The roots of the opioid epidemic in the U.S.
- Gerald Kichok
- Dec 12, 2025
- 4 min read
By Aiden Jones
December 2, 2025 6:21 pm
In the mid-1990s, a perfect storm began brewing in the United States. A storm that, over the following decades, would spiral into the worst drug overdose epidemic in the country’s history.
The broad outline of this crisis is well-known: A dramatic rise in prescription opioids, followed by expanded heroin use and, more recently, synthetic opioids like fentanyl. But beneath those waves lie structural, controlling, social and commercial currents that set the stage.
In the 1990s, the medical community’s approach to pain began shifting.
A movement to recognize pain as the “fifth vital sign” gained traction. At the same time, pharmaceutical companies and regulators permitted – even encouraged – a dramatic increase in the prescribing of opioid painkillers.
One pivotal moment was the introduction of OxyContin in 1996. Some researchers label it a foundation of the crisis, writing, “Overdose deaths involving opioids have increased since the mid-1990s, leading to the worst drug overdose epidemic in U.S. history.”
By one estimate, prescription opioid sales in the U.S. quadrupled between 1999 and 2010, and controlling oversight was weak. According to the American Medical Association in a Journal of Ethics article, “Over the past 25 years, pharmaceutical companies deceptively promoted opioid use in ways that were often neither safe nor effective…”
In short, a combination of new teachings in pain management, aggressive marketing, and lax controls meant that many patients were prescribed opioids and allowed to use them long-term than ever before.
As prescription opioids became more widely used, misused, and regulated, another track of the crisis took shape. Declines in prescription availability and rising dependence drove some users to illegal opioids.
According to The Opioid Crisis in the United States: A Brief History – U.S. Congressional research brief, “From 2010 to 2016, the rate of heroin-involved deaths increased from 1 to 4.9 per 100,000.”
This marks what many researchers call “wave 2” of the opioid epidemic. For many, the journey into heroin or other illegal opioids was not sudden but rooted in pain medication prescriptions, economic vulnerability, social isolation and other factors.
The crisis didn’t stop with heroin.
Starting around 2015, a third wave emerged, dominated by powerful synthetic opioids, especially fentanyl. The Congressional brief notes, “From 2015 to 2020, the rate of opioid-involved overdose deaths, driven by fentanyl, once again doubled, from 10.4 to 21.4 per 100,000.”
And the global data underscore how synthetic opioids now dominate fatal overdoses: “Worldwide, about 600 000 deaths were attributable to drug use in 2019. Close to 80 % of these deaths are related to opioids.” In other words, once opioid misuse entered illegal territory and shifted toward synthetics, the casualties exploded.
Beyond these broad waves there lies deeper currents.
Research shows that the opioid crisis cannot be explained by prescribing or supply alone. Some of the relevant factors include:
Regulatory gaps and agency failures : The U.S. Food and Drug Administration (FDA) and other regulators did not nicely control drug makers’ aggressive promotion of opioids. One article observed that the FDA’s oversight was “a dereliction of duty.”
Social determinants of health : Studies note that people living in poverty, lacking health insurance, or with prior incarceration are at increased risk of fatal opioid overdose.
Family and community factors : One review found that having a family history of substance use disorder can raise a person’s risk of opioid misuse by about tenfold.
Prescription practices themselves : Over-prescribing, longer durations, higher doses, all contributed to increased vulnerability. Researchers reported in the Cureus Journal of Medical Science, “Overprescribing opiates and opioids, lack of education and opportunity, and being unmarried or divorced were some of the identified contributing factors to dependence on opioids.”
Taken together, these factors show that this crisis wasn’t simply about “bad drugs” or “bad people”, but about a system of health care, control, social class and commercial interests crossing in a way that made widespread misuse tragically likely.
Why should we care? Because the stakes were extraordinary.
In 2018, the Secretary of the U.S. Department of Health and Human Services, Alex M. Azar, wrote, “In 2016, we lost more than 115 Americans to opioid overdose deaths each day… In fact, the average life expectancy in the United States decreased for the second year in a row in 2016, falling by about 1.2 months, in part due to opioid overdose deaths.”
Between 1999 and 2017, overdoses of legally prescribed and illegal opioids killed “almost 400,000 people in the United States.” The death toll and the social disturbance, families devastated, communities weakened, make it clear that this is not just a medical problem but a major public health emergency.
This is a crisis born of many interacting forces, not just a failure of individuals, or entirely the fault of one company or control, but a systemic failure across the United States.
This article was written as part of a program to educate youth and others about Alameda County’s opioid crisis, prevention and treatment options. The program is funded by the Alameda County Behavioral Health Department and the grant is administered by Three Valleys Community Foundation.
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