The basic facts of the opioid epidemic in Florida are well known. Since 2000, Florida has experienced a substantial increase in the number of deaths caused by the use of opioids. In 2000, the number of such deaths was approximately 350, split almost equally between heroin and prescription opioids. Between 2001 and 2010, however, the number of deaths caused by prescription opioid pills exploded, rising to over 2,000 deaths in 2010. (1) By 2012, the number of opioid pill deaths was on the decline, but those reductions were short-lived. Heroin returned as a leading cause of death, and Florida saw an increase in deaths caused by fentanyl.
The rise of fentanyl has been a game changer. Over 50 times more potent than heroin, fentanyl often kills quickly. According to the U.S. Drug Enforcement Administration (DEA), drug dealers now add fentanyl and fentanyl analogs to almost every type of illicit drug. The result has been a dramatic increase in the number of deaths caused by fentanyl and its analogs in Florida.
The response to opioid-caused deaths has been multifaceted and has included, among other things, new laws from the legislature, targeted law enforcement operations, increased funding for substance abuse treatment, and more widespread deployment of naloxone (a drug that can reverse an opioid overdose). Given the various responses to the opioid epidemic, it is difficult to determine the effectiveness of any particular response. This article describes some of the statistics regarding opioid-caused deaths from 2000 to 2017, and it provides an overview of some, but not all, of the efforts that have been taken to address the opioid epidemic. It also discusses some types of criminal prosecutions that can be brought against drug traffickers distributing fentanyl and other dangerous opioids.
Two general trends are noted in this article. First, the decline in deaths caused by opioid pills coincided with the passage of laws that increased the regulation of pain clinics and created the Prescription Drug Management Program (PDMP), as well as some of the other responses mentioned above. Second, the subsequent increase in deaths caused by heroin and fentanyl suggests that many users switched from prescription opioid pills to other forms of opioids as their drugs of choice.
How Opioids Cause Overdoses
Opioids are a class of drugs that includes heroin and synthetic drugs, such as oxycodone, hydrocodone, codeine, methadone, and fentanyl. (2) Opioids work by binding to and activating the opioid receptors in the brain. (3) This interaction decreases a user's subjective feelings of pain and increases a user's feelings of pleasure and well-being due to a rise in dopamine activity. (4) An opioid user will begin to crave this release of dopamine, leading to overdose and addiction. (5)
If a user takes too large a dose, the opioid causes a change in the neurochemical activity in the brain stem, which controls automatic bodily functions such as breathing and heart rate. The result is that an individual's breathing and heart rate is depressed. (6) In essence, the body forgets to breathe, and the individual dies in his or her sleep. (7)
A Summary of Overdose Data in 2000
Every year, the Florida Department of Law Enforcement (FDLE) collects data on drug deaths and publishes its findings in the "Report of Drugs Identified in Deceased Persons by Florida Medical Examiners." In 2000, the report reflected that there were 574 deaths caused by one or more of the following categories of drugs (the numbers add up to more than 574 because some deaths were found to have several drugs contributing to death): (8)
Cocaine 243 Heroin 208 Hydrocodone/Oxycodone 152 Alcohol 119 Benzodiazepines 93 Methadone 39 Amphetamines 32 GHB 6 Of those drugs, heroin, hydrocodone/oxycodone, and methadone are opioids. Heroin is processed from morphine and extracted from the seed pod of certain poppy plants. (9) Hydrocodone (sold under the brand names Vicodin and Norco) and oxycodone (OxyContin, among other brands) are semisynthetic opioids derived from codeine or thebaine, respectively. (10) Methadone comes in pill or liquid form, and it is used for detoxification and to prevent withdrawal systems for individuals who are addicted to opioids. (11)
Pursuant to the Florida Comprehensive Drug Abuse Prevention and Control Act, drugs are classified into one of five schedules, depending upon the drug's potential for abuse and whether it is accepted for medical use in the United States. (12) The schedules range from I to V, with Schedule V representing the least potential for abuse. Heroin is included on Schedule I, which means that it has a "high potential for abuse and has no currently accepted medical use in treatment in the United States and its use under medical supervision does not meet accepted safety standards." (13) Hydrocodone, oxycodone, and methadone are included on Schedule II, which means that they have "a high potential for abuse and ha[ve] a currently accepted but severely restricted medical use in treatment in the United States, and abuse of the substance may lead to severe psychological or physical dependence." (14) Schedule I drugs are not available for use by prescription, while Schedule II drugs are. In 2000, the number of individuals who died from heroin (208) was similar to the number of people whose deaths were caused by hydrocodone, oxycodone, and methadone (191). (15)
The Rise of Opioid Pills
That changed after 2000. From 2001 to 2010, the number of deaths caused in Florida by opioid pills skyrocketed to over 2,000. For purposes of this article, the term "opioid pills" refers to hydrocodone, oxycodone, hydromorphone (which is made from morphine and sold under the brand name Dilaudid), and oxymorphone (which was sold under the brand name Opana until it was voluntarily removed from the market in 2017). (16) Figure 1 shows the increase in deaths caused by opioid pills. (17)
When other opioids are added, the total number of deaths caused by opioids other than heroin increased almost five times, from 642 deaths in 2001 to over 3,200 in 2010. (18)
During the same timeframe, the number of deaths caused by heroin dropped by over 75%, from 208 in 2000 to 48 in 2010. (19) Some of that decrease may be explained by an increase in deaths caused by morphine. Starting in 2003, the Florida medical examiners' report began to itemize the number of deaths caused by morphine. Because heroin is rapidly metabolized to morphine, the Florida medical examiners' report has noted that "this may lead to a substantial over-reporting of morphine-related deaths as well as significant under-reporting of hero-inrelated deaths." (20) To address this possibility, Figure 2 combines deaths caused by heroin and morphine--it shows that the number of those deaths fluctuated between 200 and 450 from 2000 to 2010.
The Legislature's Response: 2009 to 2011
The rise in deaths caused by opioid pills did not go unnoticed. From 2009 to 2011, the Florida Legislature enacted statutes each year in response to the opioid epidemic. Each of those legislative efforts focused, in large part, on the problem of so-called "pill mills."
A "pill mill" is a term used to describe an "unscrupulous pain management clinic" that prescribes "large quantities of drugs for pain with little medical justification," and the drugs are "used primarily by persons abusing or diverting" the drugs. (21) In Florida, the primary drug dispensed at pill mills during the 2000s was oxycodone. Florida was known as the "OxyContin Express," and individuals throughout the United States traveled to Florida to visit these pill mills. (22) The result was that, by 2010, Florida had over 900 unregulated pain clinics and was "home to 98 of the 100 U.S. physicians who dispensed the highest quantities of oxycodone from their offices." (23)
In a report issued in 2014, the Florida attorney general identified three reasons why pill mills flourished in Florida in the 2000s: "weak regulatory oversight" of pill mills, "limited oversight of physician dispensing habits," and the lack of a prescription drug monitoring...