The Opioid Crisis
It is believed that the current opioid crisis began due to growing opioid prescribing practices in the late 1990s, after pharmaceutical companies informed medical experts that patients would not become addicted to opioid medications.1 42,249 people in the US died from opioid-related overdose in 2016 alone.1 2.1 million individuals misused prescription opioids for the first time, and the same number of people struggled with an opioid use disorder.1 This led to an economic cost of 504 billion dollars in dealing with the growing opioid problem.1 The amount of prescribed opioids peaked in 2010 and has since been on a slow decline.2 In Texas specifically, the Centers for Disease Control and Prevention report about half the rate of opioid misuse as compared to the national average.2 Many experts agree that the lower statistics in Texas are likely skewed, however, due to lack of data collection and documentation.3
Opioid medications can become addictive through activating the processes in the brain that control the reward center. The mesolimbic pathway in the brain is stimulated by the binding of opioids to receptors, which then sends signals to the ventral tegmental area (VTA) of the brain.4 The VTA, once activated, causes dopamine release in the nucleus accumbens.4 This overwhelming of the nucleus accumbens with dopamine leads to feelings of pleasure and euphoria. With repeated or excessive exposure, the brain creates pathways that remembers the feeling of dopamine release caused by opioid use.4 This can result in cravings and ultimately opioid dependence.4 When dependence occurs and the patient abruptly stops opioid use, they may experience withdrawal symptoms such as anxiety, insomnia, pain, nausea, and diarrhea.4 This withdrawal can encourage more opioid misuse in order to relieve the symptoms.
One way that healthcare providers can help combat the opioid crisis is to recognize patients that may be at risk for developing opioid dependence and those that may be currently suffering from dependence. Under most circumstances, patients that are prescribed opioid treatments should only receive the drug for a short amount of time. This is usually to help with pain from surgery, illness, or other injury. Healthcare providers can prevent opioid dependence from occurring by identifying patients that exhibit misuse behaviors. Knowing a patient’s history of drug use, both prescription and recreational, can help to influence prescribing patterns to minimize addiction risk. Other behaviors that may indicate higher potential for developing opioid dependence include past use of prescription painkillers, repeatedly asking for opioids or a specific controlled substance, and history of misuse of other substances such as alcohol, recreational drugs, or benzodiazepines. Some patients are prescribed opioids for longer periods of time, potentially even for years. These patients may be suffering from chronic pain, cancer, or other long term complications. Patients that are on opioids for a long course are much more likely to develop dependence. Healthcare providers may be able to identify some of the warning signs of growing dependence. These signs may include attempting to refill the prescription too early, reporting that they take more than the amount instructed or more frequently than directed, needing a stronger opioid as their tolerance increases, and using multiple doctors.5 Physical signs may appear as marked sedation, confusion, slow breathing, constricted pupils, and constipation.5 Identifying these signs of dependence and risk factors of misuse may help healthcare providers prevent dependence before it ever happens.
Even with appropriate opioid stewardship, opioid dependence may still occur. Treatments for opioid dependence are constantly evolving. Medication assisted therapy is the mainstay of treatment for resolving opioid dependence. These medications can help to relieve the symptoms of opioid withdrawal, reduce cravings, and increase the chance of opioid use cessation. Some of the most common medications used in this case include methadone, naltrexone, and buprenorphine.6 Methadone acts similarly to an opioid by blocking the perception of pain in the central nervous system.7 Because of this, methadone can be misused and may result in similar side effects such as sedation.7 For patients that are prescribed methadone, they must go to a certified clinic to receive individual doses. Naltrexone is an opioid antagonist that competitively prevents the binding of opioids at receptor sites.8 This prevents the effects of exogenously administered opioids from occuring.8 Buprenorphine is a partial agonist at the opioid receptor that causes the feeling of pain.9 The analgesic effects reduce at higher doses and allows the drug to act as an opioid antagonist.9 These medications and more may be prescribed in combination therapies, potentially leading to better outcomes (buprenorphine + naloxone, buprenorphine + naltrexone, etc.). A new device was created that helps to relieve the symptoms of withdrawal and make the transition to medication assisted therapy easier. The Bridge device is placed on the ear by a trained professional and sends electrical stimulations through the nerves of the head.10 These nervous stimulations help to control the acute withdrawal symptoms, such as gastrointestinal issues, anxiety, pain, sweating, and tremors, based on the specific targeted nerve.10
