OPIOIDS 101

What is the Opioid Epidemic? Why does it matter?

Solving a problem starts with understanding where it comes from. We’ve put together a resource for how and why opioid addiction became a national epidemic. Most importantly, we discuss some of the current, evidence-based solutions for prevention, treatment, and recovery.

WHAT ARE OPIOIDS?

Opioids are a class of drugs used to reduce pain. Legal opioids include prescription pain killers such as oxycodone (OxyContin), hydrocodone (Vicodin), and morphine as well fentanyl, a much more powerful synthetic opioid used to treat severe pain. Abuse of legal opioids often leads to abuse of the illegal opioid heroin.

WHAT IS OPIOID ABUSE?

Prescription opioids work to dampen pain signals from the body, but they also produce psychological effects like euphoria and extreme relaxation. These intensely “rewarding” side effects are what contribute to the development of drug abuse and addiction.

Over time, frequent use of opioids at increasingly high doses elicits persistent alterations to a user’s brain chemistry that may compel them to use the drug even without the presence of pain that originally necessitated their use. Essentially, this pattern of use tricks the brain into believing that taking high doses of these drugs is good for you.

OPIOID OVERDOSE DEATHS

If prescription opioid users continue to use opioids at greater quantities and longer time periods than intended, they may begin to develop anxious hunger for these feelings of euphoria and relaxation leading to substance dependence. Psychologically, users crave the drug and want to consume it despite being aware of the negative consequences. Physiologically, the body experiences negative symptoms in the absence of opioids—a phenomenon known as acute opioid withdrawal syndrome.

Both craving opioids and fearing withdrawal often leads to taking more drugs than were prescribed, which leads to a tolerance. As tolerance develops, users’ brains become less responsive to the drugs and they seek out ways to hasten or enhance the desired effect. This includes taking dangerously higher doses, using different substances with “higher” impact (such as heroin), or employing different methods of ingestion such as snorting or intravenous injection. These behaviors indicate an escalating pattern of prescription drug abuse that may result in overdose death.

THE OPIOID EPIDEMIC

Prescription opioids emerged on the scene in the 1990s marketed as a non-addictive, effective form of pain management. Physicians rapidly increased their prescribing habits (e.g. frequency and dosages) to meet the demand of long-suffering chronic pain patients. These new practices coincided with the development of new potent narcotics resulted in an increased risk for misuse and addiction of prescription pain killers which had never been seen before.

As the number of prescriptions for opioids increased, so did the number of opioid related overdose deaths. Since 1999, almost 750,000 people have died from a drug overdose, 2 out of 3 of those deaths involved an opioid.

In 2018, we lost 46,802 Americans to opioid overdose; that’s one every 12 minutes. Even more alarming, 1 out of 3 opioid overdoses were from legally prescribed medications. Today, opioid misuse, addiction and overdose deaths has led the President to declare the opioid crisis a national public health emergency.

The figure to the left is a bar and line graph showing the total number of U.S. overdose deaths involving any opioid from 1999 to 2018. Any opioid includes prescription opioids (and methadone), heroin and other synthetic narcotics (mainly fentanyl or fentanyl analogs). Opioid-involved overdose deaths rose from 21,088 in 2010 to 47,600 in 2017 and remained steady in 2018 with 46,802 deaths. The bars are overlaid by lines showing the number of deaths by gender from 1999 to 2018 (Source: CDC WONDER).

OPIOIDS BY THE NUMBERS

130+

People died every day from opioid-related drug overdoses ( estimated )

10.3 M

People misused prescription opioids in 2018

808,000

People used heroin in 2018

2 M

People had an opioid use disorder in 2018

47,600

People died from overdosing on opioids

81,000

People used heroin for the first time

15,349

Deaths attributed to overdosing on heroin (in 12-month period ending February 2019)

2 M

People misused prescription opioids for the first time

32,565

Deaths attributed to overdosing on synthetic opioids other than methadone (in12-months period ending February 2019)

Sources

  1.  2019 National Survey on Drug Use and Health. Mortality in the United States. 2018
  2. NCHS Data Brief No. 329, November 2018
  3. NCHS, National Vital Statistics System. Estimates for 2018 and 2019 are based on provisional data

Updated October 2019. For more information, visit: http://www.hhs.gov/opioids/

COMBATTING THE EPIDEMIC

With 128 Americans dying every day, it is urgent that we act now to increase our efforts and prevent further tragic loss of life.

