Government and industry are proclaiming a crisis regarding the use of opioids. Health care staff need to be informed of the nature of this crisis, what impact it has, how it came into being, and what plans are in the works to bring it under control.
After completing this course, the learner will be able to:
Overdose has become the leading cause of death in the United States for those under the age of fifty, with opioids in 2016 ending the lives of more than 115 people each day.1,2 This has led President Trump and public leaders to issue a call to arms for what is being labeled a public health emergency. Some, however, argue that what is being seen relates more to a failure of the war on pain spawned during 1996 by the American Pain Society, when they acknowledged the medical systems’ serious undertreatment of pain and called for mandatory pain assessments as “the fifth vital sign.3”
This creates a serious split on how to manage an opioid overdose epidemic. Are we dealing with a population seeking relief from poorly managed, or unmanaged pain, or is there an element seeking socially unacceptable benefits that may arise from illicit or illegal use of opioids meant for the treatment of pain?
Should we extend treatment with kindness and gentleness seeking to minimize and alleviate suffering, or should we make new laws to isolate offenders behind bars before they endanger themselves or others? Silly as these questions may seem to some, they are very real. Let’s take a look at the subject in question, opioids: their benefits and their use. How this situation of uncontrolled overuse snuck up on us. And finally, what is being done about it now and plans that are being formed for moving forward to mitigate what has become a deadly addiction.
When we say “opioid” we are talking about chemicals, both natural and synthetic, that when taken correctly mimic the pain dampening ability of opium. The word opioid is in fact derived from the name opium, the concentrated juice of the poppy Papaver somniferum which can aid in sleep, pain relief, and relaxation and from which morphine, codeine, and several other alkaloids used as or in prescription medication are taken.
Semisynthetic opiates are molecules which contain some natural opiates and a mix of synthetic chemicals.
Opium, and to a greater or lesser extent all of the “opioids,” are able to enter the brain, stimulating chemical receptor sites conveniently known as opioid receptors located in the brain, bowels, and spinal cord. When an opioid is present the activated receptors slow or block pain signal transmission to the brain, slow bowel function, and in general produce a warmly euphoric feeling in both the limbic areas of the brain that house the “reward” response and the frontal cortex which helps to mediate pleasure.4 An increase in natural endorphins, pain-relieving chemicals produced naturally by the body, accompanies opioid use, boosting feelings of wellbeing and further suppressing the perception of pain.5 The longer opioids are used, less and less endorphins are manufactured by the body, leaving natural pain fighting abilities handicapped and at a loss to function normally.
Prescription opioids are an invaluable asset for the legitimate control of moderate to severe pain.
Abuse of opioids varies. For some, the relief from stress, the warmth, the feeling of “at ease with life” that accompanies an opioid’s lowering of heart rate, widening of blood vessels, and gentle sedation is the goal. Then there are those reaching for the intense pleasure high levels of the neurotransmitter dopamine; a chemical increased by opioids, can help produce.
As the National Institute on Drug Abuse puts it in materials designed to aid teachers help youth make good decisions, “Dopamine is sometimes called the pleasure neurotransmitter because it helps you feel good.” “When something pleasurable happens, certain axons release lots of dopamine. The dopamine attaches to receptors on dendrites of neighboring neurons and passes on the pleasure message.6"
In part, according to the National Institute of Health, it is the good job opioids do managing pain and helping us to feel better that is contributing to the overuse/ misuse problem with some 21 to 29 percent of those with chronic pain using them outside of their health providers instructions. Sadly, some 8 to 12 percent of chronic pain patients develop what is referred to as an opioid use disorder, which includes both substance dependence and addiction with about 4 to 6 percent of those chronic pain sufferers who misuse opioid prescription medicines moving on to use the opioid street drug heroin. Conversely, reports indicate that around 80 percent of those who use the illegal street drug heroin has a history of first misusing prescription opioids.2
Terminology can be confusing. The term opiate is meant to indicate a natural, or only slightly modified derivative of opium such as morphine, codeine and heroin. The favored term currently, opioid, technically should be used for only the synthetic and semisynthetic opium facsimiles such as Oxycontin or Fentanyl. Opioid is now used however for the entire family of opium-like drugs. The term narcotic is also seen applied to opioids, be wary however in its use, as narcotic technically can indicate any mind-altering chemical possessing sleep-inducing properties.
