Opioid Use, Addiction, and Treatment: A Complex Public Health Crisis

Posted: April 4th, 2019

Opioid Use, Addiction, and Treatment: A Complex Public Health Crisis
Introduction
Opioid misuse and addiction have become a devastating public health crisis in many countries worldwide. Commonly prescribed opioid pain relievers such as oxycodone, hydrocodone, and fentanyl play an important medical role but also carry significant risks of dependence and overdose when misused or abused (National Institute on Drug Abuse, 2022). Heroin, an illegal opioid, is also widely abused and can lead to fatal overdoses. As a society, we must thoughtfully consider how to balance effective pain treatment with preventing diversion and harm from opioids. This requires understanding both the pharmacological properties and scheduling classifications of various opioids as well as the complex socioeconomic factors driving the crisis.
Opioid Pharmacology and Scheduling
Opioids work by binding to mu-opioid receptors in the brain, spinal cord, and other organs to reduce the perception of and response to pain (National Institute on Drug Abuse, 2022). However, prolonged use can also trigger euphoria and dependence by activating the brain’s reward system. In the United States, the Controlled Substances Act of 1970 classifies drugs into five schedules based on their accepted medical use and abuse or dependence potential (Drug Enforcement Administration, 2022).
Schedule I drugs like heroin have no accepted medical use and a high potential for abuse. Schedule II-V drugs are legally prescribed but carry increasing abuse and dependence risks the lower the schedule. For example, oxycodone (OxyContin) and hydrocodone (Vicodin) are Schedule II opioids as they are effective pain relievers but also highly addictive. Fentanyl is also Schedule II but can be diverted for illicit use and is up to 100 times more potent than morphine, increasing overdose risk (National Institute on Drug Abuse, 2022). Tighter controls on prescribing practices for Schedule II drugs could help curb diversion while still allowing access for pain patients.
Opioid Overdose and Reversal with Naloxone
Prolonged opioid use leads to tolerance, meaning higher doses are needed over time for the same pain-relieving effects. Combined with waning inhibition and respiratory depression, this sets the stage for overdose, which was a leading cause of injury death in the United States even before the current crisis (National Institute on Drug Abuse, 2022). Naloxone (Narcan) is a life-saving opioid antagonist medication that can reverse overdose by displacing opioids from receptor sites in the brain (National Institute on Drug Abuse, 2022).
While historically only carried by emergency responders, many states and localities now allow for layperson access and standing orders for pharmacists to dispense naloxone without an individual prescription (National Academies of Sciences, 2019). This “Naloxone for All” approach recognizes that bystanders are often first on the scene of an overdose. Expanding naloxone access through pharmacies, syringe exchanges, and community programs has proven effective for reducing overdose deaths (National Academies of Sciences, 2019).
Socioeconomic Drivers of the Opioid Crisis
Beyond just pharmacological properties, socioeconomic factors must also be addressed to curb the opioid crisis. Areas experiencing economic hardship or lack of opportunity have been disproportionately impacted (Kolodny et al., 2015). Mental health issues like depression commonly co-occur with substance use disorders as well (National Academies of Sciences, 2019). Widespread marketing of opioids for pain conditions in the 1990s-2000s also normalized their use (Kolodny et al., 2015).
Over-prescribing by some physicians contributed to non-medical use, especially when guidelines around dosage and duration were ignored (Kolodny et al., 2015). The affordable Care Act’s expansion of insurance helped increase access to evidence-based treatment for opioid use disorder, though capacity remains limited in many areas (Saloner et al., 2018). The crisis further exacerbated existing social inequities and underscores the need for comprehensive, culturally-sensitive solutions.
Evidence-Based Treatment Approaches
Beyond emergency overdose reversal, medication-assisted treatment (MAT) using methadone, buprenorphine or naltrexone is the gold standard for opioid use disorder according to all major medical authorities (National Academies of Sciences, 2019). MAT normalizes brain chemistry, reduces cravings, and is associated with lower rates of criminal behavior, overdose, and relapse compared to abstinence-only models.
However, due to stigma and lack of providers with necessary waivers, access to MAT remains limited in many areas (National Academies of Sciences, 2019). Harm reduction services like syringe exchanges and safe consumption sites can also help curb disease transmission and overdose without requiring abstinence (National Academies of Sciences, 2019). The goal should be meeting people “where they are” with compassion and a spectrum of voluntary, evidence-based options.
Conclusion
In summary, the opioid crisis is complex with no single cause or simple solution. A comprehensive, multi-pronged public health approach is needed that addresses both supply and demand factors. This includes optimizing pain treatment while preventing diversion, expanding overdose reversal access, increasing MAT availability through healthcare reform, and implementing comprehensive harm reduction services. It will also require addressing root socioeconomic drivers through measures like job training, treatment of co-occurring mental health issues, and equitable access to care. With sustained commitment and evidence-based solutions, communities can curb overdose deaths and help more individuals recover from opioid use disorder.