WHO'S AFFECTED?

The effects of opioid addiction are not limited to those misusing drugs. Over 44% of all Americans report knowing someone with opioid addiction problems and 20% personally know someone who has died of an overdose.

Opioid addiction also affects our society, our economy and our social infrastructure at large. In 2013, prescription opioid abuse cost our Nation $78.5 billion in costs related to crime, lost work productivity and health care. By 2015, the cost had risen to $500 billion. Almost 16% of state budgets are spent on addiction-related costs.

Employers and citizens in every industry are affected by this epidemic. In particular, the foster care system, health care industries and drug treatment facilities have been heavily impacted. Nearly a third of all hospital visits are linked to addiction Over 100,000 children are removed from homes every year due to parental drug abuse.

WHO'S AT RISK?

Part of the difficulty of addressing opioid addiction is understanding who is at risk for dependence. There is no single, simple answer to this question. Opioid users become opioid abusers or overdose victims under a unique combination of circumstances for each individual. The user’s gender, age, race, socioeconomic status, geographical area, and medical or clinical history can all factor in to the progression of opioid abuse. However, data compiled from the epidemic over the last 20 years shows clear trends in overdose risk factors including:

  • ​Poverty and/or Unemployment
  • Family or personal history of substance abuse
  • Young age (ages 18-25)
  • Criminal history
  • Risk-taking or thrill-seeking behavior
  • Heavy tobacco use
  • History of severe depression or anxiety
  • High stress environments (e.g. high-pressure jobs, high pressure school, high performance athletes)
  • Chronic pain
  • Prior treatment for drug or alcohol rehabilitation
  • Rural areas

WHAT'S BEING DONE?

To combat the opioid crisis, the Department of Health and Human Services announced its five-point Opioid Strategy, listing the five following priorities:

  1. Improve access to prevention, treatment, and recovery support services
  2. Target the availability and distribution of overdose-reversing drugs
  3. Strengthen public health data reporting and collection
  4. Support cutting-edge research on addiction and pain
  5. Advance the practice of pain management

This national strategy seems to be working; national opioid overdose deaths decreased by 4% from 2017 to 2018. New CDC data show death rates involving heroin decreased by 4%, and prescription opioid-involved overdose death rates decreased by 13.5%. However, death rates involving synthetic opioids like fentanyl increased by 10% from 2017 to 2018. This overall decrease shows that national prevention and addiction efforts are working. There is hope, but we cannot decelerate our efforts to continue to curb this crisis.

PREVENTION

With 128 Americans dying every day, it is urgent that we act now to increase our efforts and prevent further tragic loss of life.Collaboration is the key to preventing addiction and subsequent opioid overdose deaths. Medical personnel, emergency departments, first responders, public safety officials, mental health and substance use treatment providers, community-based organizations, public health, and members of the community are all important components of the solution to this complex and fast-moving problem. By coordinating efforts between these actors, we can combat this epidemic of unnecessary deaths.

There are several proven ways to reduce exposure to opioids and potential dependence. In turn, these methods subsequently help prevent opioid abuse and overdose:

  • Prescription drug monitoring programs
  • State prescription drug laws
  • Managing prescription access through insurance providers (i.e. prior authorization, quantity limits, and drug utilization review)
  • Improving provider awareness of opioid abuse risk and opioid prescribing guidelines to facilitate conversations with patients about alternative pain treatment options
  • Increased oversight of recommended prescribing practice implementation
  • Patient education on the safe use, storage, and disposal of prescription opioids
  • Improving community awareness about the risks of prescription opioids, the myths surrounding the negative stigma of addiction, and the cost of overdose on society

PRESCRIBER AWARENESS

Opioids are a necessary form of pain management for many patients. However, opioids should not be a first line defense or routine therapy used to treat pain. Unfortunately, over-prescription of opioids as a cure all without consequence for pain has led to the present public health crisis.

The CDC developed and published the CDC Guideline for Prescribing Opioids for Chronic Pain to provide recommendations for the prescribing of opioid pain medication for patients 18 and older in primary care settings. Recommendations focus on the use of opioids in treating chronic pain (pain lasting longer than 3 months or past the time of normal tissue healing) outside of active cancer treatment, palliative care, and end-of-life care. However, many opioid prescriptions are administered outside of primary care where caution is not always exercised in prescribing to unknown patients with unquantified risk of misuse; post-surgical, post-emergency, by specialists.