Relief from pain accompanied by feelings of well-being and even a touch of euphoria are the hallmarks of pain relief prescription opioids, giving them a high risk for addiction. When used for pain for more than two to three days many people begin to develop a physiological tolerance. This means that more rapid break down of the opioid chemicals by the body is occurring along with greater resistance to the opioid effects. Therefore, it takes a larger and larger amount of the medication to get the same result as before. Some begin to think obsessively about how to get more opioids and even start hoarding them so as not to run out. Others succumb to the temptation of illegal activities, such as “double doctoring,” or seeking additional medication from illicit or illegal sources.
Dependence on opioids affects an estimated 5 million adults in the United States and led to around 42,000 deaths in 2016.8 Surprisingly half of the deaths from drug overdose are attributed to use or misuse of prescription medications, with overdose fatalities raising, according to the CDC, from 6 percent per 100,000 people in 1999 to 20 percent in the year 2016.9
Be aware, tolerance to the positive effects of opioids, such as euphoria develop much faster than the body’s ability to handle opioids dangerous effects, creating a high risk for overdose by mistake.
Drug misuse is not a diagnosis when discussing prescription opioids; it indicates the presence of a problem pattern of drug use;
• Taking medication without a prescription (i.e., taking medication meant for someone else such as a family member or friend)
• Taking medication for a reason or incident other than for what it was prescribed
• Taking medication at higher doses and/or for a longer period of time than prescribed
This is not our first rodeo where opioids and their precursor opium formed the center of a storm. The mid-1800’s saw two wars between Briton and Imperial China where opium was the key to the control of all trade and entire regions of Asia. The Opium Wars, as they are correctly referred to, established just how powerfully the call of this drug could affect an entire populace and direct the course of nations. The power of opioids came home to North America during our American Civil War where medics from both sides liberally used morphine as a battlefield anesthetic, and home front households welcomed laudanum, a tincture of opium as the treatment of choice for toothaches and soothing colicky children, to belly aches and mood swings.10 Those utilizing opium-based wonder drugs faced the risk of developing tolerance and dependence, both during our previous opioid crises and now. Morphine misuse, in fact, became so troubling that it was often referred to as “the army disease” and laudanum ensnared many, such as Mary Todd Lincoln, President Lincoln’s wife, who became addicted while utilizing the tincture to aid in finding sleep.11
As though to mirror our present crisis, pharmaceutical companies (Merck and Bayer respectively) rapidly pushed to the market cocaine and heroin billing them as a means of reducing the misuse and addictions laid at the feet of morphine and related opioids.11 When in the early 1900’s the sweet poison effects of heroin and cocaine became too great to ignore, the government lurched into motion with the 1914 Harrison Act, the very first national effort to contain a drug epidemic. Effects from the Harrison legislation made codeine and heroin by physician prescription only. This limited the quantities sold, driving up the costs of the medications, and creating the beginnings of a vast underground supply and demand market system, and brought illicit and illegal opioid use into a don’t ask don’t tell type of existence where affected family members and addicts were to the best of society’s ability, ignored. The shadow existence of the drug addict fought and lost its opportunity for recognition and assistance competing against such happenings as the Spanish Flu, the Great Depression, and World War II which depleted the disposable income and empathy of the nation.
In 1970 The Controlled Substances Act became law. The new law creates schedules (groupings) on medications based on their potential for abuse. Heroin is included in Schedule I, the highest risk for abuse. Schedule II drugs include morphine, oxycodone, and fentanyl among other opioids.
A resurgence into the public eye of opioid misuse and addiction occurred in the 1960’s and 70’s as our nation went to war in the Orient. Combatants returning from Korea and Vietnam brought with them new cravings and supply contacts leading to a resurgence of opium and opioid derivatives and bringing President Richard Nixon to declare in 1971 that we as a nation were at war with drugs. The 1971 War on Drugs still continues today, with tough sentences on drug users and suppliers, and ramped up military level interdictions on illegal drug smuggling.
1900 – Heroin and Cocaine are legal OTC’s (over the counter) and popular.
1970 – Heroin epidemic rages in U.S. cities.
1988 – The crack epidemic is at its height nationwide.
2016 – The most recent year with complete numbers available.
