THE OPIOID CRISIS
By: Margaret Kadree, MD
Chief Medical Officer, Johnson Health Center
opioid crisis has risen to such proportions that it has had to be addressed at
a national level. Historically, the overuse of opioids is not a novel
situation, it can be traced back to prior to the American revolutionary war1.
Opioids were introduced to the American colonies by European settlers and was
effective in treating pain related to a variety of common ailments. With the
advent of injectable morphine, which provided soldiers substantial pain relief
during the civil war, a documented wave of morphine overuse occurred1. Because morphine appeared to be effective for
a wide array of illnesses, it was indiscriminately included in a significant
number of medications, including medicines for children. Death of infants from this type of usage prompted
the FDA to introduce the Pure Food and Drug Act of 1906 which mandated
oversight and labeling of the contents of medications – and subsequently – the
Harrison Drug Act of 1914, which limited the ability of physicians to prescribe
opioids1. These laws helped
to reduce the widespread use of opioids at that time and by so doing stemmed
that epidemic. Since then there have been several waves of opioid overuse –
however, these were related to primarily non- prescription drug use. In the
1990s, with the push to make patients suffering from pain, “pain-free”, potent
oral opioid agents became available. These agents were promoted as being safe
for patients and having a low risk of addiction1,2. Concomitantly,
the National Academy of Medicine encouraged physicians to prescribe opioids
more liberally for their patients with pain. The Joint commission for
Accreditation of Hospitals, a major accrediting body, even had as a quality
marker whether patients’ providers were managing their pain adequately1.
All of these conditions coming together at the same time have contributed
substantially to the current opioid epidemic. With the increased availability
of opioids through legitimate channels, opioids can now be found in the
medicine cabinets at home, making it available to individuals who have not been
directly prescribed these medications – and unfortunately – this includes
children – so that our current epidemic is not just one that affects adults but
also our pediatric population1,4. This is an entirely new phenomenon.
According to a report from NIDA updated in
January of 20193:
Every day more
than 130 people die from opioid overdose
In 2017 more
than 47,000 died as a result of opioid overdose [ including prescription drugs]
1.7 million people suffered from substance
use disorder related to prescribed opioids
Roughly 21 to 29 percent
of patients prescribed opioids for chronic pain misuse them
Between 8 and 12 percent
develop an opioid use disorder
An estimated 4 to 6
percent who misuse prescription opioids transition to heroin
About 80 percent of people who use heroin first misused
Opioid overdoses increased
30 percent from July 2016 through September 2017 in 52 areas in 45 states.
Opioid overdoses in large
cities increased by 54 percent in 16 states.
regards to the pediatric population, neonates and adolescents between the ages
of 12 to 17 are the most adversely affected. The incidence of neonatal
abstinence syndrome [NAS] increased five-fold between 2004 and 20144
– in spite of the fact that treatment of opioid use disorder [OUD] during
pregnancy has been the standard of care since 1998. According to the 2016
National Survey on Drug Use and Health, the most current data available, 798,000
12-17 year olds had an illicit drug use disorder, of these 153,000 were opioids5.
The majority of opioid use was due to prescription pain medications – only 1000
or so were related to a heroin use disorder.
response to the opioid crisis, the U.S. Department of Health and Human Services
(HHS)has put in place “five major priorities”3:
improving access to treatment and recovery services
promoting use of overdose-reversing drugs
strengthening our knowledge of the epidemic through better public health
providing support for cutting-edge research on pain and addiction
advancing better practices for pain management
states have also developed agendas to contain and ameliorate the situation6.
In spite of the excellent HHS plans, it can be predicted that certain populations
may not be able to reap the full benefits of such interventions. In addition, the
perspective, until recently, that substance use disorder is of necessity
associated with criminal activities as opposed to being a medical condition, has
hampered the development of comprehensive healthcare mechanisms to manage it.
While OUD crosses all socioeconomic strata, not surprisingly, the most
adversely affected segments of the population are those with limited financial or
economic resources – especially the homeless or those who find themselves in an
unstable housing situation7,8, as well as individuals in the
criminal justice population8,12. These populations are further
encumbered by a high rate of behavioral health disorders and the cyclical
relationship between opioid use disorder and homelessness [opioid use can precipitate homelessness and homelessness in and of
itself can fuel or exacerbate a proclivity for opioid use]. The disparities
are further aggravated by the often unrecognized fact that OUD is akin to a
chronic disease, in that there are two components to therapy – short-term
management and maintenance therapy. Individuals who were diagnosed with OUD,
even when they become “drug-free” and even when they are strongly committed to
remaining “drug-free” remain at risk for relapse. In other words, maintenance
therapy is essential to minimize the incidence of relapse.
