Opioid Crisis: Feeling the Pain (FL INITIAL Autonomous Practice- Pharmacology)

Drug overdose is currently the leading cause of accidental death in the United States, with opioids being the most common drug of misuse(Schiller et al., 2022). A disturbing increase in opioid related deaths has led many to call that the title of epidemic be applied to our current opioid crisis.

During just the one-year interval of 2019 to 2020 the Centers for Disease Control and Prevention (CDC) relates that in the United States (Centers for Disease Control and Prevention[CDC], 2022a; Schiller et al., 2022):

• Opioid related death rates increased by 38%
• Prescription opioid death rates increased by 17%
• Synthetic opioid (e.g., fentanyl and tramadol) related death rates increased by 56%
• Emergency Rooms had more than one thousand daily visits related to misuse of opioids with around 91 opioid deaths occurring under direct emergency care daily
• 187 Americans died every day from an opioid overdose

Many experts agree with the CDC suggestions that opioid misuse and overdose is related to the medical mismanagement of pain (CDC, 2022c; Schiller et al., 2022). Poor treatment of existing pain, according to experts, works to drive patients to seek additional and alternative methods of pain control. Frankly, as Elizabeth Schiller states in an excerpt from the 2022 book Opioid Overdose, a $2 street bag of heroin is an inexpensive supplement for overpriced, inadequate, and difficult to obtain prescription medications. With the glut of high potency fentanyl flooding across the borders of our nation, low-priced, yet dangerous, options are readily and cheaply available in the fight against pain.

This dilemma creates a serious split on how to manage the epidemic of opioid misuse. Are we dealing with a population seeking relief from poorly managed 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 further endanger themselves and others? Silly as these questions may seem, they are very real.

Let us look at the subject in question, opioids: their benefits and their use, how this situation of uncontrolled misuse crept up on us, and finally, what is occurring about it now as well as if there are plans for moving forward to mitigate what has become a deadly opioid crisis.

When we hear the word “opioid” it refers to chemicals, both natural and synthetic of origin, that when taken correctly mimic the pain dampening ability of the resin obtained from the opium plant. The word “opioid” is, in fact, derived from the substance “opium”, the concentrated juice of the poppy Papaver somniferum which can aid in sleep, pain relief, and relaxation. This is where morphine, codeine, and other alkaloids used as, or in, prescription medication originate. Below is a list of natural opiates, semisynthetic opiates, and synthetic opiates.

Opium, and to a greater or lesser extent all “opioids,” 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 slightly euphoric feeling in both the limbic areas of the brain that house the central nervous system “reward” response, and the frontal cortex which helps to mediate pleasure. 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. The longer opioids are utilized, less and less endorphins are manufactured by the body, leaving natural pain fighting abilities handicapped and at a loss to function normally (Shenoy & Lui, 2022).

Let us be clear, prescription opioids are an invaluable asset for the legitimate control of moderate to severe pain.

Misuse of opioids, however, is a problem. For some, the relief from stress, the warmth, the feeling of “at ease with life” that accompanies an opioid’s pain relief, lowering of heart rate, widening of blood vessels, and gentle sedation is the goal. Then, there are those reaching for the intense pleasure elevated levels of the neurotransmitter dopamine; a chemical increased by opioids, can help produce. As explained below, dopamine is known as the “feel-good” neurotransmitter.

In part, according to Nora Volkow, director of the National Institute on Drug Abuse (NIDA), it is the excellent job opioids do to manage initial pain and help us to feel better that contributes to the overuse and misuse problem (Petrus & Carter, 2022). Director Volkow suggests that once pain turns long-term or chronic then over-usage and over-prescription of opioid pain medication occurs by practitioners who depend on them rather than other methods of pain relief. Patients then become dependent on greater amounts of opioids, for longer durations of time, than is helpful or healthy. She suggests that limits placed on prescription opioid quantities and length of treatment allows black-market alternatives such as heroin and fentanyl to provide an unhealthy hope for pain relief desperately sought. Director Volkow emphasizes the need for research tasked with finding nonaddictive pain relievers (Petrus & Carter, 2022), while focusing on the transition from acute to chronic pain and developing reliable biomarkers for the presence and level of pain.

