U.S. Opioid Crisis

In the late 1990s health care providers began prescribing opioid pain relievers at great rates. Pharmaceuticals and health care providers played a hand in this upswing of prescriptions, as they either fabricated, misconstrued, or ignored the safety and efficacy of prescription opioids (Overdose 2017). Opioids are often prescribed to assist with the management of chronic pain. Examples of opioids are painkillers such as; morphine, methadone, buprenorphine, hydrocodone, and oxycodone, oxycontin, Percocet, palladone, Vicodin, Percodan, tylox, Demerol, and fentanyl among others. Heroin is also an opioid, and is illegal. This combination of prescription drugs, off market drugs, and an illegal drug is one of the reasons that what has been termed the opioid crisis is such a complex and multi-faceted issue.

In 2015, primary heroin admissions ranked first in New York City, Chicago Metro, Wayne County (Detroit Area), King County (Seattle Area), Los Angeles County, and San Francisco. Heroin admissions ranked second in Maine and Philadelphia (Maryland 2015). Since 2011, Maine, New York City, Philadelphia, Atlanta Metro, Southeastern Florida, and Wayne County Michigan have reported their highest numbers of heroin involved death (Heroin 2016). Opioid use had become prevalent in metropolitan areas, but the information that will be mentioned in later parts of the paper will make clear that opioid addiction and overdose had permeated to suburban and rural areas as well. According to comprehensive study that was conducted by the National Drug Early Warning System (Maryland 2015), in the 2015, 2 million U.S. patients suffered from substance abuse disorders related to opioid pain relievers, 591,000 suffered from a heroin use disorder, and more than 33,000 patients died because of opioid overdose. These overdoses included prescription opioids, heroin, and illicitly manufactured fentanyl (Overdose 2017). It has been reported that from the number of opioid related deaths from 2014 was six times greater than what was reported in 2001. It seems that the underlying reasons for opioid abuse have been present for many years, but recent events have exacerbated the issue (McGraw 2017). Of the patients that are prescribed pain killers, it has been estimated that between 8% and 12% develop an opioid use disorder (Overdose 2017). The percentage of patients that go on to develop opioid use disorders may seem miniscule at first, but if you attribute this percentage to the millions of U.S. patients that are prescribed pain killers and those that acquire access to opioids outside of professional prescriptions, the numbers quickly compile. About 21%-29% of patients prescribed opioids for chronic pain misuse them (Overdose 2017). Misuse includes abusing, addiction, and the passing on of prescriptions to others. Unfortunately, opioids are currently the most effective method of treating pain. As much as they ease the pain of many patients around the United States, opioids are addictive and require greater doses as the length of use increases (Collins 2017). People’s increased desire for stronger doses plays itself out all too often, as patients that once had sufficient and necessary need for prescribed pain killers cross over into the realm addiction and opioid injecting. In fact, 80% of people addicted to opioids, most of which are injectors, began as basic users of prescription drugs (Collins 2017). Some individuals display a habit of compounding drug use. As stated by Dr. Eric Wish, Principal Investigator of NDEWS and Director of UMD’s Center for Substance Abuse Research, “It is clear from our research that the users of these drugs tend to use many other drugs” (Poly-Drug 2017).