a homeless or “near” homeless individual whose OUD may have started with the
use of prescription drugs, but who, because of his or her dire financial
condition, is no longer able to afford the prescription drugs – he or she may resort
to using street heroin7 – which may be combined with other
sedatives, thus increasing the likelihood of overdose. Some states have
documented an increased rate of overdose-related deaths in the homeless
population when compared to the population at large8,9. Even
homeless veterans have not been spared in this statistic. In a 2019 article on
the opioid epidemic, in veterans who were homeless or “near” homeless, it was
noted that such veterans had an almost 2-fold increased risk of fatal drug
overdose when compared to the general population10. This has
occurred in spite of the Veteran Health Administration’s Opioid Safety
Initiative program which expanded access to naloxone [a drug which can be used to reverse opioid intoxication emergently]
as well increased access to its medication-assisted treatment program [MAT}. The
confounding factor precipitating this outcome applies to both homeless veterans
and the general homeless population – namely, limited or no access to the programs that can help such
individuals – naloxone, medication-assisted treatment and behavioral health –
directly due to the intricacies and limitations precipitated by the homeless
condition. So much so, the Substance Abuse and Mental Health Services Administration
[SAMHSA] has been encouraging homeless
and housing service providers to make naloxone available to the homeless and
“near” homeless populations7. In addition, they have requested that
friends, family members, potential responders and providers be trained to administer
naloxone emergently. SAMHSA developed an Opioid Overdose Prevention toolkit
which has been available since 2013. SAMHSA has also developed guides –
specifically for managing the homeless- which, among others, addresses MAT
resources as well as Behavioral Health resources7.
persons who find themselves within the criminal justice system, according to
the US Department of Justice, approximately 50 percent of state and federal
prisoners meet criteria for substance use disorder [SUD]11. Opioid
use disorder [OUD] is not usually treated during imprisonment. The risk of
death of a former prisoner, within 2 weeks of release, is 12 times that of the general population11. The leading cause of death is opioid overdose.
This phenomenon is in part related to the individual’s body having become
re-sensitized to the respiratory depression and sedative effects of the opioid.
During chronic use of opioids, the body develops a tolerance to the analgesic
as well as respiratory depression effects of the opioid. Thus an individual who
has been on opiates for a long time is able to take increasingly larger doses
of opiates without experiencing a fatal outcome. However, when that same
individual goes through a period of abstinence from opioids the body loses its
ability to tolerate high doses of opioids, hence the increased likelihood of a
fatal outcome. It is well documented that individuals who have OUD, and who do
not receive any treatment for same during imprisonment, have a high probability
of returning to drug use and so are at increased risk for overdosing.
Furthermore, untreated opioid disorders also contribute to an increased rate of
return to criminal activities and return to prison. Individuals with OUD who
participate in methadone treatment and counseling while in prison are less
likely to test positive for illicit opioids at one month following release. In
addition, prisoners who receive MAT are more likely to follow through with
therapy following their release from prison11.
survey of community correction agents’ view on MAT showed that understanding of
OUD as a medical disorder and validation of the effectiveness of the medications
used in treating the disorder, resulted in greater acceptance of such practices
in the correctional setting11. The World Health Organization has
recommended that prisoners should not be denied adequate health care because of
their imprisonment11 – which intrinsically includes therapy for OUD,
a defined medical diagnosis. Because of
the potential for diversion, the criminal justice system will of course have to
have measures in place to minimize opportunities for diversion, such as
directly observed therapy.
Can individuals, employers, organizations also
have a positive impact on the opioid crisis? Absolutely. An ounce of prevention
is said to be worth a pound of cure! A critical first step is increasing
awareness of the dangers of opioids. This can be done through self-education,
education in the home and among family and friends – as well as informal or
more structured education programs in the workplace, churches or any place
where people tend to gather. People also need to be apprised of the fact that
while OUD has been previously intimately linked with criminal activities, that
this is not necessarily the case for every individual who suffers from this
disorder. Education about non-opioid and non-pharmaceutical methods of pain
control is also equally critical.
Available data shows that between 40-50 percent
of individuals who develop opioid substance use disorder were first exposed to prescription
opioids through a relative or friend. Family exposure is particularly
commonplace with adolescents. Therefore, a useful measure is not to share
opioid prescriptions with others – no matter how well-intentioned, and further
– one should place opioid prescriptions in a secure place – so that they will
not be readily accessible.
When a person is identified as being addicted
to opioids, connecting them with organizations who manage these problems is
very important. This should be done in a non-judgmental fashion. The stigma
associated with substance use disorder is great enough to deter those who need
care – from seeking same.
We are indeed in the midst of yet another
opioid crisis – the resolution of which can be expedited if all hands are on
deck. It is not just up to governmental bodies and healthcare organizations to
resolve the problem – so I challenge each individual and each organization who
reads this article to choose to do at least one intervention which will move
the needle towards minimizing – if not eliminating the inappropriate use of opioids.
1.Levy S. Youth and the opioid epidemic.
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3. National Institute of Drug Abuse. US Dept
of Health and Human Services. Opioid Overdose Crises. https://www.drugabuse.gov/drugs-abuse/opioids/opioid-overdose-crisis; last updated January 2019. Accessed July
et al. Pediatrics 2019; Winkelman et al. Pediatrics 2018 . Dramatic increases
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samhsa.gov/data/ Accessed July 2019
6. National Alliance for Model State Drug
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support; PDMP/PMP] Accessed August 2019
7. Substance Abuse
and Mental Health Services Administration. Homeless and Housing Service
Providers Confront the Opioid Epidemic. https://www.samhsa.gov/homelessness-programs-resources/hpr-resources/homeless-housing-services-providers-confront-opioid. Accessed August 2019
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