Reframing the Prevention Strategies of the Opioid Crisis: Focusing on Prescription Opioids, Fentanyl, and Heroin Epidemic (original) (raw)
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Opioid-Related Harms: Simplistic Solutions to the Crisis Ineffective and Cause Collateral Damage
Health Services Insights
The narrative of the opioid crisis is that ill-informed and careless prescribing by physicians has led to increases in opioid-related harms including overdose deaths. Focusing on reducing the access to prescribed opioids without treating substance use disorder has led to increases in use of heroin and illicitly produced fentanyl. Overall prescribing of opioids has declined causing collateral damage to those who use opioids appropriately to reduce pain and improve function. The complexity of this issue requires a change in focus and broad changes in society's approach to substance abuse and mental health.
Reframing the Opioid Epidemic into its Proper Context: With results from survey taken in March 2018
KU Scholarworks , 2018
In this essay I will address the imperative nature of relieving pain due to its physiological consequences. I will also reference sources that illustrate comprehensively how to do this. I also recommend measure that can be taken to reduce the diversion (particularly by theft, which is responsible for most prescription drugs that end up on the black market) substantially and effectively without reducing patient access to them. I will also elucidate the differences between dependence and addiction, and explain why opioids are essential for the management of severe (or intractable) pain. The American Society of Interventional Pain Physicians (ASIPP) are by far the most recent, comprehensive, detailed, thorough, and useful guidelines formulated on opioid prescribing in light of the national crisis of overdose deaths. Utilizing the ASIPP guidelines in place of the older, and far less comprehensive CDC guidelines would be advisable, and beneficial to millions suffering from chronic pain, and steps that can be taken to reduce the number of deaths resulting from illicit fentanyl analogues such as carfentanil that are driving these deaths. Taking “high dose” –an arbitrary distinction (Kroenke and Cheville, 2017)–opioids off of the market will only cause suffering and death at worst, and inconvenience and suffering at best without reducing overdose deaths. This is especially true when one considers how the vast majority of “overdose” deaths involved illicit carfentanil and its analogues, not drugs prescribed by doctors, and as such there is no rational reason to remove these lifesaving drugs from the market or restrict access in any other manner as has been proposed by the FDA, and enacted via the CDC’s guidelines for opioid prescribing (2016), which have indisputably resulted in a great deal of pain and suffering (Kline and Lamb, 2017) The gaps and inconsistencies left in the management of pain have been profound; in every state in the U.S. since the implementation of the VA Department of Defense guidelines and the CDC guidelines, patients have been expressing disturbing amounts of suicidal ideation on social media sites such as Twitter, Facebook, and on comment threads of news articles. Their complaints and reasons for expressing such sentiments are always in relation to inadequate pain relief, typically because their doctors forcefully, involuntarily, tapered them, a practice with no research showing benefit, and plenty of research showing profound harms, as well as an abundance of testimonials.
Drug and Alcohol Dependence, 2017
Background/purpose: Recent reports indicate a sharp increase in fentanyl-related overdose deaths across the United States, much of which is likely related to the introduction of cheap, illicitly manufactured fentanyl derivatives. In this study, we sought to estimate the magnitude of illicit fentanyl use from 2012 to 2016 using a national opioid abuse surveillance system. Methods: The study program surveyed 10,900 individuals entering substance abuse treatment for opioid use disorder, with participants asked to endorse past month 'use to get high' of fentanyl drugs, stratified by identifiable (i.e., branded) fentanyl formulations or a 'type unknown' drug alleged to contain fentanyl. Main findings: Total past-month fentanyl-use rose modestly from 2012 to 2016. While use of known fentanyl products remained relatively stable (mean = 10.9%; P = 0.25), endorsements of 'unknown' fentanyl products nearly doubled from 9% in 2013 to 15.1% by 2016 (P < 0.001). Data show no discernable indication that this increase is diminishing or stabilizing. Conclusions: This first attempt to assess the prevalence of illicit fentanyl use shows that recent increases in fentanyl use seem to be due almost entirely to 'unknown' fentanyl presumed to be illicitly manufactured. Given that it is difficult to assess the extent to which fentanyl may have been substituted for another drug (i.e., oxycodone, alprazolam, etc.) or was used as a heroin admixture, our data likely represent an underestimation of the full magnitude of illicit fentanyl abuse. As such, this growing public health problem requires immediate attention and more systematic efforts to identify and track its abuse.
