Psychiatric Annals

CME 

Perspectives on the Opioid Crisis

Daniel Angres, MD; Robert DuPont, MD; Mark S. Gold, MD, FASAM

Abstract

Health care providers, addiction specialists, and legislators are in agreement that novel and more effective means of reducing opioid and other addicting substance misuse and abuse are critical at this time in our country. The statistics are dismal and increasingly alarming, with more and more individuals at risk. The widespread availability and use of the antiopiate pharmaceutical, naloxone, to reverse life-threatening overdoses is a beginning and a step in the right direction, but can only be considered an initial intervention. What should follow naloxone? We know the answer if the patient is an anesthesiologist resuscitated in the hospital. For everyone who is not a licensed health provider, it is less clear. Substance abuse treatment in the United States is predominantly outpatient, short term, and with few objective checks on the effectiveness of treatment. Substance abuse treatment of health professions is radically different in that it is not a treatment program but is a program of active care management. This management includes residential treatment and sustained monitoring of abstinence. Few addicted patients receive anything that approximates evidence-based care. [Psychiatr Ann. 2015;45(10):522–526.]

Abstract

Health care providers, addiction specialists, and legislators are in agreement that novel and more effective means of reducing opioid and other addicting substance misuse and abuse are critical at this time in our country. The statistics are dismal and increasingly alarming, with more and more individuals at risk. The widespread availability and use of the antiopiate pharmaceutical, naloxone, to reverse life-threatening overdoses is a beginning and a step in the right direction, but can only be considered an initial intervention. What should follow naloxone? We know the answer if the patient is an anesthesiologist resuscitated in the hospital. For everyone who is not a licensed health provider, it is less clear. Substance abuse treatment in the United States is predominantly outpatient, short term, and with few objective checks on the effectiveness of treatment. Substance abuse treatment of health professions is radically different in that it is not a treatment program but is a program of active care management. This management includes residential treatment and sustained monitoring of abstinence. Few addicted patients receive anything that approximates evidence-based care. [Psychiatr Ann. 2015;45(10):522–526.]

Opioid prescribing has increased 300% in the past 20 years.1 Addiction medicine and psychiatry specialists have witnessed first-hand the effects of increased opioid prescribing for nonmalignant pain. Chronic pain is a major public health problem affecting more than one-third of people in the United States and up to 30% of the world’s population. Pain problems are expected to rise with increasing rates of obesity, diabetes, cardiovascular disorders, arthritis, and cancer. Opioid use can produce beneficial temporary effects but also significant problems, such as craving, wanting, respiratory depression, mental clouding, nausea, overdose, constipation, and physical dependence. A number of chronic pain patients have become inadvertent or iatrogenic addicts in that they become physically and psychologically dependent on their pain medications with their initial intention only being relief from legitimate pain. Narcotic prescription rates and total numbers of opiate pain medications produced here in the United States have dramatically exceeded all projections2–4 (Figure 1 and Figure 2).

Bar chart showing the total number of US overdose deaths involving opioid prescription drugs from 2001 to 2013. The chart is overlain by a line graph showing the number of deaths by gender. From 2001 to 2013, there was a 2.5-fold increase in the total number of deaths. From the National Institutes of Health26 (in the public domain).

Figure 1.

Bar chart showing the total number of US overdose deaths involving opioid prescription drugs from 2001 to 2013. The chart is overlain by a line graph showing the number of deaths by gender. From 2001 to 2013, there was a 2.5-fold increase in the total number of deaths. From the National Institutes of Health26 (in the public domain).

Bar chart showing the total number of US overdose deaths involving opioid pain relievers from 2001 to 2013. The chart is overlain by a line graph showing the number of deaths by gender. From 2001 to 2013, there was a 3-fold increase in the total number of deaths. From the National Institutes of Health26 (in the public domain).

Figure 2.

Bar chart showing the total number of US overdose deaths involving opioid pain relievers from 2001 to 2013. The chart is overlain by a line graph showing the number of deaths by gender. From 2001 to 2013, there was a 3-fold increase in the total number of deaths. From the National Institutes of Health26 (in the public domain).