The terminology “opioid”, “opiate”, and “narcotic” can be confusing. The following table below reviews the differences.

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 substantial risk for the development of a dependence. When used for pain for more than two to three days many people begin to develop a physiological tolerance. This is important. It means a more rapid break down of the opioid chemicals by the body is occurring at the same time as a greater resistance is building to the positive opioid effects. Therefore, it takes larger and larger quantities of the medication to get the same result as in the beginning. Some patients begin to think obsessively about how to get larger amounts of 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 three million adults in the United States and 156 million adults worldwide (Azadfard et al., 2022). This has led to around 107,622 opioid-related deaths in the United States in 2021, which according to the CDC, is a 45% increase since 2019 and 55.6% according to other government sources (National Center for Health Statistics Pressroom, 2022; Delaware Psychological Services Staff [DPS], 2022). In fact, experts state that opioid-related death is the most lethal drug epidemic in American history (Dydyk et al., 2022).

Surprisingly, the greatest leap in deaths from drug overdose are attributed to use or misuse of synthetic opioids, such as fentanyl, with the number of opioid deaths related to prescription medication remaining stable.

Be aware, tolerance to the positive effects of opioids – which means diminishment of positive effects, such as euphoria, develop faster than the body’s ability to manage opioids dangerous effects, creating a considerable risk for overdose by mistake.

Opioid use disorder has a standard definition involving opioid use and the repeated occurrence within 12 months of two or more of eleven specific problems. The problems include items such as opioid withdrawal when the use of opioids stops, sacrificing essential life events rather than miss the use of opioids, and devotion of excessive time using opioids.

The presence of six or more of these eleven problems indicates severe opioid use disorder (Dydyk et al., 2022):

• Continued use despite worsening physical or psychological health
• Continued use leading to social and interpersonal consequences
• Decreased social or recreational activities due to use
• Difficulty fulfilling professional duties at school or work due to use
• Excessive time spent to obtain opioids, or to recover from taking them
• Takes more than intended
• Cravings for opioids
• The individual finds themselves unable to decrease the amount used
• Tolerance has built toward the effect of opioids
• Participating in dangerous or risky behaviors that are new since the start of opioid use
• Withdrawal occurs when opioid use stops

History aids us to make sense of the present, plan productively for the future, and frankly, 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 when opium became the key to the control of all trade in entire regions of Asia (Kare, 2022).

The Opium Wars 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.

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 as an aid in finding sleep (Letizia, 2022).

As though to mirror our present crisis, late 1800’s 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. In the early 1900’s, the sweet poison effects of heroin and cocaine became too great to ignore and the government lurched into sluggish motion with the 1914 Harrison Act, the very first national effort to contain a drug epidemic (Lautieri, 2022). Effects from the Harrison legislation led to codeine and heroin limited to physician prescription only. This restricted the quantities sold, driving up the costs of the medications, and creating the beginnings of a vast underground supply and demand market system. Bringing illicit and illegal opioid use into a “do not ask do not tell” type of existence where affected family members and addicts were, to the best of society’s ability, ignored. The shadowy existence of drug addiction 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, tolerance, and empathy of the nation.

During previous opioid crises, just as in our current state of opioid epidemic, claims from pharmaceutical distributers that patients would not become addicted to whichever new opiate pain medicines they had to sell were common. In response, then and now, prescribers engaged in a frenzy of prescription writing, often giving thirty or more days’ supply to those whose pain would, by normal processes, be gone within two or three days.

A detailed look at available research into the current opioid crisis shows that from 1999 to 2019 over 500,000 opioid deaths occurred in three distinct waves (Biancuzzi et al., 2022).

The surplus of available opium compounds sitting unused and available in medication cabinets in households across the country is one source of temptation to those with no ill intent who on stressful days recall the mild euphoria and feeling of relaxation (U.S. Department of Justice, 2022). Another challenge bringing risk are patients attempting to follow misunderstood prescriber orders with the presumption assuming they are to finish however large a prescription ordered. Why else were such amounts ordered for them?

