The opioid epidemic, also referred to as the opioid crisis, is the rapid increase in the overuse, misuse/abuse, and overdose deaths attributed either in part or in whole to the class of drugs called opiates/opioids since the 1990s. It includes the significant medical, social, psychological, demographic and economic consequences of the medical, non-medical, and recreational abuse of these medications.
A chart outlining the structural features that define opiates and opioids, including distinctions between semi-synthetic and fully synthetic opiate structuresFentanyl. 2mg (white powder to the right) is a lethal dose in most people. US penny is 19 mm (0.75 in) wide.
Opioids are highly effective for treating acute pain,[4] but there is strong debate over whether they are effective in treating chronic or high impact intractable pain,[5] as the risks may outweigh the benefits.[5]
From 1999 to 2021 it is estimated 645,000 Americans have died from opioid use.[6] The number of overdose deaths involving opioids in 2021 was ten times what it was in 1999.[7] What the U.S. Surgeon General dubbed "The Opioid Crisis" was theorized to have been caused by the over-prescription of opioids in the 1990s,[8] which led to the CDC Guideline for Prescribing Opioids for Chronic Pain, 2016[9] and the resulting impact on medical access to prescription opioids "outside of active cancer treatment, palliative and end of life." Opioids initiated for post-surgical pain management have long been debated as one of the causative factors in the opioid crisis, with misuse/abuse estimated at 4.3% of people continuing opioid use after trauma or surgery.[10]
When people continue to use opioids beyond what a doctor prescribes, or when opioids are over-prescribed, whether to minimize pain or induce euphoric feelings, it can mark the beginning stages of an opiate addiction, with a tolerance developing and eventually leading to dependence, when a person relies on the drug to prevent withdrawal symptoms.[11] Writers have pointed to a widespread desire among the public to find a pill for any problem, even if a better solution might be a lifestyle change, such as exercise, improved diet and stress reduction.[12][13][14] Opioids are relatively inexpensive, and alternative interventions, such as physical therapy, may not be affordable.[15]
Opioids were involved in 80,411 overdose deaths in 2021, up from around 10,000 in 1999.
In the late 1990s, around 100 million people or a third of the U.S. population were estimated to be affected by chronic pain.[citation needed] This led to a push by drug companies and the federal government to expand the use of painkilling opioids.[citation needed] In addition to this, initiatives like the Joint Commission began to push for more attentive physician response to patient pain, referring to pain as the fifth vital sign. This exacerbated the already increasing number of opioids being prescribed by doctors to patients.[17] Between 1991 and 2011, painkiller prescriptions in the U.S. tripled from 76 million to 219 million per year,[18] and as of 2016 more than 289 million prescriptions were written for opioid drugs per year.[19]:43 This was exacerbated by the aggressive and misleading marketing of drug makers, e.g. Purdue Pharma. Purdue trained its sales representatives to convey to doctors that the risk of addiction from OxyContin was "less than one percent."[20]
Mirroring the growth of opioid pain relievers prescribed is an increase in the admissions for substance abuse treatments and opioid-related deaths. This illustrates how legitimate clinical prescriptions of pain relievers are being diverted through an illegitimate market, leading to misuse, addiction, and death.[21] With the increase in volume, the potency of opioids also increased. By 2002, one in six drug users were being prescribed drugs more powerful than morphine; by 2012, the ratio had doubled to one in three.[18] The most commonly prescribed opioids have been oxycodone and hydrocodone.
The epidemic has been described as a "uniquely American problem".[22] The structure of the US healthcare system, in which people not qualifying for government programs are required to obtain private insurance, favors prescribing drugs over more expensive therapies. According to Professor Judith Feinberg, "Most insurance, especially for poor people, won't pay for anything but a pill."[23] Prescription rates for opioids in the US are 40 percent higher than the rate in other developed countries such as Germany or Canada.[24] While the rates of opioid prescriptions increased between 2001 and 2010, the prescription of non-opioid pain relievers (aspirin, ibuprofen, etc.) decreased from 38% to 29% of ambulatory visits in the same time period,[25] and there has been no change in the amount of pain reported in the U.S.[26] This has led to differing medical opinions, with some noting that there is little evidence that opioids are effective for chronic pain not caused by cancer.[27]
The opioid epidemic affects women and men differently.[28] For instance, women are more likely than men to report recent and non-recent prescription opioid use.[29] Women are also more likely to have chronic pain than men are.[30] In cases of domestic abuse and rape, women are prescribed pain medicine more than men.[30] Along with that, during pregnancy women may use prescription opioids to help with pregnancy pain, especially with post-pregnancy pain.[30] The number of women who have died from opioid pain relievers has increased 5 times from what it was in 1999 in 2010.[citation needed] To help stop the spread of opioid abuse in women, it is advised that women are educated on the drugs that they are taking and the possible risk of addiction. Additionally, alternatives should always be used when possible in order to prevent addiction.[30]
Most research gone into understanding the epidemic is mostly focused on females, specifically anticipated mothers.[31] Women are at the greatest risk for opioid addiction compared to men.[32] Usually, opioid misuse in women stems from unused prescription drug hoarding, the dependence of the drugs and higher pain levels compared to men. Women are less likely to report opioid misuse in contrast to the male population.[31] Analyzers of the epidemic stress that their main concern is the female victims, and studies tend to neglect the male population victimization, when over 70% of prescription drug intake and overdose, happen to males.[31]
Adolescents
Adolescents are another category of people that can become easily addicted to opioids. Even before their teenage years, children go through the rapid growth of their reward center, also known as the Mesolimbic pathway. The development of the Mesolimbic pathway allows children to be easily satisfied by small rewards to encourage learning, motivation, and acceptable behavior. However, this growth peaks in their adolescent years, and they start to feel a need for larger, more meaningful rewards, such as psychoactive substances which produce reward signals through direct receptor binding. Teens also have an underdeveloped prefrontal cortex which governs impulse control and decision making. The combination of underdeveloped prefrontal cortex and a rundown reward system can lead to adolescents with addictive seeking behaviors and higher susceptibility to the neurological changes developed in substance use disorder (SUD).[33] The Centers for Disease Control and Prevention estimates that In 2018, over 53 million people aged 12 years and older in the United States, reported the misuse of prescription drugs.
