Opioid Basics

What Are Opioids?

  • Opioids are a class of drugs that are derived from or stimulate the effects of the pain-relieving compounds found in opium.[1]
  • Some opioids are made directly from compounds found in opium, while others can be "semi-synthetic" or "synthetic," manufactured using chemicals with properties similar to opium.[2]
  • The most widely abused opioids include heroin and prescription medications.[3]
  • The effects opioids have depends on how much a person takes and how they take them. If they are injected, they act faster and more intensely. If they are swallowed, they take longer to reach the brain.[4]

Heroin

  • Heroin can be white, gray, brown, or black powder.[5]
  • Heroin can be taken orally, smoked, snorted, as a suppository, or injected into a muscle or vein.[6]
  • Street names for heroin include H, ska, tar, dope, china white, holly, horse, and junk.[7]
  • The purity of heroin is typically between 50% and 80%. This gives a much more intense high than in the 1980s, for example, when average heroin was only 4% or 5% pure.[8]

Prescription Opioids

  • The most common prescription opioids are hydrocodone (Vicodin), hydromorphone, oxycodone (Percocet and OxyContin), and codeine.[9]
  • Prescription opioids can be in the form of a time-released capsule or tablet, liquid, injectable syringes, suppositories, skin patches, or lozenges.[10]
  • Street names for prescription opioids include oxy, OC, M, sister morphine, hydros, tabs, and demmies.[11]

New Drugs

Effects On The Body

  • Opioids act on the limbic system, which controls emotions, creating feelings of pleasure, relaxation, and contentment. [12]
  • Opioids act on the brainstem, which controls automatic body functions, and causes slowed breathing, stopping of coughing, and reduced feelings of pain.[13]
    Opioids act on the spinal cord, which sends sensory signals to the brain, decreasing the feelings of pain. [14]
  • Opioids can cause drowsiness, nausea, and constipation. [15]
  • Depending on the amount taken, in the case of an overdose, breathing can be slowed so much that a person will eventually stop breathing and die. [16]

Why Are They Addictive?

  • The indicators of addiction are tolerance, withdrawal, and continuing to use the drug despite negative consequences.[17]
  • Opioids activate endorphin receptors in our brains, which naturally relieve pain, reduce stress, and create feelings of euphoria. Opioids activate these receptors in a much more intense way than our natural endorphins creating a "high".[18]
  • The brain develops a tolerance to the drugs after continued use which means a person needs more and more of the drug to get the same high.[19]
  • Stopping the use of the drug causes extremely unpleasant withdrawal symptoms.[20]
  • The reward of the high and the punishment of withdrawal creates a pattern that causes physical dependency.[21]

The Problem

  • "The epidemic is a wildfire roaring dangerously out of control" New Jersey Gov. Chris Christie (R)
  • The Centers for Disease Control and Prevention (CDC) has declared opioid misuse a "national epidemic". [22]
  • Drug overdose is now the number one cause of injury death in the United States, surpassing even motor vehicle accidents. This increase in overdose deaths has been fueled by the increase in opioid use.[23]
  • In 2014, there were 18,893 overdose deaths related to prescription pain relievers, and 10,574 overdose deaths related to heroin.[24]
  • In 2014, 1.9 million Americans had a substance use disorder involving prescription pain relievers and 586,000 had a substance use disorder involving heroin. [25]
  • 78 Americans die each day from prescription painkiller overdoses.[26]

Substance Use Disorders

  • A substance use disorder is recognized and characterized by the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5). Instead of separating problems into separate categories such as substance abuse chemical dependency, or addiction, it includes the full range of problematic drug use under the term substance use disorder. [27]
  • Opioid use disorder would be the term used to diagnose a person who uses heroin or prescription pills in a problematic way. [28]
Patients with opioid addiction, also called opioid use disorder, often experience the following:
  • alterations in brain chemistry
  • low pain tolerance
  • short attention span
  • greater legal, social, and familial consequences

