Fake pills manufactured to look like prescription opioid pills
Some opioid pills sold on the street or through the Black Market are made to look exactly like prescription oxycodone pills. Those who buy opioid pills without a prescription could be taking a lethal dose of fentanyl without knowing it. Photo courtesy of the Drug Enforcement Administration.

The opioid epidemic continues to be one of the most significant public health crises, with consequences for individuals, families and communities across the United States, including Nebraska

The National Institute on Drug Abuse defines opioids as a class of drugs that includes heroin, synthetic opioids such as fentanyl, and prescription pain relievers such as oxycodone, hydrocodone, codeine and morphine. 

In 2019, there were 92 opioid-related overdose deaths in Nebraska, with a rate of 4.8 deaths per 100,000 persons, according to the National Institute on Drug Abuse. While this is lower than the national average rate of 14.6 deaths per 100,00 persons, experts say the problem remains a serious concern in the state.

However, individuals have fundamentally different views of those addicted to opioids. Some may view opioid addiction as a criminal issue that deserves punishment, while others view addiction as a disease that deserves treatment. Drug use continues to be penalized, despite evidence showing punishment does not cure a drug addiction.

Patrick Habecker, a research assistant professor with the Rural Drug Addiction Research Center at the University of Nebraska-Lincoln, studied Nebraskans’ beliefs about people who use drugs and knowledge about Narcan. 

Narcan, an opioid overdose reversal medication, was approved in March 2023 by the U.S. Food and Drug Administration to be sold without a prescription. Making Narcan more widely available could reduce the number of opioid overdose deaths. Narcan is a nasal spray that counteracts the effects of an opioid overdose and can ultimately save someone’s life. Habecker said he was surprised to find out that many Nebraskans don’t know what Narcan is or where to find it. His research found that only 10% to 20% of Nebraskans are aware of Narcan.

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The Nebraska Department of Behavioral Health divides the state of Nebraska into six regions. These regions act as local government units that partner with the state to do planning and implement service. Photo courtesy of Nebraska Department of Health and Human Services.

Habecker conducted this research by surveying Nebraskans about substance use and stigmas around substance use to addresses around the state. He said when conducting this research in 2022, he contacted the Bureau of Sociological Research to purchase a list of about 8,000 addresses within the six behavioral health regions in Nebraska and sent an invite for the survey to those addresses. Out of the initial 8,000 addresses the survey was sent to, 27.7% of the respondents completed the survey.

“A majority of the respondents either agreed or strongly agreed that people in their community believe a person who uses substances is dangerous, cannot be trusted, and is to blame for their own problems,” Habecker said.

Behaviors Versus Symptoms of Addiction

According to an article from healthaffairs.org, individuals who become addicted to an opioid they were once prescribed are not deserving of punishment because they likely cannot control their addiction behaviors. The article said there should be more focus on new health initiatives to prevent and treat addiction rather than punishing it.

Dr. Ken Zoucha, division director for addiction medicine at the University of Nebraska Medical Center, said symptoms of an addiction to opioids appear as behaviors and can make a person seem foolish, untrustworthy and irresponsible.

“Because the symptoms are appearing as behaviors, a lot of people see it as you have a choice to make those decisions or behaviors, but when our brains are changed by the use of substances and you develop a substance use disorder, those behaviors no longer become a choice unless you get treatment,“ he said.

Eric Kauffman, lieutenant of the Nebraska State Patrol’s investigative division, said possessing a Schedule 1 controlled substance, such as an opioid without a prescription, is a felony in Nebraska.

Zoucha said sending addicts to jail for illegally possessing and using a substance is not an effective solution for decreasing the number of opioid addictions and overdose deaths. He said opioid addiction is a disease rather than a crime.

“We have been trying to arrest our way out of addiction for half of a century and criminalizing substance use. Despite all of that, we have more overdose deaths than we’ve ever had,” Zoucha said. “So if arresting people and putting them in jail worked, we would be seeing that less.”

How Opioid Addiction Presents Itself

Zoucha stated that opioids prescribed for chronic pain can cause patients to develop a dependence on the drug, making it challenging for them to discontinue opioid use due to withdrawal symptoms.

Zoucha said people who develop an addiction to opioids give up hobbies, stop doing normal day-to-day activities, and often have issues in their relationships with friends and family along with developing physical and psychological side effects. Individuals with addictions often avoid confronting their situation because they fear others may perceive them as foolish or irresponsible.

When doctors decide to prescribe an opioid for pain, they perform a screening to assess a patient’s risk of becoming addicted by using a Pain Management Guidance Document, according to Zoucha. The document from the Department of Health and Human Services outlines the reasons why a doctor should prescribe an opioid and how a doctor should follow up with patients to assess the function of the opioid.

Kauffman explained that different disciplines look at the opioid epidemic through their own goggles. 

“We see part of the field, but we might not see all of the field. But if we work together and collaborate, then we start to see the big picture,” he said.

Kauffman said law enforcement has been working to collaborate with healthcare workers, prosecutors, judges and behavioral health specialists to balance the need to enforce drug laws while also recognizing that addiction is a disease.

