On Opioid Overdose: Why is the Death Toll Rising?
This past week I returned to my home city of Columbus, Ohio.
The list of my favorite Ohio pastimes includes experiencing the distinct serenity of the spacious farmlands as the airplane descends, trail biking through the Columbus greenery, and catching up with friends, family, and members of my relatively small, yet close-knit community.
To my chagrin, however, a relatively recent issue has threatened the integrity of the state. For Ohio is currently topping the charts in regards to the rising opioid epidemic, placing 4th on the list for the largest increase in non-heroin related deaths from 2000-2015 in a given state (1.6 vs 17.3 deaths per 100,000 people in 2000 vs 2015), and number one for the largest increase in heroin related deaths from 2000-2015 (0.7 vs 13.3 deaths per 100,000 people in 2000 vs 2015). This data taken from the CDC (Center for Disease Control and Prevention) is startling, and, in October 2017, prompted the official governmental declaration of the epidemic as a public health emergency in not only Ohio, but the entirety of the United States.
But why are the numbers increasing?
Surely opioids are as addicting today as they were back in the year 2000; this, however, is not the whole story. While the addictive properties of opioids load the gun, so to speak, factors such as increased physician prescription of opioids, heightened availability, potency, and deadliness of newer opioids, and subpar follow-up care of users admitted to the emergency room, pull the trigger. Before discussing each of these complex subjects in turn (as well as proposed solutions), it is crucial to have a bit of background knowledge. Therefore, let us review the basics of opioids, including proper terminology, and the neurochemical mechanisms underlying their addictive qualities.
Opioids are a group of compounds that act on naturally occurring opioid receptors in the human brain. To clarify terminology, opiates are substances found in nature (i.e. from the poppy plant) in addition to their derivatives; famously, one such compound is morphine (Offermanns, 2008). Opioids, on the other hand, are synthetic or semi-synthetic (i.e. man-made) compounds and include drugs such as hydrocodone, oxycodone, and more recently, fentanyl (Freye, 2008). For the sake of clarity, I will use the word “opioids” to describe the general class of compounds. So too, due to their slightly differing structures, each of the opioids achieves varying levels of bioactive effects.
There are several different neurochemical mechanisms that contribute to the analgesic (pain reducing) and psychoactive properties of opioids. Although each opioid differs slightly, the general pattern starts with the drug binding to the μ receptor in the brain and spinal cord. While there are others, the μ receptor is most responsible for the rewarding (i.e. addicting) aspects of opioids. The neurotransmitter GABA, which is an inhibitory compound, is itself inhibited by opioids. The net result is a strong stimulation of the reward centers of the brain (Chahl, 1996). Although a simplistic approach (the true mechanism is far more complex), it will be sufficient for the purposes of this article. With this in hand, let us take a deeper look into the reasons for the stark increase in opioid-related issues.
While pain levels in the United States have remained relatively constant over the past 15 years, the prescription of opioids has nearly quadrupled, with roughly 50% of the narcotics being dispensed by primary care providers, who often report insufficient training in pain management (cdc.gov). So too, despite statistically constant levels of pain and pain-related conditions, there is a three-fold difference in opioid prescription rates between certain states. Interestingly enough, a few states, including Ohio, boast opioid prescription levels over a prescription per person, on average (cdc.gov). In order of relative risk of overdose from lowest to highest are opioids given by a friend for free, those prescribed by a physician, and narcotics obtained by a stranger or drug dealer (cdc.gov).
To be sure, prescription opioid medications demonstrate high efficacy for pain relief and improve the quality of life for certain types of individuals, including patients requiring surgical intervention and those who may have undergone a disabling physical trauma or someone otherwise experiencing a medical condition characterized by chronic pain. It is, therefore, a balancing act -- managing acute pain on the one hand, yet preventing drug abuse on the other.
A (seemingly) simple solution to this issue is to find alternative methodologies for pain relief. Non-pharmacological pain management options include massage, physical therapy, and meditation. However, although these techniques may be efficacious for low to moderate pain, they are simply insufficient for the vast majority of patients experiencing high levels of pain. Therefore, drug-based intervention may still be the best option. But we run into the same issue: addictive qualities (as it relates to the euphoric experience) are an inherent property of most pharmacologically based painkillers. For this reason, scientific research has focused on finding the “goldilox” of drugs -- effective at relieving severe pain on the one hand, yet non-addictive and with a low risk of lethality on the other. The research is ongoing (I was personally involved in one such project) and progress is being made every day.
