The opioid epidemic is an American public health crisis caused by addiction to both prescription and illegal opioid painkillers.
Opioids are powerful, highly addictive painkillers. In the past, the word opiates was used to describe drugs derived from Papaver somniferum, the opium poppy, while the word opioids referred to synthetic laboratory-made drugs that mimicked opium-derived drugs. Now the word opioids includes natural opium derivatives, semi-synthetic, and synthetic opium-like drugs. These drugs include:
- fentanyl (Actiq, Duragesic, Fentora)
- hydrocodone (Hysingla, Zohydro, Lorcet, Lortab, Norco, Vicodin)
- hydromorphone (Dilaudid, Exalgo)
- meperidine (Demerol)
- methadone (Dolophine, Methadose)
- morphine (Kadian, Kadian ER, MS Contin, Oramorph SR, Roxanol)
- oxycodone (OxyContin)
Opioids bind to opioid receptors on nerve cells in the brain, spinal cord, gastrointestinal tract, and other parts of the body. Once attached, they activate the production of a protein that blocks the transmission of pain signals, making them powerful painkillers. In the brain, they also affect the reward center and the part of the brain that controls emotions. They stimulate the release of dopamine, a neurotransmitter that decreases anxiety and can cause euphoria, making these drugs highly addictive. Over time, tolerance develops, so that the individual must take larger and larger amounts of the drug to achieve the same intensity of feelings.
Opioids also depress the respiratory system (the most common cause of overdose death), cause constipation, nausea and vomiting, interrupt the production of certain hormones, contract the pupils of the eye, and induce drowsiness. Several small studies have shown changes in the gray matter of the brain in patients using opioids for long-term pain control. Withdrawal symptoms often occur when the drug is stopped. These include strong drug cravings, diarrhea, runny nose, tremors, nausea, vomiting, restlessness, sleeplessness, and pain in the abdomen, bone, and muscle.
In the United States, opioids are regulated under the Comprehensive Drug Abuse Prevention and Control Act of 1970. Heroin is a Schedule I drug, meaning that no prescriptions can be written for it and that it is never legal to possess. The remaining opioids are Schedule II drugs. These drugs have a high potential for abuse resulting in physical and psychological addiction. They are legal only with a physician’s prescription and are subject to certain other limitations.
Materials derived from the opium poppy have been known as painkillers for thousands of years. The first widespread problem of addiction in the United States began during the Civil War. Morphine was commonly used on the battlefield as a painkiller. Many soldiers became addicted. Heroin was first produced commercially in 1898. At the time, it was thought to be less addictive than morphine. It was often given to replace morphine with the faulty idea that it would wean morphine-addicted individuals from the drug. Instead, all this did was change morphine addicts into heroin addicts. Commercial production of heroin was stopped in 1916, and the drug became illegal in the United States in 1924.
The end of the nineteenth and beginning of the twentieth centuries was a time when drugs were completely unregulated. The Pure Food and Drug Act, which was passed 1906, was the first federal law to set certain requirements for foods and medicines. The Act prohibited the manufacture, sale, or transportation of adulterated, mislabeled, or poisonous foods, drugs, medicines, and liquors. It also required active ingredients and any ingredients designated as dangerous or addictive (e.g., alcohol, opium, morphine) to appear on the label. Before the passage of this act, there were no restrictions on adding addictive drugs to medicines, and many people became addicted during the course of treatment.
In the 1920s, scientists, mainly in Germany, synthesized several new opioids in the laboratory such as hydrocodone, oxycodone, dihydrocodeine, and dihydromorphine. Oxycodone under the brand name Percodan was approved by the Food and Drug Administration (FDA) in 1950, and by the early 1960s, it had become a drug of abuse.Also during the 1960s, heroin addiction surged as soldiers were introduced to the drug overseas during the Vietnam War. In 1978, hydrocodone with acetaminophen (Vicodin) became available as a generic. At this time it was prescribed sparingly and often reserved for those patients who were terminally ill.
During the 1990s, a change in thinking occurred among the medical community concerning how to treat pain. The perception was that pain was being undertreated and that because of undertreatment, patients were experiencing unnecessary pain. In response, pharmaceutical companies developed new drug delivery systems such as a fentanyl patch and a fentanyl lollipop. Extended release versions of morphine, hydromorphone, and oxycodone, were also created, and prescriptions for opioids soared. Between 1998 and 2008, abuse and misuse of prescription opioids doubled, and has continued to rise rapidly since then. Along with increased use came an increase in opioid addiction and overdoses.
By 2015, drug overdoses were the leading cause of accidental death in the United States, having overtaken motor vehicle accidents for the top spot. A great many of these overdose deaths were the result of prescription opioid abuse. Naloxone, a drug to treat opioid overdose, was licensed by the FDA in 1971. It was administered intravenously and could only be used by medical professionals. In 2014, the FDA approved an autoinjector (Evzio) that contained a dose of naloxone for home use by family members or caregivers. As the opioid epidemic continued, in 2015, the FDA licensed a naloxone spray (Narcan) that could be carried by first responders and used on unconscious individuals. In 2016, 64,000 people died of opioid overdoses.
On October 26, 2017, President Donald Trump signed an executive order declaring the opioid epidemic a public health emergency. This order, however, did not release any extra funds to deal with the emergency. Trump advocated for an advertising campaign to make young people aware of the dangers of opioids combined with better law enforcement to stop illicit supplies and misuse of these drugs. President Trump did, however, promise to ask Congress for additional money to fight the opioid epidemic and to suspend the rule that prohibits Medicaid funding for residential addiction treatment centers that have more than 16 beds. As of late 2017, these actions had not occurred.