A 2020 review of the opioid epidemic in pediatrics stated that there were 4,094 opioid overdose deaths in people ages 14–24 in 2017.[34] Teens commonly use opioids as recreational drugs, instead of what they are supposed to be used for, pain management.[35]Centers for Disease Control and Prevention says that for every opioid death of a teen there are 119 emergency visits and 22 treatment admissions related to opioid abuse. Half a million teenagers in 2014 were reported as non medically prescribed opioid users and a third of those as having a substance use disorder (SUD).[36]
Family is widely discussed as an influence for factors affecting adolescent opioid misuse behavior and in the treatment of adolescent opioid misuse.[37] Family involvement has been shown to be effective in decreasing substance use in adolescents by addressing family risk factors that may be contributing to an adolescent's substance use. Some of these risk factors that are contributing to the increase in popularity of opioids include easy accessibility. The late 1990s increase in opioid recommendation from pharmaceutical companies created an abundance of prescription painkillers in adult households. If family members are taking opioids for pain or have taken them in the past and did not dispose of them correctly or do not protect them properly, it can make it easy for adolescents to get their hands on them.[38]
Proper disposal of these drugs is crucial to reducing adolescent misuse. A national insurance cohort reviewed almost 90,000 opioid prescribed patients, 13–21 years old, and found that 5% continued to fill their prescription 90 days or more after surgery. Medicine take-back programs are the most recommended and regulated disposal method by the United States Drug Enforcement Agency, although, it is not guaranteed that the prescribed patient will comply with this recommendation. There are also eight different at-home drug disposal products on the market but none of them is federal agency approved or in the process of being evaluated. The main concern of proper opioid disposal is trash and sewage disposal that create pharmaceutical pollution and still grants access for adolescents with substance use disorders.[34]
Not only are youth at a heightened risk of developing opioid addictions, but treating opioid use disorder in this population is also more difficult than it is for older individuals. A systematic review of the epidemiological literature has found that adolescents and young adults consistently have shorter retention times in medication treatments for opioid use disorder than do older adults. This is why it is important for schools to implement effective strategies and programs to teach young children about the dangers and consequences of opioid misuse. Although the retention time of adolescents is much lower than adults, educating them from a younger age on opioid misuse should help keep children away from these drugs.
Limited treatment
The continued prevalence of the opioid epidemic in the United States can be traced to many reasons. For one, there is a lack of appropriate treatments and treatment centers across the nation.[39] Big cities like New York City are lacking in treatment services and health offices as well as small rural areas.[39] Another reason the opioid epidemic is hard to combat is due to available housing being limited to recovering addicts.[39] Having limited housing makes it easy for recovering substance users to return to the environments and relationships that promoted drug misuse in the first place. Along with housing, jobs for recovering addicts can be difficult to find. Individuals with substance use disorders that have criminal records have a more difficult time finding jobs once they leave recovery. Having to combat job insecurity can lead to stress, which can cause someone to relapse.[39] The fact that "wraparound services", or programs that provide services for patients who have just come out of rehabilitation centers or programs,[39] are rare to non-existent, and is also a contributing reason as to why the opioid epidemic has gone on for so long.