Adding to the opioid epidemic is the heightened availability, potency, and deadliness of newer drugs. One such opioid is fentanyl, a synthetic opioid sweeping the nation -- both in terms of medicinal and recreational uses -- thereby drawing much attention to itself. The number of reported law enforcement encounters with fentanyl has increased exponentially in the past 8 years (cdc.gov). Here again, one of the highest rates of fentanyl encounters in the United States took place in Ohio, with other Midwestern and eastern states following suit.
As unprecedented as it may sound, the drastic increase in fentanyl availability stemmed from the ease in which the drug could be obtained by a simple mail order request to China. By changing the composition of fentanyl just slightly, Chinese companies can dodge law enforcement, while distributing the narcotic as a “research chemical”.
By binding strongly to the neural Mu receptors mentioned earlier, fentanyl has been shown to be about 75 times as powerful as morphine by volume, with some forms boasting 10,000 times the strength of morphine (NIDA, 2016). This drastic increase in potency has translated to an even greater increase in death rates from a given opioid, rising from 3000 deaths in 2013 to a staggering 20,000 deaths in 2016 (cdc).
Solutions to fentanyl over-usage are varied, and tackle the issue from all angles -- biological, psychological, and sociological aspects included. The “biopsychosocial” model of addiction, as it were, not only applies to fentanyl, but to opioid usage in general.
On the biological front, an opioid antagonist (blocker) can be used in the acute setting to reverse a potential overdose. One such antagonist that you may have heard of is naloxone (brand name, Narcan). Naloxone binds to the opioid receptors but in a specific manner that inhibits fentanyl from binding, without activating the receptor itself (Naloxone, ASHP). Biologics that control long-term addiction (by continuously blocking the receptor) are also available.
From a psychological and sociological perspective, various forms of psychosocial therapy contribute great efficacy in the fight against opioid abuse. Such therapies may include cognitive behavioral therapy, contingency management interventions, and a computer-based community reinforcement approach called the Therapeutic Education System. Respectively, these methods focus on modifying dysfunctional emotions, behaviors, and thoughts (Beck, 2011), providing tangible, voucher-based rewards to reinforce positive behaviors (Budney et. al., 2006), and increasing problem-solving, coping, and communication skills, especially with adolescents (NIH).
Finally, follow-up care for those admitted to the emergency room for an opioid overdose requires serious revision. In an article published in The Journal of the American Medical Association (JAMA), researchers evaluated emergency room statistics from Pennsylvania based Medicaid patients. Only 15 percent of those who survived opioid overdoses and 33 percent of heroin survivors were given one of three FDA approved medications for the long-term treatment of opioid addiction: methadone, naltrexone, and buprenorphine. This problem is not isolated to the state of Pennsylvania. As it would seem, many hospital emergency room systems do not contain proper protocols in place to handle addiction cases.
As highlighted by an article published in Scientific American, a 2015 study published out of Yale School of Medicine gives a potential solution as it relates to hospital administrative policy. Patients admitted to the emergency room for an opioid overdose were divided into three study groups and were provided the following services/products: (1) a simple pamphlet on addiction clinics, (2) an interview with a researcher who would also provide transportation to a health care provider, or (3) a combination of the interview with initial and continuous doses of one of the prophylactic medications mentioned earlier, buprenorphine. 30 days later, the patients in groups 1, 2, and 3 remained involved in treatment at a rate of 37%, 45%, & 78%, respectively.
Clearly, there is an issue, and even clearer, there is a solution. However, although physicians have the ability to prescribe up to three days of maintenance, opioid blocking medication (US Department of Justice), a measly 30,000 are legally licensed to dispense. Moreover, despite a recent increase in the number of buprenorphine doses a physician can prescribe from 100 to 275 per year (SAMHSA), access to long-term care in the form of methadone clinics is impractical for many patients, as the repositories are often located in dangerous neighborhoods (Scientific American).
To summarize: increased physician prescription of opioids, heightened availability, potency, and deadliness of newer opioids (such as fentanyl), and subpar follow-up care of users admitted to the emergency room are mainstay factors in the recent increase of opioid overdoses in the United States. By expanding scientific research into nonaddicting, low-risk pharmacological alternatives, applying a biopsychosocial approach to preventing and halting opioid outbreaks, and focusing in on protocol adaptations in our emergency room systems, a better part of the damage may be avoided.
As a volunteer EMT in New York City’s Central Park, the theoretical nature of the opioid epidemic has become all too practical. As a permanent resident of the state of Ohio, the constant drug-based news coverage has bogged down community morale. But as a citizen of the United States, I am hopeful; although a lengthy and gradual process, advances in science and healthcare policy will undoubtedly close the gap in the fight against the opioid epidemic.