An Emerging Threat Report, which was conducted by the Drug Enforcement Administration, found that of their analyzed data, a drug called fentanyl, accounted for 64% of the opioids identified. Fentanyl was also found in combination with heroin in approximately 45% of the identifications (Emerging Threat 2017). To understand the significance of these statistics; one must first understand fentanyl in this context. Fentanyl is a synthetic opioid that exhibits a rapid onset of affects and a short duration. Recently, fentanyl began being adapted by heroin users. Heroin users will use fentanyl to cut or lace their dosage. Fentanyl can be anywhere from 50 to 100 times more potent than morphine (Poly-Drug 2017). Demographically, there are several factors that lie within the intersection of opioid use (prescribed and non-prescribed), medicine, and socio-economics. Geographically, overdose deaths seem to be occurring at higher rate in areas east of the Mississippi River (Heroin 2016). Latest news coverage has pointed the public eye in the direction of opioid abuse among the middle class and upper class. However, Roger A. Mitchell Jr., MD and District of Columbia Chief Medical Examiner suggests that men, who are now middle aged, in Black communities have been using heroin for many years; and are now dying from heroin that is cut with fentanyl (Newman 2017). Dr. Mitchell has gained much experience throughout his career and has witnessed the opioid crisis first-hand, through the eyes of a health care professional. Perhaps, if Dr. Mitchell is witnessing the effects of fentanyl-laced heroin on Black men that have lived a life of prolonged use in D.C., this trend may be occurring across the nation in every inner city and metropolitan area. Dr. Mitchell goes on to reveal that in 2014 he saw 83 opiate overdoses within his line of work, primarily heroin. In 2016, that number jumped to 213, and 70% were cases in which heroin was compounded with fentanyl (Newman 2017). The drug users that fall victim to the more potent combination of heroin and fentanyl know how to use heroin, and are accustomed to s certain level of potency. These drug users have been eyeballing their dosage of heroin for years, but when their heroin is laced with fentanyl and they are unaware of its effects, their usual hit of heroin becomes deadly.

There is also the historical aspect of illicit drug use by Blacks, Hispanics, and poor Whites. These populations have been using opioids long before the coining of the opioid crisis. These opioid abusers have been seen as moral failures, wrong doers, and criminals, as the underlying health needs of these individuals went largely unnoticed. Now that opioid misuse has become more prevalent across socio-economic lines it has been deemed a nationwide medical crisis (Newman 2017). For many years the issue of heroin use was not being discussed as either a public health issue of medical, psychiatric, or physiological affliction. It was being outlawed and criminalized, while the underlying effects on individuals were not being addressed by robust efforts. The precedent of socio-economically prejudiced policy making can be observed in the comparison of the ‘crack’ cocaine epidemic of the 80s and the call for restructuring and legislation that has occurred in the wake of the opioid crisis (VOX 2017). It is important to remember that people of different races are not ‘others’, people in different communities are not ‘others’, opioid addicts are not ‘others’. The opioid crisis is affecting people that are not on the fringes of society. As Anna Lembke, a Stanford educated psychiatrist stated, “This opioid epidemic in particular, has penetrated the White middle class, and because of that, it is now being conceptualized as a disease instead of a moral failing” (VOX 2017).

This year, congress allocated $1 billion to drug treatment over the next two years. Unfortunately, the allocated amount is far short of the tens of billions of dollars that some studies have suggested will be required to address the issue of opioid abuse and addiction (Lopez 2017). Rising opioid abuse can partially be attributed to strict government monitoring of prescription pain killers. It is not the case that access to pain killers should not be adequately monitored, but the prescription medications that patients need must be easy enough to obtain as to deter pursuit illegally sold opioids and heroin (McGraw 2017). People that find it difficult to acquire prescribed medication, often turn to heroin because it is less expensive and easier to obtain. The federal government has recently engaged in discussion that will certainly affect the way in which the United States is able to deal with the opioid crisis. For one, the recent talk of appealing ObamaCare would cut access to addiction treatment that many patients rely upon (Lopez 2017). If people are not able to acquire treatment through accessing the healthcare system, they may revert to seeking self-treatment outside of professional surveillance. Fragmentation of care has also contributed to opioid abuse and the rise of the recent opioid crisis. In some situations, patients may see a different provider for prescriptions, another for primary care, and yet another if the patients are brought to an emergency room (Bernstein 2017). The federal government has also tried to reduce the prescribing of opioid pain killers; however, the latest federal data shows that opioid prescriptions are still up 300% when compared to the amount of prescriptions that were handed out in 1999 (Lopez 2017). Oval L. Miller, Sr. CEO of Black Alcohol/drug Service Information Center has a differing opinion of the prescribing habits within the medical industry. Miller feels that the “government is pushing us away from counseling. It [ federal government] just wants to medicate” (Newman 2017). In terms of treating patients that have developed polymorphisms; which put plainly, are patients that have an increased tolerance to opioids, Dr. Earl Ettienne, Assistant Professor at the Howard University College of Pharmacy states that, sometimes effectively treating individuals with polymorphisms is difficult because the FDA guidelines only allow funding for what has been deemed the maximum amount of saboxon (Newman 2017). Simply curtailing treatment, strengthening restrictions to medicated treatment, and locking access to pain killers will lead people to search for opioids such as heroin and fentanyl. The approach to solving the problem of opioid abuse must be comprehensive, wholistic, and patient-centered (Lopez 2017).