The public reaction that has made the first step in ending the opioid epidemic was the lawsuit that the state of Oklahoma put up against Purdue Pharma.[40] The state of Oklahoma argued that Purdue Pharma helped start the opioid epidemic because of assertive marketing and deceptive claims on the dangers of addiction.[41] One of the marketing strategies was to redefine "substance use disorder" as "pseudo addiction".[40] In 2019, Purdue Pharma agreed to settle and pay 270 million dollars to the state of Oklahoma that would go towards addiction research and treatment.[41] The settlement could indicate a win for other states that have taken legal action against similar opioid manufacturers.[40] Specifically, states like California are raising similar claims that Purdue Pharma marketed the drug Oxycontin as a safe and effective treatment, which led to the opioid crisis leaving thousands dead in California from opioid overdoses.[42]
Treatment within legal landscape
Title II of the Comprehensive Drug Abuse Prevention and Control Act of 1970, otherwise known as the Controlled Substance Act, established five drug schedules to regulate and control their manufacture and distribution.[43] In 2017, President Donald Trump officially declared the opioid crisis a "public health emergency."[44] In 2018, the United States federal government enacted the SUPPORT Act which aims to help Americans gain access to opioid addiction treatment and help and reduce the amount of opioids prescribed.[45] Other efforts include enacting legislation that provides funds from the Department of Health and Human Services to help support the creation and use of Syringe Services Programs.[46] Recently, legislatures have started to advocate for the implementation of supervised injection sites as another way to help the opioid crisis and reduce harm.[47] However, the United States Court of Appeals for the Third Circuit held that supervised injection sites violate the Federal Crack House Statute.[48]
Safe Injection Sites
Safe injection sites, also known as supervised injection sites are designated facilities where individuals can use pre-obtained drugs under the supervision of trained medical staff. These sites are designed to reduce the health and societal impacts of drug use by providing a controlled, hygienic environment for drug consumption. The primary goal is to prevent overdose deaths through immediate medical intervention and to reduce the transmission of infectious diseases such as HIV and Hepatitis by offering sterile injection equipment.[49] Additionally, these sites often provide a range of services, including access to addiction treatment, healthcare, and social support systems, thereby acting as critical points of contact for individuals who might otherwise be disconnected from the healthcare system.[50]
The concept of safe injection sites first emerged in Europe during the 1980s, with Switzerland opening the first such facility in 1986.[50] This initiative was driven by rising heroin use and its associated public health crises.[50] Over time, numerous studies have documented the benefits of these sites, including reductions in overdose deaths, lower rates of disease transmission, and improvements in public safety. These findings have contributed to the gradual adoption of safe injection sites in various countries.[50]
In the United States, the opioid crisis has reached unprecedented levels, prompting a growing interest in harm reduction strategies such as safe injection sites.[51] Despite facing significant legal and political challenges, several cities have taken steps toward implementing these facilities. The initiative, however, has faced considerable opposition and legal hurdles, reflecting the contentious nature of the issue.[51]
In 2021 New York City became the first city in the US to open officially authorized overdose prevention centers. Other cities, including Seattle and Denver, have explored or implemented similar measures, reflecting a growing recognition of the need for innovative approaches to address the opioid crisis.[51] These initiatives often receive support from public health advocates and some local governments, who argue that safe injection sites are a pragmatic and humane response to a complex public health issue. The U.S. government took a significant step towards evaluating the effectiveness of safe injection sites. In 2023 it approved funding for a study with a $5 million grant from the National Institute on Drug Abuse to measure the impact of these sites on overdose prevention, health care costs, and community safety.[51] The study, conducted by New York University and Brown University, focused on two sites in New York City and one in Providence, Rhode Island. Researchers enrolled 1,000 adult drug users to assess the sites' effectiveness in reducing overdoses and estimating potential savings for the healthcare and criminal justice systems.[52]
According to medical professionals supervised injection sites are effective in reducing overdose deaths and the transmission of infectious diseases.[53] These sites have been legally operating in Europe, Canada, and Australia since 1986, and have been associated with significant public health benefits. For example, a study of a supervised injection site in Vancouver, Canada, found a 26% net reduction in overdose deaths in the area surrounding the site.[53] Despite these benefits, the U.S. Department of Health and Human Services has stopped short of supporting supervised injection sites, and legal challenges have hindered their implementation in many cities .
