Prescription Drug Abuse and The Opioid Crisis in America

Opiates are one of the oldest naturally occurring drugs in the world with the first known record coming from modern-day Iraq around 3000 B.C. According to Hardey, opiates have been used for medicinal purposes for thousands of years to treat pain; however, it was not until the 20th century that there was a dramatic spike in illicit use (2019). Opioids are a class of drugs that act on endogenous opioid receptors to produce a myriad of effects with the most noticeable effect being analgesia or pain relief (CDC, 2018). Opioids come in many forms such as naturally occurring, semi-synthetic, and fully synthetic. Semi-synthetic opioids are synthesized from naturally occurring opiates, such as codeine and morphine, and include drugs such as hydrocodone, oxycodone, and heroin. Opioids can also be fully synthesized in the lab without the naturally occurring opiates; moreover, this class includes methadone, fentanyl, and naloxone.

In the United States the legal status of opioids has varied over the last century. In 1906, the Pure Food and Drug Act allowed the Federal government to oversee the manufacturing and shipment of medications for the first time, and with the addition of the act, came the creation of the Food and Drug Administration – or FDA. In 1971, the Controlled Substances Act was passed by Congress which created schedules I through V for drugs based on their current accepted medical use and abuse potential (DEA). Schedule I is the highest and includes drugs that currently have no accepted medical use and are said to be the most addictive. Schedules II through V include drugs that are available for medical use and abuse potential decreases with each schedule. Currently, heroin is the only opioid that is not available for medical use mainly due to its highly addictive nature; therefore, heroin is classified as a Schedule I drug in the United States. Other opioids such as morphine, hydrocodone, oxycodone, and fentanyl are available for use through prescription. However, all opioids are highly addictive, so they are still classified as Schedule II (DEA). Furthermore, in an effort to limit the availability of these medications, schedule II and III drugs are only available through written prescription. However, Soelberg, Brown, Vivier, Meyer, & Ramachandran argue that e-prescriptions for narcotics would be easier to track and regulate (2017). The authors argue that providers often prescribe more than is needed for a patient so he or she would not have to come back for an office visit in order to receive more medication. On the other hand, if narcotics were available through e-prescriptions, patients could more easily get a refill, and it would allow for better monitoring of doctors’ prescribing and patient consumption of opioids. Overall, prescription drug regulation is not perfect, but it has drastically improved over the past century – even more so in the past decade.

Prescription Opioid Addiction

Even though opioids are only legal in the United States through prescription, there is a massive black-market for prescription opioids. Opioids are a highly addictive substance which can easily lead to misuse even if initially prescribed by a doctor. According to the National Institute on Drug Abuse, prescription opioid misuse is characterized by any of the following: taking opioids in a way other than how it was prescribed, taking a prescription that was not intended for you, or taking the medication for the “high” effects and not desired therapeutic effects (2019). According to Ling, Mooney, and Hillhouse, there has been an estimated 13.8 million people in the United States over the age of 12 that have tried oxycodone for non-medical reasons (2011). Furthermore, according to the authors, there was a 400% increase of admissions into treatment for opioid abuse from 1998 to 2008 (2011). Ling, Mooney, and Hillhouse stated, “The broad availability of prescription pain medications, coupled with public misconceptions about the safety and addictive potential of these medications relative to illicit opiates, are factors contributing to the recent surge in non‐medical use of prescription opioids” (2011). Altogether, these facts reveal that there has been a dramatic increase in the use of and addiction to opioids in the 21st century.

Opioids alter how the nervous system works and interacts with the body, and with prolonged use, opioids can fundamentally changes the innerworkings of the nervous system. The therapeutic effects of opioids can include pain relief, cough suppression, reduction of anxiety, and euphoria. However, with any drug there are side effects that come with taking opioids such as slowed breathing, confusion, constipation, nausea, and itching (National Institute on Drug Abuse, 2019). One of the biggest effects of taking opioids over an extended period of time is tolerance (CDC, 2018). Tolerance is when a person needs to take more of a drug to achieve the same effects. Furthermore, with repeated use, a person can develop a dependence on opioids. Dependence occurs when the body and nervous system have adapted so that they does not function normally without the drug present. When a person’s life centers around a drug leading to continued use of the drug despite adverse or harmful consequences, that person would be considered addicted. Drug addiction, or substance use disorder, is a chronic disease that can be extremely difficult to manage, and opioids are one of the most abused narcotic in the United States.