Individuals who are addicted to opioids are extremely vulnerable.
  • They are hypersensitive to pain, putting them at greater risk of relapse (returning to use)
  • These patients are more likely than others to leave treatment before completing it
  • The most alarming feature of opioid use disorder is the record number of patients who die before achieving recovery. (Opioid users are at a higher risk of death from accidental overdose during relapse because of their reduced tolerance levels.) [29]

History

The Beginning of the Addiction

OxyContin was first released in 1996, and five years later it was already the best-selling pain medication in the United States. OxyContin is taken in a time-released pill that dissolves slowly to release pain treating medication. People wanting to misuse OxyContin began crushing the pill and snorting it, swallowing it, smoking it, or injecting it to get an instant high. The company that produces OxyContin stopped producing the highest dosage and started creating "crush-proof" pills. For those looking to buy the crushable pill illegally, this meant increased prices and decreased availability; turning them to find an alternative, which was often heroin. In the 90s, the purity of heroin began to increase while prices decreased. This meant heroin was a perfect alternative for opioid drug users.[30]
The use of heroin among people age twelve and older in the US increased from 373,000 in 2007 to 669,000 in 2012[31]

Low Costs

  • In the 90s, the purity of heroin began to increase while prices decreased. [32]
  • Today, a single dose of heroin costs $10, while prescription painkillers can sell for over $80 per pill. [33]
Excellent Video of the NACCHO 2015 Plenary Session on Opioid Crisis and Substance Abuse

According to Health and Human Servicess Secretary, Sylvia Burwell, the opioid crisis is one of the biggest health issues for 2016.[34]

In 2012, health care providers wrote 259 million prescriptions for opioid pain medications – enough for every American adult to have a bottle of pills.[35] Opioids are a class of prescription pain medications that includes hydrocodone, oxycodone, morphine, and methadone.[citation] Heroin belongs to the same class of drugs and four in five heroin users started out by misusing prescription opioid pain medications.[36]

About 75 percent of prescription painkiller abusers switch to heroin as a cheaper opioid source. [37]

But the dramatic rise in heroin-related overdoses – which nearly doubled between 2011 and 2013 – shows the opioid crisis is far from over.[38]

The CDC has estimated that for every death from opioid poisoning there are 10 treatment admissions, 32 emergency room visits, 130 people who abuse or are dependent on opioids and 825 non-medical users of the drugs.[39] In just six years heroin use has risen 150 percent to more than a half-million Americans.[40]

CDC Understanding the Epidemic

Of people using opioid painkillers non-medically (2009)[41] -
  • 55% got the drugs from a friend or relative for free
  • 10% bought them from a friend or relative
  • 5% took them from a friend or relative without asking
  • 18% got the drugs from one doctor
  • about 5% got the drugs from a dealer or another stranger
  • less than 1% bought them on the internet

Staggering Statistics

One study showed that more than 90% of the people who overdose can still get prescriptions to opioid pain pills.[42]

The National Rx Drug Abuse & Heroin Summit, presented by Operation UNITE, is the largest national collaboration of professionals from local, state, and federal agencies, business, academia, clinicians, treatment providers, counselors, educators, state and national leaders, and advocates affected by prescription drug abuse and heroin use. During the summit, held in Atlanta, Georgia, March 28–31, 2016, CDC Director Dr. Tom Frieden gave a presentation entitled “From Sounding the Alarm to Turning the Tide: Action to Combat the Opioid Epidemic.” He quoted statistics such as the following:
  • There have been 500,000 drug overdoses since 1999.
  • Every day, 44 people in the U.S. die from prescription drug
    overdose, and many more become addicted.
  • Health care providers wrote 249 million prescriptions for opioids in 2013, enough for every American adult to have a bottle of pills.
  • Among those reporting prescription opioid and heroin addiction in the last year, 3 out of 4 took prescription opioids first. [43]

Find Dr. Frieden’s full presentation by clicking the following link: https://vimeo.com/162843894.