The city of Providence, Rhode Island, approved the establishment of the state's first safe injection site in 2024. This site, set to operate openly, became the only such facility in the U.S. outside of New York City.[54] The approval came more than two years after Rhode Island authorized overdose prevention centers, highlighting the state's commitment to innovative harm reduction strategies.[54] The Providence Center, run by the nonprofit Project Weber/RENEW and VICTA, aims to provide comprehensive services, including drug-related resources, case management, and housing support.[54] This initiative reflects a broader trend of states and cities exploring the potential of safe injection sites to address the opioid crisis, despite facing resistance and legal challenges.[55]
Despite the documented benefits and support from certain quarters, the establishment of safe injection sites in the US remains highly controversial. Opponents argue that these sites may enable drug use and attract crime, while proponents contend that the evidence from other countries demonstrates significant public health benefits.[54]
Canada
Naloxone injection kit, pictured at a train station in Calgary, Canada
In 1993, an investigation by the chief coroner in British Columbia identified an "inordinately high number" of drug-related deaths, of which there were 330. In 2016 there were 2861 opioid related deaths in Canada. By 2017, there were 1,473 deaths in British Columbia and 3,996 deaths in Canada as a whole.[56] Between 2016 and 2022 Canada saw a two and a half fold increase in the per capita rate of opioid related deaths, reaching 20.3 per 100,000 population per year, with 1,904 deaths reported in the first 3 months of 2023 alone.[57]
Following the United States, Canada was identified in 2015 as the second-highest per-capita user of prescription opioids.[58] In Alberta, emergency department visits as a result of opiate overdose, attributable to both prescription and illicit opioids, specifically fentanyl and fentanyl analogues, rose 1,000% in the previous five years. The Canadian Institute for Health Information found that while a third of overdoses were intentional overall, among those ages 15–24 nearly half were intentional.[59] In 2017, there were 3,987 opioid-related deaths in Canada, 92% of these deaths being unintentional. The number of deaths involving fentanyl or fentanyl analogues increased by 17% compared to 2016.[60] Between April and December 2020, there was an 89% increase in opioid related deaths in comparison to 2019.[61]Saskatoon, Saskatchewan experienced a record month in opioid overdoses in May 2020 caused, authorities explained, by a combination of ever-amplifying toxic drugs and the COVID-19 pandemic's quarantine keeping individuals from family and needed mental health services. Over 28,800 Emergency Medical Services (EMS) responded to possible opioid related health crises between January and December 2020 after the COVID-19 pandemic began.[62] In May 2020 Medavie Health Services provided over 250 ambulance services for overdoses, administering the opioid antagonist nasal spray Narcan (naloxone) in record numbers.
North America's first safe injection site, Insite, opened in the Downtown Eastside (DTES) neighborhood of Vancouver in 2003. Safe injection sites are legally sanctioned, medically supervised facilities in which individuals are able to consume illicit recreational drugs, as part of a harm reduction approach towards drug problems which also includes information about drugs and basic health care, counseling, sterile injection equipment, treatment referrals, and access to medical staff, for instance in the event of an overdose. Health Canada has licensed 16 safe injection sites in the country.[63] In Canada, about half of overdoses resulting in hospitalization were accidental, while a third were deliberate overdoses.[59]
OxyContin was removed from the Canadian drug formulary in 2012[64] and medical opioid prescription was reduced, but this led to an increase in the illicit supply of stronger and more dangerous opioids such as fentanyl and carfentanil. In 2018, there were around one million users at risk from these toxic opioid products. In Vancouver Jane Buxton of the British Columbia Centre for Disease Control joined the Take-home naloxone program in 2012 to provide at risk individuals medication that quickly reverses the effects of an overdose from opioids.[65]
Outside North America
Approximately 80 percent of the global pharmaceutical opioid supply is consumed in the United States.[66] It has also become a serious problem outside the U.S., mostly among young adults.[67] The concern not only relates to the drugs themselves, but to the fact that in many countries doctors are less trained about drug addiction, both about its causes or treatment.[26] According to an epidemiologist at Columbia University: "Once pharmaceuticals start targeting other countries and make people feel like opioids are safe, we might see a spike [in opioid abuse]. It worked here. Why wouldn't it work elsewhere?"[26]
Many deaths worldwide from opioids and prescription drugs are from sexually transmitted infections passed through shared needles.[68] This has led to a global initiative of needle exchange programs[69] and research into the varying needle types carrying STIs. In Europe, prescription opioids account for three‐quarter of overdose deaths, which represent 3.5% of total deaths among 15-39-year-olds.[67] Some worry that the epidemic could become a worldwide pandemic if not curtailed.[26] Prescription drug abuse among teenagers in Canada, Australia, and Europe was comparable to U.S. teenagers.[26] In Lebanon and Saudi Arabia, and in parts of China, surveys found that one in ten students had used prescription painkillers for non-medical purposes. Similar high rates of non-medical use were found among the young throughout Europe, including Spain and the United Kingdom.[26] In 2017, 1049 people had a death related to opioids in Spain[70]
While strong opiates are heavily regulated within the European Union, there is a "hidden addiction" with codeine. Codeine, though a mild painkiller, is converted into morphine in the liver.[71] "It's a hidden addiction,' said Dr Michael Bergin of Waterford Institute of Technology, Ireland. 'Codeine abuse affects people with diverse profiles, from children to older people across all social classes."[71]
