“The epidemic of deaths involving opioids continues to worsen. Prescription opioid misuse and use of heroin and illicitly-manufactured fentanyl are intertwined and deeply troubling problems.” ~ Dr. Thomas Frieden, former Director of the Centers for Disease Control and Prevention Opioid overdoses kill 131 Americans a day. Let that number sink in for a moment. Every day, there is a new headline about some new manifestation of the ongoing opioid epidemic. Unfortunately, it’s far too easy become numb to the almost-unbelievable numbers—hundreds of thousands of lives lost and over a TRILLION dollars in economic impact. It’s just too hard to wrap your mind around such astronomical numbers. But, 131 Americans a day? That’s a number that we can all comprehend, and that’s what’s so frightening. Most of us know and interact with more than 131 people on a regular basis—our family and friends, our co-workers, people who go to our church, our children’s classmates, our favorite barista at Starbucks, etc. In other words, we may personally know someone who could be a victim of this disease. It could even be YOU. That’s more likely than you might think, because a 2017 survey revealed that 46% of Americans have a close friend or family member who is or has been addicted to drugs. But how did it get this bad?
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Staggering Overdose Death Statistics
There’s a reason the ongoing drug epidemic has been called the worst public health crisis in US history. Look how the number of annual overdose deaths has skyrocketed in the past two decades:
- 1999: 16,849
- 2000: 17,415 (+3%)
- 2001: 19,394 (+11%)
- 2002: 23,514 (+21%)
- 2003: 25,785 (+10%)
- 2004: 27,424 (+7%)
- 2005: 29,813 (+9%)
- 2006: 34,425 (+16%)
- 2007: 36,010 (+5%)
- 2008: 36,450 (+1%)
- 2009: 37,004 (+2%)
- 2010: 38,329 (+4%)
- 2011: 41,340 (+8%)
- 2012: 41,502 (+1%)
- 2013: 43,982 (+6%)
- 2014: 47,055 (+7%)
- 2015: 52,404 (+11%)
- 2016: 63,632 (+21%)
- 2017: 71,000 (estimated) (+12%)
Every new year has set a new all time “record” – for 19 consecutive years. In fact, during that timeframe, drug overdose deaths increased by 421%. And here’s the thing – roughly two-thirds of those deaths involve opioids—prescription painkillers, heroin, or synthetics. So, in 2017 alone, that is an estimation of almost 48,000 fatal opioid overdoses.
- According to the National Institute on Drug Abuse, there are approximately two million Americans have a Substance Use Disorder that involves prescription painkillers. Another 591,000 have a SUD involving heroin.
- Less than 10% are receiving professional specialized addiction treatment.
- Overdose rates are increasing among:
- Both men and women
- Non-Hispanic Blacks and Non-Hispanic Whites
- Every age group 25 and older
- A cross-sectional Canadian study published in June 2018 determined that 1 out of every 65 deaths in the US are attributable to opioids.
- Among younger adults ages 25-34, the rate was 1 in 5.
- Overall, that works out to 1.68 million years of life lost in 2016 alone.
- A 2018 report from the Federal Reserve Bank of Cleveland says that opioids are now the leading cause of death for Americans under the age of 50.
Comparing Drug Deaths
For perspective, consider this: there were more drug-related deaths in 2017 than there were:
- American battle deaths during the entire Korean War.
- Americans lost during the entire Vietnam War.
- After the worst year of the AIDS epidemic (1995).
- Throughout the worst year for car crashes (1972).
- During the worst year for gun violence (1979).
- Completed suicides.
- Female breast cancer deaths.
- Flu and pneumonia deaths.
- Deaths from kidney disease.
Every Part of the Country Is Affected
“The sharp increases and variations across states and counties indicate the need for better coordination with address overdose outbreaks spreading across county and state borders.” ~ The Centers for Disease Control and Prevention Per the CDC’s latest Vital Signs report, EVERY REGION in the US suffered a significant increase in the number of opioid-related overdoses between July 2016 and September 2017. ER trips involving opioids spiked 30% in 52 areas across 45 states.
- The Midwest region experienced a 70% increase in opioid overdoses.
- Large metro areas – +54%.
