Drug overdose is the leading cause of accidental death in the United States. On average, over 130 Americans die every day from an opioid overdose, over 70% of which are associated with prescription drugs (morphine, fentanyl, codeine).¹

While most observers believe that the Opioid Crisis endemic is mostly a recent phenomenon² , we, at Modus, would argue that this is only the beginning of the most recent of three waves - a surge beginning in the 1980s that has revealed the underlying inequities in terms of who has been affected, how access to healthcare and treatments have changed to accommodate the needs and wants of people, and how pharmaceutical companies have aggressively marketed opioids.

What is addiction?

An addiction can be defined as an individual’s physical or psychological need to pursue any object, activity, substance, or action despite the consequences. Addiction can cause both physical and mental change, particularly in the brain’s “rewards centre”, making it difficult to abruptly stop, regardless of their want to stop.³

Opioid addiction

Opioid addiction occurs as a result of a number of practice and behavioural issues. A number of practitioners in the United States possess an insatiable appetite for opioid prescription, as proven in 2015 during which 91.8 million individuals were prescribed or over-prescribed opioids⁴.

Opioid addiction is a chronic disease attributed to a number of physical, mental, and socioeconomic problems. Opioids are a class of drug most often used to treat both chronic and acute pain. They function by depressing the activity of the nervous system, alleviating pain, and inducing sleep. 

The most commonly abused opioids in America are:

• Oxycodone (OxyContin)
• Hydrocodone (Vicodin/Norco)
• Codeine
• Morphine
• Heroin (not prescribed)
  

All of the above opioids work in the same way. They attach to the pain receptors on various nerve cells to minimize pain signals. When this happens, dopamine is released from the pleasure or rewards centre of the brain, giving a sense of euphoria. Over time, the user begins to develop a desire for the continuous use of these opioids, partly due to the build-up of tolerance to the drugs, meaning that a higher dose is necessary to produce an adequate effect. This eventually leads to opioid dependence that is more often than not established or diagnosed once the damage has been done.

Individuals who become addicted may start prioritizing their access to opioids over other activities in their lives, negatively impacting their social and professional relationships. In severe cases, opioid addiction can be life-threatening.

Why is there an Opioid Crisis?

This modern-day endemic has been closely linked to the increase in opioid use and liberal prescribing practices by a number of practitioners. During the 1980s, attitudes towards pain management began to shift. Previously, opioids were used primarily for the treatment of severe or chronic pain associated with cancer, palliative care (end-of-life care), and a limited series of acute pain. Additionally, In the mid-’90s, vigorous lobbying by organizations such as the American Pain Society championed the importance of addressing pain as a public health priority in the United States. These lobbying efforts were successful, resulting in pain being designated as the fifth vital sign  the industry lobbied congress and changed the medicare ratings and payments to hospitals based upon patient satisfaction with pain management. A new measure - “Pain as a 5th vital sign” was designated by the joint commission for accrediting hospitals, which created a significant financial incentive for hospitals to pressure physicians to prescribe more opioids. 

However, various patient advocacy groups and pain specialists raised their concerns regarding the inadequate use of opioids. Articles were published expressing the need for opioid use for pain management, claiming that opioid addiction was only an irrational fear or concern held by practitioners at the time. This was echoed by the American Pain Society, of which the President stated “therapeutic use of opioids rarely results in addiction.”⁵ 

Compounded by this information, a modified-release preparation of Oxycodone was approved by the Food and Drug Administration (FDA) and marketed as a safe opioid for the management of pain. It was argued that the slow release of opioids combatted the risk of addiction in comparison to immediate-release preparations. 

Attitudes in the medical community began to change. Monitoring and treating patients’ pain became regular practices, leading to an influx of opioid prescriptions. It was not until 2001 that the FDA asked for the claim to be removed. A steady decline in the prescription of opioids in the USA began after 2012, with the lowest rates of opioid prescription being seen in 2020 at 43.3 prescriptions per 100 people⁶. Nonetheless, due to the upsurges in heroin and illicitly manufactured fentanyl, there is still an uprise in opioid overdose deaths.