PNAS nexus, 2023
In 2020, the ongoing U.S. opioid overdose crisis collided with the emerging COVID-19 pandemic. Opioid overdose deaths (OODs) rose an unprecedented 38%, due to a combination of COVID-19 disrupting services essential to people who use drugs, continued increases in fentanyls in the illicit drug supply, and other factors. How much did these factors contribute to increased OODs? We used a validated simulation model of the opioid overdose crisis, SOURCE, to estimate excess OODs in 2020 and the distribution of that excess attributable to various factors. Factors affecting OODs that could have been disrupted by COVID-19, and for which data were available, included opioid prescribing, naloxone distribution, and receipt of medications for opioid use disorder. We also accounted for fentanyls' presence in the heroin supply. We estimated a total of 18,276 potential excess OODs, including 1,792 lives saved due to increases in buprenorphine receipt and naloxone distribution and decreases in opioid prescribing. Critically, growth in fentanyls drove 43% (7,879) of the excess OODs. A further 8% is attributable to first-ever declines in methadone maintenance treatment and extended-released injectable naltrexone treatment, most likely due to COVID-19-related disruptions. In all, 49% of potential excess OODs remain unexplained, at least some of which are likely due to additional COVID-19-related disruptions. While the confluence of various COVID-19-related factors could have been responsible for more than half of excess OODs, fentanyls continued to play a singular role in excess OODs, highlighting the urgency of mitigating their effects on overdoses. Significance Statement The continued rise of illicit fentanyls in the heroin supply and COVID-19-related disruptions both contributed to the unprecedented 38% rise in opioid overdose deaths (OODs) in 2020. We used a validated simulation model, SOURCE, to enumerate their relative contributions. We estimate that there were 18,276 potential excess OODs in 2020, after accounting for increases in buprenorphine prescribing and naloxone distribution and decreases in opioid prescribing that saved lives. Forty-three percent of the excess OODs were due to a continued increase in fentanyls; 8% were attributable to declines in methadone and extended-release injectable naltrexone treatment, likely due to COVID-19-related disruptions. The remainder (49%) of the excess OODs are unexplained, at least some of which could also be attributed to such disruptions.
Current perspectives on the opioid crisis in the US healthcare system
Medicine, 2019
Introduction: The administration of opioids has been used for centuries as a viable option for pain management. When administered at appropriate doses, opioids prove effective not only at eliminating pain but further preventing its recurrence in longterm recovery scenarios. Physicians have complied with the appropriate management of acute and chronic pain; however, this short or long-term opioid exposure provides opportunities for long-term opioid misuse and abuse, leading to addiction of patients who receive an opioid prescription and/or diversion of this pain medication to other people without prescription. Several reviews attempted to summarize the epidemiology and management of opioid misuse, this integrative review seeks to summarize the current literature related with responsible parties of this opioid abuse crisis and discuss potential associations between demographics (ethnicity, culture, gender, religion) and opioid accessibility, abuse and overdose. Methods: We performed an extensive literature search in Google Scholar and Pub Med databases that were published between December 7, 1999 and January 9, 2018 in accordance with the Preferred Reporting Items for Systematic Reviews and meta-Analysis (PRISMA) guidelines. Searches were referenced using medical subject headings (MeSH) that included "opioids", "over-prescription", "opioid consumption", or "opioid epidemic". The final review of all data bases was conducted on July 24, 2018. Results: A total of 7160 articles were originally identified. After 3340 duplicate articles were removed, 3820 manuscripts were removed after title and abstract screening. Following this, 120 manuscripts underwent eligibility selection with only 70 publications being selected as reliable full-texts addressing related factors surrounding the opioid crisis. Conclusion: With approximately 100 million people suffering from both chronic and acute pain in the United States (US) in 2016, opiates will continue to remain a prominent class of medication in healthcare facilities and homes across the US. Over 66% of total overdose episodes in 2016 were opioid-related, a figure that attests to the severity and widespread nature of this issue. A three-point approach accentuating the prevention, treatment, and rehabilitation of both those currently affected and at-risk in the future may be the comprehensive solution. Abbreviations: CDC = Center for Disease Control and Prevention, DEA = Drug Enforcement Administration, HOD = heroin overdose, NIH = National Institute of Health, OATs = opioid agonist treatments, OUD = opioid use disorder, PDMPs = prescription drug monitoring programs, POD = prescription opioid overdose, SOs = synthetic opioids.