To heighten the danger, other opioids add into the current crisis. Heroin, no longer a monopoly of the far east, arrives cheaply and efficiently from neighboring Mexico, and Central American countries. Easy transport across a long, poorly secured land border makes both heroin and the glut of synthetics, such as fentanyl, cheap and easily obtainable. Many chronic pain patients readily accept inexpensive street heroin into their self-treatment when they realize there is an alternative to expensive, difficult to obtain from prescriber, prescription medication. In our current crisis, potent opioids such as fentanyl, a synthetic opioid one hundred times more powerful than morphine, has become available to street drug vendors, becoming rapid favorites to those seeking inexpensive, powerful effects. Review the following table for additional important information about fentanyl.

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 significant issue deserving more than kneejerk election-year attention by our nation’s leaders and policymakers. The economic toll of the opioid addiction and overdose crisis in the US reached $1.5 trillion in 2020 alone and is likely to grow, according to a recent US Congressional report (Dorcas, 2022). As we have seen in previous opium/opioid addiction epidemics, coming between a person’s need for pain relief and, for some, their desire for pleasure and helpful medications, no matter what the source, 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 1970s – 2020 war on drugs (Cyetkovska, 2022).

One example of a progressive change in attitude is the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5-TR [TM]), by the American Psychiatric Association (APA). The DSM-5 is the go-to reference for conditions affecting thought, moods, emotions, and behaviors, such as opioid abuse. In its newest iteration, the 2022 edition, an earnest 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 softened. 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 (APA, 2022). Views of addiction also have shifted with the diagnostic criteria of encounters with the law, i.e., the “recurrent legal problems” disappearing 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”. Below is a table including the DSM-5-TR criteria for Opioid Use Disorder.

One reason an update in attitude toward those who misuse opioids is valuable, is that the primary reason given by those misusing them is the relief of physical pain (Biancuzzi et al., 2022). While some misuse of opioids is 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.”

Molly is a 38-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. Molly 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. Because of this, Molly began increasing the dosage she was taking. This led to running out of medication early. Her PCP (primary care physician) complied with repeated early prescription renewals, each time with a more strongly worded warning about decreasing the amount of oxycodone used. After several early prescription renewals, Molly’s PCP refused to continue prescribing the medication.

Molly 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 other physicians and received extensive advice, though she was unable to get opioid pain prescriptions from them.

When a cousin introduced Molly 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 so that she might use enough pain medication to sleep soundly, which led to her termination for her frequent absences. Money became scarce so when her supplier “ran short” of oxycodone it did not take much to convince Molly to try “just a little” heroin, which proved much 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, family and friends began to severely limit contact with her, and members of her close family began discussing “an intervention” to try to help Molly.

Consideration – Incarceration alone does not cure opioid misuse.

The 1970s Nixon era “War on Drugs,” continued by every presidential administration until policy changes in March 2020, has taught us many things about substance use and addiction (Cyetkovska, 2022; Duchovny & Mutter, 2022). First, it showed us that the war on drug users does not work. Secondly, deprivation or abstinence alone from a drug of choice, including opioids, does not reduce the chance of returning to that substance when it again becomes available (Y, 2022). This has proven a deadly problem as the time away from opioids reduces the built-up tolerance a person’s metabolism has. That means the rate of overdose deaths within state prisons has surged over 600% in the last two decades. In former inmates, who, on release, often return to using their previous dosage, the overdose rates run nearly 40% higher than the general population(The Recovery Village, 2022; Finley, 2022). Please review the following table, which includes the costs of the war on drugs.

Caging opioid users whose offenses center on nonviolent use, as in past eras, need to be 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 are presenting their own, unique plan on how to combat the opioid epidemic. Let us look at concepts already implemented or that 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 presented an initiative to “confront the driving forces behind the opioid crisis". Trump’s plan, brought into action in three distinct laws passed during 2016 and 2018 contains three core focus points, each with progressive actions under them(Duchovny & Mutter, 2022):

