North America is facing an epidemic of opioid addiction and opioid overdose with an unprecedented level of mortality. The crisis was spurred by a broad expansion of medical use of opioids, which began in the 1990s as a legitimate response to the under-treatment of pain, but which was soon exploited by the unethical behavior of pharmaceutical companies eager to increase their revenue. The rise in supply fed high levels of diversion among an economically stressed and vulnerable population. The present wave of opioid dependence differs from the heroin crises of the 1980s and 1990s, both in the sheer extent and in the social backgrounds of a large part of the affected populations. In Canada, which is second only in per capita opioid consumption to the United States, the rise in fatal overdoses is more linked to higher potency or ad-mixing of other drugs in areas where there was already a relatively high incidence of heroin use.

Initial reactions were to limit prescriptions and to introduce pills that were harder to manipulate. The reduced supply of prescription opioids, however, drove an important minority of people with addiction to less expensive and more accessible street heroin. Under what has become known as the “iron law of prohibition”, cheaper and more potent opioids—including fentanyl and its derivatives— increasingly appeared on the market. This has even further accelerated the rate of fatal overdoses.

Media and government attention has primarily focused on the supply through doctors. The fact that most addictions start with diverted supplies rather than among pain patients has been largely ignored. Policymakers have also failed to address the role of economic upheaval, unemployment, inequality, and other systemic sources of despair in increasing the risk for addiction and decreasing the odds of recovery. Health systems were completely unprepared and treatment is still dominated by abstinence-focused programs, where no regulatory standards have to be met. Furthermore, among other factors, prejudice against the most effective treatments for opioid addiction—opioid substitution therapy (OST)—has translated into lack of treatment for those in need. Opioid substitution therapy has proven effective in treating addictions to heroin and should be offered to those dependent on or addicted to prescription opioids.