A new paper published online in January 2015 by Kolodny et al. provides an overview of the epidemic of addiction to opioid prescription medications and heroin which is sweeping through the United States. Numerous news outlets from the Huffington Post to the New York Times have been covering this disturbing trend. This important review paper is being released at a critical time.

You can find the complete article here.

The authors do an excellent job of outlining the epidemic from a public health perspective. I just wanted to summarize some of the paper’s main points and findings:

• Abuse of prescription opioid pain relievers (OPR) and heroin is reaching epidemic levels
  • From 1999-2011, oxycodone (a common OPR) use has increased by 500%
  • From 1997-2011, there has been a 900% increase in individuals seeking treatment to for opioid addiction
  • From 2004-2011, there has been a doubling in ER visits due to non-medical use of OPR
  • The author’s highlight that there is a disturbing correlation between the rise in opioid sales, opioid overdose deaths, and opioid addiction (See the figure below)

• The authors contend that the cause of our current epidemic is rooted in:
  • The development of new opioid medications such as OxyContin (an extended release form of oxycodone introduced in 1995)
  • The over-prescription of OPR coupled with a shift in medical attitudes towards the treatment of chronic pain
  • A series of studies suggesting that long-term opioid use does not result in addiction. We now know this to be false.
    • According to a recent study, 25% of chronic pain patients treated with OPR fit criteria for opioid addiction and 35% for opioid abuse disorder

• The public health issues related to non-medical use of OPR are significant
  • Heroin use has drastically increased over the same period as OPR abuse
  • 4 out of 5 current heroin users report that their addiction began with abuse of OPR (See here for more information).
  • Overdose deaths and hospitalizations as a result of OPR have been strikingly high since 2002. See the graphs below.

• Using an epidemiologic approach, the authors outline a prevention strategy for opioid addiction broken down into primary, secondary, and tertiary interventions.
  • Primary prevention
    • Reduce the incidence of the disease condition: opioid addiction (ie prevent new addiction cases)
    • Education of prescribers regarding OPR use
      • The risks of chronic OPR use, such as addiction and respiratory depression (difficulty breathing), are high
      • Little data exists for the effectiveness of long-term OPR use in helping chronic pain patients
    • Substitution of OPR for non-opioid pain relievers must be strongly encouraged
    • Prevention of OPR use amongst adolescents
      • Caution in OPR prescribing
        • Most youths that experiment with them get OPR from family or friends who have an OPR prescription
      • Change the perception that OPR use is less risky than heroin use
        • In reality the risk of addiction to OPR is as high as it is for heroin
  • Secondary Prevention
    • Identify and treat opioid addicts early in their disease
      • Identify users of OPR that are detected by prior to more significant health problems or transition to heroin use
      • Difficulty in diagnosing opioid addiction
        • Urine toxicology screens in some cases
        • Use of prescription drug monitoring programs (PDMPs) to identify patients who seek prescriptions from multiple doctors
  • Tertiary prevention
    • Treatment and rehabilitation of opioid addiction
      • The National Survey on Drug Use and Health (NSDUH) estimates 2.1 million Americans are addicted to OPR and 467,000 to heroin.
      • Combination of pharmacologic and psychosocial treatments
        • Psychosocial therapies (residential treatment centers, mutual-help programs, 12-step programs) can be effective for some patients but should be use in combination with pharmacologic treaments
      • Pharmacologic treatments such as methadone and buprenorphine (Suboxone) are safe and highly effective
        • They work by effectively blocking cravings without causing the “high” the OPR and heroin cause
        • However, fewer than 1 million addicts are receiving these treatments
        • Significant federal limitations exist to buprenorphine prescription
          • See my Post on this topic, which links to an important Huffington Post article on the topic
      • Harm-reduction approaches
        • Needle-exchange programs to reduce HIV transmission
        • Naloxone for treatment of overdose deaths
  • Conclusions
    • Prescription opioid and heroin addiction are reaching epidemic levels in the United States
    • A coordinated public health effort of federal and state agencies, health care providers and insurers, treatment/recovery initiatives and the research community is required to deal with this crisis.

For more statistical information, consult the National Survey on Drug Use and Health.

Also, see the data section of the Substance Abuse and Mental Health Services (SAMSHA) for statistics related to non-medical use of OPR and heroin.