Prescribers need increased education on how to thoroughly examine the risks and benefits of opioid use for each case and be sure to explore other options before administering a prescription. Greater effort is need by both the system and individual prescribers to optimize patient care and treat patients who have pain – whether physical pain, psychological pain or a combination of both – without contributing to opioid misuse and abuse.

PUBLIC EDUCATION

The opioid epidemic is fueled by inadequate education about addiction and treatment. Increasing public knowledge about prescription opioid misuse and overdose is critical to communities making safe choices about opioids and supporting those who need help.

There is also a gap in public knowledge of addiction treatment that serves as a barrier to getting those who need help into a program. Despite the fact that effective treatments for opioid use disorder do exist, only about one in four people with this disorder received specialty treatment for illicit drug use in 2017.

Unfortunately, resources aren’t always well organized or easy to find. Please visit the links below to find out more about opioid addiction, abuse, overdose, and how to get help for yourself or someone you love.

FIGHTING STIGMA

The negative social stigma surrounding addiction is another major obstacle perpetuating opioid abuse and overdose. Fortunately, society’s outdated view of addiction as a moral failing is slowly turning around. We are moving toward a more realistic, humane view of addiction as a complex disease, one that can be effectively addressed with compassion and evidence-based treatment strategies.

Additionally, 45% of people with a substance use disorder also have a mental disorder, yet only about half receive treatment for either disorder and only a small minority receive treatment for both. The stigma surrounding mental health has also made those with substance use disorders less likely to seek out help.

By talking about the disease of addiction, educating others, and choosing words which do not further stigmatize both addiction and mental health disorders we can help remove or lower the barriers for someone getting help for themselves or others.

2020 Update: New concerns are mounting related to the 2020 coronavirus pandemic; many cities and states have noticed an uptick in overdose deaths since the beginning of quarantine and lockdowns as a result of the COVID-19 global pandemic. Social isolation, unemployment and economic strain are all negatively contributing factors that exacerbate mental health issues and worsen the risk of prescription overdose. Communities should be aware of the increased risk and try to support those at risk in these difficult times.

REVERSING OVERDOSE WITH NALOXONE

​Naloxone is a non-addictive, life-saving drug that can reverse the effects of an opioid overdose when administered in time.

While naloxone has saved countless lives through programs that equip medical first responders and law enforcement groups, it is also important for community members to be aware and equipped with life-saving naloxone administration kits. This is particularly important in rural areas where EMS may take some time to arrive.

Good Samaritan Laws exist in many states. In the event of an overdose, these policies protect the victim and the person seeking medical help for the victim from drug possession charges. Learn more about access and use laws for Naloxone in your community at Prescription Drug Abuse Prevention System website.

IDENTIFYING AN OVERDOSE

Recognizing an opioid overdose can be difficult. If you aren’t sure, it is best to treat the situation like an overdose—you could save a life. Call 911 or seek medical care for the individual. Do not leave the person alone. Signs of an overdose may include:

  • Small, constricted “pinpoint pupils”
  • Falling asleep or loss of consciousness
  • Slow, shallow breathing
  • Choking or gurgling sounds
  • Limp body
  • Pale, blue, or cold skin

TREATMENT

The best way to prevent opioid overdose is to get help for an opioid abuse problem right away. Addiction treatment programs can help individuals cope with dependence and promote recovery. Entry into a certified substance abuse treatment program with evidence-based treatment strategies minimizes the potential for future opioid overdoses.

WHAT ARE MY OPTIONS?

Every year, hundreds of thousands of Americans cycle through expensive addiction treatment programs without evidence-based methods and immediately relapse the moment they are released. Even worse, many people don’t get treatment at all: they don’t know where to get help, they are afraid to seek treatment, they don’t know how they’ll afford care. Americans are needlessly dying because they don’t get the care they need.

