INSTANCES OF ADDICTION, OVERDOSE, and opioid use disorder (OUD) have escalated to a public health and socioeconomic crisis in recent years. OUD is a chronic illness involving the misuse or diverted use of prescribed or illegally obtained opioids and is characterized by relapse and increased morbidity and mortality (see Quick facts).1 This article examines the prevalence and burden of OUD throughout US history and provides an update on current government initiatives related to addiction.
Opioids include natural and synthetic substances that interact with opioid neuroreceptors.1 These include opiates, such as morphine or codeine, which occur naturally; synthetic opioids, such as fentanyl, tramadol, and methadone; semisynthetics, such as oxycodone and hydrocodone; and the illegal morphine derivative, heroin.1 All opioid forms are highly addictive and can be misused, resulting in overdose or death. Tomorrow, millions of people will misuse opioids in the US and approximately 190 of those will die.2
The abuse of legal and illegal substances is not new, however, as sensory-altering drugs have existed for centuries. The first US drug abuse policy, the Harrison Narcotics Tax Act, was passed in 1914 as people began to recognize the dangers of opioids.3 A century and several failed drug policies later, the US is in the grip of an epidemic.
As the tragedy of addiction and overdose has erupted, publicity has followed suit. Communities and policy makers are scrambling to find solutions. On August 10, 2017, 2 weeks after the first report from the President's Commission on Combating Drug Addiction and the Opioid Crisis, President Trump declared a national emergency.4 To address the opioid crisis, it is critical to understand how it evolved and to implement urgent strategies to save lives.
Evolution of an epidemic: 1800s
Opium, an extract of the opium poppy, contains morphine and codeine.1 A liquid form, laudanum, was widely used by women in the 1800s for many health problems.1 Similarly, elixirs containing opium were often given to calm fussy and teething babies. The drug was poorly understood at the time, and many women and children died of overdoses.5,6 As recreational opium tents spread west with the railroad, many men were introduced to opioids as well.5,6
During the Civil War, when morphine was used to manage pain from injuries and surgery, many soldiers developed an addiction known as “soldier's disease.”5,6 In an effort to counter morphine addiction, heroin was introduced. Developed by boiling down morphine, the new drug was promoted as nonaddictive and excellent for treating both addiction and medical disorders such as tuberculosis and bronchitis.5 Heroin was approved for general use by the American Medical Association in 1906.5
Misconceptions about heroin quickly became evident. The Harrison Narcotics Tax Act made obtaining opiates or cocaine, a powerful stimulant drug, illegal unless prescribed by a physician, creating what are now known as prescription drugs.3,7 Prescribers and pharmacists had to register for a license and were taxed for every prescription. The law also limited opium manufacturing and imports.
In the face of widespread use, these limitations created black markets and drug-related crime and marked the beginning of criminal drug use. In 1924, Congress passed the Anti-Heroin Act, which prohibited the import of opium and the use of heroin entirely.8,9
1930s to the 1950s
Between the Great Depression and World War II, drug abuse faded into the collective memories of both policy makers and the general public. Those with addictions were viewed as poor, uneducated miscreants and criminals. For healthcare professionals, however, the problem was not forgotten. Patients continued to seek help, but many were afraid of the social stigma and potential criminal liability associated with opioid use.8
In response, medically acceptable alternatives, such as amphetamines and barbiturates, were introduced, produced, and promoted.8 The addictive qualities of these drugs soon became evident, however, prompting policy makers to take new regulatory action. As amphetamines and barbiturates had legitimate medical uses and misuse seemed to be confined to White, middle- and upper-class citizens, lawmakers took limited action.8 Nonmedical use had no criminal consequences, and no restraints were placed on drug manufacturers, prescribing physicians, or consumers possessing opioids.3 Both medical and nonmedical usage soared, and these drug markets quietly grew and spread across America.3
1960s to the 1990s
Along with increased use of prescription drugs, the sixties counter-culture brought a resurgence in illegal opioid use.6 In 1970, Congress passed the Controlled Substances Act (CSA) Title II of the Comprehensive Drug Abuse Prevention and Control Act, which focused on drug enforcement efforts under the Drug Enforcement Agency (DEA) and established controlled substance scheduling.3
The CSA was followed by the Drug Abuse Office and Active Treatment Act (DATA) that defined drug abuse as an illness and placed emphasis on prevention and treatment initiatives.7,10,11 Additionally, DATA launched several agencies to combat the growing problem, including the National Advisory Council on Drug Abuse, the National Institute of Mental Health, and the National Institute on Drug Abuse (NIDA).7 Due to growing public concern, President Nixon declared drug addiction to be “public enemy number one,” and the “War on Drugs” began.12 Government and law enforcement efforts to enforce drug trafficking, distribution, and use laws intensified, and the nation saw a brief decrease in drug use and abuse.3
Progress following the passage of DATA was short-lived. Failure to differentiate between OUD and trafficking resulted in the increased criminalization of drug use and led to incarceration rather than treatment. Meanwhile, the development of new sedatives, stimulants, and analgesics continued.
