What is the American Opioid Crisis and how can it be resolved? – By Alex Lawrence
The American opioid crisis is due to the mass overuse and misuse of opioid analgesics (painkillers) with huge medical, social and economic consequences which I will later discuss in detail. Smaller opioid epidemics have occurred elsewhere in the world however the one I will be talking about here in the United States is definitely one of the most damaging. I will also go on to explain the biochemical reasons for why 130 Americans die each day due to opioid overdoses.
The term opioid means substances that act on opioid receptors to produce morphine-like effects. Some of these are far more dangerous for the user than others, for example the painkiller codeine is regularly found in over the counter/ prescription medicines such as cough syrups, painkillers slightly stronger than paracetamol (e.g. Co-codamol), and cold and flu pills. At the other end of the opioid scale are compounds such as diamorphine (heroin) and fentanyl, which is often used to lace drugs but is officially for end of life cancer medicine. These are extremely dangerous and cause the majority of opioid overdoses in the US. The sharpest rise in drug-related deaths occurred in 2016 with over 20,000 deaths from fentanyl and related drugs.
How did the crisis begin?
The opioid crisis began due to the over prescription and relaxed attitudes on giving these extremely dangerous and abusable substances to the public. This attitude was created by the way companies such as Purdue Pharma, which was responsible for creating Oxycontin, marketed their drugs to hospitals in the US as the far more effective, safer options than previously used opioids. This gave hospitals a reliance on these drugs as the “nothing can go wrong, I’ll prescribe this” attitude grew leading to far too many patients becoming reliant on these medications to alleviate their pain.
With continued use of opioid medication, a reliance begins to build, within the body, where more of the same substance is needed to receive the same benefits (and the highly addictive nature of these chemicals adds to this reliance also). Once the limited prescription of medicines to patients had run out, they began to seek this “relief” in other ways such as illegal, non-pharmacy produced pills or substances such as heroin This explains why 75% of heroin users began by taking prescription pills.
The danger doesn’t necessarily just come from substances like diamorphine but it’s also from the poor manufacturing processes of clandestine producers causing irregularities that can be extremely dangerous. Little is known about the relative toxicities of the abused drug versus those that result from drug impurities and additives. A dangerous example of this is Street heroin which been found to contain an estimated 7%-10% to a maximum of 20% pure heroin with the remainder comprising of filler substances. The most common substances used to cut heroin include baking soda, sugar, starch, crushed over-the-counter painkillers,
talcum powder, powdered milk, laundry detergent and caffeine. These aren’t so dangerous however rat poison and de-worming agents are also used which can cause huge health issues such as rupturing of veins. Now many people who are addicted to opioids will simply disregard the actual contents of their drugs as long as they get their “fix” which is what makes it so dangerous. Many drug testing kits can be purchased to test for contaminants such as fentanyl, however they can be quite expensive and hard to come by and so they don’t seem to make a huge difference in saving lives.
Street opioids are also extremely expensive. Heroin costs more than £100 per gram and oxycontin pills can cost around £95 each. This brings me on to another reason why the opioid crisis has affected as many as it has, the high price of these substances makes them out of reach for those who cannot afford them, opening up a new market for fake, cheap heroin substitutes. One of the most prominent examples of this is the compound dihydrodesoxymorphine or as it’s colloquially named “krokodil”. It thought the name krokodil comes from the scaly hard skin that forms around its injection site. This drug is most commonly used in Russia however it has also made its way to streets in the US. Krokodil is produced by combining toxic chemicals such as hydrochloric acid, household cleaners and gasoline with codeine. The damaging nature of this substance compared to pharmacy opioids where most addictions start is incomparable. Continued krokodil use can result in horrific cases of gangrene and necrosis (death of living tissue). Although these are extreme examples, the irreparable damage this substance and others like it causes cannot be overstated.
So how do opioids work in the brain?
Opioids work in the body by changing the way in which we sense pain. When we experience an injury, neurons send information from where the injury occurred to our brain. These neurons are covered in proteins called opioid receptors. These receptors slow down the neurons ability to send pain signals, when the body experiences an injury it releases chemicals called endorphins which activate these opioid receptors slowing the down the pain signals and preventing panicking. Opioid medications share a similar structure to our natural endorphins which allows them to bind to the same opioid receptors as previously mentioned. This also slows down pain signals making injuries more bearable.
This is not all these medications do however, an area in our brain called the Ventral Tegmental Area (or VTA) is full of neurons that create a neurotransmitter called dopamine. This is the chemical that produces feeling of joy and euphoria when we achieve something that makes us happy. This chemical helps teach our brains to keep seeking out good things. In order to prevent this feeling coming too often inhibitory neurons keep this chemical from being produced until necessary. Just like pain neurons these are also covered in opioid receptors. When pain medications are used, they bind to the opioid receptors and the inhibitory neurons allow the dopamine to be released. This creates the aforementioned feeling of happiness and euphoria however this is the problem. Upon continued use of these substances the neurons have to work extra hard and the releasing of dopamine becomes less frequent, this leads to less happy feelings. Users will have to keep taking more and more opioids just to feel comfortable again. When the prescription runs out user’s brain will
produce almost no dopamine at all, this means not only will the physical pain remain, but feelings of depression and anxiety will also surface.