1. Reduce opioid demand.
   • Launch a nationwide evidence-based public awareness campaign about the dangers of prescription and illicit opioid (and other narcotics) use.
   • Support research and development of therapies and technologies to prevent addiction and decrease the need for opioids in pain management. (e.g., non-addictive pain management options, the potential for a vaccine specific in the prevention of opioid addiction).
   • Reduce overall opioid prescriptions (e.g., ensure that within three years 75% of opioid prescriptions reimbursed by federal dollars are issued using best practices, with 95% compliance within five years).
   • Ensure that the nationwide Prescription Drug Monitoring Program advocated in the Affordable Care Act become operational throughout all states.
2. Stop the flood of illicit drugs across borders and within communities.
   • Secure land borders, ports of entry, and waterways against smuggling.
   • Require electronic advance documentation for 90% of all international goods-by-mail shipments and consignment shipments within three years.
   • Utilize advanced screening technologies and drug-sniffing canines with all high-risk international packages to interdict illegal shipments.
   • Engage with opioid source countries such as China and Mexico to cooperate with stopping the movement of opioids, precursor chemicals, and other illicit drugs.
   • Expand efforts to prosecute corrupt or criminally negligent prescribers, pharmacies, opioid manufacturers, and distributors.
   • Strengthen enforcement and penalties for drug traffickers.
3. Save lives with proven treatments for opioid addictions and overdose.
   • Ensure first responders supply of naloxone to reverse opioid overdose.
   • Improve nationwide overdose tracking to shift resources to areas of need.
   • Expand evidence-based addiction treatment in every state, focusing on medication-assisted treatment for opioid addiction.
   • Provide on-demand evidence-based addiction treatment to service members, veterans, and their families.
   • Identify and treat criminal offenders struggling with addiction. (e.g., screen every federal inmate for opioids on intake, facilitate treatment for federal inmates while supporting state, tribal, and local drug courts to provide evidence-based treatment as an alternative or in conjunction with incarceration and supervised release.

The U.S. Department of Health and Human Services, HHS, has pushed forward with plans for an approach to containing the opioid crisis focusing on nationwide improvement of treatment and recovery services (Strelecki, 2021):

1. Promoting the availability and use of opioid overdose-reversing medication.
2. Strengthening public health surveillance to gain a better understanding of opioid-related problems.
3. Research support on both controlling pain and minimizing addiction.
4. Advocating the actual use of better methods of pain management.

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 urging more citizens to have Narcan on hand to help those they find overdosing on opioids(Office of the Surgeon General, 2022).

Review the following table for important information regarding the acute opioid overdose medication, Narcan.

The National Institute of Health, NIH, a branch agency of the massive HHS system has already been meeting with academic researchers and the big pharmaceutical companies who bear a decent portion of blame for the current opioid flood pushing the current crisis forward. The plans NIH is busy implementing include(Strzelecki, 2021):

• Improving access to prevention, treatment, and recovery support services.
• Targeting the availability and distribution of overdose-reversing drugs.
• Strengthening public health data reporting and collection.
• Supporting innovative research on addiction and pain.
• Advancing the practice of pain management.

Although much is said regarding the pharmaceutical industry’s actions relating to this generation’s opioid epidemic, certain large corporations are stepping up with initiatives to slow the growth of addiction. Pharmacy chain CVS Caremark, for example, began implementing filling restrictions for new pain medication prescribed, limiting new opioid users to a seven-day supply of medication (CVS, 2020). Other medication dispensaries are considering coming on board with this self-limitation, and legislative plans are advocating this throttled down introduction to opioids to become a law of the land.

According to the NIH, only about 20% of those who misuse opioids progress on to moderate or severe opioid use, what we used to define as “abuse” (National Institute of Health [NIH], 2022).

Commonly accepted practices have shown success 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 patients in safe practices, and prescribers in positive actions are useful (Fernandez, 2022; Pain Management Best Practices Inter-Agency Task Force, 2019; NIH Staff Author, 2022):