For more information about the summit, including presentation slides, video, and audio recordings, the visit the National RX Drug Abuse & Heroin website.
For additional information regarding the opioid epidemic in the United States including the federal response, visit http://www.hhs.gov/opioids/ about-the-epidemic/.


National Response

U.S. Department of Health & Human Services (HHS) also launched HHS.gov/opioids as a one-stop federal resource with tools and information for families, health care providers, law enforcement, and other stakeholders on prescription drug abuse and heroin use prevention, treatment, and response. [44]

The Centers for Disease Control and Prevention (CDC) has declared opioid misuse a "national epidemic". [45]

State Response

Vermont Governor Peter Shumlin (D) dedicated his entire state of the state speech last year to heroin abuse. He said that reducing the overprescription of opiates must be a priority.[46]

West Virginia’s Department of Health and Human Resources estimates that the state has about 60,000 people in need of treatment competing for 750 beds.[47]

Rev. Jeff Allen, head of the West Virginia Council of Churches. But, he added, pastors had to do more to “change the culture of churches to take away any shame so people can turn to their pastors and congregations.”[48]

The announcement underscores Obama’s “sense of urgency that we at the federal level can do more to address this issue,” said Michael Botticelli, director of the White House Office of National Drug Control Policy.[49]

Consequences

Overdose
  • Many people who begin using heroin after using prescription opioids do not know how much to use. [50]
  • When people leave treatment or jail, they are often not aware that their tolerance has gone down and take too much of the drug. [51]

Opioid Use vs. Opioid Abuse
The following are examples of prescription opioid abuse:
  • Taking someone else’s prescription opioid.
  • Taking a prescription opioid in a way other than prescribed.
  • Taking more than prescribed.
  • Combining a prescription opioid with alcohol or other drugs.
  • Crushing pills into powder to snort or inject.
  • Taking opioid prescription medications to get high.
    Regular abuse of opioids, may change the functioning of the brain. Repeated use may result in the following:
  • Tolerance: more of the drug is needed to achieve the same “high.”
  • Dependence: the need to continue using the drug to avoid
    withdrawal symptoms.
  • Opioid use disorder: also known as addiction, a devastating brain disease where, without proper treatment, people can’t stop using drugs even when they really want to and even after it causes terrible consequences to their lives and health.[52]
Consequences of Opioid Addiction
  • Short term symptoms include reduced heart rate and breathing, reduced blood pressure, constipation, nausea, vomiting.[53]
  • Long term symptoms include tolerance, cravings, and withdrawal.[54]
  • Co-morbidities from using needles such as HIV/AIDS, Hepatitis B and C, heart and lung problems, abscesses or blood infections, and collapsed veins.[55]
  • Women who are pregnant are at risk for babies being born with birth defects or neonatal abstinence syndrome (NAS).[56]
Use of opioids also contributes to the starting of clinical depression.[57]

The combination of opioids and other medications can be very serious, and it is increasingly common.[58]

Aside from the emotional and financial burden of addiction, the are additional consequences to the opioid epidemic. The National Institutes for Health (NIH) reports that 2.7–3.9 million people are living with Hepatitis-C Virus (HCV) in the United States.[59] NIH also expects untreated HCV to rise to over 1 million people in the next 40-50 years. [citation] Injection drug users (IDUs) are at high risk for contracting HBV and HCV from shared needles and other drug preparation equipment, which exposes them to bodily fluids from other infected people....IDUs with hepatitis often suffer from several other health conditions at the same time, including mental illness and HIV/AIDS thus requiring care from multiple healthcare providers. {Also see Hep-C information.}[60]


However, there are two new safer, direct-acting antiviral (DAA) medications available (bociprevir and telaprevir), which are administered by injection with pegylated interferon. This new treatment lasts between 12-48 weeks depending on the individual and cures HCV infection, unlike treatment for HIV which lasts a lifetime and does not rid the body of HIV.[61]