Though our current opioid crisis is built on the framework created by all of the previous unresolved opium epidemics, this new wave of life-destroying overuse has features that make it unique from past outbreaks. For instance, we have an “exact” start date for our crisis, the year 1995. That was the year that the megalithic pharmaceutical industry brought forth the first of another set of wonder drugs to curb overuse and addiction to opioids. Most overlook the similarity to how the fight against morphine overuse brought heroin forward. Specific to our contemporary crisis is the new drug OxyContin, a long-acting form of oxycodone, one of the first of the time released opioids. OxyContin hit the pain relief market with great promises as an end-all to both pain and the risk of narcotic abuse.12 The assurances from Purdue Pharma, the company which aggressively marketed OxyContin, was that it was a much safer, less addictive opioid, able to be safely used for months at a time in the treatment of chronic pain.12
Forceful marketing with incentives such as ‘befriending,’ then manipulating tired, overworked prescribers and lures such as weekend first class resort training on the new medications helped pharmaceutical companies flood the market with hundreds of millions of new opioid pills and capsules.13 Meanwhile, pain suffers found themselves developing drug tolerance and addiction to the new products, just like the old, and those abusing themselves with prescription meds quickly found that crushing the tablets or capsule contents and snorting or injecting the powder, delivering a potent ‘high’ much more powerful and quicker than swallowing a pill.11
Illicit behaviors are those considered beyond the norms of society, its rules and behaviors and are usually committed in secret. Illicit acts are usually against the law, however, if circumstances change would be legally allowed, such as the trade of drugs that are banned in one country yet supplied from a country where their sale is legal.
Illegal behaviors are actions directly against the rules of law.
A key factor differentiating illicit from illegal is the secrecy which surrounds the act.
In response to the reassurance that patients would not become addicted to the new opiate pain medications, prescribers engaged in a frenzy of prescription writing, often giving thirty or more days supply to those whose pain would be diminished or gone within two or three days. The glut of available opium compounds sitting available in medication cabinets in households across the country became a source of temptation to those with no ill intent who on stressful days recalled the mild euphoria and feeling of relaxation, as well as those attempting to follow misunderstood prescriber orders on the presumption that they are to finish the prescription. To heighten the danger, other opioids add into the current crisis. Heroin, no longer a monopoly of the far east was being produced cheaply and efficiently in neighboring Mexico, and Central American countries. Easy transport across a long, laxly secured land border made the new heroin cheap and easily obtainable. Many chronic pain patients have in fact readily accepted inexpensive street heroin into their self-treatment when they realize there is an alternative to expensive, difficult to obtain from prescriber prescription medication. During the early years of our current crisis other potent opioids such as fentanyl, a synthetic opioid 100 times more powerful than morphine, began to become available to street drug vendors becoming rapid favorites to those seeking inexpensive, powerful effects.
Fentanyl and its street produced analogs (acetylfentanyl, furanylfentanyl, and carfentanil among others) are synthetic opioids meant to mimic the effects of opium. Pharmaceutical grade fentanyl is fifty times more potent than heroin, and 100 times more potent than the same amount of morphine. Medicinal use fentanyl is a very useful tool in managing severe pain such as in cancer treatment or palliative, end-of-life, care. Black market fentanyl, sometimes referred to as IMF (illicitly manufactured fentanyl), varies in strength and purity, yet remains incredibly potent. Street drug dealers often mix IMF into cocaine or heroin in order to up the drug’s effects.
Carfentanil, a fentanyl knock-off, is roughly 10,000 times more powerful than morphine and requires specialized toxicology to detect.
The seriousness of synthetic opioids, such as fentanyl and its close mimics, is reinforced by a study published in the May 2018 Journal of the American Medical Association that found in the year 2016, 46 percent of opioid deaths were attributed to a synthetic opioid. That’s up from the 14 percent synthetic opioid death rate in 2010.
It is wrong to think of the current opioid crisis as a raging lion, out to mangle and devour us all. It is, however, a serious issue deserving more than kneejerk election-year attention by our nation’s leaders and policymakers. The CDC estimates that each year the total national financial burden from prescription opioid use costs us, the taxpaying public, $78.5 billion each year, an amount which takes into account the cost of healthcare, criminal justice involvement and addiction treatment.2 As we have seen in previous opium/opioid addiction epidemics, coming between a persons need for pain relief and, for some, their desire for pleasure, and their drugs of choice is a tricky matter that takes consideration, planning, and a steadfast determination to see it through.
Consideration – Those misusing opioids are not evil people.
Somehow it was easier, and I might just be speaking for myself, when “those addicts” were simply bad people, criminals, the unsavory dregs of society, or whatever platitude you may have absorbed or grown up with. I am happy to say that you and I, and our medical profession are growing past that viewpoint popularized during the war on drugs.