As the prescribed opiate use, misuse, and dependence problems escalated, they rekindled a heroin epidemic.5 The root cause of prescription drug diversion and abuse is multifaceted. Access to pain medications is certainly one factor. In 2009, methadone accounted for 2% of painkiller prescriptions but more than 30% of prescription painkiller deaths.6 Diversion and deaths are not due to opiate addiction client diversion, but rather to its use and diversion for pain management.7 Prescriptions for hydrocodone, oxycodone slow-release, and other opiate medication became commonplace for chronic nonmalignant pain. The most recognized prescription drug of abuse is oxycodone slow-release, a Class II substance that was approved in 1995 to treat chronic, moderate-to-severe pain.

Oxycodone slow-release was originally believed to pose a lower risk for abuse because of its controlled-release formulation designed to be ingested orally and swallowed whole. However, people with substance abuse problems often interrupt this mechanism of absorption to hasten an effect by chewing or snorting the powdered version of the drug, or dissolving the powder in water and injecting it intravenously. Oxycodone slow-release can be linked to high-profile overdoses, which sensationalize the drug to certain individuals. The epidemic of opioid and heroin abuse and use disorders prompted the United States Department of Health and Human Services (HHS) to issue a formal announcement targeted at the reduction of related deaths and dependence. In addressing what HHS refers to as the “opioid crisis,” they outline three priority areas. These include aiding in opioid prescription training and monitoring, increasing the use of naloxone, and expanding the use of medication-assisted treatments.8

The Consequences of Increased Use of Opioids for Chronic Pain

The nonmedical use of prescription drugs (NMUPD) is defined as use of a controlled substance for reasons other than that for which it was prescribed or in dosages different than that usually prescribed. Physical dependence on opioids is not the same as being an addict with an acquired drive for drugs.6,7 People who abuse substances may also mix their prescription medication with alcohol, marijuana, or other drugs to get high. They sometimes not only misuse their prescriptions but save, sell, or divert them. Some do so without even knowing they are the source of opiates for nonpain “recreational” patients when their medicine cabinets are vandalized by risk-taking, pleasure-seeking adolescents or adults.8,9

NMUPD has grown with the widespread use of the Internet and over-prescribing health care professionals and pharmacist prescription diversion.11,12 Adolescents and young adults are at the greatest risk for this type of drug abuse, along with adults with poor physical health and/or mental health problems, who may have the goal of self-medicating these other conditions.13,14 Early exposure to drugs, medicines in the context of changing attitudes about drug use, and family dynamics are current challenges for young people. Young adult diversion of controlled substances is common.15 In regard to age, one study found a higher percentage of individuals who began using prescription drugs nonmedically before age 13 years are more likely to develop substance abuse and dependence later in life compared with individuals who start using after age 21 years.16 Once addiction is triggered and the brain is hijacked, it is critical to recognize the need for treatment and monitoring of this disease. Most addicts do not seek or get treatment. Some of these patients are now treated with buprenorphine in outpatient settings, with some successes.5

Relief of pain symptoms has been found to be a common motivation for prescription misuse among older adults across multiple settings,16 The rate of death by accidental drug overdose for people ages 45 to 64 years increased 11-fold between 1990 (when no baby boomers were in the age group) and 2010 (when the age group was filled with baby boomers) according to an analysis of Centers for Disease Control and Prevention (CDC) mortality data.17

Prevention of Deaths with Naloxone and What Follows

Opioid addiction is a potentially fatal chronic disease that requires lifetime management and monitoring. Today, the number of individuals who die from prescription opioids exceeds the number from heroin and cocaine combined. Prescription opioid addiction is challenging to treat due to high dropout rates in rehabilitation centers and high relapse rates after a successful treatment. It is difficult to convince individuals that they can acquire a life-long disorder (ie, substance use disorder [SUD])9 and that a valid prescription for a genuine problem is complicated and risky. Thirteen percent of those who report nonmedical use of opioids in the past year met criteria for abuse or dependence, which typically necessitates treatment.