Myanmar
On 18 May 2020, Myanmar and the U.N. Office of Drugs and Crime (UNODC) announced that, over the previous three months, police had confiscated illicit drugs with a street value estimated at hundreds of millions of dollars. Most was methamphetamine; they also seized 3,750 liters (990 US gallons) of the potent opiate liquid methylfentanyl.[72]
United Kingdom
From January to August 2017, there were 60 fatal overdoses of fentanyl in the UK.[73] In England, opioid prescribing in general practice mirrors general geographical health inequalities.[74] In July 2019, two Surrey GPs working for a Farnham-based online pharmacy were suspended by the General Medical Council for prescribing opioids online without appropriate safeguards.[75]Public Health England reported in September 2019 that half the patients using strong painkillers, antidepressants and sleeping tablets had been on them for more than a year, which was generally longer than was "clinically" appropriate and where the risks could outweigh the benefits. They found that problems in the UK were less than in most comparable countries,[76] but there were 4,359 deaths related to drug poisoning, largely opioids, in England and Wales in 2018 – the highest number recorded since 1993.[77]
Public Health England reported in September 2019 that 11.5 million adults in England had been prescribed benzodiazepines, Z-drugs, gabapentinoids, opioids, or antidepressants in the year ending March 2018. Half of these had been prescribed for at least a year.[78] About 540,000 had been prescribed opioids continuously for three years or more. Prescribing of opioids and Z-drugs had decreased, but antidepressants and gabapentinoids had increased, gabapentinoids by 19% between 2015 and 2018 to around 1.5 million.[79]
It was reported that in 2021/2022, 1.80 million patients were prescribed dependency-forming medicines in the most deprived areas in England, 1.66 times more than the number prescribed these medicines in the least deprived areas. This pattern had been consistent since 2015/2016.[80]
Continental Europe
While deaths from overdoses related to illicit fentanyl and oxycodone are relatively rare in the UK and Europe, fatal outcomes from opioid intoxications have seen a moderate increase since 2015. In continental Europe, the rise of deaths as a result of opioid/opiate use had been partly due to chronic illnesses of addicts 40 years and older, but some of the recent deaths experienced by younger users experimenting with 'designer drugs' have been more unsettling. Generally speaking, the use of fentanyl by addicts in Europe has been rare as of 2022, according to a Swiss study, but at the same time general deaths from opioid use have increased by 177% since 2019. As in other parts of the Western world, the COVID-19 pandemic has brought a reduced availability of therapies for addicts, but at the same time increased the availability of synthetic opioids on the black market.[81][82][83]
France
A study of prescription opioid use in France over 2004-2017 [84] found that the use of strong prescription opioids more than doubled over the period. There was a large increase in the use of oxycodone for chronic non-cancer pain (by nearly 20-fold). Prescription opioid-related hospitalizations increased from 15 to 40 per 1,000,000 population (+167%, 2000–2017). Heroin and methadone hospitalisations were much lower, increasing from 2.6 to 6.9 per 100,000, with all of the increase due to methadone use rather than heroin. Opioid-related deaths, including drugs of abuse, rose from 1.3 to 3.2 per 1,000,000 population (+146%, 2000–2015).
Accessibility of prescribed opioids
The worry surrounding the potential of a worldwide pandemic has affected opioid accessibility in countries around the world. Approximately 25.5 million people per year, including 2.5 million children, die without pain relief worldwide, with many of these cases occurring in low and middle-income countries. The current disparity in accessibility to pain relief in various countries is significant. The U.S. produces or imports 30 times as much pain relief medication as it needs while low-income countries such as Nigeria receive less than 0.2% of what they need, and 90% of all the morphine in the world is used by the world's richest 10%.[85]
America's opioid epidemic has resulted in an "opiophobia" that is stirring conversations among some Western legislators and philanthropists about adopting a "war on drugs rhetoric" to oppose the idea of increasing opioid accessibility in other countries, in fear of starting similar opioid epidemics abroad.[86] The International Narcotics Control Board (INCB), a monitoring agency established by the U.N. to prevent addiction and ensure appropriate opioid availability for medical use, has written model laws limiting opioid accessibility that it encourages countries to enact. Many of these laws more significantly impact low-income countries; for instance, one model law ruled that only doctors could supply opioids, which limited opioid accessibility in poorer countries that had a scarce number of doctors.[87]
In 2018, deputy head of China's National Narcotics Commission Liu Yuejin criticized the U.S. market's role in driving opioid demand.[88]
In 2016, the medical news site STAT reported that while Mexican cartels are the main source of heroin smuggled into the U.S., Chinese suppliers provide both raw fentanyl and the machinery necessary for its production.[89] In British Columbia, police discovered a lab making 100,000 fentanyl pills each month, which they were shipping to Calgary, Alberta. 90 people in Calgary overdosed on the drug in 2015.[89] In Southern California, a home-operated drug lab with six pill presses was uncovered by federal agents; each machine was capable of producing thousands of pills an hour.[89]
In 2018, a woman died in London after getting a prescription for tramadol from an online doctor based in Prague who had not considered her medical history. Regulators in the UK admitted that there was nothing they could do to stop this from happening again.[90] A reporter from The Times was able to buy opioids from five online pharmacies in September 2019 without any contact with their GP by filling in an online questionnaire and sending a photocopy of their passport.[91]