One example of a progressive change in attitude is the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), by the American Psychiatric Association (APA).15 The DSM-5 is regarded to be the go-to reference for conditions affecting thought, moods, emotions, and behaviors such as opioid abuse. In it’s newest literation, the 2013 edition, great effort has been taken to correlate it with the ICD-11, (International Classification of Disease, Eleventh Revision) a system of medical coding created by the World Health Organization (WHO) for documenting diagnoses, diseases, signs and symptoms, and social circumstances. Also, the diagnostic criteria regarding addiction have been softened and revised; for instance, there is now more effort to differentiate between the tolerance and withdrawal seen with even the appropriate use of prescription opioids and the compulsive drug-seeking behaviors that define addiction. Views of addiction also are being shifted with the diagnostic criteria of encounters with the law, i.e., the “recurrent legal problems” being removed totally from the addiction category. The section in the DSM-5 that regards opioid dependence is even phasing out terms such as drug abuse and replacing them with the more descriptive title of Substance Abuse Disorders.16
Opioid Use Disorder is defined as a problematic pattern of opioid use leading to clinically significant impairment or distress, as manifested by at least 2 of the following criteria, occurring within a 12-month period:
One reason why an update in attitude toward those who misuse opioids is beneficial is that the primary reason given by those misusing them is the relief of physical pain.18 While some misuse opioids seeking the euphoria, many, perhaps most of those caught in the web are simply chasing the ever-increasing amount needed to dull existing pain, or help them to “feel more normal”.
Darnell is a 42-year-old Licensed Practical Nurse who had received a moderate injury to her lower back sixteen months previously when she had attempted to support an elderly care client who suddenly lost balance and began to fall forward. Her managed care physician prescribed back rest, muscle relaxers and oxycodone for pain. Darnell found the muscle relaxation medication made her dizzy and did not seem as helpful as taking the pain medication regularly and as early as possible. After two and a half months she returned to work though the prescribed amount of pain medication was no longer working to control what had turned into a continual aching pain, so Darnell began increasing the dosage she was taking. This led to running out of medication early. Her PCP (primary care physician) complied with early prescription renewals several times, each time with a more strongly worded warning about decreasing the amount of oxycodone being used. After several early prescription renewals, Darnell’s PCP refused to continue prescribing the medication.
Darnell convinced herself it was time to be off the pain medication anyway. She was surprised the morning after her last dose with feelings of nausea, the presence of distressing diarrhea, aching bones, an increase in pain, and strong anxiety. Telling herself it was just a coincidence she applied cold packs to her lower back and medicated herself heavily with OTC (over the counter) pain medications, sleep aids, and tried to sleep through it. The next morning the aches, pain, nausea and anxiety were still with her as well as a strong craving for oxycodone. Desperate, she called friends and family asking if any of them had prescription pain medication she could ‘borrow.’ By that method, she was able to obtain a small supply of a variety of prescription opioids. She also made appointments with several physicians and received extensive advice, though she was unable to get opioid pain prescriptions from them.
When a cousin introduced Darnell to his “friend” who could supply her, for a price, with oxycodone she was aghast, yet relieved. She found herself calling in sick to work frequently in order to use pain medication, which led to her being fired for her frequent absences. Money became scarce so when her supplier “ran short” of oxycodone it did not take much to convince Darnell to try “just a little” heroin, which proved less expensive and better able to help her feel “more normal” than the prescription medication which had stopped having a positive effect despite doses that left her unable to work or function. Moodiness and depression became her normal and family and friends dropped or have severely limited contact with her, and members of her close family are discussing “an intervention” to try to bring Darnell out of the lifestyle she has wandered into.
Consideration – Incarceration alone does not cure misusing opioids.
The Nixon era “War on Drugs,” continued by every presidential administration since, has taught us many things about substance abuse and addiction. First of all, it showed us that wars on drugs don’t work.20 Secondly, that deprivation or abstinence alone from a drug of choice, including opioids, does not reduce returning to that substance when it again becomes available. This has proved a deadly problem as the time away from opioids generally reduces the built-up tolerance a person’s metabolism has. That means with former inmates, who on release tend to return to using their previous dosage, the overdose rates run nearly 130 times higher than the general population.21
The war on drugs has been being waged since 1971. Some of its costs include;
Caging opioid users whose offenses are centered on nonviolent opioid use as in past eras, needs revisited. New tactics need to be discussed to tame the lion of opioid overuse, and to bring the crisis back from its current record highs.
Every legislator and government agency seem to be presenting their own, unique plan on how to combat the opioid epidemic. Let’s take a look at some of the concepts that have either been already implemented or stand a good chance of being seen by healthcare professionals across the nation.
