Although opiate drugs have been in use for thousands of years, America is finding itself in the middle of a very modern problem. Addiction to this powerful pain reliever is ripping through communities across the country, and the death toll is astounding.

In 2016, some 63,632 Americans died from drug overdoses—almost equivalent to all the soldiers who died in the Vietnam war1. Two-thirds of these deaths (66.4%) involved opioids2.

How did the United States find itself in the middle of this epidemic? How do these drugs actually work? Read on for a primer on the opioid epidemic.    

The Opioid Overdose Epidemic: Statistics and Numbers

In line with higher numbers of prescriptions to painkillers, the rate of death from opioid medications has been growing every year since the mid-1990s. In 2001, there were some 12,500 deaths attributed to the drugs, but by 2016, this number had doubled to just under 35,0003.

In some areas, overdoses involving opioids are now the leading cause of death among otherwise healthy working-age adults4.

Government agencies and health practitioners alike started to notice that there were a deadly number of painkiller prescriptions being written in about 2010, and began to adjust behavior accordingly; the number of prescriptions is thought to have peaked around 20125.

Although this did help level off the rate of death from prescription drugs like OxyCotin, it seems many users who got their start with legal prescriptions simply switched to street drugs when pills were no longer available; rates of death from black-market opioids, primarily heroin, continue to climb, including preliminary data from early 20186. As of 2017, the CDC estimated that over 21 million Americans over the age of 12 had substance abuse disorder7, which means they met the clinical criteria for addiction to one or more chemicals.

The opioid addiction epidemic is also happening in the context of unprecedented numbers of overdoses and deaths from other drugs, too, like cocaine and methamphetamine8.

These increases in overdoses are happening in the shadow of growing rates of suicide and mood disorder diagnoses across the nation9. The causes of addiction are certainly complex, but “self-medication” of conditions like depression, anxiety, or PTSD is a widely observed phenomenon backed with plenty of evidence from multiple studies10.

Thus, the fact that there may be a mental health crisis underneath the addiction crisis is not surprising.   

How Can Technology Help?

Because primary care doctors are on the forefront of this crisis, technology that augments primary care abilities could help make treatment faster, more specific, and generally more effective. For example, before seeing the doctor, patients in the waiting room can complete a series of tests on an ipad. These tests are designed to help the practitioner:

  • Identify symptoms of depression, anxiety, PTSD, and other major mental health concerns at the root of co-occurring substance abuse disorders.
  • Help pain clinics and other prescribers with with opioid-using patients effectively identify risk factors for medication abuse.
  • Reduce morbidity and mortality from under-diagnosed mental health conditions.
  • Keep track of patient changes over time

Some of these programs, such as GreenLight, present this information in a “points system” with expert-developed suggestions based on scores so that doctors can quickly make informed decisions.

Additionally, the screen may invite more honest answers. For many patients with mental illness and/or substance abuse disorders, shame may make it difficult to discuss face-to-face with a practitioner. On the other hand, the displayed questionnaire may make it easier for patients to admit difficult symptoms.

Emerging research supports this, especially among younger patients11.  

What Exactly Are Opioids, and What’s the Difference Between Opiates and Opioids?  

Sometimes, the media uses these two words interchangeably, but this is incorrect. To be precise, an “opiate” is any drug naturally derived from the poppy plant.

Historically, opium and morphine were the two main opiates used by doctors and addicts alike. Drugs like hydrocodone (found in OxyCotin) and heroin are also made from the poppy plant. More recently, scientists have invented a range of artificial drugs from the powerful anesthetic Fentanyl to the weaker painkiller Tramadol that work on the same part of the brain.

This class of drugs are not opiates, but fit into the larger umbrella term of “opioids”, or any drug (artificial or natural) that affects the opioid receptors in the human brain12. Therefore, morphine is an opiate and an opioid, and Fentanyl is simply an opioid.    

Regardless of their origin, after an opioid enters the body it is metabolized into active substances that cross the blood-brain barrier. Once in the brain, opioid drugs act like artificial neurotransmitters that bind to naturally-occurring opioid receptors.

Why is our brain equipped with these receptors?

Scientists think that the receptors work with naturally occurring painkillers like endorphins that our brain produces during periods of physical stress or pain; it’s essentially a built-in pain management system13.

The opioids flood this system with powerful signals, causing nerve pain to be blocked as well as a number of other physical symptoms:

  • Dampened consciousness and reduced anxiety
  • Lowered breathing rate and blood pressure
  • Nausea and constipation
  • Euphoria in higher doses

Opioid deaths often result from a lowered breathing rate. When someone overdoses, the body simply stops signalling the lungs to breathe. Another relatively common cause of death is aspiration of vomit: if someone is unconscious and vomits, it can enter the airway, causing choking.

Opioid Addiction Signs & Symptoms

A defining characteristic of the current opioid crisis in the US is that it every socio-economic group in every region of the country has been affected.