- Large “fringe” metros – +21%
- Medium metros – +43%
- Small metros – +37%
- Micropolitan areas – +24%
- Non-core cities – +21%
- Among males – +30%
- Among females – +24%
- 25-34-year-olds – +31%
- 35-54-year-olds – +36%
- 55+ – +32%.
And that’s only over the course of a little more than a year. Over a longer period of time, the increase is much more drastic. For example, between 1999 and 2016:
- Nationally, overdose deaths shot up 528%.
- But in West Virginia, Ohio, and Kentucky, deaths mushroomed, increasing over 1000%.
- In Pennsylvania, the deaths rose 736%.
The Opioid Crisis in Every State
Here’s a quick snapshot about the opioid situation in each US state ranking them by the number of opioid -related overdose deaths per 100,000 residents, according to the National Institute on Drug Abuse. For reference, the national average was 13.2.
- West Virginia – 43.40/100,000 residents
- New Hampshire – 35.8
- Ohio – 32.9
- Maryland – 30
- Washington, D.C.—30
- Massachusetts – 29.7
- Rhode Island – 26.7
- Maine – 25.2
- Connecticut – 24.5
- Kentucky – 23.6
- Michigan – 18.5
- Pennsylvania – 18.5
- Vermont – 18.4
- Tennessee – 18.1
- New Mexico – 17.5
- Delaware – 16.9
- Utah – 16.4
- New Jersey – 16
- Missouri – 15.9
- Wisconsin – 15.8
- North Carolina – 15.4
- Illinois – 15.3
- New York – 15.1
- Florida – 14.4
- Virginia – 13.5
- Nevada – 13.3
- North Dakota – 13.1
- Montana – 12.6
- Alaska – 12.5
- Oklahoma – 11.6
- Arizona – 11.4
- Washington – 9.7
- Colorado – 8.8
- Georgia – 8.8
- Wyoming – 8.7
- Louisiana – 7.7
- North Dakota – 7.6
- Oregon – 7.6
- Alabama – 7.5
- Idaho – 7.4
- Minnesota – 7.4
- Iowa – 6.2
- Mississippi – 6.2
- Arkansas – 5.9
- Hawaii – 5.2
- Kansas – 5.1
- South Dakota – 5
- California – 4.9
- Texas – 4.9
- Montana – 4.2
- Nebraska – 2.4
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How Did It Get This Bad?
The opioid crisis didn’t arise overnight—it was a gradual progression to this point. FIRST, OxyContin was introduced in 1995, and it was falsely and aggressively marketed as a safe, long-lasting opioid with a very low potential for abuse. This opened the floodgates, and soon, several other painkillers were on the market. “Big Pharma” companies went so far as to—in effect—purchase favorable reviews and guidelines by making large donations to the American Pain Society, the American Academy of Pain Management, and even the Federation of State Medical Boards. THEN, in part because they could be punished for not following these guidelines, and in part because they were told painkillers were so safe, doctors treated pain as a vital sign. To ease patients’ discomfort, they began prescribing opioids for virtually all pain complaints—short-term and long-term alike. Some less-than-scrupulous providers even pushed opioids to keep patients coming back. In fact, doctors are still the primary source of pills for chronic painkiller abusers. NEXT, troubling reports began to surface—these “safe” drugs were in fact powerfully addictive and presented a strong risk of overdose. As it turns out, Big Pharma companies knew their opioid products were being abused as early as 1996, but chose to conceal that fact the interest of continued profits. FINALLY, when the evidence was overwhelming that a problem existed and could no longer be ignored, steps were taken – problem prescribers were arrested, Big Pharma manufacturers had to pay hefty fines, abuse-deterrent formulations were created, patient databases were built, and opioid prescribing guidelines were changed. Each of these measures were enacted with one goal only – to save lives by reducing the excessive or fraudulent prescribing of addictive painkillers. But the opioid genie is already out of the bottle and putting it back in hasn’t been so easy.
Why Are Opioids So Addictive?
