Going beyond prescription pain relievers to understand the opioid epidemic: the role of illicit fentanyl, new psychoactive substances, and street heroin

ABSTRACT

The opioid epidemic is associated with morbidity and mortality, and it has taken a vast toll on American society. While prescription opioid abuse is part of the opioid problem, it is by no means the entirety of it. Opioid abuse appears to have entered a technology-driven new world of clandestine labs all over the globe and many new synthetic analog, counterfeit, and adulterated drugs that arrive via the internet faster than the Drug Enforcement Administration (DEA) can catalog and outlaw them. To deal with opioid abuse, it must be recognized that it is more – far more – than a subset of chronic pain patients who become addicted. Indeed, to reduce the opioid epidemic to this population is to misunderstand it. The opioid epidemic involves illicit opioids, counterfeit opioids, new psychoactive substances, diverted opioids, and prescription opioids. The objective of this narrative review is to consider the roles of all substances that contribute to the opioid epidemic in America.

KEYWORDS:

• Fentanyl
• opioid epidemic
• opioid abuse
• heroin
• street drugs
• opioid overdose

Acknowledgement

The authors wish to acknowledge and thank John Bisney for his expert editorial assistance and discussions.

Declaration of interest

R Raffa was a previous employee of Johnson & Johnson and has received research support and honoraria from several other pharmaceutical companies involved in analgesics research and development – but he receives no remuneration based on sales of any product. He is a cofounder of CaRafe Drug Innovation (involved in the discovery of non-opioid analgesics) and advisor/investor with Chamounix Ventures (a medical marijuana dispensary licensee) and Neumentum (non-opioid analgesics). J Pergolizzi has acted as a consultant, researcher, and/or speaker for Inspirion, Mallinckrodt, DSI, Grünenthal, BDSI, Depomed, Adapt Pharma and Salix. He is also and partner in CaRafe and cofounder of Neumentum. The authors have no other relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript apart from those disclosed.

Additional information

Funding

This paper was prepared without external funding.