How can we address the"Opioid crisis" in our country from an ecological perspective?

My thoughts on the term “Opioid crisis” is that it is an unmanaged crisis that is a direct threat to public health. I support the public health approach and appreciate societal recognition in “responding to opioid and other substance use disorders by prioritizing prevention, treatment over criminalization as the foundation for resolving the problem.” (Wilson & Dorn, 2016). I believe it is accurate to consider the opioid use disorder (OUD) a crisis because “opioid-involved overdose deaths rose from 21,088 in 2010 to 47,600 in 2017 and remained steady in 2018 with 46,802 deaths.” (CDC, 2020). In 2018, New CDC data show death rates involving heroin decreased by 4%, and prescription opioid-involved overdose death rates decreased by 13.5%. With the decrease in opioid overdoses, “death rates involving synthetic opioids (excluding methadone) increased by 10% from 2017 to 2018; Synthetic opioids were involved in 31,335 overdose deaths — nearly half of all drug overdose deaths in 2018.” (CDC, 2020). In the following paragraphs, I explained how we can help address the opioid crisis and continue to decrease opioid-involved overdoses on a societal community, interpersonal, and individual level.

On a macro-level OUD can be addressed by universally provided free and/or affordable healthcare at the federal, state, and local levels. According to a study by researchers’ adults with children and without having common challenges to receiving and maintaining treatment, lack of personal finances, medical insurance coverage, the stigma of seeking substance abuse treatment, and access to evidence-based treatments. (Kertesz & Gordon, 2018, p. 32). “Unfortunately, these treatment options can be costly and persons of low socioeconomic status, who are already at greater risk to develop OUD, often cite lack of insurance or means to pay for treatment as a significant barrier to recovery.” (Huhn, 2018). A study conducted by researchers on the expansion of Medicaid and if it contributed to the decline of opioid overdosed deaths, findings suggests that “Medicaid expansion has been an important source of coverage for SUD treatment, including for people with opioid use disorder (OUD); Medicaid expansion was associated with reductions in total opioid overdose deaths and deaths involving heroin and synthetic opioids other than methadone.” (Kravitz et al., 2020 p. 2). By labeling OUD as a public health crisis and prioritizing social awareness, it signifies that “prevention and education are important to prevent initial use and to attenuate the development of dependence and addiction.” (Brown, 2018, p. 264). According to the American Society of Addiction Medicine (ASAM), a “lack of education among most physicians about the proper treatment of chronic pain and chronic opioid addiction disease is a considerable contributing factor to the current opioid addiction epidemic.” How we can address this risk factor is by requiring, “mandatory prescriber education on addiction prevention/treatment tied to DEA certificate to prescribe controlled substances.” (ASAM, 2014). In addition, stigma was a common risk factor in developing OUD and barrier to seeking treatment. Researchers suggest that, “stigma should be addressed with a national prevention strategy, including a public awareness campaign to educate the public and healthcare providers about addiction as a chronic brain disease that can be effectively treated with evidence- based interventions. (American Academy of Pediatrics, n.d.).

 “Community norms regarding alcohol, tobacco, and drug use can also affect the likelihood of initiation of substance misuse.” (Jalali et al., 2020). It was interesting to learn that majority of children and adults do not obtain prescription opioids through their physician but from family and friends. Although medical physicians lower the dosage when prescribing opioids, individuals usually received the same number of pills, often having more pills than needed. I believe it will be beneficial to shorten the number of prescription days. Studies have shown that reducing ten-day prescription to three days can be an effective tool to reducing the risk of becoming dependent. (Kertesz & Gordon, 2018, p.171). Within the exo-level, a protective factor in addressing OUD “drug disposal and collection sites can potentially deter misuse and discourage opioid diversion amongst patients’ friends and family by restricting the supply in households and communities.” (Jalali et al., 2020). Another risk factor for OUD concluded by researchers is the scarce availability of evidence-based medical treatment locations within all communities, particularly non-metropolitan areas. “Outside of major metropolitan areas, there is often limited treatment availability, and what treatment is available may not be affordable.” (Sharma et al., 2016) Addressing accessibility barriers, ASAM recommends “building on the infrastructure of the Drug-Free Communities (DFC) program is a cost-effective way to invest minimal federal dollars to prevent prescription drug abuse at the community level and get positive results.” (ASAM, 2014).