Their needs to be distributive policy efforts that are aimed at combating the opioid crisis. Dr. Mitchell believes that the government needs to back programs such as, education, housing, employment, access to care, economic, and criminal justice efforts, that will help individuals seeking to free themselves from addiction, and I agree (Newman 2017). The medial care that is government subsidized should not include solely medicine. A wholistic environment for opiate drug abusers to become and stay stable must be established (Newman 2017). Their needs to be distributive policy efforts because policy has the ability to reflect and influence the way society views opioid abusers. Effective treatment relies upon the ability of care givers and providers to understand the culture and behaviors of the individuals that are receiving care. Having this understanding will more adequately equip professionals to deal with the psychological, emotional, and behavioral factors of abuse (Newman 2017). Recovering drug abusers must be given the tools that will allow them to return to their community, maintain sobriety, self-esteem, and self-worth (Newman 2017).

This policy will be carried out by the federal government due to the fact that the opioid crisis is a nationwide problem that has affected people that belong to many demographics. Some areas states and local governments have attempted make strides toward improving the situations that are being faced, but there needs to be a policy of one accord that will properly approach this multi-faceted issue. This policy will be a new action of the federal government, and will be taken up by the Legislative Branch as its powers include passing laws and originating spending bill. The relapse rate of heroin users has been determined to be at about 90%, this is one reason that we must have reform (McGraw 2017). Coupled with this fact, NIDA has estimated that the relapse rate of all opioid addiction combined hovers between 40% and 60% (Bernstein 2017). Opioids have proven to have powerful physiological effects. Long term abuse use of opioids changes the chemical composition of the brain, thus the abuser’s perception and the ways with which they interact with the environment around them also changes. Pain killer use and abuse are determinants of heroin use. As I stated before, 80% of people addicted to opioids began their use via prescription drugs. Patient relapses are also connected with the inability of assistive services and programs to address patients’ underlying physical, mental, and emotional pain. Lastly, relapse rates can be decreased through the utilizing of support systems and positive social connections (Mcgraw 2017). Support systems and positive social connections redirect patient focus, provide personal support and accountability, and allow patients to build dignity and self-value. To confront the opioid crisis, the federal government, with assistance from the healthcare system and its professionals, must provide patient-centered treatment as they seek to fix the shortcomings in the way that our nation approaches opioid addiction and abuse. As patients are identified and entered into treatment services, there should be education on how to mix and use the individual’s drug/s of choice. If the patient is an abuser, they will most likely continue to abuse opioids regardless how they are able to acquire the drugs. Rather than trying to cut people off opioids cold turkey, health professionals should advise patients on how to most safely use the drugs until the individual is ready to come off the opioids (Rock). In the opinion of Stanford pain specialist Sean Mackey, there are non-opioid based ways to deal with physical pain, including acupuncture, meditation, medical marijuana, and special physical exercises (Lopez 2017). The reason that Sean Mackey’s methods will be more effective is due to the fact that these methods deal with pain management, but exclude potentially addictive opioid use. I propose that treatments and alternatives be made easier to access than opioids, specifically medication assisted treatment. Medication assisted treatment includes methadone, buprenorphine, and naltrexone. When taken as prescribed, medications like methadone and buprenorphine can eliminate someone’s cravings for opioids and withdrawal symptoms without producing the kind of euphoric high that heroin or traditional painkillers produce. Medication-assisted treatment addresses the core problem of addiction, even if in some cases it does mean a patient will have to use a certain drug for the rest of his life. But the alternative isn’t a drug-free patient; the alternative is a continually relapsing patient. One who must salve their addiction with dangerous street drugs. There is not a cookie cutter approach to treating substance abuse, but with a patient-centered and wholistic focused plan, this nation will overcome in its battle with opioids.

