The opioid crisis, also called the opioid epidemic, became formally recognized as a public health emergency in 2010. The number of deaths and hospitalizations linked to opioids for non-cancer pain had been steadily increasing since the early 1990s. As of 2019, deaths in the United States from both legally prescribed and illegally obtained opioids have risen to about 130 per day.
What are opioids?
Opioids is a class of drugs frequently prescribed for pain management. They are made from the opium poppy plant or are made synthetically in a lab. Drugs created in the lab can be made stronger or weaker than naturally derived opioids. When the drug is used in the dose and manner prescribed, it can be a safe option for the management of acute pain. But opioids are commonly misused and are often obtained illegally.
How do opioids affect the body?
Opioids work by binding to opioid receptors in the brain and other organs, blocking pain signals and increasing feelings of pleasure. The body has natural pain blocking signals called endorphins. Opioids trigger pain blocking signals like endorphins do, but at a much stronger level. Therefore they are prescribed to control pain that is beyond the level the body can naturally control.
Opioids also trigger the brain to release dopamine, another “feel good” chemical hormone. Dopamine does more than just increase feelings of well-being. It also affects movement, sleep, memory, and learning. Insufficient levels of dopamine in the body can trigger depression. The longer opioids are taken, the more tolerance builds up, so increasingly higher doses are required to achieve the desired effect. Because opioids affect the pleasure and reward centers so intensely, they are highly addictive. Users crave both the pain relief and the euphoria opioids can deliver.
While heroin is an illegal opioid, common prescription opioids include:
- Hydrocodone
- Oxycodone
- Oxymorphone
- Morphine
- Codeine
- Fentanyl
- Tramadol
- Methadone
- Demerol
- Dilaudid
Opioid side effects
Common side effects of opioids include sleepiness, slowed breathing, nausea, confusion, constipation, and euphoria. Although opioids are typically safe when used for a short time and as prescribed, they still contain the risk of addiction and the potential for overdose.
With an illegal opioid like heroin, or prescription opioids that are not used as prescribed, are illegally obtained, or used for the “high” they can deliver, there is a high risk of overdose. In 2017, the Centers for Disease Control (CDC) reported that more than 130 Americans died each day from opioid-related drug overdoses. This number of opioid-related deaths includes prescription pain medications, heroin, and synthetic opioids such as fentanyl. In 2016 synthetic opioids like fentanyl were involved in the greatest number of overdose deaths.
Signs of opioid overdose
According to the World Health Organization (WHO), “opioid overdose can be identified by a combination of three signs…referred to as the ‘opioid triad’…pinpoint pupils, unconsciousness, respiratory depression.” Respiratory depression is breathing that has become dangerously slow. When respirations decrease to a level of 8-12 breaths per minute, oxygen levels become too low and carbon dioxide becomes dangerously high. This can cause respiratory failure, coma, or death.
Other signs of an opioid overdose may include:
- Very pale, clammy skin
- Body is limp
- Fingernails or lips may have a bluish hue
- Vomiting or gagging sounds
- The person is awake but can’t speak
What is the opioid crisis?
The opioid crisis, or epidemic, refers to the alarming rate at which hospitalizations and overdose deaths associated with opioid use have increased steadily since the 1990s. This includes both the use and misuse of legally prescribed opioids and the use of illegally obtained opioids, including heroin. Drug overdose is now the leading cause of accidental death in the United States, largely due to the opioid crisis. The crisis began in the search for a drug that was less addictive than morphine but would still control severe pain.
How did the opioid epidemic start?
Despite serious side effects, morphine has been commonly used since the 1950s to control cancer pain. Morphine was, and still is, a highly addictive opioid drug, with potentially life-threatening side effects. It can be especially deadly when mixed with other drugs or alcohol. However, it was considered the best option at the time to decrease severe cancer-related pain.
In the early 1990s, doctors were looking for alternatives to morphine for control of non-cancer-related pain. To that end pharmaceutical companies began pushing opioids, reassuring doctors that they were less addictive and less dangerous than morphine for pain relief. Believing opioids had a low risk of addiction and were an effective, safe option for pain control, doctors began to widely prescribe them.
