The opioid epidemic has received national attention recently thanks to the president’s address and a growing number of lawsuits against opioid producers. However, the crisis has been steadily worsening for over a decade.
For me, opioids continue to be a growing problem in family law. They lead to parents losing custody and children losing parents, and they complicate or worsen domestic violence situations. I wrote about a case involving opioids for my firm’s blog in September, and again on this blog in October, but the discussion is far from over. As the government begins to address the opioid crisis, it is even more vital that the general public understands it.
What are opioids?
Opioids are a class of pain-relieving drugs which mimic the effect of morphine. Early opioids, called opiates, were derived from opium, which is itself derived from the opium poppy. Morphine is the predecessor to the prescription opioids we know today, such as Vicodin and Oxycontin. Other opioids include heroin, synthetic opioids such as the notorious fentanyl, opioid agonists such as naxolone (the overdose-reversing medication), and endorphins, which are produced naturally in the body.
Medically, opioids are used primarily as painkillers. Doctors prescribe opioids after surgery and for conditions such as chronic pain. Opioids can be used to stop coughing, slow breathing, and reduce diarrhea as well. However, opioids have other, adverse effects such as causing nausea, drowsiness, and constipation, as well as reducing breathing too much.
How do opioids work?
Opioids affect us by binding to specific receptors in the brain, known as opioid receptors. There are three main opioid receptors, known as mu (μ), kappa (κ), and delta (δ) receptors. When an opioid binds to a receptor, the receptor sends signals to the brain, telling it what to do. Each receptor affects the body differently – the μ receptor is responsible for the pleasurable “high” and pain relief opioids provide. Normally, these receptors are used by natural opioids in the body (such as endorphins) – these opioids cannot cause an overdose, but they also can’t block out pain. Other opioids mimic the structure of these natural chemicals, which allows them to bind to the receptors.
Each opioid binds to different receptors more strongly than others, resulting in each having a different set of effects. For example, morphine binds better to μ receptors than some other opioids.
Why are opioids addictive?
To understand the addictive potential of opioids, we first have to understand the difference between opioid addiction and opioid dependence. Opioid dependence is the brain’s adaptation to prolonged opioid use, which results in withdrawal. Opioid addiction is the repeated, compulsive use of opioids despite the negative consequences. Dependence is primarily physical or psychological – your body itself needs the substance to function normally. Addiction is pathological – you feel urges to take the drug regardless of whether your body needs it or not.
Dependence happens eventually to everyone on opioids as the body gradually gets used to regular use of the substance. Addiction, however, is in part genetic, and some people are not predisposed to addiction. Genetics are believed to account for 35 – 40% of addiction risk.
How did the opioid epidemic start?
The current opioid epidemic arose due to multiple factors. If we want to start at the very beginning, we have to go back to World War I. At this time, doctors began to use morphine to treat pain in the soldiers returning home. There were few other effective treatments for pain at the time, and so opioids were seen as miraculous. Doctors began to prescribe them for all sorts of things. However, in the 1920s the addictive potential of morphine and other opioids was recognized. The US banned all use, manufacture, and sale of heroin with the Anti-Heroin Act of 1924.
Opioids were used again to treat soldiers in World War II. Use across the states exploded. Heroin addiction became an epidemic, leading the government to panic in the 70s and pass the Controlled Substances Act as an attempt to regulate drug abuse further.
In the 90s, pain became a huge focus for doctors. It became the doctor’s responsibility not only to safeguard the patient’s health but also to prevent pain, which became the fifth vital sign. Purdue Pharma invented Oxycontin in 1996, and further emphasized pain management as part of their marketing strategy. They over-stated the safety of their drug and under-stated its potency to encourage doctors to prescribe it. This well-documented campaign, in combination with the new focus on pain, led to a dramatic increase in opioid prescriptions. Because pharmaceutical companies obscured the addictive potential and potency of opioids, many patients and doctors were not aware of the risk. As opioid prescriptions rose, so did opioid overdoses.
How bad is the opioid epidemic?
In a word: horrific.
Overdoses involving opioids killed over 165,000 people from 1999 to 2014. At least 1.9 million people were abusing or dependent on opioids in 2013. In 2014, 10.3 million people were using opioids nonmedically, and 61% of overdose deaths involved opioids. One study indicated that 12.4% of high school students use opioids nonmedically.
This epidemic is unique to the United States. Though we have only 5% of the world’s population, we consume 80% of the world’s prescription opioid supply. The problem is primarily prescription opioids –16,651 people died from prescription opioid overdoses in 2010, compared to 2,789 heroin overdose deaths. Opioid overdoses account for 82.8% of prescription overdose deaths.
The effects are not just felt by those who overdose, either. In patients who have recovered from depression, prescription opioid use makes their depression 77% to 117% more likely to recur. Long-term opioid therapy can lead to reduced spatial memory and impaired working memory. Between 2004 and 2011, emergency department visits that involved opioids increased by 153%, contributing to the $72.5 billion yearly insurance costs related to opioids.
Despite these startling numbers, 19.5% of emergency department patients believe opioids are not addictive.
Chronic pain and the opioid epidemic
Chronic pain patients are uniquely affected by both the opioid epidemic and its proposed solutions. Approximately 11.2% of Americans suffer from chronic pain, and 3 – 4% are on long-term opioid therapy, which carries the risks mentioned earlier. Of the millions with chronic pain, most prescription opioid users have a form of back pain (38 million) or osteoarthritis (17 million).
Limiting opioid prescriptions, one of many one-size-fits-all solutions suggested, puts these patients at a disadvantage. However, they are also put at risk by opioids more consistently than others due to their need for daily pain relief. The risk of overdose increases with higher doses (those greater than 100 MME, or morphine milligram equivalents), yet 50% of prescriptions are for doses higher than 90 MME.
It is undeniable that opioids work miracles for chronic pain patients. However, in attempting to combat potential restrictions on their access to pain relief, many advocates assert that chronic pain patients do not misuse their medications. This is not true. One study indicated that approximately 21 to 29% of chronic pain patients misuse opioids, and 8 – 12% are addicted. However, few patients (7 – 10%) fake their pain to obtain pills, suggesting that misuse may start as a result of increasing tolerance to the medication. More studies are needed to affirm these numbers, but the bottom line is that no demographic is free of misuse or risk.
What is the solution?
Every proposed solution has its drawbacks, and so there is no “correct” solution to this complex societal problem. There are, however, “wrong” solutions, such as those that falsely purport to be one-size-fits-all.
Suggested solutions include:
- Placing heavier restrictions on prescribing opioids
- Improving awareness and guidelines for prescribers
- Harsher criminal sanctions and a “just say no” approach
- Decriminalizing opioid addiction as a disease to reduce the stigma of addiction and increase seeking of treatment
- Increase availability of treatment
- Finding alternative methods of pain relief
- Increasing naloxone availability to save those who OD
Almost all proposed solutions have other, often negative, effects. Restrictions on prescriptions could punish chronic pain patients and prevent them from getting relief. Harsher sanctions lead to those suffering from addiction being incarcerated rather than treated. Decriminalizing drugs such as heroin could lead to increased use. Alternative methods of pain relief will likely carry their own consequences as well.
In most cases, these negative effects are not a reason to avoid a solution entirely. They must, however, be carefully considered when formulating a response to the epidemic. Most of us won’t have much influence on whatever the national “solution” is – but we must encourage (or even demand) that our policymakers design a solution that is as nuanced and diverse as the problem our society faces. Anything less risks addressing only a part of this complex and tragic problem.
All data in this article is gathered from the studies linked within. None of the above should be viewed or acted upon as medical advice.