Opioid abuse

Opioid abuse occurs when the use of opioids harms a person’s health or social functioning. It also occurs when a person is addicted to or physically dependent on opioids. Opioids are a class of drugs derived from opium, as well as synthetic or semisynthetic drugs that resemble these opium-based drugs. Examples of these highly addictive drugs include heroin, morphine, codeine, hydrocodone, oxycodone, and fentanyl. Opioids are also often referred to as narcotics.

Causes

Opioids produce a quick, intense feeling of pleasure (euphoria) and pain relief followed by a sense of well-being and calm drowsiness. Opioid drugs produce their effects by binding to the opioid receptors of the central nervous system, which respond to the body’s intrinsic opioids known as endorphins to naturally block or suppress the sensation of pain. When opioid drugs are used repeatedly, the level of natural endorphins in the body is diminished and the brain is likely to become dependent on the drug. Opioids are highly addictive.

Risk Factors

Risk factors that increase the chances of developing opioid addiction include a history of prescription drug use for pain, particularly chronic pain; a history of abuse of other types of drugs; and a mood disorder or anxiety disorder. Although men between the ages of twenty and twenty-nine were previously considered at the greatest greater risk of developing opioid abuse, opioid abuse increased sharply in the early twenty-first century in both men and women, in most age groups, and across all income levels. The US Centers for Disease Control and Prevention (CDC) has reported that the greatest increases in heroin use have occurred in groups that historically reported lower rates of heroin use, including women and people with higher incomes. Opioid abuse in the elderly also increased, with the rate of hospitalization due to opioid overuse among seniors quintupling in the twenty-first century.

Most people who develop an opioid addiction begin by overusing or misusing a prescription opioid medication, whether intentionally or unintentionally, subsequently developing a prescription opioid use disorder. Many such patients then begin using illegal opioids, such as heroin and fentanyl, when prescription opioids become too difficult or costly to reliably attain.

Symptoms

There are several symptoms of opioid abuse. One symptom is tolerance, or the need to increase the dose to achieve the same effect. Another symptom is increased amounts of time spent drug-seeking. Other symptoms include the interference of drug or drug-seeking behavior with social, occupational, or school functioning; the continued use of drugs despite social, legal, occupational, or interpersonal consequences stemming from drug use; desire or efforts made to decrease or stop drug use without success; and withdrawal, the adverse symptoms that occur when the drug is not taken.

Symptoms of opioid withdrawal are many, such as aching, fever, leg tremors, sweating, chills, and craving the drug. Some other symptoms of withdrawal are diarrhea, nausea, and vomiting; sleeplessness; abdominal pain and muscle aches; restlessness; tearing eyes and runny nose; yawning; panic; and irritability.

Screening and Diagnosis

A diagnosis by a medical expert will include questions about the symptoms of opioid abuse as well as questions pertaining to a patient’s medical history. A physical examination is also performed. Urine and blood tests may also be conducted.

Treatment and Therapy

The treatment options for opioid abuse include detoxification, rehabilitation programs, support groups, behavioral therapy, inpatient and outpatient programs, and medication-assisted treatment (MAT). Medications such as buprenorphine, methadone, and extended-release naltrexone are effective for the treatment of opioid use disorders. MAT combines medications with behavioral counseling and has been shown to decrease opioid use and overdose. Behavioral therapy is designed to modify people’s attitudes and behaviors related to opioid abuse. In therapy, a person will learn how to avoid and/or cope with situations in which he or she is most likely to use drugs.

In rehab programs, people with opioid abuse stay in a controlled environment for anywhere from a few days to several months. The length of stay is determined not by medical necessity or patient desire but by insurance companies. Many programs require that an individual detoxes from the drug before attending or being admitted. Some programs have detox units and areas incorporated in the facility so that individuals can easily transition from one phase of rehab to the next. One support group, Narcotics Anonymous, is a twelve-step program that many find helpful in maintaining sobriety. Substance use disorder, especially in relation to opioid addiction, does not have a "one size fits all" cure. Recovery is a long and arduous road to travel and a long-term, multifaceted, and multipronged approach is the most effective.

Prevention

The best way to prevent opioid use disorders on the individual level is to never use opioids. For persons taking prescription opioid medications for pain management, it is important to use the drug only at the prescribed dosages in order to prevent the development of drug dependence. Prescription opioid medications pose a risk of addiction and overdose to all patients. Doctors should discuss the risks of these drugs and alternative treatment options with their patients before prescribing opioid medications.

In 2016, the CDC released guidelines for prescribing opioids for pain management to reduce the number of people who misuse, abuse, or overdose from prescription opioids and develop opioid addictions. The guidelines for medical providers recommend using nonopioid therapies, such as exercise and cognitive behavioral therapy, and nonopioid medications, such as anti-inflammatory drugs, for the treatment of pain. If a doctor determines that opioid medications could be beneficial, the CDC guidelines recommend starting with the lowest possible effective dosage, prescribing immediate-release opioids instead of extended-release medications, conducting routine follow-up appointments to monitor patients for potential signs of harm—including misuse and addiction, and gradually tapering patients off prescription opioids when they are found to no longer be beneficial.

