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In Reply II—Root Causes of Opioid Crisis

      To the Editor:
      Dr Pendyal highlights an important point that the opioid crisis is much bigger than just the “supply side” of the problem. It is truly a biological-psychological-social-spiritual problem that impacts both the “supply side” and the “demand side.”
      • Rummans T.A.
      • Burton M.C.
      • Dawson N.L.
      How good intentions have contributed to bad outcomes: the Opioid Crisis.
      However, in his description of the social factors, of which there are many, he too fails to acknowledge many of the drivers of the opioid crisis. Many of the drivers go beyond “unemployment, poverty, and wealth inequality,” with an increasing number of those dying from opioids being employed, middle- and upper-class individuals.
      In addition to socioeconomic drivers, 50% to 80% of those who die from overdose had a history of chronic pain, which suggests they began their opioid use trying to address pain. Likewise, a history of mental health and/or substance abuse is common in opioid deaths because they are also more likely to be prescribed opioids.
      • Seth P.
      • Scholl L.
      • Rudd R.A.
      • Bacon S.
      Overdose deaths involving opioids, cocaine, and psychostimulants—United States, 2015–2016.
      These situations are not then created by social factors alone. Often the nonmedical users of opioids report getting opioids from friends or relatives to experiment or get high. Nonmedical use of opioids is higher in men than in women, but women are more often prescribed opioids. Yet, emergency department visits for overdoses are equal between them. Nonmedical use and overdose is highest in whites and American Indians/Alaska natives rather than in blacks or Hispanics, which currently make up a larger proportion of those unemployed or in the poverty range. Although much of the unemployment, homelessness, and poverty is found in the big urban areas, it is the rural areas, even more than the urban areas, that are being hit the hardest with the opioid crisis, but this too is changing rapidly. Therefore, the data that exist today point to both the “demand” side and the “supply” side contributing to the problem we have with opioids.
      So where does that leave us? Much has been and more is needed to investigate possible biological components of addiction and its treatments as well as of other mental health conditions. However, what we are dealing with now involves more than just the biology of a disease. It involves the social issues that we have been discussing. It also involves the spiritual issues for each human being living now in an increasingly secular world. Finding meaning and purpose in our lives and ability to live with the imperfections that we all have and will have must be part of the discussion if we are ever to find a solution that will begin to turn this crisis around.

      References

        • Rummans T.A.
        • Burton M.C.
        • Dawson N.L.
        How good intentions have contributed to bad outcomes: the Opioid Crisis.
        Mayo Clinic Proc. 2018; 93: 344-350
        • Seth P.
        • Scholl L.
        • Rudd R.A.
        • Bacon S.
        Overdose deaths involving opioids, cocaine, and psychostimulants—United States, 2015–2016.
        Morb Mortal Wkly Rep. 2018; 67: 349-358

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