Alternative for opioids
Alternative drug options for opioids include over the counter pain medication such as Ibuprofen, Tylenol (acetaminophen/paracetamol), and Aspirin or steroid options.[92][93] A German study comparing legal opioid use between different countries concluded that a high consumption of oxycodone could be attributed to the non-availability of the drug metamizole, a non-opioid pain reliever which is heavily used in some countries such as Germany and Austria, but which is banned in others such as the US and Canada.[94]
Along with drug alternatives, many other alternatives can provide relief through physical activities. Physical therapy, acupuncture, injections/nerve blocks, massages, and relaxation techniques are physical activities that have been found to help with chronic pain.[92] New pain management drugs like cannabis and cannabinoids have also been found to help treat symptoms of pain.[92] Many treatments like cancer treatments are using these drugs to help manage pain.[92]
Signs of addiction
People that are addicted to opioids can have many changes in behavior. Some of the common signs or symptoms of addiction include spending more time alone, losing interest in activities, quickly changing moods, sleeping at odd hours, getting in trouble with the law, and financial hardships.[95] People that notice any of these behaviors in a peer or in oneself, are usually advised to consult a physician.[95]
Treatment and prevention of addiction
Opioid use disorder can be treated in a number of different ways: Medication assisted treatment pathways offer methadone, Suboxone (Buprenorphine/naloxone) and Vivitrol (naltrexone), though naltrexone has poor treatment outcomes due to low patient retention.[96] According to the 2017 Surgeon General's report, medication (buprenorphine/methadone) assisted therapies (MAT's) remain the gold standard in evidence-based care for opiate addiction, with the highest reduction in morbidity, mortality, and general negative outcomes achieved through long term opioid replacement therapy.[97] The report makes recommendations concerning expanding access to MAT in order to combat the opioid epidemic. Social stigma regarding medication-assisted treatment in nations like the USA have been a major barrier in implementing evidence based treatments for opiate addiction.[98]
Cognitive behavioral therapies and counseling are proven effective (though less efficacious on their own than medication assisted therapies) as well as digital care programs to increase abstinence rates.[99][100]
A number of methods for the prevention of opioid addiction have been used and suggested. One method is the creation of anti-opioid advertisements. In the 1990s, advertisements depicting drug-seeking people purposefully slamming their arms into doors and crashing their cars, were unsuccessfully targeted at teens.[101]
These ads were unsuccessful because they emphasized the risk of danger, pain, and death caused by opioids.[101] While this tactic would make adults acknowledge the risks and stop using opioids, teenagers need to see that executives just use them as interchangeable customers.[101][clarification needed] The makers of these ads feel that since the internet allows teenagers to view gruesome things anyway, it is perfectly acceptable to subject them to images of self-mutilation in order to protect their lives.[102] It is felt that thirty seconds of gruesomeness is a small price to pay for sparing a lifetime (however short) of opioid abuse and its accompanying poverty and crime.[102] These advertisements, which started in the 1980s, are continuing to play on television today, utilizing donated advertisement time. The goals of the most recent advertisements are to show teenagers that addiction can begin after only five days and that feeding this addiction can consume a person's entire life.[103]
Heroin, also known as diacetylmorphine and diamorphine among other names, is a morphinan opioid substance synthesized from the dried latex of the Papaver somniferum plant; it is mainly used as a recreational drug for its euphoric effects. Medical-grade diamorphine is used as a pure hydrochloride salt. Various white and brown powders sold illegally around the world as heroin are routinely diluted with cutting agents. Black tar heroin is a variable admixture of morphine derivatives—predominantly 6-MAM (6-monoacetylmorphine), which is the result of crude acetylation during clandestine production of street heroin. Heroin is used medically in several countries to relieve pain, such as during childbirth or a heart attack, as well as in opioid replacement therapy.
Methadone, sold under the brand names Dolophine and Methadose among others, is a synthetic opioid agonist used for chronic pain and also for opioid use disorder. It is used to treat chronic pain, and it is also used to treat addiction to heroin or other opioids. Prescribed for daily use, the medicine relieves cravings and removes withdrawal symptoms. Withdrawal management using methadone can be accomplished in less than a month, or it may be done gradually over a longer period of time, or simply maintained for the rest of the patient's life. While a single dose has a rapid effect, maximum effect can take up to five days of use. After long-term use, in people with normal liver function, effects last 8 to 36 hours. Methadone is usually taken by mouth and rarely by injection into a muscle or vein.
Oxycodone, sold under various brand names such as Roxicodone, Endone, and OxyContin, is a semi-synthetic opioid used medically for treatment of moderate to severe pain. It is highly addictive and is a commonly abused drug. It is usually taken by mouth, and is available in immediate-release and controlled-release formulations. Onset of pain relief typically begins within fifteen minutes and lasts for up to six hours with the immediate-release formulation. In the United Kingdom, it is available by injection. Combination products are also available with paracetamol (acetaminophen), ibuprofen, naloxone, naltrexone, and aspirin.
