Components of the Opioid Crisis
Definitions
Index
Introduction
Let us begin with the following question: What are the components of the opioid crisis?
In 2020, an estimated 2.7 million people aged 12 or older, in the United States had an opioid use disorder (OUD)—including 2.3 million people with a prescription opioid use disorder. [1] An estimated 20 million people in the United States meet the criteria for substance use disorder (SUD) [*]. In 2015, the opioid epidemic alone had an estimated economic cost of 504 billion USD when taking into account healthcare, criminal justice, and loss of productivity [*]. The Centers for Disease Control and Prevention (CDC) estimate more than 63,600 drug overdose deaths occurred in 2016—a 21% increase from 2015 [*]. The President’s Commission on Combating Drug Addiction and the Opioid Crisis recommended declaring the epidemic a national emergency in their final report in November 2017 [*] and the National Institutes of Health (NIH) HEAL initiative (Helping to End Addiction Long-term) launched in June 2018 to provide scientific solutions to the national opioid overdose epidemic, including improved treatment strategies for pain and opioid use disorder (OUD) [*]. [0.5]
After thorough research, what was found was that there are four sides to the opioid crises.
Access & Distribution
Firstly, is the seemingly straightforward introduction channels to opioids on the street via prescription access and illegal distribution.
In a 60 Minute investigation [2], they found just how easy it was to get prescriptions for things like pain. This enabled them to get prescription opioids the same day as they were evaluated. Things like back pain, for example, are subjective to individual experience. Therefore, when someone is addicted to an opioid like Tapentadol [3] or Hydromorphone [4] receiving multiple prescriptions (often within the same day) is possible.
There must be a better system to assess whether an opioid should be prescribed or not. Two challenges arise with this ask: 1. Doctors are incentivized [5] to prescribe drugs by the manufacturer. 2. Opioid tolerance [6] in patients that need the pain-reducing substances during life changing treatment, such as cancer treatment.
Pharmaceutical companies have paid doctors billions of dollars for consulting, promotional talks, meals and more. A new ProPublica analysis finds doctors who received payments linked to specific drugs prescribed more of those drugs. -ProPublica
We can all agree that these drugs have a place in the world. However, how they enter the world is where the problems can begin.
Opioid tolerance implies a lesser susceptibility to the effects of opioids—both therapeutic and adverse—and it may develop in individuals with long-term use of opioids.?Patients who are prescribed opioids for management of cancer pain or chronic noncancer pain or who have an opioid addiction may become opioid tolerant. -US Pharmacist
Value & Addiction
Second, once these drugs leave the hands of a pharmacist, the risk of them entering the hands of those getting drugs illegally increases. [7] To say that the market for illegally sold drugs is massive would be an understatement.
"With estimates of $100 billion to $110 billion for heroin, $110 billion to $130 billion for cocaine, $75 billion for cannabis and $60 billion for synthetic drugs, the probable global figure for the total illicit drug industry would be approximately?$360 billion. -World-o-Meters
Due to the lack of available monitoring of illegal drug purchases, the annual presumption of total sold is around $400 billion, per year. [8] If you are a dealer looking to have a guaranteed customer base, you won't be stopping the use of opioid distribution anytime soon. Drugs laced or cut with opioids are almost impossible to get clean from, therein keeping your customers coming back for higher (and more expensive) doses of the drug of choice.
Prescription drugs can also be acquired from street dealers and health care establishments?by way of fraudulent prescriptions and other illicit means?(SAMHSA, 2011). This suggests that the illegal market for prescription drugs is different from that of more traditional street drugs. -Journals.Sagepub.com
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Mental Health & Monitoring
Thirdly, is the mental health component. Many patients that have come into contact with opioids do so by way of needing them for serious and legitimate pain and treatment. That's not what we are unpacking here. When these extremely powerful drugs enter the illegal market, they fall into the hands of individuals that are searching for an ailment to an internal pain.
According to the Minnesota Department of Health prescription opioids such as hydromorphone, oxycodone, fentanyl, and morphine are Schedule II drugs, because of their “high potential for abuse” that may lead to “severe psychological or physical dependence”. Methamphetamine and cocaine are also Schedule II drugs.?Heroin, LSD, and ecstasy are Schedule I drugs because of their “high potential for abuse” and “lack of accepted safety for use of the drug under medical supervision”. (Minnesota Statute 152.02?for more information on schedule II-V controlled substances.)
The National Institute of Drug Abuse (NIDA) reports that 80% of heroin users first used, and then misused, prescription opioids.?The reverse is not true; not all people who use prescription opioids move to heroin.?According to the National Survey of Drug Use and Health, less than 4% of people who had misused prescription pain medicines started using heroin.???
For acute pain, 90% of patients don’t use the entire first prescription.?This indicates that current prescriptions are written for too long, and that the majority of people’s pain is managed in fewer days.?Those who need a refill during a post-acute period are more likely to develop opioid dependence and/or addiction.?In a 2012 cohort study published in JAMA, patients receiving an opioid prescription within seven days of surgery were 44% more likely to become long-term opioids users within 1 year compared with those who received no such prescription.?
With the increased awareness around opioid use disorder and opioids overdose deaths, many prescribers have worked to reduce the duration (number of days a prescription is written for) and dose (the strength or potency of a drug) of prescribed opioids.??Patients who are already dependent and/or addicted to opioids require chemical and/or behavioral health treatment, including medication assisted treatment (MAT), to address the underlying cause of their opioid use.?Eliminating opioids does not eliminate addiction.??
Approximately 30% of patients are misusing opioids (taking more than directed, taking medications not prescribed to themselves), and 10% of patients are addicted. For patients who are prescribed opioids for more than 45 days, one in ten develop a substance use disorder from prescription use. [9]
“These illnesses, especially depression and opioid use disorder—we know how to treat them. The real problem is getting people into treatment and getting them to stay on treatment. If they stay on treatment, they do better. They don’t die. They don’t have overdoses; they don’t have suicide attempts. They get jobs; they do better.” -Katherine Watkins, M.D., M.S.H.S., a psychiatrist and policy researcher at the nonprofit RAND Corporation in Santa Monica, California. [10]
Consequently, we must not be so quick to medicate in cases where mental health services should be the aid to the inner pain. Strict monitoring of individuals prescribed highly addictive medications should be a standard not an option.
Figure 1. [11]
The Collaborative Care team is made up of the patient, a primary care provider, a therapist, and a care manager. The care manager communicates with a psychiatrist who makes recommendations about treatment.?
Key Points:
APPENDIX