THE OPIOID EPIDEMIC

Opioid addiction is not new and the rise in use and abuse is probably not a big surprise to people working in healthcare. Opioids have been around for a long time, are a mainstay of acute and chronic pain treatment, and also have been included in the fast mover section of retail pharmacies for as long as I can remember (which means that they are one of the most frequently dispensed medications in the pharmacy). According to the CDC, nearly two million Americans abused or were dependent on opioids in 2014. The CDC also states that as many as 1 in 4 people who use opioid painkillers get addicted.

Opiods (morphine, heroin, methadone, oxycodone, hydrocodone, oxymorphone, codeine, etc...) work by binding to receptors in the brain - the major ones being the mu, delta, and kappa receptors. The response produced by this binding is pain relief, slower breathing, and an overall calming, anti-depressant effect.

Though opioid abuse is not a new phenomenon, overdose from opioids is on the rise. Drug overdose is the leading cause of accidental death in the U.S. with over 50,000 deaths in 2015. Of those deaths, over a third was from overdose with prescription pain relievers. And according to a national prescription audit, around 650,000 opioid prescriptions were dispensed every day! Clearly, opioids are a frequently used and prescribed drug.

I've read so many articles speculating on "what caused the opioid epidemic" and "what's the root cause?". They cite overprescribing by doctors, a growing population of people with pain, and marketing by big pharma. Though these high prescription numbers seem alarming, most of the medications are being prescribed and dispensed to people who are in severe chronic or acute pain. These causes may or may not contribute but the bottom line is that the problem is multifactorial and will need many approaches to be successful. This is not a "one size fits all" problem. 

In medicine, we are taught to treat the underlying condition rather than the symptoms; many times pain is caused by an acute event such as a broken bone or dental procedure. The body heals and usually the pain goes away. But, sometimes pain is chronic - neurological, idiopathic, cancer.... and the underlying condition is much harder to identify let alone treat. Mental health sometimes comes into play as well and public health resources for mental health are usually low.

What makes pain difficult to treat is the subjectivity and nature of it. Everyone experiences, expresses, and rates it differently.
From what I've experienced, I do think providers and legislators are being thoughtful in their approach. Passing of new legislation, having registries, and making naloxone available are all good steps towards getting it under control.

Let's go over a few things about opioid addiction:

First, what do we mean by addiction?
Misuse means that you aren't following a doctor's instructions when taking the medicine; or you are acquiring it (without a prescription) by different means.

When you abuse a drug, the pleasurable affect of the drug makes your body body want to keep using it.

Addiction affects your brain and behavior. You are addicted if your brain and body can no longer function without the narcotic/opioid.

What does it mean to be physically dependent?
To be physically dependent means that someone has developed a tolerance to a drug to the point that they would develop withdrawal symptoms if the substance is discontinued abruptly. Tolerance means that you need to take more of the drug to get the same effect.

How do I recognize an opioid overdosage?
An opioid overdose (to heroin, morphine, methadone, oxycodone, fentanyl, hydrocodone, codeine, etc...) is usually characterized by respiratory depression (very slow breathing), a depressed level of consciousness or unresponsive as, and pinpoint (small) pupils.

If you know or suspect that someone is suffering from an overdosage, call 911 immediately. EMS personnel carry reversal agents that can quickly save a life if administered in time.

What is naloxone?
Naloxone is and complete or partial opioid antagonist which means that it competes for opioid receptors sites in the central nervous system. By blocking the opioid from the binding site, naloxone is able to stop or reverse the effects.

When given IV, the effects will work within two minutes. It is also able to be given in the muscle (five minutes) or the nasal spray (depending on the dosage form you have).

Naloxone lasts between 30 minutes - 1 hour so you may may need multiple doses especially since many opioids are in your system longer than an hour.

hrough grants, access to naloxone has continued to expand to high-need and rural areas and in 2015 an intranasal formulation was approved.

In many states, naloxone is available in the pharmacy without a prescription. This opioid reversal agent can be life-saving if administered in time.

What is being done to stop the opioid epidemic?
Restricting prescription pain relievers is very hard. Many people legitimately needs these drugs and shouldn't have to jump through hoops to manage their cancer pain, etc.... But the rise of overdoses and abuse has spurred the need to have many restrictions in place. Is it helping? With state-wide tracking systems, I do think it makes it harder for people to doctor shop and jump from ER to ER. Are the numbers of overdoses going down? Not yet, 2017 is predicted to have the highest numbers yet. But, awareness and education is spreading.

The recently passed 21st Century Cures Act had money allocated fight opioid addiction. Education to healthcare providers on proper medication selection and dosing as well as alternative therapies is also key.

In NC, a drug control bill is being worked on that puts restrictions on medical providers who prescribe and dispense opioids. Doctors and pharmacists would be required to participate in the state's controlled substance database system to evaluate a patient's prescription drug history and prevent overprescribing. They may also add a restriction limiting the days supply that can be prescribed for an acute pain medication. The bill also includes $20 million for local substance abuse treatment and recovery centers.

If you or someone you love is suffering from narcotic misuse or abuse, there are resources available. It is easy to feel alone and like you are the only one going through this. Many treatment centers and support groups are available. 


#pharmacy #pharmacist #pharmacology #opioids #theopioidepidemic #opioidaddiction #morphine #oxycodone #hydrocodone #21stcenturycuresact