Many users will have no problem with stopping use of opioids and returning to normal but for others that are more prone to addiction this is not the case. In order to return to normal addicts feel like they must find more pills after the prescription has run out and if this can’t be done they will find more dangerous substitutes, as I have already mentioned. This is how the opioid crisis is the number one cause of accidental death in the US and how it can all stem from as little as a fractured bone or hurt back.
So, what are the consequences of the opioid crisis?
Since 2000, America’s drug overdose rate has more than doubled, from 6.2 per 100 000 persons, to 14.7 per 100 000 in 2014. In 2015 alone, over 30,000 deaths were attributed to opioid overdose which is an increase of nearly 5000 people compared to the previous year. This is the first time where opioid overdose has surpassed firearms and motor vehicle injuries as the most common cause of accidental deaths for adults in the country. The United State’s life expectancy has dropped for the first time in over ten years and the highest increase in cause of death was from accidental reasons such as drug overdose.
The epidemic has shown to affect a large majority of the country’s population as a study by the Kaiser Family Foundation showed that more than half of participants had a connection to painkiller abuse and about 16% knew someone who had died from overdose. Addiction to these substances destroys entire families and even whole communities and towns. Many believe it is mainly inner-city communities that are effected by this however this is not the case, rural areas are affected to same degree if not greater. According to the American Addiction Centres organisation, one of the cities that experiences the most drug use is Omaha, Nebraska. A reported 3.4% of its inhabitants have used heroin, the highest of any city in the country. It is safe to assume that the vast majority if not all of these user’s addictions stemmed from prescription misuse.
Rural areas have shown to be the most affected by prescription opioid mortality rather than illegal street drugs such as heroin. The main reason rural areas are affected like this is attributed to an industrial decline where many are left unemployed or underemployed with some form of workplace disability. And in many cases the treatment given out for these injuries happens to be opioid painkillers, which as previously mentioned will cause the majority of these deaths.
The epidemic also has huge social impacts that aren’t as easily studied. Those who die from opioid overdoses are not the only ones affected, many family members and loved ones of those killed are also personally affected. Children growing up in families where members are abusing opioids are extremely vulnerable to neglect and abuse. In many cases, for most addicts, drugs become the number one priority over even caring for their own children. Needles and other drug apparatus also pose a significant danger to the health of children if for example they accidentally become pricked by a needle there is a likelihood that a bloodborne disease such as hepatitis or HIV could be contracted.
Issues such as these have led to the need and creation of many foundations whose goal is to rehabilitate those who are addicted and to offer counselling for those who are close to addicts. These services however are not accessible for all and are perhaps least accessible for those who most need it. The best drug rehabilitation centres in the US are all private and can cost almost $15,000 for naltrexone treatment. Naltrexone is an opioid antagonist that works by blocking the effects of opioids and continued use will end opioid cravings. With the US’s average wage being just over $55,000 per year this is a significant portion of person’s income and requiring this much money to be spent can leave a huge financial strain on suffering families and individuals. Those who are addicted in rural areas will also have more trouble seeking help as rehabilitation clinics are most often based in and around cities.
How could the crisis be resolved in the future?
Opioid addiction or even just drug addiction in general can never be fully prevented however measures can be made to reduce the amount of people that become addicted as well as reducing the harm that comes to those who already are addicted.
Harm reduction is extremely important, and addicts should not be punished for their addiction but rather should receive medical and psychiatric help. Other world governments such as the Netherlands allow users to get their drugs tested for contaminants and unwanted additives for an extremely small fee of around €3. This has shown to be very effective at negating the risks to those who use these substances. Services such as these should be widely implemented across the US and be available in the areas of greatest addiction across the country.
In order to further reduce opioid overdoses more research should carried out into developing a wider range of Abuse Deterrent Opioid Painkillers. Abuse deterrent painkillers are especially engineered to target the expected routes of abuse such as crushing to be snorted or dissolved to be injected. By making these types of opioids more available and more research being completed into further advancing the effectiveness of these many more addictions could be prevented and lives could possibly be saved.
The government should also work to reduce the stigma behind substance abuse disorders to stop those who are vulnerable not getting treatment for themselves or others. Addiction should be treated as a mental health disorder and not as something to be ashamed of. If people aren’t ashamed of their addiction, they are far more likely to get help for themselves or others. Once under medical care, a recovery is highly likely for patients and they can get their life back on track.
Sources: https://www.youtube.com/watch?v=9hOyjFyE3Ek – BBC documentary on the crisis https://www.poison.org/articles/opioid-epidemic-history-and-prescribing-patterns-182 https://www.ncbi.nlm.nih.gov/pubmed/2054004 https://americanaddictioncenters.org/heroin-treatment/cut-with https://www.nationalgeographic.com/video/shorts/1095881283902/
Centers for Disease Control and Prevention (CDC). CDC grand rounds: prescription drug overdoses – a U.S. epidemic. MMWR Morb Mortal Wkly Rep. 2012;61:10–3. https://www.kff.org/health-reform/poll-finding/kaiser-health-tracking-poll-november-2015/ – Kaiser Family Foundation Study https://www.aap.org/en-us/advocacy-and-policy/aap-health-initiatives/Substance-Use-and-Prevention/Pages/addressing-the-opioid-epidemic.aspx https://www.jellinek.nl/vraag-antwoord/why-do-they-test-drugs-the-netherlan