This is the second in a series of columns on opiate addiction in America.

A new epidemic related to heroin smuggled from Mexico began in the mid-1990s.

Unlike powdered heroin smuggled into the U.S. from Asia, black tar heroin was produced from poppies grown in the state of Nayarit on Mexico's Pacific Coast. It was sold as a sticky, black solid. The dealers, who mostly originated in a cluster of villages in Nayarit, developed a sophisticated system for marketing and delivery. California's San Fernando Valley was the first significant entry point.

Masterminds behind the new drug avoided large cities where gangs controlled traditional, powdered heroin. Selecting a new medium-sized city, a regional dealer would establish his operation. Initially, he would befriend people, making daily visits to clinics that dispensed methadone for addicts. He might initially provide free samples of his product.

Young men recruited from Nayarit worked on salary to deliver heroin, changing residences and cars periodically to avoid being tailed. Contacted by cellphones, also frequently changed, the delivery men would schedule a time and a place to hand over the drugs. Tiny doses were placed in small balloons which the delivery man concealed in his mouth. If stopped by police, he simply swallowed the balloons. Six balloons, each containing one-tenth of a gram of heroin, might sell for $100.

The network expanded steadily across the country, generating huge profits and addicting many thousands of Americans.

Paralleling the robust market in black tar heroin, new prescription opiates were aggressively marketed to physicians to treat severe pain. For decades, pain was undertreated because of fears of causing addiction. As new information emerged, however, physicians recognized that persons with severe, chronic pain, including those with metastatic cancer, would benefit from aggressive management of their disabling symptoms.

Oxycodone, a semi-synthetic derivative of opium, had been available for decades. Beginning in the mid-1990s, it was aggressively promoted for the treatment of severe or chronic pain of multiple causes. Perhaps as potent as heroin, oxycodone could be taken orally; it was effective in relieving severe pain.

Risk of addiction was minimized. "Pill mills," unethical clinics that existed merely to write prescriptions for oxycodone, sprang up to meet the needs of countless persons who became addicted to the drug. Portsmouth, Ohio, was one of the first and most notorious cities with such operations.

With few questions asked and a large cash payment, a person could emerge from a pill mill with a prescription for large numbers of oxycodone pills which then could be resold for substantial profits.

Pill mills dotted interstate interchanges in states with lax regulations for opiates. Vanloads of addicts might be transported hundreds of miles to obtain their oxycodone. Deaths due to opiate overdose steadily rose across the country.

And when prescription opiates were no longer available, addicts could switch to black tar heroin — which generally cost less.

Fentanyl, another highly potent opiate, was marketed as a sustained-action patch to be applied to skin. Illicitly manufactured fentanyl powder, which can be smoked or injected, is an increasing problem in addiction.

Data from the Centers for Disease Control and Prevention documents the extent of the double-barreled opiate epidemic attributable to black tar heroin, oxycodone and other new, potent opiates. From 2000 to 2014, the number of prescriptions written for opioids increased four-fold — and a four-fold rise in deaths due to opioids accompanied the soaring sales. West Virginia, New Mexico, New Hampshire, Kentucky and Ohio had the highest death rates.

Data from 2012 shows striking differences among states in the number of opiate prescriptions per 100 residents. Tennessee and Alabama led with 143 prescriptions per 100 residents; California at 57 and New York at 60 were the lowest numbers.

In 2014, 47,000 deaths resulted from drug overdose in the U.S., the CDC reports. Sixty-one percent, or 28,647, were due to some form of opiate, including heroin, the CDC says, and, for the year, deaths from drug overdose exceeded deaths from motor vehicle accidents.

In Tennessee in 2014, 1,206 deaths from drug overdose represented a 7.7 percent increase from the previous year, according to the CDC. Georgia witnessed 1,269 deaths, too, representing a 10.2 percent increase, while Alabama experienced 723 deaths, a 19.7 percent rise, CDC figures show. Beyond the deaths are millions of lives devastated by insatiable addiction.

Reining in the epidemic of opiate abuse requires robust, coordinated interdiction on heroin by federal and state officials. Black tar heroin must be blocked at its Mexican source, which would require a new level of cooperation with that nation's government.

Tightening of regulations related to prescribing of opiates must be carefully balanced so patients who truly suffer from chronic, severe pain are not denied access to appropriate medications. Each state must act vigorously to shut down pill mills and prosecute unethical providers. The status quo condemns too many people to wasted lives of addiction and death from overdose.

I urge you to read "Dreamland" by Sam Quinones to learn about this intensifying threat to our nation's health.

Contact Clif Cleaveland at