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Feature:
Understanding Opioids

Understanding The Opioid Overdose Epidemic

Responding to the crisis. Prescription opioids are powerful drugs commonly used to reduce pain after surgery or injury. They are also used for pain from health conditions like cancer. However, opioids can produce harmful side effects, including drowsiness, mental fog, nausea, constipation, and respiratory depression (slowed breathing) that can lead to overdose deaths. Continued use can lead to addiction, making it hard to stop using opioids even after the cause of pain is gone.

Wilson Compton, MD, deputy director of the National Institute on Drug Abuse (NIDA)
Photo: NIDA

An estimated 1.9 million people in the United States have a prescription opioid use disorder. Another 586,000 have a heroin use disorder. Heroin is an opioid drug that is produced from morphine and sold illegally. Although most people who use heroin (80 percent) started by misusing prescription opioids, most people who abuse pain relievers (96 percent) do NOT go on to use heroin.

Health care providers wrote nearly a quarter of a billion opioid prescriptions in 2013—enough for every American adult to have his or her own bottle of pills.

Anyone taking an opioid can suffer an overdose, which slows a person’s breathing so much that the person passes out and is at risk for death. This can happen when someone takes more than prescribed, combines opioids with depressants (such as Xanax®) or alcohol, or has a medical condition that makes them more sensitive. In 2014, more than 28,000 people died from an opioid overdose, and more than half of those deaths involved a prescription opioid.

“There is a very complex set of issues leading to this public health crisis,” says Wilson Compton, MD, deputy director of the National Institute on Drug Abuse (NIDA).

“We can’t just stop treating pain,” Compton says. “But now that we’re discerning some of the risks, we must balance the need for pain treatment with the abuse potential. The goal is to minimize the risk for this substance use disorder while discovering better ways of treating pain.”

The U.S. Department of Health and Human Services (HHS) launched the Opioid Initiative. It focuses on three priority areas to tackle the opioid crisis.

1. Improve Opioid Prescribing

Pain is one of the most common reasons for health care visits. A doctor who wants to alleviate a patient’s pain may be thinking, “You’ve got pain; I’ve got a pain reliever.” But opioids are not always the best treatment option for pain.

Part of the National Pain Strategy is providing pain education for health professionals and pain management care for patients. Because it’s not always covered in clinical training, more than a dozen NIH Institutes and Centers are working together to improve the quality of education about pain treatment for medical, nursing, dental, and pharmaceutical schools.

New Prescribing Guidelines

In 2016, the Centers for Disease Control and Prevention (CDC) released new guidelines suggesting that long-term opioid therapy for chronic pain, outside of end-of-life or cancer care, remains limited. The risks for misuse and overdose remain high. The checklist when considering long-term opioid use includes:

  • Setting realistic goals for pain and function based on diagnosis
  • Checking that non-opioid therapies (such as anti-inflammatories) and non-pharmacologic therapies (such as exercise and cognitive behavioral therapy) have been tried
  • Discussing benefits and risks for harm or misuse
  • Setting criteria for stopping or continuing opioids
  • Assessing baseline pain and function
  • Scheduling reassessment within one to four weeks
  • Prescribing short-acting opioids using the lowest dosage

Improving the way opioids are prescribed can ensure patients have access to safer, more effective chronic pain treatment options while reducing the number of people who misuse or overdose on these drugs.

Compton says, “We have started to see prescribing patterns change with modest reductions in opioid prescriptions.”

U.S. Surgeon General Dr. Vivek Murthy sent a direct plea in late August to 2.3 million doctors and other health care workers to help fight the opioid epidemic by treating pain “safely and effectively.” A website for his “Turn the Tide” campaign highlights alternative, nonaddictive treatments for pain at turnthetiderx.org Opens new window.
Photo: Office of the Surgeon General

2. Expand Access to Medication-Assisted Treatments

There are three approved medications to help treat opioid addiction. All are designed to help patients stop their opioid drug use and improve their overall health and functioning.

  • Methadone is a liquid that is taken daily. It reaches the brain slowly, and is long-acting, preventing withdrawal symptoms and reducing opioid craving. It requires that you go to a special clinic every day to receive it.
  • Naltrexone blocks the action of opioids and is not addictive or sedating. The Food and Drug Administration (FDA) approved an injectable, long-acting formula in 2010, which can be taken once a month.
  • Buprenorphine, a daily tablet that can be prescribed by a doctor, prevents withdrawal in patients with opioid use disorder and helps these patients manage cravings so they can return to their daily routines. An implantable formulation of buprenorphine was recently approved that provides six months of continuous medication for patients stabilized on buprenorphine and eliminates the need for daily dosing.

What the Research Tells Us

Research suggests that medication-assisted treatment is much more effective than behavioral therapies alone.

Opioid use disorders change the way the brain works, causing alterations in the brain circuits responsible for reward, habit, and decision making. All three of these medications directly target opioid receptors and either stabilize these circuits or block the action of illicit opioids.

Studies have shown that methadone, naltrexone, and buprenorphine are all effective treatments that significantly reduce opioid use and help patients stay in recovery.

“Opioid addiction is a long-standing problem,” Compton says. “But we’re working hard to engage the medical community, using research to convince them, and working with our health care partners to help shape prescribing practices.”

3. Increase Access to and Use of Naloxone for Overdose

More than 28,000 deaths in 2014 were linked to opioid overdose. In 1971, the FDA approved the drug naloxone to prevent overdose death or to reverse overdose, which has since become a standard of care for emergency medical personnel.

However, in the past two years, the FDA has approved both a naloxone auto-injector and a nasal spray, which make the drug easier for families and loved ones to administer. This will prevent opioid-related deaths and give patients a second chance to enter into long-term treatment.

Compton describes the auto-injector for naloxone, which is the size of a pack of cards. “You can simply take the cap off and it will start talking, giving step-by-step instructions on administering the opioid antidote,” Compton says. “It’s a very easy way for non-medical people to save a person’s life.”

He also sees promise with the nasal spray. “It’s inexpensive and very easy to use, so there are broader implications for getting the drug into the hands of those on the front lines in an overdose—family members, friends, or first responders.”

Safe Disposal of Opioid Medications

Opioids may be especially harmful and, in some cases, fatal in a single dose if they are used improperly. Once you no longer need them, dispose of them promptly to avoid harm to others and the environment.

If you properly dispose of these medicines, they cannot be stolen and misused, or accidentally taken or ingested by children, pets, or anybody else.

Safely dispose of opioid medications by mixing them with something unappealing like kitty litter or used coffee grounds in a sealed plastic bag before throwing them into your household trash.

Co-Prescribing Provides Better Results

NIDA funded research suggests that co-prescribing naloxone may reduce opioid overdose. “Prescribing naloxone along with an opioid is one way of making sure this lifesaving drug is in the hands of people who may overdose or be around someone who may overdose,” Compton says.

Research shows that even if the naloxone prescription is not filled, the health care provider has educated the patient using opioid pain relievers about the potential dangers of opioids, and fewer patients end up in the ER with adverse side effects.

NIDA and its partner institutes in the search for solutions to the opioid crisis continue to look for different approaches to treat pain. “Certainly, there are some people who are responding well to opioids, but all too often, patients become addicted without achieving long-term pain relief,” Compton says. “As long as that’s the case, we will continue to look for other treatment options to improve the lives of those suffering with chronic pain.”

Read More "Understanding Opioids" Articles

Understanding The Opioid Overdose Epidemic / Beyond Opioids: Mind and Body Practices

Fall 2016 Issue: Volume 11 Number 3 Page 12-14