“It has become increasingly clear that opioids carry substantial risk but only uncertain benefits – especially compared with other treatments for chronic pain. We lose sight of the fact that the prescription opioids are just as addictive as heroin.” ~ Dr. Thomas Frieden No one ever initiates drug use with the intention of becoming addicted. However, with opioid painkillers, tolerance, dependence, abuse, and addiction are often the result, even when the medication is taken for a legitimate condition and exactly as prescribed. Keep in mind the fact that prescription opioids don’t eliminate the reason for the pain. Instead, they mask pain by blocking signals from the brain. EVERYTHING starts in the brain. In addition, opioids also produce heightened feelings of euphoria, well-being, and freedom from worry or stress. Other addictive intoxicants such as alcohol, marijuana, and methamphetamine also trigger similar effects. This happens every time. But the long-term use of prescription painkillers causes changes within the reward pathways of the brain. Because the action – drug use – results in a reward – pleasure and euphoria – the brain is “trained” that the action is worthy of repeating. This is the motivation for continued use escalating to non-medical abuse – to feel good. Over time and with chronic use, however, the brain becomes fatigued by the constant artificial overstimulation. At first, it compensates by reducing the response to opioids. As a result, the “positive” sensations are diminished, and it takes more and more of the drug, taken with greater frequency, to reach the same level of pleasurable effects. That is the perfect definition of “drug tolerance”. But with continued use, the brain’s reward system becomes so disrupted that the person is unable to feel motivation or pleasure except when they are under the influence of opioids. This is why addicts lose interest in everything else – work or school performance, socializing, family obligations, etc. Eventually, the person becomes unable to function, because all of their time and energy is spent trying to satisfy their constantly-growing craving for drugs.
Opioid Withdrawal – “Dope Sickness”
Finally, when the use of painkillers stops – or is even nearly delayed –a by-now-dependent person will feel harshly unpleasant symptoms of withdrawal. These symptoms can begin to present within a matter of just a few hours following the last dose:
- Joint pain
- Muscle cramps
- Inability to concentrate
- Excessive sweating
- Runny nose
- Uncontrollable shaking/tremors
- Alternating cycle of chill and fevers
Although opioid withdrawal isn’t particularly dangerous, it can be so physically and emotionally painful as to push a person into a relapse – active drug use. At this point, the addiction is in complete control. Where once the person used opioids to feel good, now, they must use to keep from feeling bad.
The Link Between Lengthy Prescriptions and Opioid Abuse
“We also identified another danger area. The overwhelming majority of people who died were chronic users, meaning they were on the same medication for 3 consecutive months or more. That is a warning.” ~ Dr. Roneet Lev, Director of Operations, Emergency Department, Scripps Mercy Hospital In March 2017, the CDC released a report saying that if an opioid is prescribed for more than a handful of days, it may be dangerous to even take it exactly as recommended. The Morbidity and Mortality Weekly Report indicated that when a painkiller prescription is for 3 days or less, the likelihood of chronic abuse goes down. However, the risk increases significantly if the opioid prescription is for 5 days or more, and it spikes yet again if a 30-day supply is given. The ability to refill second opioid prescription also plays a major role in determining the likelihood of long-term use. About 14% of patients who receive an opioid refill were still using some type of prescription painkiller a year later. Other pertinent findings:
- Just 6% of patients who only receive a one-day painkiller prescription still use opioids a year later.
- If the initial prescription is for 8 or more days – 15%
- 31 days or more – 30%.
- Long-acting opioids also present a risk. Among patients initially given a long-acting painkiller such as OxyContin or Dilaudid, 25% continued to use opioids for a year, and 20% were still using at 3 years.
Prescription Painkillers—Is the Tide Turning?
“We’re at a really critical moment in the country when everybody’s paying attention to this issue. People really don’t want them if they can avoid them.” ~ Director Michael Kleinrock, Iqvia Institute for Human Data Science Prescribing rates can be indicative of a state’s potential problem with opioids. The more prescription dispensed, the more opportunities for dependence, diversion, addiction, and overdose. HIGHEST
- Alabama – 120.3 opioid prescriptions per 100 people
- Tennessee – 118.3
- Arkansas – 111.2
- West Virginia – 110
- Indiana – 109.1
- South Carolina – 109
- Mississippi – 107.5
- Louisiana – 103.2
- Oklahoma – 101.7
- Michigan – 96.1
- Hawaii – 45.3 opioid prescriptions per 100 people
- California – 47.9
- New York – 51.3
- Minnesota – 54.2
- New Jersey – 55
- Alaska – 57
- Texas – 58
- Massachusetts – 59.9
- North Dakota – 60
- Illinois – 60
There IS good news, however. Per a recent report, people are filling far painkiller fewer prescriptions than in the past. For example, opioid prescriptions dropped 12% in volume. This is the largest single-year decline in 25 years. Other positive signs:
- The total number of painkiller prescriptions filled fell by more than 10%.