Prescription Drug Misuse and Abuse - SAMHSA addresses prescription drug misuse and abuse using a public health approach that includes early intervention, prevention, treatment, and recovery support services. [62]

Populations At Risk

Youth
  • Many young people have the misconception that prescription drugs are safer because they come from the pharmacy. [63]
  • Many teens who start with pills are quickly progressing to heroin because of its easier availability, lower cost, and higher purity. [64]
  • Nearly one in twenty high school seniors has taken Vicodin and one in thirty has abused OxyContin, according to the National Institute on Drug Abuse Monitoring the Future study.[65]
  • In 2014, approximately 467,000 adolescents were using prescription painkillers non-medically, and 168,000 were addicted to prescription pain relievers.[66]
  • In 2014, an estimated 28,000 adolescents reported using heroin in the past year, and an estimated 16,000 were current heroin users.[67]
  • In 2014, an estimated 18,000 adolescents had a heroin use disorder[68]
  • The prescribing rates for prescription opioids among adolescents and young adults nearly doubled from 1994 to 2007.[69]
  • The estimated number of emergency department visits involving the non-medical use of prescription painkillers more than doubled between 2004 and 2008 for patients younger than 21 years. [70]
  • In 2014 there were about one and a half times more deaths from drug overdose than from car crashes, and 61 percent of those overdose deaths involved opioids. [71]
  • People who use opioids non-medically before the age of eighteen are more likely to develop prescription opioid addiction than those who start later in life. [72]
Prescription Drug Users; Mental Health & Drug Use; Pregnant Women
  • Rise in opioid prescriptions to pregnant women for discomfort and back pain.
  • 28% of pregnant women enrolled in Medicaid were prescribed an opioid in 2007, up from 18.5% in 2000. While 14% of privately insured women were prescribed opioids.[73] [find original study/source]
  • Long-term risks are not understood.
  • Research shows a link between first-trimester use and malformations of the spine and brain in the developing fetus. [74]
  • Prolonged use can lead to addiction in both the mother and infant, causing birth defects or neonatal abstinence syndrome (NAS). [75]
  • Symptoms of NAS include tremors, convulsions, high-pitched cry, sweating, and fever. [76]
  • Weaning newborns off of opioids is incredibly expensive and carries additional health risks.[77]
  • With about half of pregnancies unplanned, women who misuse opioids and become pregnant are at great risks. [78]
The people most at risk for heroin addiction include whites, males, 18- to 25-year-olds, people making less than $20,000 a year, Medicaid recipients and the uninsured, the CDC report found.[79] However, the biggest increases in heroin use in recent years were found in groups that typically aren't expected to go near the drug, including women, people with private insurance and higher-income individuals, the report said. [80]

This expansion of heroin abuse can be largely chalked up to an earlier wave of prescription opioid drug abuse -- including such drugs as Vicodin, OxyContin and Percocet -- and government efforts to counter that trend, said Brad Lander, an addiction medicine specialist at the Ohio State University Wexner Medical Center.[81]

The CDC's new report bears this out. About 45 percent of people who used heroin also were addicted to prescription narcotics from 2011 to 2013, researchers found. That's more than double the rate from 2002 to 2004, the report revealed.[82]
According to the Coalition Against Insurance Fraud, prescription drug misuse, abuse and fraud cost private health insurers almost $25 billion a year.[83]

A 2009 study by the U.S. Government Accountability Office found fraudulent or abusive purchases of controlled substances in Medicaid programs in California, Illinois, New York, North Carolina and Texas, which cost $63 million in Medicaid payments, not including fees for office visits.[84]

Indiana Governor Mike Pence announced a health disaster of HIV caused by opioid misuse and injecting heroin. Between January and April of 2015 135 people contracted HIV (vs. 5 per year historically). They responded with a needle exchange and other wholistic steps. [85]

