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.   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 (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.” 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.
Instruments 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. 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) .
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.  
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.
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