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How did the Opioid Crisis evolve?

As various states began to produce legislation limiting opioid prescriptions, those who were already addicted or dependent on opioids started to turn to illegal substances. This may include turning to drug dealers online or on the streets and in severe cases, heroin.

Who did the Opioid Crisis affect?

The opioid epidemic in the United States has become a widespread problem, affecting both rural and urban communities. The Center for Disease Control and Prevention (CDC) stated that the Opioid Crisis is an economic burden, costing over $70 billion, including the costs of healthcare, criminal justice involvement, and addiction treatment.

Recent research has suggested that not only is the opioid crisis a cause for financial insecurity but has also caused a drastic effect on the following populations across the United States:

1. Children

The Department of Health and Human Services has stated that over three-quarters of the States have seen an uprise in children requiring foster care, primarily due to parental substance abuse. Just as troubling, the CDC reported an increasing number of cases of Neonatal Abstinence Syndrome - a drug withdrawal syndrome that affects the babies of opioid-dependent pregnant women.

2. The rural communities

Employment opportunities are often limited in Rural America. In addition, the rates of motor vehicle accidents, falls, and musculoskeletal injuries are around 50% higher than in urban areas. The prescription of opioids to manage pain, in accordance with the limited availability of care services in rural areas has led to a fourfold increase in opioid-related deaths among rural communities⁷.

3. Emergency services

The already overloaded emergency services resources are further taxed and disrupted by the increase in 911 calls for opioid-related accidents and overdoses. Instead of responding to other, more sinister emergencies, first responders have to spend a lot of their time attending to the needs of overdose patients. This not only drains the Emergency Services resources, but also leads to a reduction in bed availability, medication, and eventually, higher insurance costs.

Combatting opioid misuse

Just as with other challenging diseases, healthcare professionals have actively sought out ways to put an end to the endemic. There have been varying responses to the current interventions in place, but true eradication will not occur if a standard is not set.

Updated guidelines

Updating and introducing new guidelines and the provision of real time morphine milli-equivalent data to clinicians when prescribing opioids had the intent to reduce the risk of harm related to overuse and over-prescribing of opioids. Multiple guidelines were produced over the years showing the same consensus, the most influential of which being set by the CDC. However, these guidelines are yet to be law-enforced and have since been deemed unnecessary by a number of patients and pain specialists, and even opposed by pharmaceutical companies⁸.

Public health surveillance

Public health surveillance is of paramount importance, allowing practitioners and medical boards to understand the magnitude of opioid misuse. Unfortunately, improvements in collecting data must be implemented before any real change can be seen. The lag in the collection of data on both the use of opioid-reversing drugs (naloxone) and overdose-related deaths has led to misuse and misinterpretation of information which reflects on treatment and recovery outcomes.

Prevention

Preventing the development of new cases of opioid misuse is just as important as treatment and care for current sufferers. There is a high prevalence of opioid misuse amongst those with chronic pain disorders. To prevent addiction, practitioners should take caution when prescribing opioids. This highlights the necessity of further education implementation for both new and existing prescribers⁹.

Reducing stigma

Stigma is a real through to opioid addicts and their families. It can lead to individuals hiding their issues out of fear or judgement, resulting in the delay of treatments. An introduction of a variety of approaches to help fight the stigma of opioid addiction can significantly help the vulnerable feel safe and give them the courage to seek help. The first step we can take is to treat opioid addiction as a disease, and not as its misconception as a moral weakness¹⁰.

There’s still a long way to go

Despite the currently implemented interventions to reduce the socioeconomic burden of the Opioid Crisis, the number of overdose-related deaths is staggeringly high. There are so many effective tools available to combat this endemic that are not deployed effectively in the communities that are in need. 

Recovering from opioid addiction is slow and painful, and the stigma behind addiction only prevents people from getting the help they need. However, by carrying out the appropriate research on practitioners performing medical malpractice and understanding the reasons for which opioids should be used you can drastically reduce your risk of being subject to the over-prescription of opioids.

Bibliography

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