Within the microsystem level, “A family history of substance use disorder can influence opioid misuse through both genetic and environmental factors.” (Jalali et al., 2020). According to researchers’ genetics plays a minor role in developing an addiction but recently “with more advanced genetic techniques, several specific loci have been associated specifically with opioid use and OUD, with moderate opioid-specific heritable vulnerability.” In addition, “there are certainly unique environmental influences that differentially increase the risk of OUDs specifically. Such influences include exposure to opioids as a specific class of substance; non-medical use; exposure to medical opioid analgesics; use of opioids by family, peers, and other influential role models; permissive attitudes toward opioid use by influential role models; and access to opioids as a specific substance class.”(Sharma et al., 2016). In order to identify the genetic and environmental factor in familial histories, a medical professional should “complete assessment for an opioid use disorder requires a thorough medical and social history” (Sharma et al., 2016). Research shows that “family, friends, and co-workers significantly shape the beliefs, attitudes, and behaviors of individuals to influence the likelihood of individuals’ initiation and misuse of substances.” (Jalali et al., 2020). Using informal and formal support systems can help address the opioid overdoses by engaging all members to help prevent overdoes in their families and communities. I think it is an advantage that “many communities are providing/prescribing naloxone overdose kits to first responders, addicts, and addicts’ families, social workers, along with efficient training to decrease the number of opiate overdoses and deaths.” (Sharma et al., 2016). “Increasing the availability and targeted distribution of naloxone is a critical component to ending this epidemic. (AAP, n.d.).

Within the ontogenic level, developmental age is a risk factor for OUD exposure, use, and misused. “Early initiation of opioid misuse is a significant risk factor for the development of OUD and, thus, adolescence and young adulthood are key risk periods for opioid misuse.” (Jalali et al., 2020)” “Because opioid addiction creates long-term changes in the brain, people undergoing treatment not only experience debilitating withdrawal symptoms but are also prone to relapse because of cravings. According to many research findings, detoxification alone cannot prevent relapses or use of other illicit drugs, without maintaining sobriety with medical management. “Treatment, therefore, is most successful when it comprises two phases: detoxification from the painkillers, followed by a longer (and sometimes indefinite) maintenance phase. (AL, et al., P. 4). Study findings have shown that “buprenorphine, methadone, and extended-release naltrexone have all showed efficacy in reducing the risk of relapse and maintaining long-term recovery for persons suffering from OUD.” (Huhn, 2018). I agree with the researcher’s assessment that, social workers would be a vital role in helping with harm reductions and addressing drug addiction, dependency, and relapses. “An essential function of public health social workers is to be to work within a collaborative multidisciplinary structure; to successfully address addiction, a comprehensive-integrated care approach combining clinical evidence-based care and a sound social support system is required. (Wilson & Dorn, 2016, p. 7).

Historically, research has shown that males are affected by OUD at higher rates, “gender can also play a role in risk for opioid misuse. For example, women are more likely than men to receive an opioid prescription.” (AAP, n.d.). In addition, research studies show that “many users are women of childbearing age.” (Romanowicz et al., 2019, p. 1). It was important to learn that “the rise in untreated OUD has also led to a troubling increase in newborns experiencing neonatal abstinence syndrome (NAS). NAS may result from illicit opioid use or medication-assisted treatment.” (AAP, n.d.). “There is evidence that medication-assisted treatments are beneficial for both pregnant women and parents.” (Kertesz & Gordon, 2018, p. 35). Interestingly, according to researchers, MAT is preferable treatment and is proven significant for pregnant women with untreated OUD, also it is an incentive for women in receiving medication management and prenatal care simultaneously; and “together with prenatal care, has been demonstrated to reduce the risk of obstetric complications among pregnant women with OUD.” (AAP, n. d.). Discovering that women with children that have an untreated OUD which can lead to other substances, called polysubstance abuse, can affect the maternal-child attachment, child development, and child behaviors. (Romanowicz et al., 2019, p. 9). To adequately address this issue, “the focus must remain on the mother-baby relationship; include placing the child with their parent in a residential SUD treatment facility designed to treat both of their needs together, so that seeking treatment does not mean family separation.” (AAP, n.d.).