Overdoses have increased, and those who escape overdoses are presenting to emergency departments and rehabilitation centers in numbers not seen in decades, if ever. By 2014, the CDC added opioid overdose prevention to its list of top five public health challenges.18 Overdoses appear to be stabilizing at an alarmingly high level.19 An opioid overdose is life-threatening and demands life-saving interventions. Besides health care providers, training and providing family members and friends of opioid-addicted individuals and nonparamedic first responders with naloxone can be an effective acute strategy for rescuing overdose victims.20,21 There are nearly 200 community-based naloxone distribution programs in 15 states and the District of Columbia.

However, the dilemma is not whether to administer a life-saving drug to an individual that overdoses, but how to intervene following the overdose to prevent future threats to their life. This is often complicated due to the presence of denial or foggy thinking in the addict, lack of financial or supportive networks that encourage treatment, and a general feeling of hopelessness that often persists in addicts and their loved ones after addiction has been solidified in an individual.

The most common drug of abuse for anesthesiologists is opioids.22 Overdose in this population occurs in the operating room, locker room, and hospital bathrooms. Their addiction is commonly identified in this tragic manner. An immediate referral to a state physician’s health program for a comprehensive evaluation is the typical course of action, followed by long-term treatment, and 5 or more years of careful monitoring through a physician health program (PHP). Physicians are offered and receive PHP treatment but nonphysicians with the same history do not. Naloxone reversal is a good place to start seriously addressing addiction, with a PHP-like program with tested 5-year outcomes.

Prevention

Prevention comes in many forms. Persistent education beginning at an early age has been shown to be useful in reducing the onset of drug use in teens and young adults. Many adolescents and young adults are diverting prescription drugs from their parents, often without their knowledge. Educating the adolescent or young adult without the support or knowledge of the parent is often futile. It would be advantageous to have parents or caregivers be a part of the solution. If drug or alcohol abuse begins before age 13 years, the propensity for abuse is greatly heightened. Not exposing an adolescent to unnecessary opiate medications for athletic injury or other pain is another way to begin prevention.23

A meticulous assessment of all patients, one that includes an alcohol and drug history of the patient and their family members, is the first step. If the patient admits to opioid dependence or abuse, it is necessary to determine if the patient will need a medical detoxification. A determination for detoxification is always essential with certain substances such as barbiturates, benzodiazepines, opiates, and alcohol. Treatment for substance use disorder can occur in a variety of settings (inpatient, residential, outpatient) and is typically determined by the severity of the abuse or addiction.

Using the Physician Health Program Model for Optimal Outcomes

If a physician with SUD is revived from an overdose, they are almost unquestionably referred to their licensing authority and subsequently referred for a comprehensive assessment to determine appropriate recommendations. Treatment at a professional’s program for SUD is usually recommended, along with long-term follow-up and random drug testing by their state physician health program. A large percentage (approximately 80%) of opioid-addicted physicians, when treated with a PHP model, are drug-free, report feeling more satisfied, and are back to work after 5 years of follow-up (the length of monitoring). So, physicians with SUD benefit from unambiguous intervention and a well-developed PHP model of evidence-based treatment that has been highly successful.22 It only makes sense that the general public adopt these successful PHP strategies.

Aftercare includes well-established psychosocial approaches, caduceus mutual-help groups, participation in 12-step programs, and the integration of nonchemical coping skills into a daily regime (ie, exercise and meditation) introduced at the treatment programs. These techniques work very well, as demonstrated by the 5-year outcome studies reported by DuPont et al.22 Physicians use and abuse more prescription medications as compared to the general population, but alcohol remains the drug of choice for most physicians. The key to the success of the PHP model is structure (ie, enough psycho-social-spiritual supports, accountability, appropriate medication-assisted treatment supports when indicated) for a long enough time to allow for healing and the emergence of internal cohesion and capacity for self-governance and capacity to benefit from mutual help. For many, especially younger adults without the inherent structures available to health care professionals, longer structured support such as months in sober-living settings are necessary to facilitate long-term abstinence and sobriety. Pharmacotherapies for opioid addiction are often used in nonhealth providers, including agonist maintenance with methadone, partial-agonist maintenance with buprenorphine, and antagonist treatment with naltrexone. Preferable pharmacotherapies for physicians may include injectable naltrexone, because the use of suboxone (being less favorable) is banned in some states and hospitals.