Fentanyl is a highly potent synthetic piperidine opioid primarily used as an analgesic. It is 20 to 40 times more potent than heroin and 100 times more potent than morphine; its primary clinical utility is in pain management for cancer patients and those recovering from painful surgeries. Fentanyl is also used as a sedative. Depending on the method of delivery, fentanyl can be very fast acting and ingesting a relatively small quantity can cause overdose. Fentanyl works by activating μ-opioid receptors. Fentanyl is sold under the brand names Actiq, Duragesic and Sublimaze, among others.
Naloxone is an opioid antagonist: a medication used to reverse or reduce the effects of opioids. For example, it is used to restore breathing after an opioid overdose. Effects begin within two minutes when given intravenously, five minutes when injected into a muscle, and ten minutes as a nasal spray. Naloxone blocks the effects of opioids for 30 to 90 minutes.
A drug overdose is the ingestion or application of a drug or other substance in quantities much greater than are recommended. Typically it is used for cases when a risk to health will potentially result. An overdose may result in a toxic state or death.
Opioids are a class of drugs that derive from, or mimic, natural substances found in the opium poppy plant. Opioids work in the brain to produce a variety of effects, including pain relief. As a class of substances, they act on opioid receptors to produce morphine-like effects.
Opioid use disorder (OUD) is a substance use disorder characterized by cravings for opioids, continued use despite physical and/or psychological deterioration, increased tolerance with use, and withdrawal symptoms after discontinuing opioids. Opioid withdrawal symptoms include nausea, muscle aches, diarrhea, trouble sleeping, agitation, and a low mood. Addiction and dependence are important components of opioid use disorder.
Buprenorphine, sold under the brand name Subutex among others, is an opioid used to treat opioid use disorder, acute pain, and chronic pain. It can be used under the tongue (sublingual), in the cheek (buccal), by injection, as a skin patch (transdermal), or as an implant. For opioid use disorder, the patient must have moderate opioid withdrawal symptoms before buprenorphine can be administered under direct observation of a health-care provider.
Oxymorphone is a highly potent opioid analgesic indicated for treatment of severe pain. Pain relief after injection begins after about 5–10 minutes, after oral administration it begins after about 30 minutes, and lasts about 3–4 hours for immediate-release tablets and 12 hours for extended-release tablets. The elimination half-life of oxymorphone is much faster intravenously, and as such, the drug is most commonly used orally. Like oxycodone, which metabolizes to oxymorphone, oxymorphone has a high potential to be abused.
An opioid overdose is toxicity due to excessive consumption of opioids, such as morphine, codeine, heroin, fentanyl, tramadol, and methadone. This preventable pathology can be fatal if it leads to respiratory depression, a lethal condition that can cause hypoxia from slow and shallow breathing. Other symptoms include small pupils and unconsciousness; however, its onset can depend on the method of ingestion, the dosage and individual risk factors. Although there were over 110,000 deaths in 2017 due to opioids, individuals who survived also faced adverse complications, including permanent brain damage.
A pill mill is an illegal facility that resembles a regular pain clinic, but regularly prescribes painkillers (narcotics) without sufficient medical history, physical examination, diagnosis, medical monitoring, or documentation. Clients of these facilities usually receive prescriptions only against cash. Pill mills contribute to the opioid epidemic in the United States and are the subject of a number of legislative initiatives at the state level.
Buprenorphine/naloxone, sold under the brand name Suboxone among others, is a fixed-dose combination medication that includes buprenorphine and naloxone. It is used to treat opioid use disorder, and reduces the mortality of opioid use disorder by 50%. It relieves cravings to use and withdrawal symptoms. Buprenorphine/naloxone is available for use in two different forms, under the tongue or in the cheek.
There is an ongoing opioid epidemic in the United States, originating out of both medical prescriptions and illegal sources. It has been called "one of the most devastating public health catastrophes of our time". The opioid epidemic unfolded in three waves. The first wave of the epidemic in the United States began in the late 1990s, according to the Centers for Disease Control and Prevention (CDC), when opioids were increasingly prescribed for pain management, resulting in a rise in overall opioid use throughout subsequent years. The second wave was from an expansion in the heroin market to supply already addicted people. The third wave starting in 2013 was marked by a steep 1,040% increase in the synthetic opioid-involved death rate as synthetic opioids flooded the US market.
Opioid agonist therapy (OAT) is a treatment in which prescribed opioid agonists are given to patients who live with Opioid use disorder (OUD). In the case of methadone maintenance treatment (MMT), methadone is used to treat dependence on heroin or other opioids, and is administered on an ongoing basis.
Prescription drug addiction is the chronic, repeated use of a prescription drug in ways other than prescribed for, including using someone else’s prescription. A prescription drug is a pharmaceutical drug that may not be dispensed without a legal medical prescription. Drugs in this category are supervised due to their potential for misuse and substance use disorder. The classes of medications most commonly abused are opioids, central nervous system (CNS) depressants and central nervous stimulants. In particular, prescription opioid is most commonly abused in the form of prescription analgesics.