Coinciding with increased pressure on the medical community for better pain management, OxyContin, a sustained released version of oxycodone, was released in 1996 and promoted as less addictive.3,6,13 OxyContin became the most prescribed and abused opioid in the US 2 years after its debut.14 Annual prescriptions rose from 670,000 to 6.2 million in 5 years.13
Cause and effect: the 2000s and beyond
Addiction rates and OUD-related morbidities have skyrocketed in the last 2 decades:14
- Opioid prescriptions increased 400%.
- Addiction treatment admissions grew 600%.
- Deaths from prescribed painkiller overdoses doubled.
- Deaths from heroin overdoses quadrupled.
Drug overdoses have surpassed motor vehicle crashes as the leading cause of accidental death in the US.14 The overprescription of opioids combined with the social stigma of addiction and limited access to substance abuse treatment have resulted in a national crisis.14-17
Overprescribing and prescription monitoring
The medical community has long recognized an ethical obligation to treat pain. Regulatory agencies, such as the Centers for Medicare and Medicaid Services (CMS) and The Joint Commission, have focused on pain assessment and management to improve patient care since the early 2000s. Known as the fifth vital sign, pain has become tied to the patient experience.6,18
Many patients equate pain treatment with opioids, resulting in increased pressure on providers to prescribe them (see Annual volume of opioids sold in the US). In 2012, more than 259 million opioid prescriptions were written in the US.15 The DEA estimates that 13% of all US prescriptions are for controlled substances.19
Research shows the prevalence of addiction in patients using opioids for chronic noncancer pain may be as high as 43% in certain subpopulations, but this figure is generally accepted to be 3% to 16% in the overall population.13,20 Current research reported by NIDA found 9.7% of those using opioids for chronic pain have mild OUD, 28.1% have moderate OUD, and 3.5 % have severe OUD.21 By 2010, regulatory efforts to reduce inappropriate and fraudulent prescribing intensified, and prescriptions began to grow scarce.20,22 This may have had a preventive effect, but the sudden scarcity also created panic. Many with OUD began obtaining prescriptions from other providers and EDs or diverted opioids from family and friends.19
Prescription monitoring programs (PMPs) overseen by the DEA were created as a prevention tool for states. Websites were used to monitor patients' recent prescriptions in an effort to prevent the prescription of opioids that had already been prescribed.20 As of 2011, however, studies found no evidence that PMPs had decreased opioid consumption or overdose rates, and, by 2014, research demonstrated an 11% increase in overdose rates associated with PMPs.20 Unable to obtain opioids from healthcare providers or shop for physicians due to PMPs, patients turned to illicit markets.15,19 Buying prescription opioids on the street is very expensive, however, which caused many to turn to heroin.15 According to NIDA, about 80% of heroin users first misused prescription opioids.2
Social stigma and treatment access
Substance abuse is recognized by the scientific community as a physical and mental health disorder, but those recovering from addiction still face public scorn. People with substance abuse disorders often report feeling alone and misunderstood, leading to emotional distress, guilt, and depression. Relief from these emotions becomes almost as necessary as relief from pain or withdrawal symptoms, causing many to self-medicate and perpetuate the cycle.16
Stigmatizing patients with a history of substance abuse is also common among healthcare professionals, including nurses, and may lead to poor communication, diminished rehabilitation, and inadequate therapeutic outcomes. A lack of knowledge, education, and training regarding addiction etiology and treatment propagates this stigma.17
Despite evidence supporting the effectiveness of each service, the availability of acute inpatient treatments, medication-assisted treatments (MATs), and long-term intensive outpatient treatments is deficient. Limited treatment centers, high insurance denials, and laws that inhibit providers from obtaining prescriptive authority for opioid agonists such as methadone and buprenorphine present roadblocks to treatment.23
In 2008, the Mental Health Parity and Addiction Equity Act mandated equality in substance abuse therapies related to medical-surgical treatment.24,25 The Affordable Care Act (ACA) placed further requirements on insurers, but evidence of enforcement remains unseen and significant obstacles persist in treatment access.25 In the US, just 11% of those seeking substance abuse treatment gained access as of 2013.23
Response and solutions
President Trump established the President's Commission on Combating Drug Addiction and the Opioid Crisis with an executive order on March 29, 2017. Operating under the Office of National Drug Control Policy the commission examines “the scope and efficacy of the Federal response to the crisis and recommend[s] future actions by focusing on current funding, treatment accessibility and availability of overdose reversal agents, evidence-based practice prevention, educational resources, and evaluation of current Federal programs.”26
The Substance Abuse and Mental Health Services Administration (SAMHSA), along with the National Institutes of Health (NIH) and NIDA, revealed their top five priorities at the National Rx Drug Abuse and Heroin Summit in April 2017:2
- improving access to treatment and recovery services
- promoting use of overdose reversal agents
- utilizing epidemiologic surveillance
- supporting pain and addiction research
- improving pain management practices.
