Background on Opioid and Heroin Epidemic

A Training Resource

Prologue

Prescription drugs are essential to improving the quality of life for millions of Americans living with acute or chronic pain. However, misuse, abuse, addiction, and overdose of these products, especially opioids, have become serious public health problems in the United States. A comprehensive response to this crisis must focus on preventing new cases of opioid addiction, identifying early opioid-addicted individuals, and ensuring access to effective opioid addiction treatment while safely meeting the needs of patients experiencing pain.

Prescription drug abuse and overdose is a serious public health problem in the United States. Drug overdose death rates in the U.S. increased five-fold between 1980 and 2008, making drug overdose the leading cause of injury death.3 In 2013, opioid analgesics were involved in 16,235 deaths — far exceeding deaths from any other drug or drug class, licit or illicit. According to the National Survey on Drug Use and Health (NSDUH), in 2012 an estimated 2.1 million Americans were addicted to opioid pain relievers and 467,000 were addicted to heroin. These estimates do not include an additional 2.5 million or more pain patients who may be suffering from an opioid use disorder because the NSDUH excludes individuals receiving legitimate opioid

prescriptions.

A public health response to this crisis must focus on preventing new cases of opioid addiction, early identification of opioid addicted individuals, and ensuring access to effective opioid addiction treatment, while at the same time continuing to safely meet the needs of patients experiencing pain. It is widely recognized that a multi-pronged approach is needed to address the prescription opioid epidemic. A successful response to this problem will target the points along the spectrum of prescription drug production, distribution, prescribing, dispensing, use and treatment that can contribute to abuse; and offer opportunities to intervene for the purpose of preventing and treating misuse, abuse and overdose.

(Johns Hopkins School of Public Health (2015) The Prescription Opioid Epidemic: An Evidence-Based Approach)

The Neurobiology of Substance Use, Misuse, and Addiction

Substance use disorders result from changes in the brain that can occur with repeated use of alcohol or drugs. The most severe expression of the disorder, addiction, is associated with changes in the function of brain circuits involved in pleasure (the reward system), learning, stress, decision making, and self-control.

Every substance has slightly different effects on the brain, but all addictive drugs, including alcohol, opioids, and cocaine, produce a pleasurable surge of the neurotransmitter dopamine in a region of the brain called the basal ganglia; neurotransmitters are chemicals that transmit messages between nerve cells. This area is responsible for controlling reward and our ability to learn based on rewards. As substance use increases, these circuits adapt. They scale back their sensitivity to dopamine, leading to a reduction in a substance’s ability to produce euphoria or the “high” that comes from using it. This is known as tolerance, and it reflects the way that the brain maintains balance and adjusts to a “new normal”—the frequent presence of the substance. However, as a result, users often increase the amount of the substance they take so that they can reach the level of high they are used to. These same circuits control our ability to take pleasure from ordinary rewards like food, sex, and social interaction, and when they are disrupted by substance use, the rest of life can feel less and less enjoyable to the user when they are not using the substance.

Repeated use of a substance “trains” the brain to associate the rewarding high with other cues in the person’s life, such as friends they drink or do drugs with, places where they use substances, and paraphernalia that accompany substance-taking. As these cues become increasingly associated with the substance, the person may find it more and more difficult not to think about using, because so many things in life are reminders of the substance.

Changes to two other brain areas, the extended amygdala and the prefrontal cortex, help explain why stopping use can be so difficult for someone with a severe substance use disorder. The extended amygdala controls our responses to stress. If dopamine bursts in the reward circuitry in the basal ganglia are like a carrot that lures the brain toward rewards, bursts of stress neurotransmitters in the extended amygdala are like a painful stick that pushes the brain to escape unpleasant situations. Together, they control the spontaneous drives to seek pleasure and avoid pain and compel a person to action. In substance use disorders, however, the balance between these drives shifts over time. Increasingly, people feel emotional or physical distress whenever they are not taking the substance. This distress, known as withdrawal, can become hard to bear, motivating users to escape it at all costs. As a substance use disorder deepens in intensity, substance use is the only thing that produces relief from the bad feelings associated with withdrawal. And like a vicious cycle, relief is purchased at the cost of a deepening disorder and increased distress when not using. The person no longer takes the substance to “get high” but instead to avoid feeling low. Other priorities, including job, family, and hobbies that once produced pleasure have trouble competing with this cycle.

Healthy adults are usually able to control their impulses when necessary, because these impulses are balanced by the judgment and decision-making circuits of the prefrontal cortex. Unfortunately, these prefrontal circuits are also disrupted in substance use disorders. The result is a reduced ability to control the powerful impulses toward alcohol or drug use despite awareness that stopping is in the person’s best long-term interest.

This explains why substance use disorders are said to involve compromised self-control. It is not a complete loss of autonomy—addicted individuals are still accountable for their actions—but they are much less able to override the powerful drive to seek relief from withdrawal provided by alcohol or drugs. At every turn, people with addictions who try to quit find their resolve challenged. Even if they can resist drug or alcohol use for a while, at some point the constant craving triggered by the many cues in their life may erode their resolve, resulting in a return to substance use, or relapse.

(HHS Office of the Surgeon General (2016). Facing Addiction in America: The Surgeon General’s Report on Alcohol, Drugs, and Health)

Epidemic Defined

The CDC's official definition of an epidemic is: "The occurrence of more cases of disease than expected in a given area or among a specific group of people over a particular period of time.”