Treatment can help struggling opioid users address the underlying causes of their addiction, while building the skills to manage cravings and resist triggers preventing future substance abuse. There are thousands of programs designed to fit individual needs. There are a few main options:

  • Inpatient/Residential treatment– involves an extended stay (~1 month- 1 year) at a live-in treatment facility, hospital or clinic. These programs provide a sober environment for recovering individuals with a large support staff and community for greater oversight during their recovery. They will work through detox, treatment, and recovery while living at the center, allowing them to focus completely on their recovery without the stress of potential triggers they might encounter while undergoing treatment living at home.
  • Outpatient treatment– allows people to live at home as they work through treatment. These programs require regular check-ins at a treatment facility, so people opting for these programs must trust their ability to self-motivate in the face of triggers at home to use. Outpatient treatment is best for people willing to attend regular appointments and counseling sessions. Since there is no overnight care, it’s important to have a stable living environment, reliable transportation, and supportive family or friends.
  • Interim care- for when immediate admission to other care isn’t available. Many inpatient facilities have long waitlists, interim care provides daily medication and emergency counseling. This can be a helpful bridge from beginning recovery to admission to a regular outpatient, inpatient, or residential setting.
  • Transitional housing- a temporary space to stay while transitioning from an intensive treatment setting. Sometimes called a halfway house or sober living facility.As part of the path to independent living, these facilities support people in recovery with temporary places to live. They may also have support programs around employment and education, or case managers to help residents succeed during and after their stay.
  • Self-help groups—these options are generally free and less intensive than treatment programs. Support groups can be a tremendous help to people who are unable to regularly get to a treatment facility or as a supplement for those having just left inpatient care or transitional housing. These community programs can also help recovering individuals build a support network of sober-minded peers which helps with adjusting into abstinence.

Learn more about what is involved in these treatment types and about medications used in medication assisted treatment here.

WHERE TO FIND HELP

If you or someone close to you needs help for a substance use disorder:

WHAT IF I CAN'T AFFORD IT?

Substance abuse treatment can be an expensive undertaking. Understanding the costs of and how to pay for treatment can be hard and confusing and often act as a barrier for those in need to get the help they need.

There are free and low-cost facilities across the country, and many others accept Medicaid, private insurance, Veterans Administration benefits (if you’re a military family), Employee Assistance Programs (EAP), student health services, clinical trials, financial aid, payment plans and a sliding fee scale. Your state also has funding set aside to help people without insurance afford treatment, contact your state agency for information on how the process works in your state.

The Mental Health Parity and Addiction Equity Act (MHPAEA) of 2008 requires health insurers and group health plans to provide the same level of benefits for mental and/or substance use treatment and services that they do for medical and surgical care. That means your insurance company can’t tell you “we don’t do substance abuse treatment” or “mental health isn’t covered.” Denying you coverage is breaking the law.

If you’ve been denied coverage for treatment, the Department of Health and Human Services has a Mental Health and Addiction Insurance Help tool that can help you find the right resources to solve issues with your insurance.

RECOVERY

After successfully completing a treatment program, the recovery journey begins for addiction patients just like any other disease . For substance use disorders, disease management can last a lifetime. Patients will need help and support to maintain sobriety. But sustaining recovery is possible.

THE FIRST 3 MONTHS

Patients have very different recovery journeys unique to their individual challenges and the kind of treatment they received. And many patients will struggle to adjust back into their “normal” lives post-treatment. For those coming from in-patient treatment centers, re-exposure to the stresses and temptations that led to initial substance use means they will need to rely on the coping skills they learned in treatment and find support systems. They’ll need to adjust to these changes and make efforts to avoid relapse.

Research has shown that the risk of relapse and accidental overdose is highest in the first 1-3 months following addiction treatment. But the same studies show that persons who continue some form of treatment in the first 90 days after treatment have a greater chance at maintaining recovery over their lifetime. So getting the support you need right out of the gate is critical.

Each patient should meet with their doctor or addiction specialist to discuss personal needs and decide on an individualized plan of action. This is an important step on the first day of post-treatment recovery, and important for checking in over a lifetime. Recovery, is a never ending process.

MAINTAINING SOBRIETY

Successful long-term recovery from opioid addiction isn’t just a matter of never using opioids again- although that’s of course a major part of it. Ultimately, recovery from substance abuse is about someone to keeping a steady job, having healthy relationships, and living a meaningful and rewarding life without drugs.

Every person in recovery is different, and will need a different plan for long term success. Plans may include medication therapy, behavioral therapy, job support, family counseling, or peer support. The importance of cultivating a sense of purpose outside addiction treatment is also critical to ongoing recovery. For example, the Harvard Medical School Special Health Report “Overcoming Addiction” identified two basic steps that are necessary for recovery: replacing addiction with other interests, and exercising. Activities like hobbies and exercise help people invest in other people, who will in turn invest in you.

No matter what you choose, having a support system is vital to maintaining sobriety. Talk with a healthcare professional about whether incorporating some of these steps in a treatment plan can help you or your loved one, as you work toward sustained recovery.