This article on the role of drug company influence of the FDA and various research reports puts a lot of the blame on them for creating this problem.
  • The American Geriatrics Society changed its guidelines in 2009 to recommend opioids in place of the cheaper and non-addictive pain drugs ibuprofen and naproxen. Half the experts on the panel who made the recommendations "had financial ties to opioid companies, as paid speakers, consultants or advisers at the time the guidelines were issued."[86]
  • The University of Wisconsin's Pain & Policy Studies Group took $2.5 million from opioid makers even as it pushed for looser use of narcotic painkillers.[87]
  • A pain guide called Finding Relief: Pain Management for Older Adults, endorsed by the American Geriatrics Society and funded by the drug company who makes the opioid products Duragesic, Ultram ER and Nucynta, claimed that opioids "allow people with chronic pain to get back to work, run, and play sports." In truth, study after study shows patients became less active on opioids and return to work is delayed. The guide defends the safety of long-term opioid use though studies show no value in long-term opioid use and serious harm. [88]
This report looks at studies of substance abuse in different populations over many years. One encouraging note is that misuse of prescription opioids by college students seems to be declining.[89]

Big Pharma is lobbying to fight state efforts to reduce opioid use. [90]

Carfentenil is creating huge problems in Ohio [91]

Canada is starting to prescribe heroin to addicts.[92]

Veterans
  • Veterans Face Greater Risks Amid Opioid Crisis[93]
    • About 60 percent of those returning from deployments in the Middle East, and 50 percent of older veterans suffer from chronic pain, according to Veterans Affairs officials. That’s compared to about 30 percent of Americans nationwide.
    • 68,000 - The number of veterans with opioid-use disorders. The figure represents about 13% of all veterans currently taking opioids.
  • Mitigating Risks of Long-Term Opioid Therapy in Veterans[94]
    • 56% incoming veterans from present conflicts have musculoskeletal pain
    • Similar to US civilian populations, opioid overdose deaths increased significantly among veterans from 2001 to 2009
    • Returning veterans have high rates of co-occurring pain and PTSD
    • VA and DoD are shifting current health care delivery, which is problem-based disease care, to one that provides patient-centered health care
  • VHA Pain Management[95] The VHA has created guidelines regarding Opioid Safety. The 2017 updated guideline is based on a systematic review of both the clinical and epidemiological evidence available as of December, 2016....The VHA recognizes the clinical challenges to successfully managing pain and prescribing safely for our Veterans while implementing the Opioid Safety Initiative (OSI) Directive and the Informed Consent Directive. The National Pain Management Program office convened a national task force comprised of multidisciplinary pain exerts to create an OSI Toolkit (evidence-based to the extent possible) to help guide the field....The Opioid Therapy Risk Report (OTRR) is a patient-focused, actionable and provider-specific report that is available to Primary Care Providers (PCP), Primary Care Managers, PAC Teams, Clinical Pharmacists and others who need to identify patients receiving long-term Opioid Therapy (OT).
Small Cities & Rural Populations
  • Small Cities Struggle to Battle the Rise in Heroin Abuse - Tod Newcombe (Governing columnist)[96]
    • According to the Substance Abuse & Mental Health Services Administration, the number of new heroin users jumped by 80% between 2008 to 2012
    • Small cities suffering from economic decline are fearful of the latest increase in usage due to their limited resources to combat the problem
    • Heroin users find it debilitating making it more difficult to hold down jobs, thus driving up crime and disorder, according to John Roman, senior fellow with Justice Policy Center at the Urban Institute
    • A small city- Taunton, Mass saw 64 overdoses and 5 deaths in less than 2 months in 2012
    • Newburgh, NY, population 30,000 has been over-run with gangs operating drug markets
    • Several police departments have begun to carry the antidote to heroin overdoses, naloxone- Ocean County, NJ & Massachusetts
    • Studies show that students in Michigan are "scared of [heroin]" and less than 1% have claimed to try it, so there is hope in focusing on anti-drug education

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