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
DSM-5 Opioid Use Disorder Criteria Sum-up9,15,17
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:
- Craving present to use opioids
- Opioids used in larger amounts or for longer than was intended
- Excessive time spent obtaining, using, or recovering from opioid use
- Unsuccessful efforts or desire to control or cut back on opioid use
- Continued opioid use despite knowing of persistent psychological or physical problems that will be caused by the use
- Opioid use in physically hazardous situations
- Tolerance as demonstrated by larger amounts of opioids needed to achieve previous effect, or decreased effect of opioids with continued use of same amount
- Withdrawal as demonstrated by symptoms of opioid withdrawal syndrome, or taking opioids to relieve or avoid withdrawal
- Persistent or recurrent interpersonal or social problems that are exacerbated by use of opioids, or continued use of opioids despite social or interpersonal problems
- Failure to fulfill major role obligations at home, work, or school as a result of recurrent opioid use
- Reduced or given up important social, occupational, or recreational activities due to opioid use
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”.
Case Study: Darnell
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
Costs of The War on Drugs3,20,21
The war on drugs has been being waged since 1971. Some of its costs include;
- More than $1 trillion spent
- Millions of people arrested and imprisoned
- Over half of those currently in federal prison are incarcerated on drug-related charges
- Increases in prescription drug costs
- Increases in illegal, illicit drug use
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.