Opioids (pronounced OH-pee-oyds) are derived from opium, and are substances that act on opioid receptors in the brain to produce pain relief. They are used medically for pain relief and anesthesia. However, they are also being used recreationally to produce a “high” in which the person’s physical and emotional pain is numbed and they experience a sense of pleasure and reward in the brain. Heroin is one example of an illicit form of opioids use to alter mood and evoke feelings of well-being and happiness.
Why are opioids a problem?
The growing crisis with reference to opioids is related to the use and abuse of prescription opioids. They are powerful pain killers, true, but they are also highly addictive. A recent survey by the Substance Abuse and Mental Health Services Administration estimated that more than 5 million people in the United States are addicted to opioids, and that this addiction leads to approximately 17,000 deaths each year.
And this number is rising. According to the Centers for Disease Control and Prevention in the US, rates of opioid overdose deaths jumped significantly, from 7.9 per 100,000 in 2013, to 9.0 per 100,000 in 2014, an increase of 14%. https://www.cdc.gov/mmwr/preview/mmwrhtml/mm6450a3.htm?s_cid=mm6450a3_w
Statistics for 2000 to 2014 show that opioid-involved drug overdoses accounted for 33,091 deaths, approximately half involving prescription opioids. https://www.ncbi.nlm.nih.gov/pubmed/?term=28033313
Half of deaths due to drug overdose (around 22,000 per year) are related to prescription drugs, according to a report on the leading cause of deaths from injury in the United States. This is clearly preventable, which is why there is now an increasing focus on the issue of opioid abuse and what can be done about it.
Is it a global problem?
The United Nations Office on Drugs and Crime offers detailed statistics on drug-related deaths and drug use. Their 2017 report makes global estimates based on (more or less) accurate reporting of the cause of death.
The report states:
Mortality rate per million persons aged 15-64
• Africa 61.9
• North America 172.2
• Latin America and the Caribbean 14.9
• Asia 22.5
• Western and Central Europe 26.4
• Eastern and South-Eastern Europe 55.6
• Oceania 102.3
• Global 39.6
North America has a considerable higher rate compared to the rest of the world, with the US leading in the number of those addicted to prescription pain relievers.
Why might this be the case? Let’s look next at some of the possible reasons.
Why Has Opioid Addiction Become A Serious Public Health Concern?
Opioid addiction has become a serious public health concern in the last 15 years or so for a number of reasons. As the number of drug-related deaths has tripled in the US, it has led to questions about prescribing, use, and overuse of these drugs.
It has also highlighted the growing issue of prescription drugs being used for recreational use. Some people might pass along their medicines with good intentions. Others might sell their medications for financial gain. A 2007 study showed that 78% of those seeking helps for an opioid addiction were never prescribed the medication.
A recent study showed that 94% of people who used heroin did so because they found it difficult to get opioid prescriptions, and the prescription drugs were more expensive. https://www.asam.org/docs/default-source/advocacy/opioid-addiction-disease-facts-figures.pdf
Why are opioids prescribed?
The most common reason is pain relief, especially after an injury, or surgery. A recent study has shown that orthopedists, who usually deal with bone breaks, knee or hip replacement surgery, and recovery from injury after events like car accidents and sports-related injuries account for the third highest percentage of opioid prescriptions being written. This is only logical, since they are dealing with people who are often in extreme pain.
One might also assume that oncologists, that is, doctors who treat cancer patients, might write a lot of prescriptions for opioids to offer pain relief to their patients. Surprisingly, they are not the main prescribers of opioids either.
In fact, the 2 main categories of doctors who prescribe opioids most often are actually family doctors and internists, in other words, primary care physicians. https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2474400
Why might this be the case? There are several possible reasons.
One of the reasons why well-meaning primary care physicians (PCPs) might be fueling the addiction epidemic is they don’t take potential addiction into account fully. They underestimate the power of these drugs. In part, this might have to do with relative degrees of active ingredients, and the purity of those active ingredients.
Generic drugs, over the counter medications, and herbal remedies, for example, can vary considerably in terms of active ingredients. And what may work well for one person may not work as well for another, causing one person to become addicted, while another person is completely fine. This difference might cause someone to increase their dosage because they think the opioid is not working, and end up addicted as a result.
Drug resistance can build up over time. With many opioids, their affect wears off eventually, leading to the person needing more of the drug in order to achieve the same pain relief. This can lead to both physical dependence, and mental dependence over time, with the person feeling they “can’t live without” the drug.
How much does it hurt?
Another key prescribing issue is the subjective nature of pain. When a doctor hears, “It hurts,” they immediately start trying to treat the symptom. However, what is painful for one person may not even be noticeable to another. A pain scale with a rating of 0 for no pain, up to 10 for the worst pain ever, can be helpful, such as the Wong-Baker Scale. http://wongbakerfaces.org/
Originally developed for use in children, it can give doctors a better idea of what pain relief methods should be used, and at what dosage. But what is a 5 for one person might be a 2 for another, or a 9 for other. It all depends on their perceptions and sensitivity.