- The number of high-dose pain meds shrunk over 16%.
Why Did Prescribing Rate Go Down?
In response to almost two decades of record opioid overdose deaths, various agencies responded with positive moves:
- Prescription Monitoring Program (PMPs) were put in place to facilitate the sharing of information between providers and pharmacies. This helps curb the practice of “doctor shopping” to obtain multiple prescriptions.
- Law enforcement agencies started targeting pill mills and problem prescribers who improperly dispensed opioids.
- Drug companies reformulated many of their medications to be abuse-deterrent.
- 2016: The Food and Drug Administration released new prescribing guidelines recommending that providers should only offer painkillers as a “last resort”. Other first-line options for pain management include:
- Weight loss
- Physical therapy
- Over-the-counter remedies
- When an opioid absolutely MUST be prescribed, it should be for the shortest duration possible and at the lowest allowable dosage.
- For patent safety, frequent checkups and medication reviews should be scheduled.
- Some doctors now require their patients to sign opioid contracts, in which they agree to take their medication only as prescribed or risk being fired as a patient.
- Opioid painkillers are no longer recommended for chronic pain. This is the exact opposite of past prescribing policies, when patients were given indefinite refills.
- Even large chain pharmacies have taken steps to curb painkiller abuse and overdose deaths. Walmart and CVS each now limit opioid prescriptions to no more than seven days’ worth.
This combination of policies is having a tangibly positive effect. Pre-2010, the average growth rate of prescription opioid deaths was over 13%. Since that time, the growth rate has slowed to less than 5%.
Same Addiction, Different Drug
But while reducing the number of available prescriptions will hopefully create a ripple effect that may eventually mean fewer opioid overdose deaths, that hasn’t happened yet. In fact, the nation experienced its largest single-year increase ever between 2016 and 2017—almost 7400 more deaths, a one-year spike of 21%. The first reason for this paradoxical upward trend is the resurgence of heroin. With these new guidelines, limits, and PMPs, it became harder for people already addicted to opioids to get their fix. When there are fewer diverted prescriptions available for sale on the black market, the price goes up. It’s the law of supply and demand. Desperate painkiller -dependent people are left scrambling for an easier-to-find and cheaper alternative, and they find it with affordable an readily-available heroin. Because it is also an opioid, heroin targets the same areas of the brain as prescription painkillers, thereby satisfying their compulsive drug cravings. And because the supply is so high, prices are ridiculously low. For example, on the black market, OxyContin can cost as much as $80 per pill, while a small bag of heroin costs less than a pack of cigarettes. How much does this REALLY happen? More than you might guess—4 out of 5 people in opioid treatment program for heroin addiction say that they began by misusing prescription opioids. Even more significant, 94% admits that they switched because black market pain pills were “far more expensive and harder to obtain.”
Heroin – the Deadly Import from Mexico
Why is heroin so cheap and so easy to find? Believe it or not, it starts with marijuana. Now that more states are decriminalizing medical and recreational marijuana, the demand for product from Mexico has dropped significantly. As a response, many Mexican drug cartels have largely moved on from planting and harvesting marijuana. Instead, they cultivate the opium poppy, the plant that is the source of most opioids, including heroin. Between 2016 and 2017, the amount of Mexican land on which opium plantations were discovered and then destroyed by federal authorities grew by 26%. During that same time period, the amount of Mexican land used for marijuana cultivation decreased by 24%. As of February 2018, there were almost 70,000 acres in Mexico dedicated to opium poppy production, and about 10,000 acres used for marijuana. This makes Mexico third-largest the opium poppy producer in the world. The Drug Enforcement Administration has reported that over 90% of the heroin seized in this country is from Mexico. Similarly, a DEA survey revealed that 44% of responding law enforcement agencies cite heroin as the largest drug problem in their area. In recent years, there has been a troubling surge in fatal heroin overdoses:
- In 2012, there were 5925 overdose deaths involving heroin.
- By 2015, that number had more than doubled, to 12,990.
- In 2017, heroin-related deaths spiked again, to an estimated 15,446.
