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Opioid use disorder (OUD), which is “often secondary to non-medical use of prescription opioids” is a major public health issue in the United States to the extent that it has been called an epidemic.1 In October 2018, President Trump announced that his administration was declaring the opioid crisis a national public health emergency under federal law and directing all executive agencies to “use every appropriate emergency authority to fight the opioid crisis.”2 Opioid-related overdoses have risen “exponentially,” increasing at a rate of 9% annually.3 According to US Department of Health and Human Services, in 2016 and 2017, 11.4 million people misused prescription opioids, 2.1 million people had an OUD, and 42,249 people died of opioid-related overdoses.4
The authors of a review article sought to conceptualize the complexity of the OUD epidemic, “using a conceptual model grounded in the disease continuum and corresponding levels of prevention” and examined studies and reviews conducted during the last 15 years to formulate evidence-based interventions for the treatment of OUD.1Senior review author Robert Pack, PhD, MPH, professor of Community Behavioral Health, associate dean for Academic Affairs, and executive director of the Center for Prescription Drug Abuse Prevention and Treatment, East Tennessee State University, Johnson City, told Clinical Pain Advisor: “Many of my colleagues have been personally affected by the opioid problem, and it has touched my life as well.”
He added: “[The article] is an exposition on the fact that there are a number of different interventional approaches to address the opioid crisis, and no single approach will be sufficient.”
Drivers of Nonmedical Use of Prescription Opioids
Nonmedical use of prescription opioids “results from a complex, cumulative interaction of multiple drivers,” which include “market forces, misguided policy, perceptions of risk, and stigma,” the authors note. One of the key drivers is a “copious supply of prescription opioids,” which are used for the treatment both of pain and of opioid addiction (eg, with buprenorphine). Prescription opioid sales have quadrupled since 1999, a rise that is accompanied by increases in hospital admissions related to prescription opioids and in overdose deaths. States with the highest rates of nonmedical use of prescription opioids and overdose deaths were found to have the highest rates of opioid prescribing. “We really have to do better at prescribing,” Dr Pack remarked. “In Tennessee, where I live, we have a serious overprescribing problem. In fact, according to the Drug Enforcement Agency’s 2017 data, Tennessee had a record number of opioid overdoses.”
This rise in prescribing of prescription opioids in the last 2 decades of the 20th century occurred at a time during which medical professionals were urged to resort to prescription opioids to manage untreated and chronic noncancer pain. In 1996, the American Pain Society proposed that pain be regarded as the “fifth vital sign,” thereby “elevating the importance of pain assessment to equal that of established vital signs,” and urging physicians to respond to or proactively treat patients’ pain. “Highly intertwined with this shift toward more aggressive use of prescription opioids” was aggressive marketing on the part of pharmaceutical companies, understating addictive risk and overstating advantages of prescription opioids. This led to a low perception of risk/harm on the part of the medical and lay communities.
In addition, there is considerable stigma toward individuals with addiction, which can “hinder help-seeking behaviors, the availability of treatment and other support, and perhaps the implementation of interventions across all levels of prevention,” noted the review authors. Individuals who have become addicted are often regarded as morally weak or enacting a choice, rather than suffering from a “chronic, relapsing disease,” with additional stigma surrounding evidence-based strategies that address the condition. “Thus, stigma, whether toward addiction or toward strategies aimed at alleviating its harms, can foster a socio-cultural environment unsupportive of responding to [nonmedical use of prescription opioids], thereby perpetuating the problem,” according to the authors.
Potential Interventions
The conceptual model suggested in the review is predicated on the “continuum of the disease of addiction, from non-use to dependence, addiction, and ultimately, premature death.” Targeted public health strategies “need to be brought to bear against different points all along the disease continuum for measurable progress to be made against the epidemic.”
Primary prevention “aims to prevent the development of a disease, and addiction is a preventable disease”; therefore, “[p]reventing the initiation of [nonmedical use of prescription opioids] or any illicit opioid should be the highest goal.” Primary interventions can be delivered in an array of settings and target diverse populations. Making them culturally relevant and tailored to each population can facilitate their acceptance and sustainability in community settings. Primary prevention also includes training and continuing education for healthcare professionals.
Secondary prevention “involves the early detection of a disease to decrease its severity and consequences.” In the case of OUD, this can involve “identifying non-medical use and diversion as a means of averting progression to addiction and the sequelae of untreated addiction.”