A Review of Responses to the Opioid Epidemic: A Scoping Review
Abstract Opioids, both prescription and illicit, are responsible for an estimated 115 American deaths every day, that is roughly one death every 13 minutes. The most recent total economic burden in 2015 is determined to be $504 billion. Over 85% of the estimated burden is attributed to fatalities and cost of healthcare. The government and government organizations such as the Centers for Disease Control (CDC) have intervened by establishing physician oversight resources, raising awareness, and outlining opioid prescribing practices that have stabilized opioid prescribing. Also signed into law, is the first major federal addiction legislation in over 40 years. Despite these interventions, as the national prescribing rates decline, abuse of illicit opioids and overdose deaths from all opioids are increasing (Hagemeier, 2018). The continuing rise in abuse and deaths points to the realization that there are gaps in knowledge associated with the underlying factors motivating and driving the epidemic that is likely multidimensional and dynamic. Knowledge gaps may be filled by recognizing that the opioid crisis is not isolated to the United States, the opioid crisis has impacted our world globally. A better understanding of the opioid epidemic in the U.S. and the development of new methods of intervention may be found through the global analysis of trends, issues, solutions, and outcomes. The dynamic, multidimensional nature of the opioid crisis and new research indicating the continuous rise in deaths and overdoses considering evidence pointing to reduced prescribing, is troubling. There is a need to evaluate the existing knowledge available surrounding the opioid epidemic in the United States (U.S.) and identify gaps in the current knowledge base. The scope and breadth of the factors impacting the opioid crisis contribute to research that is sparse and insufficient. The purpose of this scoping review is to analyze and map the currently available research literature, grey literature, narratives, and expert opinions to begin building a more thorough understanding of the overall effectiveness of policy interventions on overdoses and deaths. As the nation moves forward, it is essential to analyze the effects and outcomes of the current interventions to evaluate the impact and examine behavior changes that may contradict the intended goals and objectives. Identifying behavior changes and determining drivers of those changes can provide valuable information needed to discover a healthy balance between oversight and controls. Additionally, understanding behavior change will likely improve the accuracy of future predictive research models. Results of this of the research will available once the data analysis has been completed. Keywords: opioid epidemic, drug abuse, prescribing laws, opioid-related deaths and overdoses
The Opioid Epidemic: Moving Toward an Integrated, Holistic Analytical Response
Journal of analytical toxicology, 2018
In many jurisdictions, public safety and public health entities are working together to enhance the timeliness and accuracy of the analytical characterization and toxicology testing of novel synthetic opioids. The improved sharing and early detection of these analytical data are intended to inform surveillance, interdiction efforts, patient intervention and treatment, all of which are critical to curbing the opioid epidemic. Forensic practitioners working to identify novel synthetic opioids struggle to provide timely results when encountering new or unknown substances, such as the fentanyl analogs. These compounds, which mimic heroin in pharmacologic effect but can be far more potent, are inconsistently present in chemical identification libraries, and are currently largely unavailable as reference materials for analytical comparison. Additionally, federal, state and local governments as well as nongovernmental organizations require potency, toxicity and potential-for-abuse data to ...
PLoS ONE, 2013
The historical patterns of opiate use show that sources and methods of access greatly influence who is at risk. Today, there is evidence that an enormous increase in the availability of prescription opiates is fuelling a rise in addiction nationally, drawing in new initiates to these drugs and changing the geography of opiate overdoses. Recent efforts at supply-based reductions in prescription opiates may reduce harm, but addicted individuals may switch to other opiates such as heroin. In this analysis, we test the hypothesis that changes in the rates of Prescription Opiate Overdoses (POD) are correlated with changes in the rate of heroin overdoses (HOD). ICD9 codes from the Nationwide Inpatient Sample and population data from the Census were used to estimate overall and demographic specific rates of POD and HOD hospital admissions between 1993 and 2009. Regression models were used to test for linear trends and lagged negative binomial regression models were used to model the interrelationship between POD and HOD hospital admissions. Findings show that whites, women, and middle-aged individuals had the largest increase in POD and HOD rates over the study period and that HOD rates have increased in since 2007. The lagged models show that increases in a hospitals POD predict an increase in the subsequent years HOD admissions by a factor of 1.26 (p&amp;amp;amp;amp;amp;lt;0.001) and that each increase in HOD admissions increase the subsequent years POD by a factor of 1.57 (p&amp;amp;amp;amp;amp;lt;0.001). Our hypothesis of fungibility between prescription opiates and heroin was supported by these analyses. These findings suggest that focusing on supply-based interventions may simply lead to a shift in use to heroin rather minimizing the reduction in harm. The alternative approach of using drug abuse prevention resources on treatment and demand-side reduction is likely to be more productive at reducing opiate abuse related harm.