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    Why is there an opioid crisis?


    Hillbilly Elegy meets the OxyContin economy

    Those who have read J.D. Vance’s Hillbilly Elegy and our readers from Appalachia will have a vivid image of the unique combination of Ulster-Scot stubbornness, social isolation, and grinding poverty that has plagued Eastern Kentucky, Southeast Ohio, Southwest Virginia and West Virginia for decades. These characteristics proved fertile soil for proliferation of pill mills, and OxyContin addiction. The collapse of manufacturing and the coal industry led to chronic unemployment and a spike in federal Supplemental Security Income (SSI) disability claims and Medicaid coverage. This, in turn, paid for OxyContin.

    Eventually, towns like Portsmouth developed an entire OxyContin economy where goods and services were bought and sold using pills of varying dose “denominations.” An entire cottage industry sprang up with Medicaid recipients going to pill mills for their OxyContin and then selling the pills for substantial dollar amounts. Rates of addiction and overdose deaths exploded, economic decline accelerated and the very social fabric of these rural communities unraveled. Indeed, the Ohio Valley and Appalachia, along with Maine and Alabama, became the epicenter of OxyContin abuse with rates 5 to 6 times the national average.7 But, incredibly, the worst was still to come.

    Black tar heroin, a narco-criminal disruptive innovation

    Traditionally, heroin has been sold in big cities at fixed locations by gangs and organized crime. Sources included Asia, the Middle East and Colombia and quality was poor due to serial dilutions by middlemen and intrinsic impurities. Most addicts were poor, urban, and members of minority groups.  But in the early 1990s, a group of undocumented immigrants from Xalisco, Nayarit, an impoverished farming area in Southwest Mexico, developed an ingenious, innovative and diabolical strategy to sell locally grown heroin, called black tar, in the United States. They used cell phones to take orders and direct drivers to deliver the drug to customers. The drug was pure, the cost low, and the so-called Xalisco boys were non-violent, polite and efficient. Starting from the San Fernando Valley in California, they spread eastward, targeting white neighborhoods in small to moderate size cities to avoid conflicts with gangs, cartels, and other organized crime groups. They particularly targeted younger people.

    Black tar heroin reached Columbus, Ohio in 1998, just as OxyContin sales and pill mills were spreading westward.3 Here these two malevolent forces met and interacted. Within a few years, addicted OxyContin users were switching to black tar heroin, which was cheaper and easier to access. Indeed, survey data suggest that 80% of heroin users began their OUD with nonmedical consumption of prescription opioids.9   

    Ominously, as Xalisco drivers and local cell “managers” were arrested and often deported rather than imprisoned because they carried only small quantities of drugs, they were quickly replaced by other eager, poor, young Xalisco rancheros who saw this as a relatively low-risk but very lucrative employment opportunity. And I have to reluctantly admit that a porous US-Mexican border exacerbated the problem. Later, other groups entered the market, often abandoning their cocaine or methamphetamine business in favor of the more lucrative opioid trade. Overdose deaths from heroin, which had been far less common than those from prescription opioids, began accelerating in 2011 and by 2014 had exceeded prescription-related deaths.1 The crisis hit home as high school football stars began to die in bathroom stalls and middle-class college coeds overdosed in their dorm rooms.

    The biology of addiction and adolescent susceptibility

    It was not an accident that the Xalisco boys sought out adolescent victims. Opioids work through various receptors but reduce pain through high-affinity binding to the mu (µ) opioid receptor (MOPR). However, MOPRs are found throughout the brain and those located in the mesolimbic system, when activated, promote dopaminergic neuron transmission to create sensations of pleasure, relaxation and contentment.1 Adolescents are particularly vulnerable due to the immaturity for these pathways, coupled with their propensity for risk taking and the increased responsiveness to reward.10 Indeed, no group was more vulnerable to the ready availability of both the prescription opioid and heroin.

    NEXT: Take-home message

    Charles J. Lockwood, MD, MHCM
    Dr. Lockwood, Editor-in-Chief, is Dean of the Morsani College of Medicine and Senior Vice President of USF Health, University of South ...


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