Treatment and recovery
Addiction treatment is essential for those with OUD, and recovery is considered a lifelong process. When combined, detoxification and treatment of physiologic withdrawal followed by MATs and addiction therapy offer the best chance of relapse prevention.27 Additionally, fear of withdrawal symptoms often inhibits those with OUD from seeking treatment. In May 2018, the FDA approved the first nonopioid medication “for the mitigation of withdrawal symptoms to facilitate abrupt discontinuation of opioids in adults.”27
The Mental Health and Parity and Addiction Equity Act holds insurers accountable for excessive coverage denials for acute inpatient treatments and requires coverage of proven MATs, such as methadone and buprenorphine.23 These opioid agonists bind to opioid receptors in the brain without the effects of opioids.2 Without MATs, a substance abuse relapse following detoxification and treatment is likely, along with an increased risk of overdose.2
Even when treatment options are available, recovery may be hampered by judgmental attitudes among healthcare providers. Improved education and training initiatives for nurses and other healthcare professionals could change attitudes about addiction. Reducing bias and stigma could improve therapeutic relationships between healthcare providers and patients with a history of substance abuse.17
The opioid antagonist naloxone treats opioid overdose by displacing opioids from opioid receptors in the brain, effectively reversing respiratory depression and hypoxemia.28 Increasing the availability of naloxone where it is most needed is a primary goal of the President's Commission, NIDA, and SAMHSA. Two bills have been introduced in Congress: the Opioid Crisis Response Act and the Opioid Abuse Prevention and Treatment Act.29 If passed, each would require the FDA to reclassify naloxone as an over-the-counter drug.29
Similarly, state legislatures and communities across the US are working to pass laws and create policies to make naloxone more readily available to first responders. Paramedics carry and administer naloxone, but they are not always the first on the scene in overdoses.28 As of 2014, 24 states had modified policies allowing EMTs and law enforcement officers to carry and administer naloxone.30 Additionally, Rhode Island became the first state to allow pharmacists to dispense the drug with instructions for use to laypeople who may encounter an overdose victim.31
By July 2017, legislation had been passed in all 50 states to improve naloxone access and availability. The legislation aims to provide “civil, criminal, and disciplinary immunity for medical professionals who prescribe or dispense naloxone, as well as laypeople who administer it.”30 As of December 31, 2018, 46 states have Good Samaritan laws in place to protect overdose victims and those who seek to help them from arrest and prosecution.30
Future directions in research
The CDC uses specific methodologies in responding to public health emergencies, and strategies associated with infectious disease outbreaks should be employed to target geographically specific responses.28,32,33 Current mandatory reporting regulations do not include substance abuse and overdose, however, and do not support the level of comprehensive data collection required for public health surveillance. A 2015 article in the American Journal of Public Health suggested legislative and regulatory changes to allow public health professionals access to substance abuse, overdose prevalence, and PMP data to launch an effective public health response to the opioid epidemic.28
NIH is pushing for increased research on pain management, overdose reversal, and addiction treatment. For example, the use of calcium channel blockers, neurostimulation, gene therapy, and transcranial magnetic stimulation may lead to new pain relief options.34,35 Additionally, although naloxone is effective for overdose reversal, it is not always readily available, has a short half-life, and sometimes requires multiple doses. Similarly, it is not always effective at normal doses in reversing “overdoses due to highly potent synthetic opioids such as fentanyl.”36 Research into other opioid receptor antagonists and serotonin receptor targets may yield alternative reversal agents.34
NIDA has been tasked with accelerating, promoting, and funding research efforts to combat the opioid epidemic.2,8,34 Recent neurobiology research has identified new receptors and opioid agonists that may help those in which methadone or buprenorphine have been ineffective.34 Early research shows promise in opioid immunity through vaccines, and modifying neurocircuits in the brain may alter addictive tendencies as well.34
Urgent need for action
Having evolved and escalated for more than a century, OUD affects millions of people and causes tens of thousands of overdose deaths every year in the US. National expenditures for medical and mental health treatment are projected to reach hundreds of billions by the end of the decade, and the epidemic shows no signs of abating.2,37 Its broad impact on communities across the country has created urgency for government officials to find a solution. As such, multiple government agencies, including NIH, NIDA, and SAMHSA, have aligned to combat the opioid crisis by focusing on treatment and recovery, overdose reversal, public health surveillance, research, and pain management.
Morbidity and mortality
As of 2016, 11.8 million people have misused opioids in the US.
- 11.5 million have misused prescription pain relievers.
- 948,000 have used heroin.
The CDC estimates that opioid overdoses are responsible for more than 67,000 deaths annually in the US.
The economic burden associated with the misuse of prescription opioids alone exceeds $78.5 billion annually, due to:
- lost productivity
- medical and addiction treatment
- criminal justice.
According to SAMHSA, mental health and substance abuse treatment expenditures totaled $171.7 billion in 2009. This is expected to reach $280.5 billion by 2020.