- Between 2012 and 2017, the number of deaths increased by 261%.
And that might be only part of the story, because the CDC estimates that heroin deaths may actually be underreported—by as much as 30%!
Fentanyl—America’s Deadliest Drug
“In terms of danger level, opioids are bad, heroin is worse, and fentanyl is the worst. When these pills hit the street and you as an addict think you`re taking Oxy, and you take 10 pills, it’s very likely they could contain fentanyl, and just one of those pills could kill you.” ~ Tom Lenox, DEA Agent But…there’s an even deadlier drug threat—illicitly-produced fentanyl. Fentanyl is an extremely-powerful synthetic opioid that is up to 100 times more potent than morphine, and some of its chemical analogues are 10,000 times stronger. That means that a fatal dose can be measured in micrograms. To give you a better idea, a dosage the size of just six grains of salt is enough to kill a full-grown man. While it does have a legitimate medical use as a pain reliever for cancer or end-of-like patients, the US is currently being flooded with counterfeit analogues from clandestine foreign drug labs. How bad is the fentanyl problem in America? Within the past three years, fentanyl-related overdose deaths have skyrocketed by 540%. In 2017, there were over 26,000 fatal fentanyl overdoses in the US, more than double the previous year’s total. Significantly, fentanyl and its analogues have surpassed heroin as the single largest drug threat, and now account for over half of all opioid-involved deaths. Fentanyl is cutting into heroin’s market share so much that it’s impacting prices. Some Mexican poppy farmers are even switching back to marijuana out of financial desperation. Roberto Alvarez, spokesman for the security forces in the Mexican state of Guerrero, says, “The increase in synthetic drugs is causing the price of naturally grown drugs like opium to fall, and that is hitting the income of the criminal groups.”
The Import That Kills
“I am demanding negotiators impose real pressure on China to stop the export of fentanyl. As the scourge spreads and addiction grows, China’s authorities continued to turn a blind eye. Negotiators must not leave the table without addressing the export of fentanyl. This issue must be a major priority, because too many lives have been lost, and too many others are at stake…” ~ New York Senator Chuck Schumer Fentanyl is an attractive product for illicit drug manufacturers because, unlike heroin, it is a completely synthetic opioid. And while heroin production requires a huge commitment of resources—manpower, land, facilities, security, and time—fentanyl is made entirely in a laboratory. This makes fentanyl extremely profitable—a kilogram of fentanyl can be purchased in China for $3800, pressed into tablets, and sold on the street for up to $30 MILLION. In comparison, a kilo of heroin has a wholesale price of $50,000 and a street value of “just” $250,000. Because the necessary ingredients aren’t as tightly controlled there, 90% of the fentanyl-class drugs in America originate in illegal Chinese laboratories. This reality is such a problem that it has become part of the US-China trade discussion. And thanks to the Internet, they can be easily ordered in a matter of minutes. A search on a leading “Dark Web” marketplace will produce over 21,000 listings for opioids and more than 4000 fentanyl/analogue listings. Ordered anonymously and paid for with untraceable digital currency, the drugs arrive courtesy of the US Postal Service or private carriers. In fact, 75% of all the smuggled fentanyl seized by US Customs is confiscated at international mail facilities. 50,000 doses of fentanyl will fit into a normal envelope. Former State Department Special Agent Scott Stewart says, “Fentanyl is a smuggler’s dream. It’s compact. It’s valuable. It’s fantastic for the smugglers and it’s terrible for law enforcement.”
