper and more easily accessed alternative for pain relief.

Why do people develop substance use disorder?

Substance use disorder is a complex condition that is characterized by a combination of physical dependency and a set of persistent behavior patterns where substances negatively impact an individual’s daily functioning. Historically, there have been two main narratives explaining substance use disorder, neither are accurate.

  1. A moral failing where the individual in unable to prevent their own substance use related downfall
  2. That substances are inherently addictive to all persons in all circumstances—even after a single use

While some substances, including opioids do cause physical and psychological dependency, the development of dependence and substance use disorder arise from a complex set of individual, community, and social factors. Thus, the substance (chemistry) is just as important as the setting in which the substance is used or misused (environment). Many of the bio-psycho-social-environmental factors that can lead to developing problematic substance use are also those that expose individuals to marginalization and oppression in society. Though not all individuals that are marginalized develop substance use disorder, nor are all individuals with substance use disorder marginalized, these broader set of circumstances increase the likelihood of individuals engaging with problematic substance use.

  • Biological factors
    • Physical developmental disabilities
    • Genetics
    • Changes to the physical brain from repeated substance exposure
    • Physical ailments and conditions
  • Psychological factors
    • Psychological developmental disabilities
    • Cognitive and intellectual disorders
    • Mental health conditions including
      • Depression
      • Anxiety
      • PTSD
      • Schizophrenia
      • Bi-polar disorder
      • Borderline personality disorder
      • Anti-social personality disorder
  • Social and environmental factors
    • Being gay, lesbian, bisexual, or transgender
    • Being part of an oppressed racial or ethnic group
    • Having a history of adverse childhood experiences (ACEs)
    • Having a history of trauma including domestic violence and/or sexual assault
    • Experiencing homelessness
    • Having unstable housing
    • Epigenetics
    • Living in poverty
    • Experiencing incarceration

While these are risk factors, it is critical to note that many of these factors can serve as protective factors against problematic substance use if the individual is well supported. For example being part of the BIPOC or LGBTQ+ communities can serve as a sense of pride and a connection to one’s community, that supports an individual’s overall wellbeing. This is also true for those who experience mental illness, identify as differently abled, or identify membership in any number of strong and resilient communities.

How is the State of Maine responding to the overdose crisis?

While Maine has been disproportionately affected by the opioid crisis with an estimated 5,432 victims of fatal drug overdoses from 1997-2021, it is also leading the country in both effective and novel efforts to curb overdose mortality. The State has made fighting the opioid epidemic a priority, and it has outlined a strategic action plan for addressing the crisis directly. That plan can be viewed here:

Maine Opioid Response Strategic Action Plan, 2021.

Though the State’s opioid response is vast, and is large enough to have its own info-brief, one item from each of the five focus areas of the Strategic Action Plan—leadership, prevention, harm reduction, treatment, and recovery—are highlighted below.

Focus Area: Leadership
Priority A: Take decisive, evidence-baed and community focused actions in response to Maine’s opioid crisis
Strategy #1.h.: Support and implement an overdose fatality review panel.

On June 21, 2021, Governor Mills signed into law L.D. 1718, An Act to Establish the Accidental Drug Overdose Death Review Panel. The law establishes an Accidental Drug Overdose Death Review Panel to review a subset of deaths caused by accidental drug overdoses and to recommend to state, county and local agencies methods of preventing deaths as the result of such overdoses, including modification or enactment of laws rules, policies and procedures. The panel is made of up fifteen (15) individuals representing a number of state offices, law enforcement agencies and including impacted family members and persons in recovery.  The panel also will include one or more physicians who treat substance use disorder, an EMS representative and a harm reduction specialist.  The panel is chaired by the state’s Director of Opioid Response and is staffed by the Rural Drug and Alcohol Research Team at the Margaret Chase Smith Policy Center at the University of Maine.

Focus Area: Prevention
Priority C: Reduce the number of prescribed and illicitly obtained opioids.
Strategy #13: Strengthen law enforcement efforts to intercept and reduce illicit opioid supply.

As seen in the charts below, MDEA task-forces serve on the front line of keeping potent illicit substances out of Maine communities. MDEA seized a record amount of fentanyl and methamphetamine during 2021 and despite the covid-19 pandemic and related workforce shortages made all time high drug trafficking arrests in 2020 and 2021 for fentanyl.

Source: MDEA director.

Focus Area: Harm Reduction
Priority D: Reduce the number of fatal and nonfatal overdoses.
Strategy #15: Ensure widespread distribution and ease of access to naloxone by the general public

Since 2019, the State of Maine has made State-supplied naloxone available to organizations and members of the community that wish to have-it-on-hand in case of an opioid overdose emergency or to distribute to individuals that use opioids as well as their loved ones. During its first two years, from July 2019 to July 2021, the Maine Naloxone Distribution Initiative and the Maine Attorney General’s Naloxone Distribution Program has distributed over 110,000 doses of naloxone to communities throughout Maine. These doses of naloxone have directly contributed to the successful reversal of 3,378 overdoses as reported to Maine Naloxone Distribution Initiative community partners as of December 2021.

Source: Maine Naloxone Distribution Initiative, Margaret Chase Smith Policy Center, University of Maine

Focus Area: Treatment
Priority G: Ensure the availability of treatment that is local, immediate, affordable, and best fit.
Strategy #22.d: Continue supporting county jails and Department of Corrections in adding Medication for Opioid Use Disorder treatment programs.

In total there were 1,001 residents of the Department of Corrections treated for substance use disorder with medication for opioid use disorder (MOUD) and over 350 county jail residents treated with MOUD.

Clients served by MDOC’s MOUD pilot program2019
Number completing MOUD while incarcerated115
Percent attending community treatment post-incarceration84%
Percent released from DOC MOUD programs receiving naloxone100%
Source: Maine Department of Corrections, Medication-Assisted Treatment Pilot. Evaluation Report, 2020.
Clients served by MDOC’s MOUD program 2020MaleFemaleTotal
Number of residents admitted into MDOC institutions assessed as having substance use treatment need(76%) 554(86%)59 613
Number of residents transitioned to the community with a community treatment provider44290532
Number active in treatment in a correctional facility at the end of 202016917186
Percent released from DOC MOUD programs receiving naloxone100%100%100%
Source: Maine Department of Corrections, Year End MDOC Adult Data Report, 2020.

Focus Area: Recovery
Priority I: Support individuals in recovery

During 2021 237 recovery coaches were trained and certified with a total of 359 individuals completing advanced trainings in topics like ethics, emergency department care, and supervision. Further, 11 new recovery residences were opened in that State of Maine and the percentage of recovery residences accepting persons on MOUD increased from 43% to 56%. In addition, the number of recovery community centers has expanded to 18 across the state of Maine with three additional planned to be opened at the beginning of 2022.

Source: This info-brief was created by Jamie-Lynn Kane a graduate student research assistant at the Margaret Chase Smith Policy Center at the University of Maine with data and collaboration from the Rural Drug and Alcohol Research Program.