The following statistics give a picture of the opioid epidemic's breadth and depth in the United States.
- More females than males use prescription painkillers, but more men (5.3%) abuse these drugs than women (4%).
- Americans are 4.6% of the world’s population, but use 80% of the world’s supply of opioids, including 99% of all Vicodin.
- In 2016, 64,000 Americans died of drug overdose. This is a 19% increase over 2015. Of these deaths, 20,000 were related to fentanyl and synthetic fentanyl-like opioids.
- According to the Centers for Disease Control and Prevention (CDC), in 2015, the states with the highest death rates from opioids were West Virginia, New Hampshire, Kentucky, Ohio, Rhode Island, and Pennsylvania. Opioid abuse is more common in rural areas than in urban areas.
- In 2015, nationwide the highest rate of fatal overdoses was in the 45–54 year age group (30 deaths per 100,000 population), while the greatest percentage increase in overdose deaths was in the 55–64 year age group.
- According to the American Society of Addiction Medicine (ASAM), in 2015, 2 million Americans had a substance abuse disorder involving prescription painkillers, and 571,000 were addicted to heroin.
- The ASAM estimates that 23% of opioid abusers go on to become heroin users.
- In 2016, the CDC estimated that the economic cost of opioid abuse in the United States was $78.5 billion per year.
- Worldwide, in 2015, about 300 million opioid prescriptions were written, with more than 80% being written in the United States. Opioid sales generate about $24 billion for pharmaceutical companies, with drugs to treat opioid addiction generating even more income.
Recovery and rehabilitation
Opioid intoxication and overdose can be treated with the drug naloxone. This drug works by competitively binding with the opioid receptors in the brain and on other nerves. When this happens in the brain, dopamine is not released and a feeling of euphoria does not occur. Naloxone acts rapidly, usually within 2–5 minutes. Its life-saving property is that it quickly reverses respiratory depression. Naloxone can be given intravenously only by medical professionals. It can be administered by intramuscular injection or as a nasal spray by anyone. Good Samaritan laws protect members of the public from legal challenges if they administer the drug to reverse intoxication or overdose.
As with any addiction, recovery and rehabilitation are long, difficult, and often have limited success. Withdrawal symptoms are common and often pose a barrier to quitting. Methadone maintenance therapy (MMT) has been used to help people with opioid addiction, especially heroin addiction. MMT helps the individual cope with withdrawal symptoms and cravings for heroin, a drug that is more dangerous than methadone. Methadone is a long-acting drug that stays in the body from 24–36 hours. A once-daily dose blocks the euphoria or high that comes with heroin use and controls withdrawal symptoms.
Methadone is a highly regulated Schedule II drug. It is only available at specialized clinics. If misused, methadone can cause life-threatening complications. MMT helps stabilize the addicts life by reducing criminal behavior associated with acquiring heroin and eliminating the need for needle sharing, as well as allowing better functioning by controlling withdrawal symptoms. As of 2017, methadone clinics can serve only 15–20% of heroin users. Establishment of drug treatment clinics is often hampered by neighborhood opposition and lack of funding. President Trump’s 2017 declaration of the opioid epidemic as a public health emergency did not provide additional funds for clinics.
Buprenorphine, often combined with naloxone, (Suboxone, Zubsolv, Bunavail) is another drug that works similarly to methadone in that it binds with opioid receptors to suppresses withdrawal symptoms and cravings. Buprenorphine is safer than methadone and consequently is a Schedule III drug with fewer restrictions on use. Both these drugs can be effective in helping to prevent relapses, although they may not work equally well in all individuals.
In addition to pharmaceutical therapy, opioid abusers often benefit from cognitive behavioral therapy, group therapy, aversion therapy, and attendance at Narcotics Anonymous. Although counseling and therapy are helpful, alone they are almost always unsuccessful because they do not treat the physical symptoms of craving and withdrawal.
Opioids can be abused by swallowing whole tablets, chewing tablets, smoking, snorting, and injecting. In 2013, the FDA issued guidelines to manufacturers on creating barriers to opioid use. These include making tablets harder to crush or chew, making tablets that do not dissolve well in water or alcohol to make intravenous injection more difficult, and adding chemicals to opioid drugs that reduce the euphoria factor while maintaining the painkilling properties of the opioid.
Another way to reduce opioid abuse is to limit access to these drugs. In 2016, Connecticut passed a law limiting prescriptions to minors and first-time outpatients to a 7-day supply of opioids under most circumstances. In September 2017, CVS pharmacies announced that beginning February 1, 2018, it would limit opioid prescriptions to seven days for all patients new to pain therapy. The program will also limit the daily dosage of pain pills based on their strength and require immediate-release pills be tried before extended-release pills are dispensed.
In addition to limiting the quantity of opioids dispensed, all fifty states as of late 2017 have developed or are developing prescription drug registries to track opioid prescriptions. The registries serve two purposes: to prevent a single individual from getting multiple prescriptions simultaneously from different doctors and to track doctors who write prescriptions for excessively large amounts of opioids. In addition, the drug Enforcement Agency (DEA) has reduced production quotas for manufacturers of most schedule II drugs by 25% beginning in 2017. The exception is Vicodin (hydrocodone with acetaminophen) which will be decreased by as much as 66%. This approach will reduce the amount of opioids available by prescription but will not change illegally produced opioids or those smuggled into the country and sold as street drugs or drugs available through internet sites.