American Academy of Pediatrics. (n.d.). Addressing the opioid epidemic. AAP.org. https://www.aap.org/en-us/advocacy-and-policy/aap-health-initiatives/Substance-Use-and-Prevention/Pages/addressing-the-opioid-epidemic.aspx (Links to an external site.)

American Society of Addiction Medicine. (2014, July 31). Overdose Prevention and Opioid Addiction Treatment Recommendations. ASAM. https://www.asam.org/docs/default-source/advocacy/letters-and-comments/opioid-epidemic-recommendations_secy-burwell_2014-07-31.pdf?sfvrsn=4#search=%22opioid%22 (Links to an external site.)

Aaron R. Brown (2018) A Systematic Review of Psychosocial Interventions in Treatment of Opioid Addiction, Journal of Social Work Practice in the Addictions, 18:3, 249-269, DOI: 10.1080/1533256X.2018.1485574 (Links to an external site.)

CDC. (2020, March 19). New data show significant changes in drug overdose deaths. Centers for Disease Control and Prevention. https://www.cdc.gov/media/releases/2020/p0318-data-show-changes-overdose-deaths.html (Links to an external site.)

Feder, K. A., Mojtabai, R., Musci, R. J., & Letourneau, E. J. (2018). U.S. adults with opioid use disorder living with children: Treatment use and barriers to care. Journal of Substance Abuse Treatment, 93, 31-37. https://doi.org/10.1016/j.jsat.2018.07.011 (Links to an external site.)

Huhn, A. S. (2018, May). Serious about the opioid epidemic? Expand Medicaid. PubMed Central (PMC). https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6404773/ (Links to an external site.)

Jalali, M. S., Botticelli, M., Hwang, R. C., Koh, H. K., & McHugh, K. (2020). The opioid crisis: A contextual, social-ecological framework. Health Research Policy and Systems. https://health-policy-systems.biomedcentral.com/articles/10.1186/s12961-020-00596-8#Sec1 (Links to an external site.)

Kertesz, S. G., & Gordon, A. J. (2018). A crisis of opioids and the limits of prescription control: United States. Addiction, 114(1), 169-180. https://doi.org/10.1111/add.14394 (Links to an external site.)

Kravitz, N., Davis, C. S., Ponicki, W. R., Riverera-Aguirre, A., L. Marshall, B. D., Martins, S. S., & Cerda, M. (2020, January 10). Association of Medicaid expansion with opioid overdose mortality in the United States. JAMA Network | Home of JAMA and the Specialty Journals of the American Medical Association. https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2758476 (Links to an external site.)

Romanowicz, M., Vande Voort, J. L., Shekunov, J., Oesterle, T. S., Thusius, N. J., Rummans, T. A., Croarkin, P. E., Karpyak, V. M., Lynch, B. A., & Schak, K. M. (2019). The effects of parental opioid use on the parent-child relationship and children’s developmental and behavioral outcomes: A systematic review of published reports. Child and Adolescent Psychiatry and Mental Health, 13(1). https://doi.org/10.1186/s13034-019-0266-3 (Links to an external site.)

Sharma, B., Bruner, A., Barnett, G., & Fishman, M. (2016, March). Opioid use disorders. PubMed Central (PMC). https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4920977/ (Links to an external site.)

A systematic review on the use of psychosocial interventions in conjunction with medications for the treatment of opioid addiction. (n.d.). PubMed Central (PMC). https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4795974/ (Links to an external site.)

Wilson, M. H., & Dorn, C. (2016). NASW social justice brief offers an overview of the nation’s opioid, heroin addiction crisis. socialworkblog.org. https://www.socialworkblog.org/practice-and-professional-development/health-care/2016/09/nasw-social-justice-brief-offers-overview-of-nations-opioid-heroin-addiction-crisis/ (Links to an external site.)

Stotts AL, et al. (Aug. 2009) Painkillers fuel growth in drug addiction "Opioid Dependence Treatment: Options in Pharmacotherapy," Expert Opinions in Pharmacotherapy Vol. 10, No. 11, pp. 1727–40.