Opioid Use Disorder

BRIEF HISTORY OF THE CURRENT OPIOID EPIDEMIC

Beginning in the early 1800s, opium and morphine use became widespread; opiate-containing “patent medicines” were heavily marketed for several medical conditions, especially toward women. Morphine prescribing peaked in 1890, and in 1898, Bayer started marketing heroin as a treatment for morphine addiction. In 1914, changes in domestic and international policy, spurred in part by the Opium Wars in China, led to the passage of the Harrison Act (discussed in Chapter 12). This act banned physicians from prescribing opioids for the treatment of opioid use disorder (OUD) and made any medicinal use of heroin illegal.

The current opioid epidemic is not the first in this nation’s history. The roots of the current opioid crisis began in the 1990s, when prescription opioid prescribing was greatly expanded along with pharmaceutical marketing of these agents as “minimally addictive.” Opioid prescribing reached a zenith in 2010 when there were an astounding 81 opioid prescriptions per 100 people. Other causal factors for the current opioid epidemic include declining economic opportunities and the rise in self-reported psychological distress. Because of the alarming rates of opioid-related overdoses, the United States declared a public health emergency because of the opioid epidemic in 2017.

One critical factor in the current opioid epidemic was the change in clinical practice toward the treatment of pain (see Chapter 11). Treatment of chronic pain became an important research focus, particularly pain caused by cancer. Several articles and small retrospective studies were widely circulated in support of the claim that treatment of chronic pain with opioids rarely led to the development of a substance use disorder. In 1995, the American Pain Society launched a campaign to standardize the treatment of pain symptoms and promoted pain as “the fifth vital sign.” The Federation of State Medical Boards, the Drug Enforcement Agency, and the Joint Commission also issued statements promoting pain assessments and analgesic treatment. Physicians were now pressured to provide aggressive pain control, as hospital administrations were under pressure to assess and treat pain to receive federal health care funds. Starting in 1996, OxyContin, an extended-release oxycodone, was heavily marketed by the pharmaceutical industry and its use for the treatment of noncancer chronic pain skyrocketed. The United States subsequently saw an extraordinary increase in the prescription and consumption of opioid medications.

EPIDEMIOLOGY OF OPIOID USE

Key facts to remember:

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  The rate of drug overdoses has increased more than threefold between 1999 and 2017 from 6.1 per 100,000 standard population to 21.7, according to data from the Centers for Disease Control and Prevention (CDC).

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  In 2017, drug overdoses were the leading cause of accidental death among people aged 15 to 64 years.

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  In 2018, the prevalence of past-year illicit drug use from prescription pain relievers in people aged 12 years and older was 3.6%; it was the second most commonly used drug following marijuana. Of people aged 12 years and older, 2.1% have used heroin at some point in their lives (NSDUH, 2018).

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  According to the CDC, the overdose rate from synthetic opioids (including fentanyl and its analogues) was 12 times higher in 2019 than in 2013. Between 2018 and 2019, overdose deaths from synthetic opioids increased by 16%.

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  Close to half of people on chronic opioid therapy meet the criteria for an OUD.

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  Age: The average age of first heroin use is in the early 20s, with the 25 to 34 age group experiencing the most opioid overdose deaths in 2019.

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  Sex: Even though woman are prescribed opioid medication more frequently than men, men have 1.5-fold the risk of prescription opioid misuse and threefold the risk of heroin use. Between 1999 and 2010, overdoses from prescription opioid medication increased four times in women and over two times in men according to data from the CDC; however, men are still more likely to die from a prescription opioid overdose.

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  Race: Among racial/ethnic groups, the highest opioid overdose rates are among Native Americans and non-Hispanic Whites. Approximately 90% of new heroin users in the past decade are non-Hispanic Whites.

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  Geography: Between 1999 and 2015, although the greatest proportion of drug overdoses occurred in the metropolitan areas, the rate of increase in overdose deaths has been greatest in nonurban areas (nonurban: 325%; urban: 198%).

KEY REGULATIONS, POLICIES, AND GUIDELINES