The Opioid Addiction Epidemic: A Significant Challenge to Health Care Delivery Systems

The opioid addiction epidemic represents a significant challenge to health care delivery systems, social services, law enforcement, medicolegal services, and forensic systems as deaths associated with opioid use rise. Recent statistics indicate that opioid drug overdoses accounted for 66.4% of 63,632 drug overdose deaths in the United States in the year 2016, adding to 351,630 opioid deaths out of 568,699 total drug overdose deaths in the 16 years immediately prior.[1] [2] [3]  Several factors may be attributed to the increase in deaths due to opioid use: (1) Overprescribing or inappropriate prescribing of opioids, (2) Increased availability of opioids, (3) Addiction subsequent to treatment with opioid painkillers, (4) Complications from intravenous (IV) opioid use.

Opium Poppy #2
Opium poppy (Papaver somniferum): white flowers, seed capsule and seeds. Coloured zincograph, c. 1853, after M. Burnett. Credit: Wellcome Collection. CC BY

 

Addiction is defined as “a chronic, relapsing disorder characterized by compulsive drug seeking and use despite adverse consequences.”[4]  Epidemics of opioid addiction have been recorded globally for centuries and in the United States since the mid to late 1800s. During those early years, consistent nationwide standards for best practices for opioid prescription and use were few to non-existent. Even if best practices were pervasive and routinely used by clinicians, few alternatives to opioid painkillers for moderate to severe pain were available. The pharmacologic activity, and physiologic actions of opioid medications had not been elucidated, and the biology of addiction was poorly understood.

Opium InstrumentsInstruments used by John Young to collect opium. Credit: Wellcome Collection. CC BY

Spikes in opioid addiction throughout history have coincided with the introduction of the hypodermic needle for intravenous (IV) injection of morphine in the late 19th century, the infiltration of heroin in the inner cities during the turbulence of the 1960s, the continued problem of IV drug use in the inner cities that coincided with the crack epidemic, and the introduction of OxyContin (extended release oxycodone) in the mid-1990s.[5] Since then, deaths from prescription opioid deaths began to rise in 1999, followed by a significant increase in deaths from heroin overdoses in 2010, and finally a large spike in synthetic opioid (e.g. fentanyl) .

Opium Tincture
Empty bottle for opium tincture, London, England, 1880-1940. Credit: Science Museum, London. CC BY

The Centers for Disease Control and Prevention (CDC) released a Guideline for Prescribing Opioids for Chronic Pain – which includes several recommendations and best practices for the prevention of overprescribing opioids. Ideally, health care providers should thoughtfully consider best practices prior to prescribing opioids to their patients. CDC-recommended practices for opioid prescription include: ensuring that opioid treatment is evidence-based and appropriate, thoroughly reviewing the patient’s history prior to opioid prescription; utilizing alternatives to opioid painkillers, if possible; screening for prior history of overdose; making sure that both clinicians and their patients are clear about treatment goals; conducting a thorough discussion and/or evaluation of risks of opioid therapy; using care in the prescription of opioids with other medications; prescreening the patient (e.g.) for pre-existing substance abuse and/or the presence of other medications that might adversely interact with the prescribed opioid; accurately assessing prescribing the lowest possible dosage of opioid; and periodically reassessing whether or not previously prescribed opioid dosages remain appropriate over time.[6] [7] [8]

 

Dorkina Myrick, MD, PhD, MPP, is a physician-scientist and pathologist trained at the National Institutes of Health. Dr. Myrick also previously served as a Senior Health Policy Advisor on the United States Senate.  She obtained her Master of Public Policy degree at the University of Oxford in Oxford, England. Dr. Myrick is currently a JD candidate at the Boston University School of Law.

References:

[1] Holly Hedegaard, M.D., Margaret Warner, Ph.D., and Arialdi M. Miniño, M.P.H. (December 2017). Drug overdose deaths in the United States, 1999-2016. NCHS Data Brief, Number 294. National Vital Statistics System, Mortality. https://www.cdc.gov/nchs/data/databriefs/db294.pdf. Retrieved 10 April 2018.

[2]  Seth P, Scholl L, Rudd RA, Bacon S. Overdose Deaths Involving Opioids, Cocaine, and Psychostimulants — United States, 2015–2016. MMWR Morb Mortal Wkly Rep 2018;67:349–358. DOI: http://dx.doi.org/10.15585/mmwr.mm6712a1. Online:

https://www.cdc.gov/mmwr/volumes/67/wr/pdfs/mm6712a1-H.pdf. Retrieved 10 April 2018.

[3] Puja Seth, Rose A. Rudd, Rita K. Noonan, Tamara M.Haegerich, “Quantifying the Epidemic of Prescription Opioid Overdose Deaths”, American Journal of Public Health 108, no. 4 (April 1, 2018): pp. 500-502. Online: https://ajph.aphapublications.org/doi/abs/10.2105/AJPH.2017.304265?journalCode=ajph.

Retrieved 10 April 2018.

[4] Drugs, Brains, and Behavior: The Science of Addiction. National Institute of Drug Abuse (NIDA) Online: https://www.drugabuse.gov/publications/drugs-brains-behavior-science-addiction/drug-misuse-addiction. Retrieved 16 January 2019.

[5] Andrew Kolodny, David T. Courtwright, Catherine S. Hwang, Peter Kreiner, John L. Eadie, Thomas W. Clark, G. Caleb Alexander. 2015. Retrieved 11 April 2018.

“The Prescription Opioid and Heroin Crisis: A Public Health Approach to an Epidemic of Addiction.” Annual Review of Public Health. Volume 36, Issue 1, 559-574. Online: https://www.annualreviews.org/doi/pdf/10.1146/annurev-publhealth-031914-122957. Retrieved 11 April 2018.

[6] Deborah Dowell, MD, Tamara Haegerich, PhD, Roger Chou,MD. March 18, 2016. “CDC Guideline for Prescribing Opioids for Chronic Pain – 2016.” Morbidity and Mortality Weekly Report. (MMWR). Recommendations and Reports. United States Department of Health and Human Services (HHS) Centers for Disease Control and Prevention (CDC), Center for Surveillance, Epidemiology, and Laboratory Services. Volume 65. Number 1. pp. 1-49. Retrieved 10 April 2018.

[7] Errata. 2016. Volume 65, Number RR-1. Morbidity and Mortality Weekly Report. (MMWR). 65 (11):295. Online: https://www.cdc.gov/mmwr/volumes/65/wr/mm6511a6.htm?s_cid=mm6511a6_w#suggestedcitation . Retrieved 11 April 2018.

[8] “Checklist for prescribing opioids for chronic pain.” March 2016. United States Department of Health and Human Services (HHS) Centers for Disease Control and Prevention (CDC). Online: file:///Users/dorkinamyrick/Downloads/cdc_38025_DS1.pdf. Retrieved 11 April 2018.

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