Since 1999 the rate of overdose deaths involving opioids including both prescription pain medication and heroin nearly quadrupled

Heroin use has increased across the US among men and women, most age groups, and all income levels

Factors Driving the Epidemic

Interrelated factors

• Wider availability of prescription opioids
• 1999-2013 the amount of prescription opioids dispensed in the US nearly quadrupled
• Increasing non-medical use and overdose
• Changing economics and supply of heroin
• Cheaper, available, higher purity, synthetics
• Increasing heroin use and overdose
• Lack of access to treatment
• 80% with SUD are not in treatment

Epidemic by the numbers

On an average day:

• 650,000 opioid prescriptions dispensed
• 3,900 people initiate nonmedical use of prescription opioids
• 580 people initiate heroin use
• 91 people die from an opioid related overdose

Heroin Deaths in the USA in 2015

Re-emergence of Fentanyl

• Schedule II synthetic opioid analgesic
• Up to 50-100x more potent than morphine and 30-50x than heroin
• Mixed with adulterants and sold as “synthetic heroin”
• 2015 death rate from synthetic opioids increased 72.2%
• Comes from several sources
  • Diverted from legal medical use
  • Clandestine – manufactured in Mexico or China

Synthetic Opioid Deaths in 2015

Risk Groups for Prescription Opioid Misuse

• Men ages 25-54
• White and American Indian/Alaska Natives
• People in rural areas, especially in the Appalachian region
• People who obtain multiple controlled substance prescriptions from multiple providers
• Teens and young adults (One in four teens has misused or abused a prescription drug at least once in their lifetime)
• People who take high daily dosages of opioid pain relievers (veterans with injuries, those with occupational injuries)
• Increasingly women and older adults over 65

Risk groups for Heroin Addiction

• People who are addicted to prescription opioid painkillers are at most risk for addiction to heroin
• People who are addicted to cocaine
• People without insurance or enrolled in Medicaid
• Non-Hispanic whites
• Males
• People living in large metropolitan areas, particularly in the Northeast and Midwest

The relationship between Heroin and Prescription Opioids

• Both prescription opioids and heroin are chemically related and just as addictive
• Act on nerve cells in the brain and nervous system the same way – pleasurable effects and relieve pain
• People who are addicted to prescription opioid painkillers are at high risk for addiction to heroin 19x more likely to use
• Injecting drug use (IDU) increases the risk of serious, long-term viral infections such as HIV, Hepatitis B and C
• 11% of new HIV infections are from Injecting Drug Use (IDU)
• 50% of new Hepatitis C infections are from Injecting Drug Use (IDU)
• 114% increase in Emergency Room and Doctor visits
• Neo-natal abstinence syndrome
• Increase in fractures in older adults due to falls
• Significant co-occurring Myocardial Infarction (health attacks) with SUD
• Anxiety, mood disorders, depression

The Hepatitis Infection Epidemic

• 150% increase in new infections 2010-2013
• Almost 50% of new cases associated with injection drug use
• Occurring in young people (<30), in rural and suburban areas
• Use of oral prescription opioids before transitioning to injecting

• HCV Current
• Online and in-person curriculum and training
• Downloadable provider tools

How a Florida Community is Facing this Crisis 

Read about how Sarasota created a Coalition in it's community to address this epidemic and how their efforts are working. Read article on the SAMSHA website at: https://captcollaboration.edc.org/story/florida-coalition-forges-strong-partnerships-reduce-opioid-misuse

Strategies for Addressing this Epidemic

A. Evidence Based

Some evidence-based interventions exist to inform action to address this public health emergency; these should be scaled up and widely disseminated. Furthermore, many promising ideas are evidence-informed, but have not yet been rigorously evaluated. The urgent need for action requires that we rapidly implement and carefully evaluate these promising policies and programs. The search for new, innovative solutions also needs to be supported.

• Supported by research and/or promising practices
• Understanding that SUD’s are a brain disease that can be treated

B. Cross System

The desired goal is developing approaches that intervene all along the supply chain, and in the clinic, community and addiction treatment settings. Interventions aimed at stopping individuals from progressing down a pathway that will lead to misuse, abuse, addiction and overdose are needed. Effective primary, secondary and tertiary prevention strategies are vital. The importance of creating synergies across different interventions to maximize available resources is also critical.

• Legal, health, government, private/public, education, research/science, law enforcement, first responders, all personal need to be engaged.

C. Comprehensive

Used appropriately, prescription opioids can provide relief to patients. However, these therapies are often being prescribed in quantities and for conditions that are excessive, and in many cases, beyond the evidence base. Such practices, and the lack of attention to safe use, storage and disposal of these drugs, contribute to the misuse, abuse, addiction and overdose increases that have occurred over the past decade. What is needed are efforts to maximize the favorable risk/benefit balance of prescription

opioids by optimizing their use in circumstances supported by best clinical practice guidelines.

• Address the combined and interrelated epidemics
• Prevention, intervention, and treatment

Evidence informed Public Policy

• Maximize use of Prescription Drug Monitoring Programs (PDMP’s) Using Prescription Drug Monitoring Program Data to Support Prevention Planning
• Payment policies that expand access/linkage to treatment/medications
• Prescriber education requirement
• Opioid prescribing guidelines: Preventing Prescription Drug Misuse: Overview of Factors and Strategies 
• Review data and practices of Medicaid, workers comp programs, benefit managers
• Syringe services programs: HIV and Injection Drug Use Syringe Services Programs for HIV Prevention
• Good Samaritan laws
• Increase access to and training on use of Naloxone (Narcan)
• Physical exam requirement prior to prescription
• ID requirement prior to dispensing controlled substances
• Laws to eliminate pill mills (State of Florida Legislature Initiative)
• PSA’s
• Governor led task forces: National Governors' Association's Finding Solutions to the Prescription Opioid and Heroin Crisis: A Road Map for States