Almost immediately the rise in prescribed opioids began to translate into an increasingly high death rate linked to the drugs. By the late 1990s areas of the country where opioids were most prescribed began to exhibit the highest rates of opioid abuse, addiction, and diversion. Diversion occurs when legally prescribed drugs are used or sold by someone for whom they were not prescribed.
Is the opioid crisis getting worse?
When it became obvious that opioid use, misuse, and death had become a crisis in this country, doctors attempted to prescribe opioids more selectively. The CDC issued guidelines that advised patients to be carefully assessed before receiving a prescription for an opioid, and that non-opioids be tried first. Doctors were warned that prescription opioids should be a last resort, and, if prescribed, the duration should be short term, and patients must be closely monitored throughout.
Unfortunately, the harder it was to get a prescription for legal opioids, the more people turned to heroin. Heroin was potent, relatively inexpensive, and easy to get. Consequently, between 2002-2013 heroin overdose deaths rose by approximately 286%.
In 2017 more than 70,000 Americans died from an overdose of prescription opioids or illegal drugs. This death rate has doubled in the last decade. In 2019 the National Institute on Drug Abuse published revised data on national drug overdose rates. The data shows the highest increase of drug overdoses was related to fentanyl, a synthetically produced opioid. Most fentanyl deaths were traced to illegally made fentanyl, and not to fentanyl that was legally prescribed and then diverted.
Attempts to control the crisis
Many states have now placed restrictions on the prescribing of opioids and other controlled substances. Training for health care providers on addiction, pain management, and safe prescribing standards are among the most important steps toward controlling the opioid crisis.
A Prescription Drug Monitoring Program (PDMP) is a statewide database that tracks all prescribed controlled substances. This can alert health providers to patient behaviors, such as “doctor shopping”. It is also a valuable tool for tracking whether a patient may have been prescribed a drug his or her doctor was unaware of, that could interact with other drugs or medications. One cause of drug overdose can be a deadly interaction between drugs or alcohol.
The National Center for Biotechnology Information (NCBI) feels the answer to reversing the crisis lies with the education of physicians. Doctors are the ones trying to help patients control their pain, and most, if not all, doctors have patients who are abusing or addicted to pain medications. Medical schools need to provide their students with addiction and pain management education. The NCBI stresses the importance of including opioid prescription techniques, as well as a better understanding of how heroin and fentanyl both play a large role in the crisis.
A recent CNBC report states that only about 15 of 180 medical schools in the U.S. provide any addiction education. In 2015 The University of Massachusetts Medical School became the first to add opioid addiction classes to their program. Hopefully, many more medical schools will follow their example. Education at the medical school level will arm future doctors with non-opioid pain management techniques and a better understanding of addiction.
Meanwhile, what can doctors do when patients request treatment for pain?
- Try non-opioids first
- Prescribe only short-term
- Be open with patients about why opioids are short-term only
- Educate patients on the dangers of opioids
- Educate patients on non-opioid approaches to pain relief
- Recommend therapies like physical therapy, massage or acupuncture
- Recommend treatments using radio waves to short circuit the pain signal
- Recommend Transcutaneous Electrical Nerve Stimulation (TENS)
- Suggest biofeedback or relaxation techniques
- Recommend spinal cord stimulation
- Try injections, nerve blocks, or pain pump
If other methods fail and opioids are indicated, prescribe according to the World Health Organization (WHO) analgesic ladder.
The WHO analgesic ladder suggests prescribing pain medications in the following order:
- Non-opioids like acetaminophen
- As necessary, mild opioids like codeine
- Then stronger opioids
What are your options if you’re addicted to opioids?
Treatment for opioid addiction often takes place at a hospital or inpatient treatment facility. The treatment approach is usually a combination of medications, individual and group counseling, and behavioral therapies. Medication-Assisted Therapy (MAT) is an effective holistic approach that includes these components. Medications commonly used to treat opioid addiction include methadone and buprenorphine, which help lessen withdrawal symptoms and cravings. Start by talking with your doctor about your addiction. He or she can guide you with treatment options and resources.