“Unfortunately, there’s a lot of people that will only seek help if they’re forced to by being initiated into the criminal justice system, and that’s the piece of the pie that law enforcement sees,” he said.

Kauffman said he would much rather get an opioid addict help through a treatment or recovery center than sending them through the criminal justice system. 

“That’s not always up to us as law enforcement, but that’s why we collaborate with these other disciplines,” he said. 

According to research by the American College of Neuropsychopharmacology, more than half of inmates in prison have untreated substance use disorders, which typically increase after being released. Addicts who do not receive treatment for opioid addiction in prison are likely to overdose upon release because their tolerance to the drug has decreased.

Dayne Urbanovksy, the communications director for the Nebraska Department of Correctional Services, said there are a few different substance use programs for residential and outpatient addiction treatment. Urbanovksy said the department performs comprehensive planning for individuals with substance use disorders before releasing them.

Urbanovsky said the department has strong relationships with community providers, some of whom work with individuals before and after release to provide a continuum of support.”

Zoucha said the criminal aspect of drug addictions pertains to the people who manufacture pills and sell them on the street or through the Black Market. 

“I just really think that people who have actual substance use disorders, we need to think of them as not bad people who need to be punished but sick people who need help getting well,” Zoucha said.

The Future of Opioid Prescriptions

As the opioid crisis continues to impact Nebraska, medical professionals are taking extra steps to ensure the opioids they prescribe will not negatively affect the patient.

“There are definite changes with how prescribers are using opioid medications,” Zoucha said. 

If a patient requires a prescription for an opioid, providers now consider giving patients a small amount of opioid pills at a time along with looking at a patient’s potential of developing an addiction, according to Zoucha.

“In the past, many times patients would leave from a procedure getting a lot of tablets of an opioid medicine. And now our providers are rethinking that process,” he said.

There are also a lot of discussions surrounding the use of non-opioid medications without addiction potential for pain management, according to Zoucha.

Expanding knowledge about Narcan and how it works is another way to prevent opioid overdoses. Kauffman said all Nebraska State personnel carry Narcan, which they can administer in the field if they encounter someone experiencing an overdose.

Addiction prevention efforts are also growing within the state. The Nebraska Department of Health and Human Services provides resources to increase awareness and education about opioid use and misuse.

“We partner with the behavioral health regions across Nebraska to coordinate with local law enforcement and the DEA to promote drug take-back events and work with local pharmacies to promote safe medication disposal,” said Delaney Johnson, the state opioid response, prevention, and risk reduction coordinator.

The Nebraska Department of Health and Human Services also started Project ECHO. This project brings together physicians across Nebraska to discuss treatment for opioid addictions and safe prescribing practices, according to Johnson.

“The purpose of Project ECHO, which is the Extension for Community Healthcare Outcomes, focuses on the treatment of opioid and other substance use with primary care providers and other prescribers,” Johnson said.

Habecker said after doing research on drug addictions, he believes there should be more discussion surrounding why people are using substances, rather than if it is a criminal or medical issue.

Counterfeit Pills: A Lethal Game of Chance
When in the wrong hands, fentanyl can be one of the most lethal opioids and is currently classified as one of Nebraska’s top two drug threats by the Drug Enforcement Administration.

Fentanyl is a highly addictive opioid that is 50-100 times stronger than morphine. Doctors prescribe fentanyl for chronic pain, but when people become dependent on the drug and develop addictions, the opioid can cause overdoses and even death.

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Counterfeit pills are manufactured to look like oxycodone, but really contain a lethal dose of fentanyl. These counterfeit oxycodone pills are usually sold on the Black Market, according to Lieutenant Kauffman. Photo courtesy of the Drug Enforcement Administration.

“There’s a lot of innocent people out there who may not be addicts. They’re taking a pill believing it could be something else,” Kauffman said.

In Nebraska’s Omaha and Lincoln communities, numerous street dealers who engage in illegal opioid sales have started vending fake oxycodone pills that contain a lethal dose of fentanyl, according to Kauffman.

Zoucha said hospitals primarily use fentanyl for inpatient care, but some cases permit prescriptions of fentanyl for outpatient care.

“Fentanyl, specifically, is considered more of an in-hospital medicine that is used intravenously to help people with severe pain associated with procedures or injuries but there are some forms that are used outpatient. The medications are incredibly good at taking away pain,” Zoucha said.

Kauffman said counterfeit opioid pills containing fentanyl are overwhelmingly present in Nebraska’s communities.

“One pill can kill,” Kauffman said. “There is no quality control; there is no science involved with these counterfeit pills. One pill could be a safe dose, the next pill could be a deadly dose.”

Both Zoucha and Kauffman said those lacing pills with fentanyl and selling them on the street contribute to the criminality aspect of drug addiction.

“The criminal aspect is the people that are making and bringing to the U.S. and distributing these pills as oxycodone that are really fentanyl,” Zoucha said.

Emily Diesing is a senior journalism major at the University of Nebraska-Lincoln.