Opioids overdoses now kill more Americans than car accidents or guns, with more than 350,000 Americans having succumbed to the painkillers since 2000.

“The opioid misuse and overdose crisis touches everyone in the United States,” Health and Human Services Secretary Alex Azar said in this recent report. “The effects of the opioid crisis are cumulative and costly for our society — an estimated $504 billion a year in 2015 — placing burdens on families, workplaces, the health care system, states, and communities.”

Now, new research led by Stanford shows that not only have opioid-related deaths jumped fourfold in the last 20 years, but that those most affected by the epidemic, and where they live, has also shifted dramatically. In fact, the District of Columbia has had the fastest rate of increase in mortality from opioids, more than tripling every year since 2013.

“Although opioid-related mortality has been stereotyped as a rural, low-income phenomenon concentrated among Appalachian or midwestern states, it has spread rapidly, particularly among the eastern states,” writes Mathew V. Kiang, ScD, a research fellow at the Center for Population Health Sciences at the Stanford University School of Medicine, in an original investigation published in JAMA Network Open.

The study found the highest rates of opioid-related deaths and more rapid increases in mortality were observed in eight states: Connecticut, Illinois, Indiana, Massachusetts, Maryland, Maine, New Hampshire and Ohio. Two states, Florida and Pennsylvania, had opioid-related mortality rates that were doubling every two years — and tripling in Washington, D.C.

Kiang and his co-authors, including Stanford Health Policy’s Sanjay Basu, MD, PhD,an assistant professor of medicine at Stanford Medicine, used data from the National Center for Health Statistics and corresponding population estimates from the U.S. Census. The other authors are Jarvis Chen, ScD, at the Harvard T.H. Chan School of Public Health, and Monica Alexander, PhD, in the Department of Sociology at the University of Toronto.

“It seems there has been a vast increase in synthetic opioid deaths in the eastern states and especially in the District of Columbia because illicit drugs are often tainted with fentanyl or other synthetic opioids,” Kiang said in an interview.  “People aren’t aware their drugs are laced and more potent than they expected — putting them at higher risk of overdose.”

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Synthetic opioid deaths now outnumber heroin deaths in these eastern states, which suggests fentanyl has spread to other illegal drugs and is no longer limited to heroin.

“The identification and characterization of opioid `hot spots’ — in terms of both high mortality rates and increasing trends in mortality — may allow for better-targeted policies that address the current state of the epidemic and the needs of the population,” the authors write.

The research suggests the opioid epidemic has evolved as three intertwined, but distinct waves, based on the types of opioids associated with mortality:

1. The first wave of opioid-related deaths was associated with prescription painkillers from the 1990s until about 2010.
2. From 2010 until the present, the second wave was associated with a large increase in heroin-related deaths.
3. And in the third and current wave, which began around 2013, the rapid increase is associated with illicitly manufactured synthetic opioids, such as tramadol and fentanyl.

“The evolution has also seen a wider range of populations being affected, with the spread of the epidemic from rural to urban areas and considerable increases in opioid-related mortality observed in the black population,” they write.

The Centers for Disease Control and Prevention reports that African-Americans experienced the largest increase in opioid overdose deaths among any racial group from 2016 to 2017, with a 26 percent surge.

“The identification and characterization of opioid ‘hot spots’ — in terms of both high mortality rates and increasing trends in mortality — may allow for better-targeted policies that address the current state of the epidemic and the needs of the population,” the researchers write.

States are trying to combat the epidemic by enacting policies, such as restricting the supply of prescription drugs and expanding treatment and access to the overdose-reversing drug naloxone.

“Treating opioid use as a disorder should be our top priority to curb the problem,” said Kiang. “Similarly, we have the ability that counteract the effects of an overdose — these life-saving drugs should be easily accessible and widely available.”

In a Q&A, Stanford postdoctoral fellow Darika Saingam explains why Thailand's battle against drugs continues and what is needed to introduce good policy that works to prevent illegal drug trade and supports recovering addicts.

Despite Thailand’s decade-long crackdown on drugs, demand for illegal substances has risen. A green leaf drug known as ‘kratom’ is a symbol of this rise as young people eagerly adopt the drug for entertainment and join an older generation of laborers who chewed it to survive long hours of work in the fields—and are now heavily addicted. Curtailing substance abuse and its consequences takes good public policy and solutions must be area-specific and evidence-based, according to a Stanford postdoctoral fellow.

Darika Saingam, the 2015-16 Developing Asia Health Policy Postdoctoral Fellow, has conducted two cross-sectional surveys and more than 1,000 interviews with drug users, recovered addicts, and local public officials in an effort to better understand the evolution of substance abuse in southern Thailand.

At Stanford, she is preparing two papers that offer policy options suitable for Thailand and other developing countries in Southeast Asia. Saingam spoke with the Shorenstein Asia-Pacific Research Center (APARC) where she will give a public talk on May 17. The interview text below was edited for brevity.

