Over the past two decades the United States has experienced an uncontrollable epidemic of drug related deaths. In 2016 sixty-three thousand Americans died of drug overdoses, two out of three of these deaths were due to opioids. In times like this whilst law enforcement and public health services grapple for solutions most may ask the question; “who is to blame for our current situation?” The simple answer to this question is, there is no single person or group that can be held culpable for this predicament. Epidemics never occur as a result of one factor, usually multiple factors need to occur concurrently to sustain an epidemic of any type. This is just as true in addressing ebola or cholera epidemics as it in drug addiction. Uncontrollable fires do not happen in the middle of winter; they occur towards the end of the summer when there is an excess of dry leaves and an absence of water to control them.
In July this year Dr. Barry Schultz a Florida physician was sentenced to 157 years in Jail for irresponsible prescribing. In his defense Dr. Schultz says he is been used as a scape goat and was just helping his patients.
Did irresponsible prescribing get us to where we are today? Providers like Dr. Schultz who prescribed up to 600 pills a day to one patient could be said to be throwing caution to the winds and were probably more interested in the money they made both from the visit and the medications that they sold from their own pharmacies. The overwhelming consensus is that physicians prescribing opioids to their patients were doing what they needed to do to help their patients. 
Map of US showing states by drug overdose death rate – Data source – CDC: http://wonder.cdc.gov
In 1999 the rate of overdose deaths in New Mexico was 15.1 per 100,000 person years in that year New Mexico was the state with the highest rate of overdose death in the nation. 2016 data however shows West Virginia to be the most afflicted state with a rate of 52.0 per 100,000 persons a rate that has gone up more than 10 times from 4.1 per 100,000 in 1999. A quick look at the map above shows that currently the states with the highest rates of fatal overdoses are in Appalachia. This is not surprising; in the early 2010s most physicians on the East Coast became aware of a form of medical tourism The Oxycontin Express. The system of low cost flights from Appalachian states like Kentucky, Ohio, Tennessee and West Virginia to Florida to acquire Oxycodone mostly for sale in cities and towns in small in rural Appalachia. Most of those making these flights were addicts funded by dealers back home. One patient made this statement about the doctors who provided his Oxycodone; “They are not doctors, they are drug dealers with degrees”
Whilst this started out mostly driven by prescription medications from pharmaceutical companies within the US, since 2014 the number of deaths related to synthetic opioids like fentanyl have been on the rise. In recent times fentanyl with a potency of about 50 times compared to heroin is contributing to most of these deaths. Fentanyl is usually mixed with other Street drugs by dealers creating a deadly cocktail. Most experts believe that the recent uptrend in drug related deaths from 2014 to now is due mostly to the influx of fentanyl from illegal factories in China. 
DRUG RELATED DEATHS USA 1999 to 2017
While addressing the supply side issues some of the underlying causes of this epidemic are;
- Lack of opportunity and poor social advancement in rural counties and towns affected by a declining coal industry and global outsourcing of manufacturing jobs.
- An inadequate healthcare system driven by under insurance, profit driven productivity targets and pharmaceutical companies seeking to increase market share.
- Significant drops downturns in independent primary care physicians with long term relationships with their patients and the emergence of big health systems.
- Significant declines in the mental health system infrastructure across most of the United States.
To address the opioid crisis our nation would need more than just policies directed towards the healthcare arena. The nation would require a social and economic overhaul of its systems. Without such comprehensive multi-pronged approach to health we would only achieve easy gains that would not be sustained.
Dr. Leonard Sowah is an internal medicine physician in Baltimore, Maryland