Wealthy, educated families in Boston and New York are battling the same addiction that is burning through blue-collar communities in Lansing and Detroit. By extension, the possibility of having a drug addict among friends or family is unfortunately present for every American14.

Besides evidence like missing pills (or pills that don’t have a prescription), needles, or other drug paraphernalia, there are also physical and behavioral signs common in people using opioids. These include:

  • “Pin-point” or abnormally tiny pupils
  • Nausea and vomiting
  • Itchiness
  • Reduced level of alertness; drowsing or “nodding off”  
  • “Track marks” or small, oval-shaped bruises with skin damage on arms, feet (including between fingers and toes), legs, or neck
  • Labile or “all over the place” emotions; extreme irritability
  • Missing money or valuables    

If someone has used too much of an opiate, an overdose will occur. If these common signs of overdose are observed, the person should be placed on their left side and 911 should be called immediately. These signs include:

  • Loss of consciousness that doesn’t respond to stimuli like shaking or yelling
  • Loud snoring, gasping, or labored breathing
  • Cool, clammy skin and blue-grey nail beds
  • Cardiac arrest (stopped pulse)

There is an antidote for opioid overdose called Naloxone; it is carried by firefighters and EMS, and sometimes even by families or friends of addicts. It’s easy to administer and if given in time it can immediately reverse the acute effects of opioid intoxication.

Naloxone has saved hundreds of thousands of lives15.

Treatment Options for Opioid Addiction

Because of the powerful effect that opioids have on the brain, addiction to these drugs is difficult to beat.

That’s why, regardless of course of action decided on, people in recovery are much more likely to stay sober if they have counseling and support from professionals16. The main two options for treatment are abstinence or opioid substitution therapy.

Abstinence or the “cold turkey” method requires the individual to go through detox and withdrawal, which is best done at a facility run by medical professionals. After detox is complete, the addict should ideally enter a treatment program to undergo counseling, group therapy, and support to help him or her stay clean during the difficult early days of sobriety, as well as work through any issues like depression or trauma that may have led to the drug abuse in the first place.

Opiate substitution therapy is the replacement of illicit opioid drugs with prescription medication given under the care of a doctor. Just like abstinence, it is most successful if undertaken in combination with therapy and support from addiction specialists17.

Methadone used to be the treatment of choice for substitution therapy, but today a newer drug called Buprenorphine  (Suboxone) is more commonly used.

Buprenorphine actually combines an opioid medication with naloxone, the same treatment used to reverse overdoses. This helps limit the “high” that can be achieved and lowers its potential for abuse.

One of the most important things loved ones of addicts can do is insist on treatment. If the addict refuses, the loved one must be prepared to stop seeing the addict or enabling their destructive behavior.

Needless to say, this can be very difficult, which is why experts also often recommend counseling or Al-Anon groups to families and/or spouses of an opioid addict, too. During meetings, loved ones can learn how to enact firm boundaries and support the recovery of the addict once he or she decides to become sober.    

What is Kratom and Can it Help With Opioid Withdrawal Symptoms?

Many people looking up information about opioid addiction may have run across mentions of Mitragyna speciosa, or “Kratom.” This evergreen plant is related to coffee and is native to the forests of Southeast Asia18.

Because it works on similar parts of the brain as known opioid drugs, it has traditionally been used to help with opioid withdrawal symptoms, as well as used as a narcotic in its own right. Very little scientific information exists about whether or not Kratom actually helps with withdrawal symptomsor whether it is safe to use at all19.

Until recently, Kratom remained legal to import and use in the US, but the growing popularity of the substance combined with reports of deaths have pushed the FDA to work toward banning the substance. Until more research is done, Kratom should not be used as a “do it yourself” treatment for opioid addiction.  

Opioid Addiction Recovery and Outlook

As the opioid epidemic has finally started to be noticed by the upper echelons of public health and political offices, is there reason for optimism or the sense that the worst of the outbreak may be behind us?

Unfortunately, the answer is, “not so fast.”

Preliminary data from 2018 are ominous20 and greater awareness does not yet seem to be slowing the numbers of overdoses. This may be because although outreach and education programs have increased across the country, increased funding for treatment and other essential programs have not grown as fast as the public need would suggest.

Until more detox and treatment beds are opened up, first responders and primary health providers–neither of whom are formally trained addiction experts—will remain at the forefront of the crisis.

Stopgap measures like providing free or low-cost naloxone at all pharmacies and allowing primary care providers to prescribe Buprenorphine will need to be undertaken by local governments to help save lives21.

Primary care offices can also look into assistive technology, like screening apps and telemedicine, to better help serve patients who are struggling with addiction.     

America’s Addiction Epidemic: What’s Next?

If 60,000 Americans were dying every year as a result of war or terrorism, there would undoubtedly be sustained outcry—and our government would take whatever measures were necessary to bring the situation back to normal and protect the lives of its citizens.