A number of US states have established prescription drug monitoring programs (PDMPs), which are state-run electronic databases that are used to track the prescribing and dispensing of controlled prescription drugs, in an effort to detect abuse or diversion. PDMPs can be used to identify so-called “pill mills,” which are operations in which a doctor, pharmacist, or clinic prescribes and/or dispenses opioid drugs without a legitimate medical purpose to make a profit. PDMPs can also provide a patient’s prescription history to health care practitioners and pharmacists to help them identify patients at a high risk for abusing opioids and divert them to early interventions to prevent or treat opioid abuse. To reduce overdose deaths, a number of states have enacted Good Samaritan laws, which protect overdose victims and the people seeking medical help for them from drug possession charges, to encourage more people to seek medical help for overdoses. Many organizations have also sought to increase the availability of naloxone, a medication that can combat the effects of an overdose, including in easy-to-use nasal spray form.

In September 2015, the CDC selected sixteen states with the highest burden of prescription drug overdose to receive funds through its Prevention for States program. The funding was intended to help states implement opioid-abuse prevention strategies, such as improving safe prescribing practices and preventing prescription drug overuse, misuse, and abuse. In March 2016, an additional thirteen states were funded through the program, and that September fourteen states were provided with supplemental funds. Eight more states received supplemental funding in September 2017. In September 2019, the CDC began the Overdose Data to Action (OD2A) program in collaboration with state and local level government organizations to collect data on overdoses and use the information to improve response and prevention.

Insurance strategies to prevent opioid misuse and abuse include prior authorization, quantity limits, and drug utilization reviews.

United States Opioid Epidemic

Between 1999 and 2019, the rate of overdose deaths involving opioids—including legally prescribed pain relievers and illegal drugs such as heroin—quadrupled in the United States. The CDC identified three waves of this opioid epidemic: in the 1990s there was a major increase in opioid prescriptions, and a corresponding rise in overdose deaths from prescription drugs; around 2010 a spike in heroin overdose deaths began; and in 2013 there was a marked rise in deaths from synthetic opioids, especially fentanyl. In 2016, drug overdose became the leading cause of death among Americans under the age of fifty, surpassing the peak number of annual deaths caused by car accidents (in 1973), by guns (in 1993), and by human immunodeficiency virus (in 1995). That same year, the US surgeon general released a report stating that only one in five people who needed treatment for opioid use disorders were actually receiving it.

In the mid-2010s, some states and local jurisdictions began pursuing lawsuits against pharmaceutical companies for their role in triggering the opioid epidemic by heavily pushing prescription opioids and downplaying their addictive potential. For example, in 2015 the attorney general of Mississippi filed suit against Purdue Pharma and seven other drug manufacturers, noting that throughout the 2000s, Purdue aggressively marketed its controlled-release opioid Oxycontin as a safe and nonaddictive treatment for chronic pain, a strategy that other drug manufacturers soon followed. In May 2017, the state of Ohio filed a lawsuit against several drug companies for conducting marketing campaigns that allegedly misled doctors and patients about the dangers of opioid addiction. Ohio’s lawsuit sought to recover funds it spent on addiction treatment and insurance coverage for opioids through programs such as Medicaid. Various other states, cities, and counties launched similar lawsuits against drug manufacturers and distributors.

In 2018, the first major federal legislation dealing with the opioid crisis, the Support for Patients and Communities Act, was signed into law. The act took various approaches to reducing the opioid abuse problem, including attempting to make it more difficult for opioids such as fentanyl to be brought into the country, expanding a program encouraging more first responders to carry the overdose-reversing drug naloxone, making it easier for Medicaid and Medicare to pay for addiction treatment, and increasing penalties for drug manufacturers and distributors related to the overprescribing of opioids. The American Medical Association applauded the legislation for its wide-ranging effects. However, some criticized the act for not committing sufficient funds to addressing the crisis. In 2022, the CDC issued new guidelines easing some of the restrictions on prescription opioids. However, to adopt the guidelines, many states that have already implemented their own opioid policies would have to amend their laws.

Amid ongoing controversy over the opioid crisis, Purdue Pharma notably filed for bankruptcy in 2019. In October 2020, it was reported that Purdue agreed to a settlement with the US Department of Justice (DOJ), pleading guilty to criminal charges over its part in the opioid epidemic and paying an $8.3 billion fine that would result in the company's dissolution and the creation of a new entity, Knoa Pharma, that would continue to sell drugs but use its earnings for public benefit. The deal was immediately controversial, as activists argued it would interfere with the many state lawsuits against the company, and pointed out that legal action against Purdue in 2007 had not prevented the company from aggressively pushing opioids. Critics also noted that the Sackler family behind Purdue Pharma would avoid criminal charges, admit no wrongdoing, and pay only a small fraction of their personal wealth gained from opioid sales. Other settlements by pharmaceutical companies and related businesses followed.

Although a federal appeals court approved the Purdue Pharma bankruptcy settlement plan in May 2023, the DOJ subsequently asked the Supreme Court to issue a temporary hold on the settlement while it heard the US Trustee's case against the plan in Harrington v. Purdue Pharma. At issue was whether the plan's provision to shield members of the Sackler family from future lawsuits was authorized under the US bankruptcy code. In June 2024, the Supreme Court ruled that the plan was unauthorized because it shielded the Sacklers from liability even though they had not filed for bankruptcy themselves nor made their own assets part of the settlement. While the Biden administration and some relatives of overdose victims praised the Court's decision, saying that it would allow the Sackler family to be brought to justice, other victims' families criticized it, saying that the plan had been their best chance to receive substantial relief and to fund much-needed community addiction treatment programs.

Bibliography

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