As of 2012, Americans accounted for 80% of the world’s opioid painkiller prescriptions. This might not sound too surprising—we’re a big country with a big population, after all. It stands to reason that we’re taking more prescription pain meds than other countries. But consider this: we take 80% of the world’s painkillers—yet we have less than 5% of the world’s population.

5% of the population. 80% of the drugs.

There’s something very wrong with this picture.

Opioid painkillers and heroin: kissing cousins of the pharmaceutical world

Opioids have been around for a very long time. They’re derived from the juice of the opium poppy—or are synthetic versions of the same active compounds—and include not just Darvocet, Vicodin, OxyContin, codeine and morphine, but also opium and heroin. They’re all chemically very similar, affecting the same receptors and provoking the same reaction in the brain. All are also highly addictive, and until the past decade or so all were reserved for treatment of only the most severe pain like that of end-stage cancer patients.

Over the last decade or so, though, the number of opioid prescriptions has risen by some 600%. They’re no longer limited to the most intense and intractable kinds of pain. Today they’re prescribed not just for things like palliative care of cancer patients or for postoperative pain but for chronic back pain, neuropathy, and often even for mild pain such as sprains and strains. Rather than trying to manage pain by more conservative means, doctors all too often reach for the prescription pad.

OxyContin: a triumph of pharmaceutical marketing

The overprescription of painkillers began in the 90s. Pain, once viewed as a symptom, came to be seen as a problem in its own right. Doctors were encouraged to fight pain wherever they found it. The pain initiative, launched by the Joint Commission on Accreditation of Healthcare Organizations, focused heavily on opioids.

Drug makers, led by OxyContin manufacturer Purdue Pharma, saw this as a gift from heaven. Doctors, especially primary care physicians, were hit with a massive marketing campaign. Purdue wanted OxyContin to become the go-to drug for pain, and spent hundreds of millions of dollars promoting it—patients were even offered free 30-day supplies. When the question of addiction came up, physicians were assured that it wasn’t a problem. Less than 1% of patients, they were told, became addicted.

By 2010 OxyContin alone was a $3 billion dollar-per-year cash cow and we had become a nation of opioid addicts.

How does this relate to heroin?

Whereas non-opioid pain relievers merely reduce pain, opioids also result in a feeling of euphoria—that’s to say, they get you high. This tempts many people to use them other than directed, or when their pain is only minimal, or even just “for fun.” Painkillers such as Percocet, hydrocodone, and OxyContin are commonly bought and sold on the street at exorbitant prices.

Even those who take painkillers exactly as directed aren’t immune from addiction; long-term opioid use leads to tolerance. This means that it takes larger and larger doses of the drug to achieve the same effect—in this case, pain relief. By prescribing opioids for chronic pain conditions, minor complaints, and other non-acute conditions, medicine guaranteed a population with a continuing need for ever-higher doses of these drugs.

This magnifies the likelihood of accidental overdoses. As of 2010, opioid overdoses accounted for 82.8% of deaths from prescription drugs. And it gets worse. Once a certain threshold is reached, opioid users who try to cut down or quit suffer also suffer painful withdrawals.

Prescription painkiller abuse has been a real problem for a number of years, and a serious effort to curb their use has been made. It’s more difficult to get a prescription filled today than it was just a couple of years ago. Some manufacturers have reformulated their product to make it less susceptible to abuse. The DEA has stepped in and limited the amount of opioids pharmacies have access to each month.

The result has not been what was expected. Prescription painkiller use has gone down in the past couple years, but the number of heroin users is on the rise. Why? Because once addicted to opioids, it’s almost impossible to quit. Users will do whatever is necessary to get access, and to avoid withdrawals, including substituting heroin if the prescription drug supply is cut off.

The war on prescription painkillers, while well-intentioned, has created an even worse problem. Instead of prescription addicts who can at least be monitored when they get their prescriptions, we now have a growing body  of illicit drug users who are invisible unless the sink to crime to feed the habit.