For decades, Thailand has been an epicenter of drugs. Can you describe the extent of the problem today?

According to a 2014 report, 1.2 million people were involved in illegal drug activities across Thailand. The total number of drug cases saw a 41 percent increase from 2013 to 2014. New groups of drug traffickers are mobilizing while existing groups are still active. Drug users who are young become drug dealers as they get older. The number of drug users below 15 years of age has increased dramatically.

According to your research, what drives Thais toward illegal drug use and the trafficking business?

Adults in Thailand use drugs to relieve stress and counteract the effects of work. Adolescents use them for entertainment. Historically, farmers and laborers from rural areas of Thailand would use opium for pain relief. More recently, a consumable tablet known as yaba has become popular along with crystal methamphetamine and marijuana. Young people are increasingly using yaba and kratom.

Thailand is still a developing country, but it is industrializing quickly. Social and cultural norms have been shifting and people want an improved quality of life. A lot of young people are unemployed and lack social support and are therefore more likely to turn to drug trafficking for economic opportunity. The economic recession and political strife in countries bordering Thailand have exacerbated the situation.

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Photos (left to right): A man holds up a kratom leaf. / Saingam examines kratom leaves as part of her research to understand illegal cultivation practices.

What is kratom and why is it popular?

For nearly a century, the native people of Thailand have chewed kratom. It is a leaf that grows on trees resembling a coffee plant. Historically, kratom was used to reduce strain following physical labor, to be able to work harder and longer, and to better tolerate heat and sunlight. Kratom is also embedded in Thai culture and given as a spiritual offering in religious ceremonies. My field research in the southern province of Nakhon Si Thammarat has shown that these motivations are still true today.

Within the past seven years, kratom use has skyrocketed and people are using it in increasingly harmful ways. Chewing kratom is not immediately harmful to health, but combining it with other substances is. This is the recent trend. Users have created new ways to consume it such as in a drink known as a ‘4x100.’ It contains boiled kratom leaves, cough syrup and soft drinks. Additional methamphetamines and benzodiazepines are sometimes added to that mixture.

What strategies must be employed to control substance abuse?

The first step is to realize that the patterns of substance abuse are specific to each location therefore solving the problem must also be. Drug usage is also dynamic. Placing hard control measures on one substance often provokes the emergence of another in its place therefore a holistic approach is important.

Thailand should employ multiple strategies toward effective prevention and control of substance abuse. These strategies include examining the problem and creating policies from an economic perspective (supply and demand), an institutional perspective (national and international drug control cooperation), and a social perspective (structural supports for recovered addicts and mobilization of public participation).

What is the Thai government doing to address the drug problem, and what could they be doing better?

Politicians in Thailand must do a better job at representing the people. Government health workers are often gathering information, assessing needs, and reporting findings to politicians, but these needs are not being accurately addressed. An example of this is politicians ordering to cut down kratom trees – a public display that does not get at the root cause of the problem. The reality is that drug users will quickly find substitutes. According to my study, of the regular users that stopped using kratom, more than 50 percent turned to alcohol instead and did so on a daily basis. This is merely a shift from one substance to another.

On the upside, a crop substitution program created under King Bhumibol Adulyadej offers a successful working model. The program works to replace opium poppy farming with cash crop production. It began in 1969 and is cited for helping an estimated 100,000 people convert their drug crop production to sustainable agricultural activities. Crops cultivated can be sold for profit in nearby towns. The program has also introduced a wide variety of crops and discouraged the slash-and-burn technique of clearing land. It is win-win because it stymies drug trade and provides economic opportunity while also being ecologically sound. This type of program should continue to be scaled up.

Can this model be co-opted elsewhere? What lessons from other countries could inform Thailand’s approach?

Yes, the model could plausibly be implemented in other areas in Thailand and in other Southeast Asian nations.

I think a judicial mechanism such as the kind seen in France could benefit the rural areas in Thailand. The French government has established centers across the country that act as branches of the court that try delinquency cases of minor to moderate severity, and also recommend support services for drug users. Members of the magistrate and civil society actors manage center operations thus placing some responsibility back onto the local community.

I believe an opportunity also exists for Thailand to legalize kratom. Legalization would show a respect for the cultural tradition of chewing kratom leaves and allow the government to suggest safer ways of using it. Bolivia has created a successful model of this through its legalization of coca leaves. Coca in its distilled form is cocaine, but left as a leaf, it is not a narcotic. Indigenous peoples are allowed to chew coca leaves. The government policy is being credited for a decrease in cocaine production as well.

Beatriz Magaloni, director of CDDRL's Program on Poverty and Governance (PovGov), and Zaira Razu, a research associate and project manager at PovGov, recently released a piece in Current History on Mexico's ongoing drug war and the rise of violence. Although democratic structures have helped improve certain freedoms throughout the country in the past decade, institutionalized injustice is slowly jeopardizing stability and security for much of the Mexican population.

Click here to read their piece.