The healthcare provider can serve a vital role in helping patients that are prescribed opioids for pain to prevent adverse outcomes from occurring. One method is to reduce the habit of prescribing opioids. Not all conditions warrant the use of an opioid. Most resources recommend opioids for a short term (typically a week or less) after surgery and for patients suffering from cancer.11 The use of opioids for chronic pain patients is now being questioned due to the increased risk of growing dependence. By restricting the amount prescribed and shortening the length of treatment, doctors can help prevent development of cravings and withdrawal. Prescribers should also attempt to limit polypharmacy and the use of multiple different opioid agents for one patient. Another way that healthcare providers can prevent unwanted outcomes is to counsel over various pain management modalities that are not opioids. Patients can use over-the-counter pain relief medications, such as acetaminophen or ibuprofen. These can help relieve pain without the risk of developing addiction. Topical creams and ointments can reduce pain in localized areas and are less likely to be absorbed and have systemic effects. Heat or cold supplementation, when appropriate, has been shown to help control pain levels from muscle, joint, and bone sources. Stretching, yoga, and massage therapies can reduce pain in the short term and long term. Physical therapy is very important for patients that have experienced an injury. Participating in a physical therapy regimen can help to correct the issue at the underlying source and prevent pain from continuing chronically. Healthcare providers may also educate patients and caregivers over the differences between dependence and abuse of opioids. Abuse occurs when an opioid is taken in higher doses or more frequently than prescribed. It may also occur if a patient takes an opioid that was not originally prescribed to them. Dependence can develop when patients use opioids either correctly and as prescribed or in the manner of opioid abuse. The brain adjusts and adapts to the presence of the opioid and dopamine release as dependence increases. Pharmacists, specifically, can now distribute naloxone in a community setting without a prescription. A naloxone standing order was implemented in Texas in 2016 for pharmacists to use clinical judgement and sell naloxone to patients or caregivers they feel may benefit from having the medication on hand.12 Naloxone binds at opioid receptor sites and prevents the action of the opioid, thereby reversing the effects. This is used when a patient is experiencing an overdose, has central nervous system suppression, and breathing is slowed or stopped. Administration of naloxone can often save someone’s life when overdose occurs. Through the standing order, Texas pharmacists can become naloxone certified and distribute the agent to patients they deem at high risk of overdose.12 This policy can potentially prevent many deaths due to opioid overdose from occurring. The cash price of naloxone (syringe for injection formulation) is estimated at about $45.13 Unfortunately, Medicare does not cover the cost of naloxone at this time.13
Solutions have been proposed to combat and ultimately resolve the ongoing opioid crisis. One way is the creation of abuse deterrent opioids.14 These formulations make it more difficult to crush, inhale, and other forms of opioid misuse. Although effective to prevent diversion and abuse, the high cost of these opioids limits their use.14 Proper drug disposal is also important to reduce the chance of abuse after an opioid unneeded and discarded. Medication take-back programs or Drug Enforcement Agency authorized collectors may be utilized to give up unwanted medications.15 These organizations will then de-identify submitted medications to protect patient information and dispose of the drug in the appropriate way. The Food and Drug Administration recommends that opioids be flushed down the toilet immediately when use is no longer needed.16 This is due to the fact that opioids can be very harmful, potentially fatal, when someone other than the prescribed patient is exposed. Another solution is database lookups before prescribing or distributing an opioid to a patient. The Centers for Disease Control and Prevention recommends using prescription drug monitoring programs, or PDMPs.17 These programs allow prescribers to obtain information about a patient’s opioid filling history. Pharmacies enter opioid prescriptions into a statewide database for providers to access. Prescribers can then use this information to determine whether or not an opioid is the best option for their patient, based on evidence of misuse.17 Pharmacists can also access the database to view a patient’s opioid history and evaluate risk of misuse for patients attempting to fill opioid prescriptions.17 One way that patients may obtain large quantities of opioids is through utilizing multiple prescribers and several pharmacies. A proposed solution for the growing opioid crisis is to limit the number of providers a patient may see and have patients use only one pharmacy. Through these patient review and restriction programs (PRRs), patients would fill all prescriptions from one prescriber at a single pharmacy.18 The pharmacy would then have access to the patient’s full medication history and would have the ability to determine excessive opioid use. This would also stop the patient from obtaining several different opioids from multiple pharmacies. PRRs could help prevent opioid overdoses by limiting the amount of medication the patient receives.18 Laws regarding opioids and pharmacies have become stricter in an effort to fight the opioid epidemic. For example, a bill has been passed that increases the criminal penalties in Texas for burglaries of controlled substances. The theft of opioids is now considered a third-degree felony, regardless of the actual value stolen.19 This type of felony is punishable by a prison sentence of two to ten years.19 Nationally, the opioid epidemic was declared a public health emergency by President Trump last fall.20 Congress allotted six billion dollars in funds to try and resolve the opioid crisis.21 Some suggested solutions from a national perspective include invoking the death penalty for large international drug traffickers and development of a federal campaign to educate and dissuade use.21
Healthcare providers are in a critical position to help patients on an individual level. By utilizing clinical judgement, recognizing those at risk of opioid dependence, offering education and counseling services, and providing support and treatment when needed, professionals can make a positive impact against the epidemic occurring in their communities. With the effort and dedication of the healthcare provider, individual outcomes can drastically improve and the opioid crisis can be extinguished one patient at a time.