Scott E. Hadland is a Canadian-American physician and scientist who serves as a pediatrician, and addiction specialist at Massachusetts General Hospital and Harvard Medical School, where he is the Chief of the Division of Adolescent and Young Adult Medicine. He previously served as an addiction specialist at the Grayken Center for Addiction at Boston Medical Center.
Harm reduction consists of a series of strategies aimed at reducing the negative impacts of drug use on users. It has been described as an alternative to the U.S.'s moral model and disease model of drug use and addiction. While the moral model treats drug use as a morally wrong action and the disease model treats it as a biological or genetic disease needing medical intervention, harm reduction takes a public health approach with a basis in pragmatism. Harm reduction provides an alternative to complete abstinence as a method for preventing and mitigating the negative consequences of drug use and addiction.
New Jersey's most recent revised policy was issued September 7, 2022 pursuant to P.L.2021, c.152 which authorized opioid antidotes to be dispensed without a prescription or fee. Its goal is to make opioid antidotes widely available, reducing mortality from overdose while decreasing morbidity in conjunction with sterile needle access, fentanyl test strips, and substance use treatment programs. A $67 million grant provided by the Department of Health and Human Services provides funding for naloxone as well as recovery services. This policy enables any person to distribute an opioid antidote to someone they deem at risk of an opioid overdose, alongside information regarding: opioid overdose prevention and recognition, the administration of naloxone, circumstances that warrant calling 911 for assistance with an opioid overdose, and contraindications of naloxone. Instructions on how to perform resuscitation and the appropriate care of an overdose victim after the administration of an opioid antidote should also be included. Community first aid squads, professional organizations, police departments, and emergency departments are required to "leave-behind" naloxone and information with every person who overdosed or is at risk of overdosing.
In response to the surging opioid prescription rates by health care providers that contributed to the opioid epidemic in the United States, US states began passing legislation to stifle high-risk prescribing practices. These new laws fell primarily into one of the following four categories:
Prescription Drug Monitoring Program (PDMP) enrollment laws: prescribers must enroll in their state's PDMP, an electronic database containing a record of all patients' controlled substance prescriptions
PDMP query laws: prescribers must check the PDMP before prescribing an opioid
Opioid prescribing cap laws: opioid prescriptions cannot exceed designated doses or durations
Pill mill laws: pain clinics are closely regulated and monitored to minimize the prescription of opioids non-medically
↑ Bonnie RJ, Ford MA, Phillips JK, eds. (2017). "4. Trends in Opioid Use, Harms, and Treatment". Pain Management and the Opioid Epidemic: Balancing Societal and Individual Benefits and Risks of Prescription Opioid Use [PART II. Addressing the Opioid Epidemic]. The National Academies Press. ISBN978-0-309-45954-9. Responsible parties: National Academies of Sciences, Engineering and Medicine; Health and Medicine Division; Board on Health Sciences Policy; Committee on Pain Management and Regulatory Strategies to Address Prescription Opioid Abuse. Archived from the original on May 14, 2021. Retrieved January 10, 2022.
↑ Mohamadi A, Chan JJ, Lian J, Wright CL, Marin AM, Rodriguez EK, von Keudell A, Nazarian A (August 2018). "Risk Factors and Pooled Rate of Prolonged Opioid Use Following Trauma or Surgery: A Systematic Review and Meta-(Regression) Analysis". The Journal of Bone and Joint Surgery. American Volume. 100 (15): 1332–1340. doi:10.2106/JBJS.17.01239. PMID30063596. S2CID51891341.(subscription required)
↑ PHE, 'Dependence and withdrawal associated with some prescribed medicines An evidence review' (2019) 12, "The totals for each medicine were: antidepressants 7.3 million people (17% of the adult population) opioid pain medicines 5.6 million (13%) gabapentinoids 1.5 million (3%) benzodiazepines 1.4 million (3%) z-drugs 1.0 million (2%)
↑ Preissner S, Siramshetty VB, Dunkel M, Steinborn P, Luft FC, Preissner R (2019). "Pain-Prescription Differences - An Analysis of 500,000 Discharge Summaries". Current Drug Research Reviews. 11 (1): 58–66. doi:10.2174/1874473711666180911091846. PMID30207223. S2CID52192130.
1 2 "Opioid Abuse". American Society of Anesthesiologists. Archived from the original on December 15, 2019. Retrieved December 9, 2019.
↑ "Opioid Use Disorder". The Lecturio Medical Concept Library. Archived from the original on June 25, 2021. Retrieved June 25, 2021.
↑ Association for Behavioral and Cognitive Therapies. "Opioid Use Disorder Fact Sheet". Association for Behavioral and Cognitive Therapies. Archived from the original on June 3, 2020. Retrieved June 8, 2020.
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