In a March 19, 2018, public address on the current opioid crisis President Donald Trump outlined an initiative to “confront the driving forces behind the opioid crisis".22 President Trump’s plan contains three core focus points, each with progressive actions under them22,23 :
HHS, the U.S. Department of Health and Human Services has pushed forward with plans for a five-fold approach to containing the Opioid Crisis2:
Yes, Narcan (naloxone) can reverse an acute opioid overdose, when given in time. The timing issue is so important that our current United States Surgeon General issued a rare national advisory in April 2018 urging more citizens to have Narcan on hand in order to help those they find overdosing on opioids.
Naloxone is an opioid antagonist that binds to opioid receptors in the body, preventing and reversing the effects of opioid medications. Positive effects of restoring breathing last from 30 to 90 minutes, precious time in which medical assistance can be initiated.
Narcan/ Naloxone comes in three forms:
NOTE: Once Narcan is given, turn the person onto one side if it is safe to do so. Narcan administration can provoke vomiting, and its never good to risk emesis entering the lungs.
Remember that any Narcan administered will wear off, so observation for at least two hours after the last dose is given is crucial, lest any opioids still present in the person’s system places them once more into an overdose situation.
NIH, the National Institute of Health, through a branch agency of the massive HHS system has already been meeting with academic researchers and the big pharmaceutical companies who bear a goodly portion of blame for the current opioid flood pushing the crisis forward.2 The plans NIH is busy implementing include:
Say what you will about the pharmaceutical industry’s actions relating to this generation’s opioid epidemic, some of the large corporations are stepping up with initiatives to slow the growth of addiction. Pharmacy chain CVS Caremark, for example, began implementing a filling restriction for new pain medication patients prescribed opioids, limiting them to a seven-day supply of medication. Other medication dispensaries are considering coming on board with this self-limitation, and some legislative plans are advocating this throttled down introduction to opioids become a law of the land.12
Yes, some practices have been shown successful in both bringing users back from their opioid misuse, and keeping others from wandering into the trap of overuse and addiction. For preventing opioid misuse, for instance, encouraging clients in some safe practices and prescribers in some positive actions are useful5,18:
Be alert for signs of opioid dependence, such as9:
Frederick (call me Fred) is a 32-year-old bricklayer who fell from scaffolding seven months ago. During his three-month recuperation, he became opioid tolerant, developed a dependence, and subsequently continued using opioids after his injuries had healed and he was released from medical care. As Fred puts it in a return-to-treatment interview session, “Bricking is an unforgiving occupation. When I can’t concentrate, I make mistakes. Mistakes get me injured or fired.”
Fred attempted to wean himself off opioids. When that failed, he went “cold turkey” trying to stop using abrupt withdrawal. However, the intense symptoms of withdrawal and constant cravings proved too much for him. He has subsequently entered a formal medication-based treatment program for opioid abuse.
In his first six weeks of the treatment program, Fred is switched from his drug of choice, OxyContin, to buprenorphine, a partial opioid agonist used to diminish physical dependence to opioids.26 The treatment produces a lack of cravings, and urine testing shows that Fred is staying opioid-free. The buprenorphine is gradually lowered to a maintenance amount, and Fred returns to full-time work.
Eventually, feeling cured of his cravings, Fred stops going to treatment and stops the buprenorphine. A few months go by, and another injury brings Fred into contact with oxycodone prescribed at the urgent care clinic he visits. Use of the prescription pain medication quickly increases, and he finds himself with thoughts focused on his next dose of medication. Having experienced some of the downsides of opioid dependence, as well as the benefits of regaining control, Fred presents himself to the opioid treatment center to get control of his life back again.
Opioid abuse is an epidemic of our times. We can learn from previous generations’ struggle with opioid misuse and form strategies for early detection and positive interventions. Interventions such as replacing opioid pain management with other interventions (i.e., physical therapy, thermal therapies, electronic pain management options, regional pain blocks, etc.). The interdiction of non-prescribed supplies of opioids and making pain management alternatives inexpensive and readily available, also providing those who do need higher levels of pain management with the means of controlling their pain within the health system, allowing for treatment for dependence when needed, so they are not forced into illicit and illegal methods to meet their pain control needs. Remember that detoxification doesn’t really mean much if supportive measures are not also present to help prevent relapse.
Prevention measures need to be formed at high levels of the government and the health profession, with actions and goals that we can all buy into. A uniform, united approach is the beginning of an answer to our opioid crisis, and in order for health professionals to contribute our best, we must stay informed regarding the changing landscape surrounding the pain of our opioid crisis.