Summary

In the past 2 decades the misuse and addiction problems in the United States have worsened, caused mainly by the rise in prescriptions for pain medications. Physicians should start by looking at their own prescription misuse, roles in diversion, and epidemic of overdose and dependence.24 Opiate drugs of abuse are natural and synthetic chemicals that stimulate the brain’s reward center far more intensely than occurs naturally. This intense stimulation leads people to repeat drug use behaviors and to work more diligently for the drug reward than for natural rewards.25 There is universal potential to acquire a chronic, relapsing drive for drugs and dependence among all mammals, including humans.9 Although the individual with legitimate pain and a prescription for opioids is also at risk, a serious public health epidemic of prescription drug abuse has emerged, with the nonmedical use of opiate pain medicines driving up the rates of overdose deaths and leading to a rekindled heroin epidemic. The burgeoning opiate epidemic and the emerging heroin epidemic bring this crisis to light and offer opportunities to create a better drug policy in the interests of the nation’s public health with leadership from the health care community. The goal of this future drug policy should be to reduce nonmedical drug use, including the abuse of prescribed controlled medications. We have evaluated, intervened, and treated many physician opiate addicts, some whose first presentation was an overdose. They are never simply given naloxone and sent home, but rather it is the first step in their evaluation and PHP-led treatment process. The message must include that administering naloxone to an overdose victim is not the end of the public health response; it is just the beginning. Table 1 summarizes the opinion of Dr. Bertha Madras, Harvard University and Office of National Drug Control Policy and US Drug Czar regarding naloxone. The widespread use of naloxone for drug overdose is an excellent first step, preserves life and gives the addict or user a second chance.

Naloxone Use in Overdose Remediation

Table 1.

Naloxone Use in Overdose Remediation

References

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Naloxone Use in Overdose Remediation

Make it available to first responders (eg, emergency medical technicians, police) without legal jeopardy to all professionals nationwide

Make certain first responders are well trained in the recognition of signs of opioid, alcohol, and drug overdose, and the ABCs (airway, breathing, circulation)

Bring all overdose patients to a hospital emergency department (one study showed that >20% of patients required overnight stays and repeated dosing of naloxone or other essential medical services)

In a hospital setting, do SBIRT and offer the patient an opportunity and motivate them to speak with an addiction treatment specialist. Try to get the patient into treatment that day, but intervention and treatment should be more like that applied to health professionals and less like an asthma attack with just epinephrine administration. Long-term, lasting recovery is the only tool to prevent fatality in an addict

Authors

Daniel Angres, MD, is the Medical Director, Positive Sobriety Institute; the Chief Medical Officer–Addiction Services, RiverMend Health; and an Adjunct Associate Professor of Psychiatry, Northwestern University Feinberg School of Medicine. Robert DuPont, MD, is a Principal and Senior Resource, Bensinger, DuPont & Associates; and the President, Institute for Behavior and Health. Mark S. Gold, MD, FASAM, is the Chairman, Scientific Advisory Boards, RiverMend Health; and an Adjunct Professor, The Keck School of Medicine at USC, and Washington University School of Medicine.

Address correspondence to Daniel Angres, MD, Positive Sobriety Institute, 680 N. Lake Shore Drive, Suite 800, Chicago, IL 60611; email: dangres@positivesobriety.com.

Disclosure: Robert DuPont discloses a salary from Bensinger, DuPont & Associates and from the Prescription Drug Research Center. Mark S. Gold discloses consulting fees from RiverMend Health. The remaining author has no relevant financial relationships to disclose.

10.3928/00485713-20151001-08

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