Giving too much medicine
Giving too much medicine is a question of both dosage, and the quantity of pills. Doctors should start with the lowest possible dose for the shortest period of time.
The trouble is that prescribing patterns show opioid prescriptions are often written for many days’ worth of pain relief. A large number of patients will keep taking the pills until they run out, either because they assume they have to, or because they “want to get their money’s worth” and not waste any drugs.
Issues with safe disposal of unwanted medications
Those who do not take every tablet, however, often don’t know what to do with their unwanted but highly addictive opioids. Patients are unfortunately not usually given instructions regarding safe disposal, or drug return programs.
The US Food and Drug Administration provides guidelines which doctors should inform patients about. https://www.fda.gov/ForConsumers/ConsumerUpdates/ucm101653.htm
Unwanted medicines should not be thrown in the trash, since children, pets or wildlife such as raccoons can fish them out and consume them. They should also not be flushed down the toilet, since alarming levels of prescription drugs have been found in water supplies and groundwater. https://www.scientificamerican.com/article/pharmaceuticals-in-the-water/
It’s estimated that around 40 million people are drinking water that has been contaminated by a range of medications, from opioids to even AIDS antiviral medications.
The dangers of drug sharing
Drug sharing may be done with the best of intentions, or the worst. If a person has leftover pain relievers in the house and someone in the family gets injured, they might pass along their medications in an effort to help them with their bad back or ankle sprain, for example. This can lead to addiction and to drug seeking as the person gets their own prescription and then starts to develop strategies for trying to get more and more.
One strategy is to go to a range of different doctors and pharmacies. Another is to report in to various emergency rooms and clinics complaining of pain in order to try to get more medications.
Well-meaning doctors in hospitals can be fooled by desperate drug seekers. Measures are now being taken in hospital pharmacies to run more careful checks with respect to dispensing opioids.
Some people have found that people are willing to pay good money to “get high” from certain opioids. They will share their pills, or sell them to others. They will go for repeat prescriptions in order to continue making money from selling these prescription medications illegally. They will also engage in drug-seeking behaviors.
In some cases, they might even try to rob a pharmacy, or a veterinarian’s office, since many human opioids are also used for pain relief in animals and are therefore stocked by vets.
Multiple doctors, multiple drugs
The more doctors a person sees, especially as they age, the more likely they will end up with a prescription if they report pain. The trouble is, they might get more of the same opioids they are already on, or one with a different name, but similar effects.
Polypharmacy, as this is referred to, is also a growing problem in addition to the opioid crisis. Estimates show that the average person over age 50 takes an average of 8 drugs per day, plus over the counter medicines, herbal remedies, and vitamins.
Since many of these carry a risk of side effects, it is possible that a doctor might actually be prescribing medicines to relieve the side effects of other medicines.
Dealing with polypharmacy
There are a number of solutions for this. The first is to keep a list of all medicines each person takes, and update it regularly. It should also be brought to any appointment the person has with any doctor.
A detailed list can be created here:
and printed out as a full-sized sheet, and as a wallet-sized card that can be carried anywhere and referred to in case of emergency.
Another solution is or people to use their PCP as their “gatekeeper” to review all medicines regularly, especially if the patient has been seeing other specialists and getting prescriptions from them.
Pills, patches and potions
Many people also associate addiction with “popping pills,” but overlook the fact that there might be other sources of addiction. For example, fentanyl pain patches that deliver their medicine transdermally, that is, through the skin, are often not seen as “risky” compared to pills, but they are increasingly being abused and sold on to addicts.
Some opioids are combined with other medicines. People often do not realize this until they have had an accidental overdose. One example would be codeine, commonly used in cough syrups and cold and flu remedies as a cough suppressant. It is also used in Tylenol 3. It is commonly mixed with other prescription drugs as well, thus increasing the risk of addiction and overdose.
Acetaminophen, the active ingredient in regular Tylenol, is now in more than 600 prescription and over the counter medications. http://www.knowyourdose.org/ Even taking the equivalent of 3 pills can lead to liver damage or even death in some people. (This is referred to as acetaminophen toxicity.)
At the bottom of this page: https://medlineplus.gov/druginfo/meds/a682065.html
you will see a list of dozens of drugs which contain codeine, including Robitussin AC and other cough medicines.
Cough syrups are easily abused, particularly by teens. Drinking them in large quantities can produce euphoria (happiness) from the opioids. Note that some over the counter cough and cold remedies also contain large percentages of alcohol, leading to drunkenness, and posting a greater risk of death.