THE OPIOID CRISIS
By: Margaret Kadree, MD
Chief Medical Officer, Johnson Health Center
The 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 prescription opioids
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.
With 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.
In response to the opioid crisis, the U.S. Department of Health and Human Services (HHS)has put in place “five major priorities”3:
1. improving access to treatment and recovery services
2. promoting use of overdose-reversing drugs
3. strengthening our knowledge of the epidemic through better public health surveillance
4. providing support for cutting-edge research on pain and addiction
5. advancing better practices for pain management
Individual 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.
For 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.
For 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.
A 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. Pediatrics 2019; 143 e20182752
2. US department of health and Human Services; What is the US Opioid Epidemic? http://www.hhs.gov/opioids/about-the-epidemic/index.html. Accessed August 2019
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 2019
4. Honein et al. Pediatrics 2019; Winkelman et al. Pediatrics 2018 . Dramatic increases in Maternal Opioid Use and Neonatal Abstinence Syndrome. Source: National Institute on Drug Abuse; National Institutes of Health; U.S.Department of Health and Human Services. https://www.drugabuse.gov/related-topics/trends-statistics/infographics/dramatic-increases-in-maternal-opioid-use-neonatal-abstinence-syndrome; Accessed August 2019
5.Substance Abuse and Mental Health Services Administration. (2017). Key substance use and mental health indicators in the United States: Results from the 2016 National Survey on Drug Use and Health (HHS Publication No. SMA 17-5044, NSDUH Series H-52). Rockville, MD: Center for Behavioral Health Statistics and Quality, Substance Abuse and Mental Health Services Administration. Retrieved from https://www. samhsa.gov/data/ Accessed July 2019
6. National Alliance for Model State Drug Laws; https://www.nasmdl.org/topics [prevention-intervention; treatment; recovery 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
8. Bauer LK, Brody JK, León C, Baggett TP. Characteristics of homeless adults who died of drug overdose: a retrospective record review. J Health Care Poor Underserved.2016;27(2):846–59.
9. Massachusetts Executive Office of Health and Human Services, Department of Public Health. An assessment of fatal and nonfatal opioid overdoses in Massachusetts Boston (MA): The Department; 2017 Aug – accessed august 2019 https://www.mass.gov/files/documents/2017/08/31/legislative-reportchapter-55-aug-2017.pdf
10. Amanda M. Midboe, Thomas Byrne, David Smelson, Guneet Jasuja, Keith McInnes, and Lara K. Troszak: The Opioid Epidemic In Veterans Who Were Homeless Or Unstably Housed; HEALTH AFFAIRS 2019.00281 38, NO. 8 (2019): 1289–1297 ©2019 Project HOPE—The People-to-People
Health Foundation, Inc.
11. NIDA. [2018, June 8]. Medications to treat Opioid Use Disorder. https://www.drugabuse.gov/publications/research-reports/medications-to-treat-opioid-use-disorder. Accessed August 2019
12. By Noa Krawczyk, Caroline E. Picher, Kenneth A. Feder, and Brendan Saloner. Only One In Twenty Justice-Referred Adults In Specialty Treatment For Opioid Use Receive Methadone Or Buprenorphine. 10.1377/hlthaff.2017.0890 HEALTH AFFAIRS 36,NO. 12 (2017): 2046–2053 ©2017 Project HOPE—The People-to-People Health Foundation, Inc.