• Educating people, both young and old, about the potential dangers of opioid misuse.
• Encourage patients only to take the medication and amounts prescribed.
• Store opioids safely, to keep others away from them.
• Encourage prescribers to keep a close watch on client opioid use and pull the medication while replacing it with other pain control interventions quickly when misuse is determined.
• Using alternatives to opioids:
  • Other medications in conjunction or to replace opioids – Over the counter (OTC) analgesics, anticonvulsants, antidepressants, musculoskeletal agents, antianxiety medications.
  • Restorative therapies – Cold or heat, therapeutic exercise, transcutaneous electrical nerve stimulation, traction, bracing, therapeutic ultrasound, therapeutic laser application, physical therapy.
  • Interventional procedures – Steroid injections, use of nerve blocks, cryoneuroablation, radiofrequency ablations, medication pumps, joint injections.
  • Behavioral health interventions – Behavioral therapy, cognitive behavioral therapy, acceptance therapy, mindfulness meditation, emotional awareness.
  • Complementary and Integrative health – Spirituality, acupuncture, acupressure, massage, chiropractic, naturopathic, nutritional therapies.
• Be clear to patients they must not accept pain medication from others, nor share their pain medication with others.
• Schedule talks with or phone calls by the physician about how things are really going to decrease anxiety and therefore medication needs, schedule contacts or calls with a nurse at least weekly.
• Encourage patients to return unused medication to their pharmacy or another drug take-back location as soon as they no longer need it. No “saving” medications “just-in-case.”

It is important to be aware of the signs and symptoms of possible opioid dependence. Be alert for signs of opioid dependence, including (CDC, 2022a; Texas Recovery Centers, 2022; Sachdev, 2022):

• Presence of Withdrawal Symptoms
• Behavioral Changes– Avoids making eye contact even with friends or family, experiences mood swings, quickly becomes irritable, is nervous or unusually excited or euphoric. Abrupt changes in energy levels at times accompanied by becoming hostile without warning.
• Physical Changes– Noticeable changes in physical appearance, weight loss or weight gain, constricted pupils, drowsiness, slurred speech, constipation, slowed breathing, malnutrition, even an increase in skin and other infections.
• Drowsy, Distant, and Detached– Frequently appears drowsy and vague, becoming detached from family or friends. Exhibiting a lack awareness of the people and things around them, are inattentive, and are no longer interested in doing their usual hobbies. Personality seems different, and there is often trouble making decisions.
• Memory, Relationships– Confusion, disorientation, difficulty concentrating, all of which adversely affects relationships and other life aspects. With opioid use, patients tend to become slow to respond to questions, avoid problem-solving, and ignore obligations.
• Obligation Problems– Work performance slips or grades lower in school. Difficulty maintaining bonds with friends and family, remembering appointments, or paying attention to loved ones, missing gatherings. Noticeable is a tendency to skip out on plans without notice. Things become neglected, like daily chores, calling family, or taking care of personal hygiene and appearance.
• Multiple Providers – Patients obtaining opioid prescriptions from multiple healthcare providers, without the prescribers knowing about the other prescription. It is also a common claim to have lost their prescription and need another one filled, or complain the pain is so bad they need a stronger prescription.
• Moving on to Heroin Use –Sadly, when prescription drugs are too challenging to obtain, patients misusing opioids turn to the more available “street” drugs, like heroin. Heroin works similarly to most prescription opioids, fulfills the urges and cravings, and is more powerful when injected. Many heroin addictions stem from initial prescription opioid use.
• Ownership of Odd Items– Opioid consumption can be oral, snorted, smoked, or injected. Odd items related to opioid use might include hose clamps, syringes, or needles, bent spoons, rolled-up dollar bills, straws, or tubes that someone has cut into smaller pieces.

Overdose of opioids is not what television, or the media portray. It is rarely dramatic. It is, in fact, difficult to tell if someone is just opioid inebriated – disoriented, sluggish, slow to respond, or if they are in the grips of a potentially fatal overdose (Santos-Longhurst, 2022).

Remember, anyone utilizing opioids, including patients taking them exactly as prescribed and who are under direct supervision, may overdose. Many situations can lead to an adverse response when a higher level of opioid is in their system than they can tolerate:

• A new opioid or opioid derivative that their metabolism is not used to
• A larger dose than they typically use
• The presence of a health condition that contributes to unwanted effects
• A product contaminated with other opioids (fentanyl for example)
• Mixing alcohol or other drugs with opioids
• Crush and snort, or liquify and inject opioids intended for oral use

Visible indications that an opioid overdose may be occurring include (Ashong-Katai, 2021):

• Pinpoint pupils
• Unconsciousness, even to shouting and shaking
• Breathing difficulty, shallow breathing, or a choking snore-like gurgle
• Cyanotic lips, skin
• Clammy skin
• Pulse that is slow or weak

It is common for death due to opioid overdose to take time, not be instantaneous. Most deaths occur due to the individual being alone (Santos-Longhurst, 2022).

