Opioids are a class of analgesic drugs typically prescribed for pain relief. They bind to opioid receptors in the central nervous system, effectively reducing pain and stimulating dopamine release. Whilst opioids can be effective at treating moderate to severe pain, they are also highly addictive and as a result, opioid misuse has drastically increased and led to what is now referred to as the ‘opioid epidemic’.
The Facts on America's Opioid Epidemic
The term opiate refers to derivatives of the poppy plant, such as opium and morphine. The term opioid refers to synthetic or partly synthetic molecules that act via a mechanism similar to that of opiates. In reality, the terms are often used interchangeably. Common opioids include codeine, fentanyl, hydrocodone, methadone, and oxycodone.
Opioid tolerance and opioid addiction
Developing tolerance to a medication is not uncommon. This occurs when a person takes a drug for an extended period of time and as a result, the physiological response begins to diminish. This means that the person may need to increase the dose of the drug to achieve the same effect. Tolerance is not limited to opioids and can occur with a range of medications.
Opioid addiction is referred to as opioid use disorder. Diagnosis with opioid use disorder requires multiple criteria to be met, which may include tolerance and withdrawal, as well as inability to control use, opioid cravings, failure to fulfill obligations, and continued use despite knowledge of a problem. This is not an exhaustive list and other symptoms may also be involved in the diagnosis.
Not every person who takes opioids develops an opioid use disorder. There are a variety of socioeconomic and genetic factors that can contribute to the likelihood of developing an opioid use disorder.
Factors contributing to the opioid epidemic
The Centers for Disease Control and Prevention (CDC) describes the rise of the opioid epidemic as occurring in three distinct phases; the first beginning in the 1990s with a large increase in opioid prescriptions contributing to an increase in deaths caused by prescription opioid overdose. The second phase is said to have begun in 2010, which saw an increase in deaths involving heroin overdose. The third is then said to have begun in 2013, where a large increase was seen in deaths involving the overdose of illicitly manufactured synthetic opioids, such as fentanyl.
This is still a significant problem- in 2019 alone, the United States reported over 70,000 deaths caused by drug overdose. Of these deaths, over 70% involved opioids, and over 50% involved synthetic opioids. Although the opioid epidemic is most prevalent in the United States, a similar trajectory is being observed in the UK.
Combating the opioid epidemic
Combating the opioid epidemic requires a multi-faceted approach that can take into account the various factors contributing to opioid misuse.
As overprescription of opioids was a major contributor to the rise of the opioid epidemic, it is clear that a more careful and considered approach should be taken when prescribing opioids. Although the prescription of opioids has been in decline since 2010, it remains significantly higher than before the onset of the opioid epidemic.
Before an opioid is prescribed, it should be considered first of all if it is an appropriate medication for the issue in question, or if an alternate medication can be used. The prescribed dose and duration of prescription are also important, and a patient should be prescribed as little as possible to remain effective.
Careful consideration should also be given to the risk factors specific to that patient, for example, their medical history and if possible, their genetic predisposition to opioid use disorder. Although this would be a useful tool, genetic testing for such genes is not widely offered and it may be more appropriate to consider family history.
Whilst risk factors should be considered, they are not definitive predictors of whether or not a person will develop an opioid use disorder. It is therefore important that every person receiving an opioid prescription is clearly educated on the potential risks. This is particularly important when considering that it is not uncommon for opioids to be transferred from a person with a prescription to another person with an opioid use disorder. This particular phenomenon can be tracked via prescription drug monitoring programs.
Alternative treatments for chronic pain
As opioids are primarily used as analgesics, further research should be done into effective treatments for chronic pain. The scale of the opioid epidemic serves as proof that this class of drug carries increased risks compared to others. For this reason, new options must be explored for the management of chronic pain, to further reduce opioid prescription.
Reducing stigma and creating access to treatments
One of the easiest steps that many people can take is to reduce the stigma around opioid use disorder, using the proper terminology and reducing the spread of misinformation. This includes more widespread education on both the risks of misuse of prescription opioids, as well as the increased risks associated with the use of illicitly produced opioids.
This should be accompanied by accessible and non-judgemental help for those dealing with opioid use disorder, whether that be through support and therapies, or a medication-based approach. Additionally, there is a range of treatments aimed at reversing or minimizing the effects of opioid overdose. These treatments must be easily accessible to those who may require them.
Although the opioid epidemic is still prevalent, we now have a strong understanding of the contributing factors, which in turn have allowed the development of plans to combat it. By combining these approaches, it is possible to greatly reduce the incidence of opioid misuse and prevent thousands of opioid-related deaths.
- CDC (Centers for Disease Control and Prevention) (2017) Understanding the epidemic. Centers for Disease Control and Prevention, National Center for Injury Prevention and Control, Division of Unintentional Injury Prevention. https://www.cdc.gov/drugoverdose/epidemic/index.html
- Centers for Disease Control and Prevention (CDC). Vital signs: overdoses of prescription opioid pain relievers—United States, 1999–2008. MMWR MorbMortal Wkly Rep. 2011 Nov 4; 60(43):1487-1492.
- Guy, G. P., Jr, Zhang, K., Bohm, M. K., Losby, J., Lewis, B., Young, R., Murphy, L. B., & Dowell, D. (2017). Vital Signs: Changes in Opioid Prescribing in the United States, 2006-2015. MMWR. Morbidity and mortality weekly report, 66(26), 697–704. https://doi.org/10.15585/mmwr.mm6626a4
- Lyden, J., & Binswanger, I. A. (2019). The United States opioid epidemic. Seminars in perinatology, 43(3), 123–131. https://doi.org/10.1053/j.semperi.2019.01.001
- Volkow, N. D., & McLellan, A. T. (2016). Opioid Abuse in Chronic Pain--Misconceptions and Mitigation Strategies. The New England journal of medicine, 374(13), 1253–1263. https://doi.org/10.1056/NEJMra1507771