We frequently hear that America is experiencing an opioid crisis, an opioid epidemic, or even a public health emergency. These terms generally refer to the sharp increase in opioid-related overdose deaths over the past five years. As most people know, opioids are a class of analgesic drugs that provide pain relief and euphoria. These drugs include commonly prescribed painkillers (Codeine, Percocet, Vicodin), heroin, and synthetic variations (Fentanyl). Last year, about 70,000 Americans died from a drug overdose, and about two thirds of these cases involved the use of opioids (often mixed with other drugs or alcohol). The rate of opioid-related overdose deaths in 2017 was six times higher than what was observed in 1999. In Maryland, about 2,000 deaths over the past year were attributed to opioids.
Not a New Problem
To provide some perspective, we are not experiencing the first American opioid crisis. What might be considered the first crisis dates back to the beginning of the 20th century, and was the culmination of many years of unregulated opioid use in the United States. From colonial times, opium was prescribed as a painkiller and used to treat a variety of medical and even psychological conditions. Many physicians grew their own poppy plants, and opium was often a “surprise” ingredient in commonly sold medications.
It is interesting that middle- and upper-class women were thought to be the most common users of opioids. It must have been a real shock to many people to see what was in the medicines they were using. Many parents did not know that they were giving opioids to their children to help them sleep. They only knew that the baby was sleeping very well!
It was not until the mid- to late-1800s that America experienced a noticeable increase in recreational opioid use, with more and more people injecting morphine or smoking opium. While the root cause of this first opioid crisis remains unclear, some attribute it to the high rates of opioid distribution required to treat Civil War soldiers, while others point to the impact of opium dens operated by Chinese immigrants that ultimately attracted gamblers and other delinquents.
Whatever the reason, increasing rates of opioid use drew the attention of the U.S. government, which eventually drafted legislation to properly label food and medicines (the Pure Food and Drug Act of 1906) and to more specifically regulate the import, manufacture, and distribution of opioids (Harrison Narcotics Tax Act, 1914). Heroin was banned about 10 years later. The strong stance against opioid use had a lasting impact on routine medical practice for those with chronic pain disorders, which affects almost a third of the people in this country and remains one of the most common reasons for visiting a doctor. Throughout most of the 1900s, physicians remained quite reluctant to use opioids to treat chronic pain disorders. People with unexplained pain were ordinarily thought to be malingering or drug-seeking, and even those with cancer-related pain were strongly encouraged to taper off opioid medications.
A Crisis Is Born
All of this seemed to change rather quickly during the 1990s, which saw a dramatic increase in the production of opioids designed to treat a variety of chronic pain syndromes. This followed the call by the American Pain Society for more humane care for chronic pain patients as well as the new guidelines drafted by The Joint Commission to evaluate and treat pain conditions. As a result, providers more commonly prescribed drugs like oxycodone (Percocet) and hydrocodone (Vicodin) for long-term pain management. From 1997 to 2002, for example, prescriptions of oxycodone increased from 670,000 to 6.2 million. Of course, patient satisfaction skyrocketed, but so did the number of vulnerable people exposed to opioid medications. It turns out that about 10% of those prescribed opioids for pain developed an opioid use disorder, and that about a quarter misused their medications, either by taking medications in a non-prescribed fashion or diverting them to others.
The other major factor responsible for the increase in opioid-related overdose deaths is the emergence in 2015 of the drug Fentanyl, a synthetic opioid that is about 50 times stronger than heroin, which has become increasingly prevalent on city streets. Fentanyl is created in labs in China and smuggled to the United States, where it is laced in heroin and other illicit drugs, including marijuana. While there are many different fentanyl compounds, all of them are relatively easy to make, inexpensive, and powerful. One example of the strength of Fentanyl is that it is often resistant to the overdose-reversing drug Narcan, and first responders are often required to deliver multiple doses of Narcan to save a life.
Addressing the Crisis
A number of initiatives have been launched in the United States to address the opioid crisis. First, The Joint Commission, an independent, not-for-profit organization that accredits and certifies nearly 21,000 health care organizations and programs, has published new public standards for the treatment of chronic pain. In addition, many types of education programs are available to help providers administer evidence-based treatment for pain, including explicit guidelines developed by the Center for Disease Control. Also, many states have enacted Prescription Drug Monitoring Programs to track controlled-substance prescriptions. Finally, those with opioid use disorder have more options to participate in medication-assisted treatment, and much better access to Narcan.
Yet, despite the fact that opioid prescription rates have declined since 2010, the number of opioid-related overdoses have increased each year. There remains a strong desire among many people with severe substance-use disorders to use opioids, especially among those who live in impoverished communities with high drug availability. Perhaps most worrisome is the high prevalence of Fentanyl on the street, with drug dealers in competition to sell the strongest opioids. As Chris Rock once said in his stand-up routine about drug dealers: “People don’t sell drugs. Drugs sell themselves.” As long as there is a demand to get high, there will be a market for powerful drugs like Fentanyl.
It is important to recognize that most people who are prescribed opioids will not develop a problem. In the United States, over 200 million opioid prescriptions are filled each year! Yet rates of opioid use disorder have remained relatively low (less than 1% of the population). In general, many people are not willing to take opioids over long periods of time. They simply do not like the feeling of opioids, which in addition to pain relief induces an uncomfortable sluggishness and nausea. And most of those who are prescribed long-term opioid therapy take their medications as prescribed.
Vigilance and Education
Health providers must nevertheless remain vigilant about prescribing opioids to people who are vulnerable to addiction. As we have noted in past articles, people with current or prior substance-use disorders or untreated (or under-treated) psychiatric disorders are at most risk for misusing opioids and suffering an overdose. Evaluating risks may require changes to usual practice which might include more careful screening techniques and more frequent drug testing.
Parents must spend time educating their children about opioids, and inform them that just because a drug is prescribed does not make it safe. In fact, after alcohol and marijuana, prescribed opioids are the most frequently-used drugs among teenagers. Parents should take care to safely store opioid prescriptions and safely dispose of them when they are no longer needed. And children with any substance use disorders should be referred quickly to treatment as misuse of any substance places children at higher risk to transition to opioids.
Dr. Kidorf is Associate Director of Addiction Treatment Services and Associate Professor, Psychiatry and Behavioral Sciences, at Johns Hopkins University School of Medicine. This article is part of the series presented by Chayeinu, a new organization dedicated to providing education and guidance to our community regarding substance use disorder.