When suspecting an opioid overdose, act:

The absence of opioids in a person with dependence and tolerance typically leads to withdrawal. Opioid withdrawal can be a brutal affair, and contrary to conventional shared wisdom amongst health providers, opioid withdrawal can indeed be life-threatening.

Withdrawal symptoms may begin at once after the administration of an opioid antagonist (e.g., naloxone or naltrexone) or a partial opioid antagonist (e.g., buprenorphine). Stopping opioids after a prolonged period of use results in withdrawal symptoms around 6 hours after the last dose of a short-acting opioid, and up to 48 hours after stopping the longest acting opioid, methadone (Drugs.com, 2022).

The peak of withdrawal tends to be within 24-48 hours yet persists days for the short-acting agents and up to 2 weeks for methadone, with sleep and mood disturbances often persisting for months. Those who have undergone opioid withdrawal compare it with the “worst case of flu imaginable” and with justification as symptoms of withdrawal parallel those of food poisoning, or the gastrointestinal effects of influenza. Muscle and abdominal cramping, nausea, diarrhea, runny nose, tearing eyes, dizziness, and restlessness to name the more common opioid withdrawal symptoms.

Opioid withdrawal is known to cause brief, but severe, episodes of depression that can lead to suicide attempts and completed suicide. Accidental opioid overdose, particularly among those desperate to avoid withdrawal, is common and healthcare staff should not mistake it for a suicide attempt.

Emergency help should respond when these symptoms occur (Drugs.com, 2022):

• The person has a seizure
• Those present cannot rouse the person

Christopher is a 29-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 medical had discharged him. As Christopher puts it in a return-to-treatment interview session, “Bricking is an unforgiving occupation. When I am in pain I cannot concentrate, I make mistakes. Mistakes get me injured or fired.”

Christopher 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, Christopher stopped his drug of choice, OxyContin, and began buprenorphine, a partial opioid agonist used to diminish physical dependence to opioids(Miller, 2022). The treatment produced a lessening of cravings, and urine testing showed that Christopher was staying opioid-free. The buprenorphine gradually reduced to a maintenance amount, and Christopher returned to full-time work.

Eventually, feeling cured of his cravings, Christopher stopped going to treatment and stopped the buprenorphine. A few months went by, and another injury brought Christopher into contact with oxycodone prescribed at the urgent care clinic he visited. Use of the prescription pain medication quickly increased, and he found himself with thoughts focused on his next dose of medication. Having experienced the downsides of opioid dependence, as well as the benefits of regaining control, Christopher presents himself to the opioid treatment center to get control of his life back again.

Management of opioid withdrawal occurs on an outpatient basis in most instances. For severe withdrawal, or in the presence or other serious comorbid conditions, hospital stay, or in-patient drug treatment facility care might be prudent.

Detox is the process of eliminating opioids in a client during withdrawal. These programs typically take place in a hospital, inpatient treatment center, or opioid treatment center although there has been an increase in at-home assisted detox programs with varying levels of support. Detox treatment allows family or staff to administer medications to alleviate symptoms, provide support, and prepare patients for additional treatment.

Medications approved for opioid withdrawal support are methadone, buprenorphine (Suboxone), and naltrexone (Vivitrol). Evidence-based studies have shown reduction in dependence, reduction in drug cravings, lessening in uncomfortable symptoms, and an increased ability and motivation for participation in behavioral counseling and therapy using these medications (Texas Recovery Centers, 2022). In general buprenorphine is preferred over methadone for opioid treatment (Strain & Peavy, 2022).

Behavioral therapy is the most usual form of generalized addiction treatment and works well with counseling and support services to change destructive patterns of behavior along with how a person thinks about substances of misuse. Two common behavioral therapies with proven efficacy for treating opioid addiction include cognitive-behavioral therapy (CBT) and dialectical behavior therapy (DBT). These treatments involve developing coping skills and healthy habits for long-lasting recovery.