US Department of Health and Human Services. About the US Opioid Epidemic. Available at: https://www.hhs.gov/opioids/about-the-epidemic/. Accessed March 12, 2018.
Centers for Disease Control and Prevention. Opioid Prescribing. Available at: https://www.cdc.gov/vitalsigns/opioids/index.html. Accessed March 12, 2018.
The Daily Texan. Scale of opioid epidemic in Texas likely obscured by bad data, experts say. Available at: http://www.dailytexanonline.com/2017/11/17/scale-of-opioid-epidemic-in-texas-likely-obscured-by-bad-data-experts-say. Accessed March 12, 2018.
Kosten TR, George TP. The neurobiology of opioid dependence: implications for treatment. Sci Pract Perspect. 2002;1(1):13-20.
Patterson E. Opiate Abuse. Available at: https://drugabuse.com/library/opiate-abuse/. Accessed March 12, 2018.
Substance Abuse and Mental Health Services Administration. Medication assisted treatment. Available at: https://www.samhsa.gov/medication-assisted-treatment. Accessed March 12, 2018.
Methadone in Lexi-Drugs. Lexicomp Online. Hudson, Ohio. Updated periodically.
Naltrexone in Lexi-Drugs. Lexicomp Online. Hudson, Ohio. Updated periodically.
Buprenorphine in Lexi-Drugs. Lexicomp Online. Hudson, Ohio. Updated periodically.
US Food and Drug Administration. FDA grants marketing authorization of the first device for use in helping to reduce the symptoms of opioid withdrawal. Available at: https://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm585271.htm. Accessed March 12, 2018.
Scully RE, Schoenfield AJ, Jiang Wei, et al. Defining optimal length of opioid pain medication prescription after common surgical procedures. JAMA Surg. 2018;153(1):37-43.
Hoban B. Standing order announced expanding pharmacists ability to provide naloxone. Available at: http://www.texaspharmacy.org/news/294228/Standing-Order-Announced-Expanding-Pharmacists-Ability-to-Provide-Naloxone.htm. Accessed March 12, 2018.
Naloxone cash price. Available at: https://www.goodrx.com/naloxone. Accessed March 12, 2018.
Curfman, GD, Beletsky L, Sarpatwari A. Benefits, limitations, and value of abuse deterrent opioids. JAMA Intern Med. 2018;178(1):131-132.
US Food and Drug Administration. Disposal of unused medicines. Available at: https://www.fda.gov/drugs/resourcesforyou/consumers/buyingusingmedicinesafely/ensuringsafeuseofmedicine/safedisposalofmedicines/ucm186187.htm#Flushing. Accessed March 12, 2018.
US Food and Drug Administration. Flushing of certain medicines. Available at: https://www.fda.gov/Drugs/ResourcesForYou/Consumers/BuyingUsingMedicineSafely/EnsuringSafeUseofMedicine/SafeDisposalofMedicines/ucm576167.htm. Accessed March 12, 2018.
Centers for Disease Control and Prevention. What states need to know about PDMPs. Available at: https://www.cdc.gov/drugoverdose/pdmp/states.html. Accessed March 12, 2018.
American Pain Society. Use of multiple pharmacies can predict opioid overdosing. Available at: http://americanpainsociety.org/about-us/press-room/predict-opioid-overdosing. Accessed March 12, 2018.
Texas Pharmacy Business Council. TPBC wins tougher penalties for break-ins. Available at: https://www.txopioidcrisis.org/legislation.html. Accessed March 20, 2018.
Johnson J, Wagner J. Trump declares the opioid crisis a public health emergency. Available at: https://www.washingtonpost.com/news/post-politics/wp/2017/10/26/trump-plans-to-declare-the-opioid-crisis-a-public-health-emergency/?utm_term=.0508a220232f. Accessed March 20, 2018.
Merica D, Gray N, Drash W. Trump’s opioid plan to take three-pronged approach. Available at: https://www.cnn.com/2018/03/18/politics/trump-opioid-plan/index.html. Accessed March 20, 2018.