Prescription drug monitoring programs are often overseen by state departments of health or boards of pharmacy, and can be used to identify potential abuse/diversion of controlled substances, obtain data on a given patient’s controlled substance history, and detect problematic prescribing/dispensing practices. Additional interventions include the regulation of pain management clinics to reduce a significant source of prescription opioids often used for diversion or nonmedical use. Screening, brief intervention, and referral to treatment is a “public health approach…that incorporates universal screening, detection of risky or hazardous substance use, early intervention, and referral to treatment for individuals identified with substance use disorder within a single, evidence-based model.”
Tertiary prevention “focuses on decreasing the complications of a disease through treatment and other support.” This includes referring patients to medication-assisted treatment involving pharmacotherapies such as methadone, buprenorphine, and naltrexone, often in combination with psychosocial interventions. No single treatment approach is effective for all individuals with opioid use disorder; therefore, approaches and settings need to be individualized.
Neonatal abstinence syndrome can be addressed by treating the mother and the infant, as well as preventing a second pregnancy.
A pregnant woman who has addiction should receive medication-assisted treatment, as well as nonpharmacologic interventions after childbirth.
Drug courts have been shown to facilitate the integration of evidence-based addiction treatment into the criminal justice system, as drug abuse, criminal activity, and involvement with the criminal justice system are often intertwined. Approximately half of incarcerated inmates meet diagnostic criteria for drug abuse or dependence, but only a minority receive treatment. Drug courts are typically operated by a multidisciplinary team and target criminal defendants and offenders, juvenile offenders, and parents with pending child welfare cases.
Finally, the review authors recommend training the public on using naloxone. Although some concerns have been raised that the presence of naloxone may be regarded as a “safety net,” the drug has been found to be effective in saving countless lives.
Education of Healthcare Professionals
On a policy level, there have been attempts to restrict the supply of opioids. “Constraining the supply of prescription opioids, which is a current strategy for attempting to curb the opioid epidemic, means that a number of people who are dependent on opioids have moved into a situation where they’re looking for the same type of physical effect that their prescribed opioids had,” noted Dr Pack. These individuals often “move either to diverted opioids that were prescribed to someone else or, in some cases, to heroin or fentanyl, and this is part of what has been driving the second and third waves of the opioid epidemic.” To counter this phenomenon, healthcare professionals must be “vigilant about identifying patients who are physically dependent [on opioids] and are moving into OUD, and are becoming impaired in ways that are really impacting their lives,” he advised. “We need to move these patients to medical assistance quickly, and do that at a better and larger scale, ideally alongside a primary care provider who can also then modify the extent to which the patient’s other medications are also affecting their lives.” To achieve this goal, prescribers should become familiar with facilities that offer these medical treatments and refer patients. Prescribers should also become familiar with professionals, such as caseworkers, who might facilitate the practicalities of receiving treatment, such as financial or logistical access. “Recognize that some patients might feel stigmatized about the fact that they need this type of treatment and providers should approach the subject nonjudgmentally,” recommended Dr Pack. “Healthcare professionals need to talk to each other about their respective patients; for example, a pharmacist might see that a doctor prescribed 2 medications that interact negatively and may advise the patient to talk to the physician, but the pharmacist may not necessarily pick up the phone to talk to the physician.”
A Message of Hope
The risk factors and key drivers of nonmedical use of prescription opioids and for OUD are “amenable to change,” the review authors noted. “The most important thing to remember is that people do get better,” emphasized Dr Pack. “It may be a complicated situation for the patient, but I have a lot of people around me on a daily basis who have dealt with their own [OUD] problems and are living great lives, both on and off medically assisted treatment. It is imperative that physicians and clinicians in the whole orbit of patient care, including nurse practitioners, physician assistants, and pharmacists, take a long view on the patient and know that even very desperate cases can wind up as success stories.”
References
1. Mathis SM, Hagemeier N, Hagaman A, Dreyzehner J, Pack RP. A dissemination and implementation science approach to the epidemic of opioid use disorder in the United States. Curr HIV/AIDS Rep. 2018;15(5):359-370.
2. The White House. The Opioid Crisis. https://www.whitehouse.gov/opioids/. Accessed December 18, 2018.
3. Buchanich JM, Balmert LC, Burke DS. Exponential growth of the USA overdose epidemic. bioRxiv. 2017;134403.
4. US Department of Health and Human Services (HHS). What is the U.S. Opioid Epidemic?https://www.hhs.gov/opioids/about-the-epidemic/index.html. Updated January 22, 2019. Accessed December 18, 2018.4.