The Mayo Clinic defines a substance use disorder as, “A disease that affects a person's brain and behavior and leads to an inability to control the use of a legal or illegal drug or medication,” (2017). A study by Fleming, Balousek, Klessing, Mundt, and Brown sought to explore the effects of daily opioid therapy on patients, specifically whether or not they had developed a substance use disorder from the prolonged use of opioids (2007). The authors conducted interviews of 800 patients with diagnosed chronic pain that received daily opioid treatments overseen by a primary care physician. During the interview the Diagnostic and Statistical Manual of Mental Disorders – IV (DSM-IV) was used to determine if the participants meet the criteria to be diagnosed with a substance use disorder or opioid addiction. The findings of the study show that those who are currently undergoing daily opioid therapy for chronic pain are three times more likely to develop a substance use disorder than the general population (3.8% vs. 0.9%). Additionally, the authors found that 24% of the participants also tested positive for other illicit drugs besides opioids suggesting an association between substance use disorder and illicit drugs. Moreover, nearly half of the participants that tested positive for illicit drugs lied to the researchers about their drug use even when promised anonymity. This finding suggests that chronic pain patients might mislead their doctors when it comes to illicit drug use. Overall the authors report that the risk of developing a substance use disorder do not outweigh the benefits of daily opioid therapy for most patients. Moreover, they support the use of daily opioid treatments supervised by a doctor to treat chronic pain.

The Opioid Crisis

Around 2010, it was evident that there was a large spike in the number of prescriptions written for opioids, number of people taking and or addicted to prescription opioids, and the amount of deaths due to opioid overdose since the drugs were first released in the late 20th century. With the rising numbers, it was obvious that there was an opioid crisis in the United States. Loisel describes the onset of the opioid crisis in the early 21st century as a combination of the over prescribing of opioids, introduction of fentanyl into mainstream treatment, and a spike in heroin related overdoses and deaths (2019). According to Loisel, when marketing opioids in the 1990s, pharmaceutical companies claimed that opioids carried a low potential for abuse and were safe to prescribe to patients as a pain reliever (2019). Due to marketing, physicians started prescribing opioids, such as hydrocodone and oxycodone, frequently for pain which largely contributed to the beginning of the opioid crisis. Additionally in the early 2000s, the synthetic opioid fentanyl became widely popular. Fentanyl is a fully synthetic opioid typically used to treat chronic pain when a patient has developed a tolerance to traditional semi-synthetic opioids. This drug is extremely potent, and without tolerance, it is very easy to overdose on fentanyl. With the introduction of fentanyl into modern medical treatment, it was much easier to get a hold of and began popping up on the black-market.

One of the major issues with the opioid crisis is a lack of long-term research into treatment options for opioid addiction. A study by Weiss et al. sought to understand how different courses of opioid treatment affected the likelihood of participants misusing the drug again (2015). One thing that sets this study apart from others on opioid addiction therapy, is the researchers followed to participants through the therapy itself and then for 42 months in order to compile short-term and long-term data. In the study, the authors focused only on patients with a prescription opioid addiction and not patients with an addiction to heroin. The first treatment tested in the study was a standard medical management (SMM) treatment. SMM involved regular visits with a physician, buprenorphine-naloxone, a drug to treat narcotic dependence, and counseling. The second treatment tested was SMM plus individual opioid drug counseling (ODC). ODC treatment included everything in the SMM treatment but with more in depth counseling which focused on relapse prevention, help with withdraw symptoms, and lifestyle changes. Participant underwent either SMM or ODC treatment and received check-ins at 18, 30, and 42 months post-treatment. This paper did not specifically discuss the outcome between different treatment groups, but the overall results from end of the study. The long-term tracking allowed the authors to gain a more wholesome picture of what happens once a patient is out of therapy and on his or her own. After the 42 month follow-up, the authors reported that generally participants showed a decrease use of opioids and other illicit substances, and participants reported a general improvement in health. The main factor that indicated a return to substance abuse was that some of the participants started using heroin in place of prescription opioids. Overall, the study found that people addicted to opioids might have a better chance at recovery when compared to those addicted to heroin. The authors highlight the importance of more long-term studies in order to more fully understand addiction treatment and recovery.

Conclusion

All in all opioid addiction and the opioid crisis have become prevalent in today’s society. With the number of people using opioids still increasing and the opioid crisis in full swing, everyone is searching for a way to decrease the availability of opioids and for treatment options for the millions of people using opioids in the United States. In order to effectively combat the opioid crisis, there needs to be a decrease in prescriptions written for opioids, an increase in awareness of opioids and their harmful effects, and treatment options that make people want to quit abusing opioids. Combating the opioid epidemic could take years, but hundreds of thousands of lives have already been lost to drugs. Addiction is a disease, and more research needs to be done in order to learn how to effectively treat it.