On the other hand, the drug addiction problem in the US wasn’t noticed until a truly shocking number of people were dying due to shame, stigma, and a persistent culture of treating addiction as a weakness instead of a medical disease. Overcoming negative attitudes and a reluctance to talk about addiction may be the first foundational step the American people need to take to address the problem.

Of course, the addiction epidemic did not start overnight, and it will not be solved overnight, either. Stagnant wages and a perceived lack of opportunity in many areas combined with a lack of access to mental health services are both complex problems that require political will and frank discussion in American communities.

Other fixes, like dramatically increasing treatment beds and finding ways to stem the flow of massive quantities of Fentanyl and other powerful synthetic opioids into America’s black markets are more straightforward but will still need significant funding.

To stem this deadly epidemic will also require what could be unprecedented levels of cooperation between law enforcement and EMS, treatment specialists and primary care doctors, Federal health agencies and local officials, as well as between friends and family members who have loved ones who need help. In the past, America has dealt with existential threats head-on, and this problem is no different: solving it will require a quintessentially American mix of hard work and ingenuity.  

Notes

  1. 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. DOI: 10.2105/AJPH.2017.304265
  2. IBID
  3. American Society of Addiction Medicine, “Opioid Addiction 2016 Facts & Figures”, 2016. Available at www.asam.org/docs/default-source/advocacy/opioid-addiction-disease-facts-figures.pdf
  4. National Institute on Drug Abuse, “Overdose Death Rates,” Sept 17, 2017. Available at https://www.drugabuse.gov/related-topics/trends-statistics/overdose-death-rates
  5. American Society of Addiction Medicine, “Opioid Addiction 2016 Facts & Figures”, available at www.asam.org/docs/default-source/advocacy/opioid-addiction-disease-facts-figures.pdf
  6. 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. DOI: 10.2105/AJPH.2017.304265
  7. Centers for Disease Control and Prevention, “FastStats – Illegal Drug Use” May 3, 2017. Available at https://www.cdc.gov/nchs/fastats/drug-use-illegal.htm
  8. National Institute on Drug Abuse, “Overdose Death Rates,” Sept 17, 2017. Available at https://www.drugabuse.gov/related-topics/trends-statistics/overdose-death-rates
  9. Chan, Olivia, “The Current State of Suicide in America”, Hippocrates Med Review, November 6, 2017. Available at http://hippocratesmedreview.org/the-current-state-of-suicide-in-america/
  10. Drake, R. E., Mercer-McFadden, C., Mueser, K. T., McHugo, G. J., & Bond, G. R., “Review of integrated mental health and substance abuse treatment for patients with dual disorders.” Schizophrenia Bulletin, 24 no.4 (1998): pp. 589-608. DOI: /10.1093/oxfordjournals.schbul.a033351
  11. Joinson, Adam M., “Self-Disclosure in Computer-Mediated Communication: the Role of Self-Awareness and Visual Anonymity,” European Journal of Social Psychology, 31 no. 2 (March 27, 2011): pp. 177-192. DOI: doi.org/10.1002/ejsp.36  
  12. Nsikan Akpan, “How a Brain Gets Hooked on Opioids”, PBS News Hour, Oct 9, 2017. Availalbe at https://www.pbs.org/newshour/science/brain-gets-hooked-opioids
  13. IBID
  14. Andrew Kolodny, David T. Courtwright, Catherine S. Hwang, Peter Kreiner, John L. Eadie, Thomas W. Clark, G. Caleb Alexander, “The Prescription Opioid and Heroin Crisis: A Public Health Approach to an Epidemic of Addiction”, Annual Review of Public Health 36, no 1 (2017): pp., 559-574.
  15. Beheshti A, Lucas L, Dunz T, et al. An Evaluation of Naloxone Use for Opioid Overdoses in West Virginia: A Literature Review. American medical journal. 6, no.1 (2015): pp. 9-13. DOI: 10.3844/amjsp.2015.9.13.
  16. Tiberg, F et al., “Substitution Therapy With Flexible-Dose Depot Buprenorphine Injection To Treat Opioid Use Disorder In The United Kingdom: A Pharmacoeconomic Assessment” Value in Health 20 , no. 9 (2017): pp. A711 DOI: https://doi.org/10.1016/j.jval.2017.08.1880
  17. IBID
  18. Kavita M. Babu, Christopher R. McCurdy & Edward W. Boyer, “Opioid receptors and legal highs: Salvia divinorum and Kratom,” Clinical Toxicology, 46 no. 2 (2009): pp 146-152. DOI: 10.1080/15563650701241795
  19. IBID
  20. 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. DOI: 10.2105/AJPH.2017.304265
  21. Andrew Kolodny, David T. Courtwright, Catherine S. Hwang, Peter Kreiner, John L. Eadie, Thomas W. Clark, G. Caleb Alexander, “The Prescription Opioid and Heroin Crisis: A Public Health Approach to an Epidemic of Addiction”, Annual Review of Public Health 36, no 1 (2017): pp., 559-574.

 

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