Opioid misuse is truly an epidemic for our times. We can learn from previous generations’ struggle with opioid problems and form strategies for early detection and positive interventions. We learn from the past, for example, that taking an attitude of caution towards all new products introduced by merchandizers is the most important and earliest positive action that can be taken to prevent addiction related disaster (Gross, 2022; St. Louis Post-Dispatch Editorial Board, 2022).

What else can we do? Making pain management alternatives inexpensive and readily available could help. Also, providing those who do need higher levels of pain management with the means of controlling their pain within the health system. Making this allowance for treatment of dependence when needed makes it so that those with higher levels of pain are not forced into illicit and illegal methods to meet their pain control needs. Interventions include replacing opioid pain management with other methods of care (i.e., physical therapy, thermal therapies, electronic pain management options, regional pain blocks) is also a positive option.

Prevention measures need to be formed at elevated levels of the government with the assistance of the health profession, with actions and goals that we can all buy into. Supportive and positive options need to be established at all levels of illness and pain management. For those needing support, the process of detoxification and therapeutic interventions are among the most helpful measures considered necessary for individuals seeking escape from the trap of opioid misuse, combined with prevention of relapse. For health professionals to contribute our best for the sake of our patients and our nation, we must stay informed regarding the changing landscape surrounding the pain of our opioid crisis.