---

References

Abuse, National Institute on Drug. “Opioid Overdose Crisis.” NIDA, National Institute on Drug Abuse, 1 June 2017, www.drugabuse.gov/drugs-abuse/opioids/opioid-overdose-crisis.

Bernstein, Lenny. “Many people keep taking prescription opioids during addiction treatment.” The Washington Post, WP Company, 23 Feb. 2017, www.washingtonpost.com/news/to-your-health/wp/2017/02/23/many-people-keep-taking- prescription-opioids-during-addiction-treatment/?utm_term=.ebdea13cda81.

Collins, Francis. “NIH Director Francis Collins on America’s opioid crisis.” Https://Www.washingtonpost.com, The Washington Post, 20 Sept. 2017, www.washingtonpost.com/video/postlive/nih-directorfrancis-collins-on-opioid-crisis-in-the- us/2017/09/20/cfb04e68-9e41-11e7-b2a7-bc70b6f98089_video.html?utm_term=.15a0814fa84a. Accessed 6 Dec. 2017.

“Emerging Threat.” Emerging Threat Report, Drug Enforcement Administration, 2017, ndews.umd.edu/sites/ndews.umd.edu/files/emerging-threat-report-2017-quarter3.pdf.

Lopez, German. “How to stop the deadliest drug overdose crisis in American history.” Vox, Vox, 1 Aug. 2017, www.vox.com/science-and-health/2017/8/1/15746780/opioid-epidemic-end.

Lopez, German. “When a drug epidemic's victims are white.” Vox, Vox, 4 Apr. 2017, www.vox.com/identities/2017/4/4/15098746/opioid-heroin-epidemic-race.

McGraw, Caroline. “Why Heroin Relapse Rate Is So High.” Residential Rehab & Recovery, The Clearing, 14 Jan. 2017, www.theclearingnw.com/blog/why-heroin-relapse-rate-is-so-high.

“New Hampshire HotSpot Study Finds Extensive Poly Drug Use in Fentanyl-Related Deaths.” Edited by University of Maryland, New Hampshire HotSpot Study Finds Extensive Poly Drug Use in Fentanyl-Related Deaths | NDEWS l National Drug Early Warning System l University of Maryland, National Institute on Drug Abuse, Sept. 2017, ndews.umd.edu/featuredcontent/1960.

National Institute on Drug Abuse. NDEWS Sentinel Community Site Advance Report 2016: Selected Findings for Heroin, Fentanyl, and Methamphetamine. National Institute on Drug Abuse, 2016, pp. 1–8, NDEWS Sentinel Community Site Advance Report 2016: Selected Findings for Heroin, Fentanyl, and Methamphetamine.

Newman, Rock, et al. “Opioid Crisis on the Rock Newman Show.” WHUT, Howard University Television, 17 Nov. 2017, www.whut.org/home/opioid-crisis-on-the-rock-newman-show/. Accessed 20 Nov. 2017.

University of Maryland. “Admissions to Treatment for Substance Use Disorder.” Edited by Center for Substance Abuse and Research et al., Admissions to Treatment for Substance Use Disorders (2015) | NDEWS l National Drug Early Warning System University of Maryland, National Institute on Drug Abuse, 2015, ndews.umd.edu/sentinel-sites/admissions-treatment-substance-use-disorders-2015.