The opioid crisis continues to rob global communities of our family members, friends and patients. From 1999 to 2018, more than 760,000 Americans died from drug overdoses, the majority of which involved an opioid. These deaths disproportionately occur early in life, and the resulting potential years of life lost from opioid-related deaths now exceed those from hypertension, HIV/AIDS, and pneumonia. Among Americans aged 24 to 34, fully 1 in 5 deaths now involves an opioid.
The genesis of the crisis is complex and multifactorial, but a major contributor was the relaxation of attitudes regarding the prescribing of opioids for both acute and chronic pain. This practice took root in the mid-1990s when increased emphasis was placed on the treatment of pain in hospitalized patients, best exemplified by the campaign to recognize pain as the fifth vital sign.
These initiatives were financially driven by opioid manufacturers. From 1999 to 2012, the number of U.S. adults who received a prescription opioid increased by nearly 40%, while the percent of those who received an opioid more potent than morphine more than doubled, from 17% to 37%. The increased prescribing of opioids was accompanied by a more than threefold increase in the age-adjusted rate of drug overdose deaths, and a 67% increase in the diversion of medically prescribed opioids.
A key tenet of pharmacotherapeutics is the benefits of a drug should substantially exceed its harms. In the case of analgesics, pain relief and functional improvement must outweigh the risk of adverse drug events, including addiction and death. Clinical experience over the past two decades has shown that with chronic opioid therapy in particular, this goal is often unmet, underscoring the importance of more judicious prescribing, the use of non-opioid and non-pharmacologic therapies when appropriate, and the recognition and treatment of opioid use disorders.
Moreover, all opioid addictions begin with an opioid exposure. While most patients with acute or chronic pain will not ultimately have any signs of disordered use, their unused opioids represent a risk for their family and community. The non-medical use of prescription opioids (for example, the use of someone else’s medications) is a major pathway to heroin/fentanyl use disorder. Adolescents and young adults are particularly vulnerable to these non-medical opioid exposures, which often occur through the leftover medications.
The opioid crisis has changed considerably over the past decade. In 2010, heroin-related deaths began to increase dramatically. Deaths involving synthetic opioids began to increase sharply in 2013, reflecting contamination of the illicit supply chain with fentanyl and its analogues. Non-medical opioid use has never been more dangerous. Sold alone, in combination with heroin, or as counterfeit pills, non-pharmaceutical fentanyl and other high-potency opioids are responsible for the striking increase in deaths since 2013.
In the landscape of these high-potency opioids, urgent interventions are required to save lives. A landmark 2016 study followed 17,568 Massachusetts adults who survived an opioid overdose between 2012 and 2014. Within the following year, 807 of these adults died. In this study, people treated with methadone or buprenorphine were respectively 59% and 38% less likely to die of an opioid overdose than those who did not receive medication for opioid-use disorder. Yet, less than one-third of the patients in the study received any medication for their illness. Medications for opioid use disorder must be considered standard treatment, and barriers to prescribing (including stigma and access to trained prescribers) must be systematically removed.
The striking numbers of overdose deaths has increasingly led to calls for integration of traditional treatment options with other harm reduction strategies to prevent overdose deaths. Bystander naloxone distribution is a cost-effective approach to preventing overdose deaths while international communities have modeled supervised consumption facilities (or safe injection sites) to reverse overdoses and engage patients into treatment.
Dr. Kavita Babu is an attending physician in the UMass Memorial Department of Emergency Medicine, Division of Medical Toxicology. Jeffrey Brent and David N. Juurlink are her co-researchers from the University of Colorado and University of Toronto.