• American Psychological Association. (APA). (2022). Diagnostic and Statistical Manual of Mental Disorders (5th ed., text rev.). Arlington, VA, USA. Visit Source.
• Ashong-Katai, A. (2021, December 27). What are the symptoms of opioid overdose? Codac Behavioral Healthcare. Visit Source.
• Azadfard, M., Huecker, M. & Leaming, J. (2022, September 9). Opioid Addiction. National Library of Medicine. Visit Source.
• Babu, K. (2022, May 10). What is fentanyl and why is it behind the deadly surge in US drug overdoses? UMass Chan Medical School. Visit Source.
• Biancuzzi, H., Dal Mas, F., Brescia, V., Campostrini, S., Cascella, M., Cuomo, A., Cobianchi, L., Dorken-Gallastegi, A., Gebran, A., Kaafarani, H., Marinangeli, F., Massaro, M., Renne, A., Scaioli, G., Bednarova, R., Vittori, A., Miceli, L. (2022, September 17). Opioid misuse: A review of the main issues, challenges, and strategies. International Journal of Environmental Research and Public Health. 19(18): 11754. Visit Source.
• Centers for Disease Control and Prevention. (CDC). (2022a, August 30). Opioid use disorder. Centers for Disease Control and Prevention (CDC). Visit Source.
• Centers for Disease Control and Prevention. (CDC). (2022b, May 24). Prescription opioids: The basics. Centers for Disease Control and Prevention (CDC). Visit Source.
• Centers for Disease Control and Prevention. (CDC). (2022c, June 1). Understanding the epidemic. Centers for Disease Control and Prevention (CDC). Visit Source.
• Conklin, A. (2021, December 16). Fentanyl overdoses become no. 1 cause of death among US adults, ages 18-45: ‘A national emergency’. Fox News.Visit Source.
• CVS. (2020, December 17). CVS Caremark opioid quantity limits pharmacy reference guide. Caremark. Visit Source.
• Cyetkovska, L. (2022, March 5). 31 war on drugs statistics & facts that are hard to believe. Loud Cloud Health. Visit Source.
• Delaware Psychological Services Staff. (DPS Staff). (2022, April 15). The differences between illicit and pharmaceutical fentanyl. Delaware Psychological Services. Visit Source.
• Dorcas, A. (2022, October 3). Mounting burden of opioid-related deaths in the United States. MedIndia. Visit Source.
• Drugs.com. (2022, December 2). Opioid withdrawal. Drugs.com. Visit Source.
• Duchovny, N., & Mutter, R. (2022, September 1). The opioid crisis and recent federal policy responses. Congressional Budget Office. Visit Source.
• Dydyk, A., Jain, N., & Gupta, M. (2022, June 21). Opioid use disorder. National Library of Medicine. Visit Source.
• Estrellado, N. (2022, November 10). Narcan uses, side effects, & risk factors. Addiction Group. Visit Source.
• Fernandez, L. (2022, August 15). Opioid misuse prevention in Arizona. Illuminate Recovery. Visit Source.
• Finley, E. (2022, August 3). Overdose deaths and other problems in America’s prison system. Prison Journalism Project (PJP). Visit Source.
• Fookes, C. (2022, July 15). Opioid vs opiate- What’s the difference between them? Drugs.com. Visit Source.
• Gross, T. (2022, August 2). New book chronicles how America’s opioid industry operated like a drug cartel. NPR. Visit Source.
• Guy-Evans, O. (2022, February 22). The role of dopamine as a neurotransmitter in the human brain. Simply Psychology. Visit Source.
• Kare, D. (2022, August 16). Opium wars in China- First and second opium war. UPSC Civil Services. Visit Source.
• Lautieri, A. (2022, May 6). Heroin history and statistics. American Addiction Centers. Visit Source.
• Letizia, L. (2022, November 30). “As gunpowder to the ordnance”. The United States’ first opioid crisis. Civil War Institute. Visit Source.
• Liebhaber, L. (2022, March 2). Over 1 million Americans are seeking treatment for substance use disorder- here’s how it breaks down by state. Zinniahealth. Visit Source.
• Merriam-Webster. (2022, December 1). Illicit. Merriam-Webster.com Dictionary. Visit Source.
• Miller, L. (2022, December 7). Buprenorphine for addiction treatment. American Addiction Centers. Visit Source.
• Muller, J. (2022, January 11). Narcan vending machines installed across U.S. to fight opioid crisis. Axios. Visit Source.
• National Center for Health Statistics Pressroom. (2022, May 11). U.S. overdose deaths in 2021 increased half as much as in 2020- But are still up 15%. Centers for Disease Control and Prevention (CDC). Visit Source.
• National Institute of Health. (NIH). (2022, November 10). Stopping opioid misuse in its tracks. National Institutes of Health. Visit Source.
• Office of the Surgeon General. (2022, April 8). U.S. Surgeon General’s Advisory on naloxone and opioid overdose. U.S. Department of Health & Human Services. Visit Source.
• Pain Management Best Practices Inter-Agency Task Force. (2019). Pain management best practices inter-agency task force report: Updates, gaps, inconsistencies, and recommendations. U.S. Department of Health and Human Services. Visit Source.
• Petrus, E., & Carter, L. (2022, April 6). Opioid addiction and chronic pain NIH pain consortium symposium highlights. Intramural Research Program. Visit Source.
• Recovery First Treatment Center Editorial Staff. (2022, November 5). War on drugs statistics. Recovery First Treatment Center. Visit Source.
• Sachdev, P. (2022, March 28). Are addiction and substance abuse disorder the same? Medicine Net. Visit Source.
• Santos-Longhurst, A. (2022, February 17). Understanding the difference between opiates and opioids. Healthline. Visit Source.
• Schiller, E., Goyal, A., & Mechanic, O. (2022, September 19). Opioid overdose. National Institute of Medicine. Visit Source.
• Shenoy, S. & Lui, F. (2022, June 20). Biochemistry, endogenous opioids. National Library of Medicine. Visit Source.
• Stevens, A. (2022, May 15). Drug misuse definition: How to know if you or someone you love is misusing drugs. Ascendant. Visit Source.
• St. Louis Post-Dispatch Editorial Board. (2022, December 17). Editorial: A costly fentanyl Frankenstein carrying DNA from Big Pharma’s opioids. St. Louis Post Dispatch. Visit Source.
• Strain, E., & Peavy, K. (2022, April 26). Approach to treating opioid use disorder. UpToDate. Visit Source.
• Strelecki, M. (2021, December 20). Five to know: The opioid workforce act. Critical Values. Visit Source.
• The Recovery Village. (2022, May 5). Released prisoners at shockingly high risk for opioid overdose deaths. The Recovery Village. Visit Source.
• Texas Recovery Centers. (2022, April 12). 7 signs of opioid use and addiction. Texas Recovery Centers Addiction Campuses. Visit Source.
• U.S. Department of Justice. (2022, November 28). Opioid facts. U.S. Department of Justice. Visit Source.
• Y, B. (2022, October 26). How many addicts relapse after jail. Addiction Talk Club. Visit Source.