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Counterfeit Drugs—The Hidden Opioid Danger
“It is a phenomenon that is an absolute game changer in the world of drug abuse. Because people unknowingly come across these counterfeit pills or they buy something on the street that resembles heroin they’ve been using forever, and if it contains fentanyl it can be lethal.” ~ Carol Falkowski, CEO, Drug Abuse Dialogues In the past, drug cartels would improve the potency of low-grade heroin by mixing in a small quantity of illicit fentanyl. But in recent years, the practice has changed considerably. Now, fentanyl is not only mixed in with other products, it may replace them altogether. And without a chemical test, there is virtually no way to tell the difference. In powdered form, for example, heroin and fentanyl look identical, and both are odorless and tasteless. When fentanyl is pressed into pill form and purposefully mislabeled as another drug – Vicodin, Xanax, OxyContin, etc. – the eventual user is completely unaware. This is where the potentially-deadly problem arises. When the drug abuser purchases counterfeit fentanyl that they think is heroin or Vicodin and then takes their “normal” dose, they could fatally overdose. All opioids affect the central nervous system – heart rate, blood pressure, and especially, breathing. But fentanyl does this for both a longer period of time and to a greater degree. Significantly, fentanyl disrupts normal respiration without causing the pronounced sedation produced by other opioids. This is an important distinction, because without this “red flag” a person may mistakenly believe that they are still within their tolerance threshold and take even more of the drug. And here’s the thing – counterfeit fentanyl may interfere with rescue efforts during an overdose. In a life-or-death emergency situation, mislabeling fentanyl as another drug – Xanax, for example – will prevent first responders from administering life-saving Narcan, the overdose reversal medication that is only effective against opioids. And by the time medical personnel uncover the truth, it may be too late. Additionally, fentanyl’s potency is such that it may take multiple administrations of Narcan to reverse the overdose. If the rescue efforts are being performed by a bystander, it’s unlikely that they will have multiple doses close at hand.
A Complicated Problem with No Easy Solution
On an individual level, addiction is a complicated disease – and incurable illness that can only be managed effectively with specialized professional treatment, a strong support system, lifestyle changes, and daily vigilance and commitment to a clean and sober lifestyle. But on a grander social scale, the public health problem of opioid addiction and overdoses becomes even more complex. There are so many factors involved:
- Unscrupulous Big Pharma companies
- Problem prescribers and pill mills
- Prescription painkiller abuse
- Pain management vs abuse potential
- Drug tolerance and dependence
- Opioid divergent and misuse
- Prescribing guidelines and federal regulations
- Cross-addiction, switching from painkillers to heroin
- The growing fentanyl menace
- Smuggled drugs from Mexico and China
- The Dark Web
- Counterfeit drugs
- Inadequate supply of rescue medication
- Lack of treatment options
For the opioid epidemic to spread the way it has, each of these factors play a role. But here’s the good news – as evidenced by the recent reduction in the number of opioids prescribed, concerted efforts CAN make a difference.
Efforts on Every Level
Because this is a public health crisis affecting virtually every community in America, that just might be the best way to address the problem – cooperatively, at the community level. While federal guidelines and the medical community can provide a basic framework, there are many actions that can be taken locally: Health Departments
- Keep the community informed with regular events and campaigns
- Draft and implement a community-level response plan
- Make overdose reversal medications available to the public
- Connect substance abusers with treatment services
- Serve as the central link connecting local resources
Law Enforcement and First Responders
- Receive periodic training on how to recognize and respond to an overdose situation
- Carry overdose reversal medications
- Proactively share information about local drug trends with other community agencies
- Use contacts as an opportunity to promote local treatment options
- Prominently feature drug take-back and disposal sites
- Connect overdosing patients with support groups and treatment services
- Issue overdose reversal medications and provide training to the families and friends of overdose patients
- Draft a contingency plan in the event of local overdose spikes
Mental Health and Drug Rehab Programs
- Increase availability of services – morning and evening options, weekends, off-site events, etc.
- Offer Medication-Assisted Treatment
- Work cooperatively to help patients with co-occurring addictive and mental disorders
- Target efforts to those who are most at-risk
- Provide harm-reduction services to IV drug users
- Train employees in the use of overdose reversal medications
- Dispense overdose reversal medications to clients
- Connect clients with local treatment programs
- Be aware of what is going on in your neighborhood
- Report suspicious drug-or-gang-related activity
- Familiarize yourself with local anti-drug resources
- Carry opioid antidotes
Local communities have a flexibility not found at the state or federal level. As such, programs and responses can be tailored to the local situation and implemented much faster.
What’s the Bottom Line?
Addressing the opioid epidemic is not about morality or judgment or “right” or “wrong” – it is about saving lives. If nothing is done, some experts forecast that this crisis could claim up to 650,000 lives within the next decade. That’s roughly the population of Portland…or Oklahoma City…or Las Vegas. On an individual level, it means this—if you or someone you care about is struggling with a dependence on prescription painkillers, the best time to get help is ALWAYS right now. Don’t be a statistic.