Drug overdoses became the leading cause of accidental death in the U.S., after more than 50,000 people died from lethal drug overdoses in the past year. Opioids account for two-thirds of this epidemic with 20,000 prescription pain medications overdose deaths (40% of the total) and nearly 13,000 heroin overdose deaths (26%). For perspective, consider that in the U.S., drug overdose deaths tripled from 1999 to 2014 and sales of prescription pain relievers quadrupled from 1998 to 2010. Four of five new heroin users started with prescription pain medications and, in a 2014 survey of heroin users, 94% of respondents stated they chose to use heroin because prescription pain meds were "more expensive and harder to obtain."
What Are Opioids and How Do They Work?
Opioids are a class of drugs that includes prescription pain relievers such as oxycodone, hydrocodone, codeine, morphine, fentanyl; and illicit drugs such as heroin, clandestine fentanyl and other synthetic opioids such as carfentanil, which is 10,000 times more powerful than morphine. There are several types of heroin common in the U.S.: "black tar" from Mexico, "white powder" from southeast Asia and "brown powder" from southeast Asia and Colombia. Most street heroin is cut with a wide variety of ingredients. It is worrisome that new and stronger drugs are becoming widely available. Fentanyl, a Schedule II narcotic, is 50 to 100 times more powerful than morphine and fentanyl analogs ( "designer drugs" that mimic the original) are at epidemic levels, significantly contributing to overdose deaths. Fentanyl can be absorbed through the skin, which has created problems for first responders.
All opioid drugs work by attaching to receptors in the brain and body (including the GI tract). Our bodies normally manufacture endogenous opioids that are activated by attaching to receptors. When these receptors are stimulated, they block pain, create sleepiness and euphoria and depress respiration. Opioid drugs attach to and commandeer these receptors. Dependence (needing more of the drug to have the same effect) can quickly develop and unsupervised withdrawal causes nausea, anxiety, vomiting and gastrointestinal pain. While severe, these withdrawal symptoms do not result in death. Opioids are inherently dangerous both because of the uncertainty of what adulterants may be mixed in with a street drug, and the small and sometimes unpredictable difference between creating the desired effect and overdose. Most opioid deaths are the result of respiratory depression.
How Does the Opioid Epidemic Intersect With HIV/AIDS?
The risk of opioid use and new cases of HIV is best exemplified by the 2015 outbreak in a rural Indiana town with a population of 4,200. Injection drug use of heroin and a lack of harm reduction services led to 175 new cases of HIV, an incidence rate that topped that of sub-Saharan Africa. Thomas Frieden, the director of the U.S. Centers for Disease Control (CDC) at the time of the Indiana outbreak, called it a sentinel event, one that warns of potentially catastrophic outcomes. Injection drug use (IDU) has generally accounted for about 6% of new HIV cases in the U.S. Data are still lacking about the impact of IDU on the current opioid epidemic but the situation in Indiana is a clear warning. White heroin may present more risk for HIV because it is water-soluble and is associated with HIV due to increased rates of injection versus other heroin that is more commonly snorted or smoked. Because persons living with HIV/AIDS (PLWHA) may have more issues with pain, there is an increased risk of drug misuse. In PLHWA with a prior history of substance use, a current mental health disorder and/or a history of poor antiretroviral therapy adherence, there is increased likelihood of problematic opioid misuse.
What About Harm Reduction?
Harm reduction is a nonjudgmental set of strategies that reduce the harmful impact of drug use. Syringe service programs (SSPs, sometimes called syringe exchange programs) are the most important of these strategies, providing clean syringes that reduce the spread of HIV, HCV and other bloodborne infections. Most SSPs also provide other prevention materials such as sterile water, alcohol swabs and condoms, as well as education on safer injection practices, wound care and referrals to treatment. Despite their proven effectiveness, resistance to SSPs remains high in the U.S. This could change with the Consolidated Appropriations Act of 2016, which allows local and state governments the opportunity, under limited circumstances, to use federal funds for SSPs, although purchase of sterile syringes for illegal drug injection remains prohibited. You can find a list of SSPs here.
What About Overdose Prevention?
The effects of an opioid overdose can be reversed by administering a drug called naloxone (brand name Narcan). Naloxone has a more powerful affinity to opioid receptors than other opioid drugs like heroin or Percocet, effectively knocking those drugs off the receptor and blocking it without the mood-altering effects. Naloxone is administered with an auto-injection device (similar to an EpiPen) and has no effect on people who have no opioids in their system. Naloxone works almost immediately and has saved countless lives, and first responders and many families of drug-addicted persons keep it on hand to reverse overdoses. Although relatively expensive, it is available without a prescription in 33 states and Washington, D.C., through a program at CVS and Walgreens.
What Is Medication Assisted Treatment?
Addiction is a chronic illness that can be managed. Medication Assisted Treatment (MAT) combines medications with counseling and is considered the best choice for treating opioid addiction. MAT programs utilize several different drugs. Two of these, methadone and buprenorphine, trick the brain into thinking it is still getting the problematic opioid but there is no feeling of being high; the person feels normal. A third drug, naltrexone (basically a long-acting version of naloxone, mentioned above), also blocks receptors and eliminates the mood-altering effects of the drug. It takes away the feeling of being high if an opioid drug is used, making it especially helpful to prevent relapse. Naltrexone can also be used to reduce cravings from alcohol withdrawal. By law, MAT programs must also include behavioral therapies such as individual and group counseling, care or case management, various levels of care such as inpatient or partial hospitalization, and peer support groups. You can find an opioid treatment provider here.
What Are Other Recovery Resources?
As brain science evolves we are expanding our understanding of addiction. Some new models propose that it is a form of learning disorder or receptor disorder rather than a disease. There is concern that traditional 12-step approaches to recovery, commonly found in treatment centers, unnecessarily frame addiction as an issue best addressed by surrendering to a higher power, prayer or confession, while science shows that cognitive behavioral therapy and motivational therapy are highly effective. ( ( Personal note: I believe that there is a place for both; 12 step programs have saved countless lives of clients and friends, including my own). In my experience, 12 step programs work because they promote social connection and belonging, both of which have been shown to be essential components for recovery from addiction. Either as a complement to MAT or on their own, recovery support groups offer help to many addicts. The best fit for opioid addiction is Narcotics Anonymous (NA). Founded in 1953, it is a drug-focused version of the 12-step program Alcoholics Anonymous. NA describes itself as nonprofit fellowship of men and women, and meetings are not facilitated but rather peer-led. You can search for an NA meeting near you here. In addition, families and close friends are particularly hard hit when someone they love is struggling with addiction. Support can be found at Al-Anon, the counterpart to Alcoholics Anonymous and Nar-Anon, for families of people struggling with drug addiction.
The American drug control strategy of punishment and morality is over 100 years old and continues to harm the very people it is intended to protect. The opioid epidemic is affecting persons of all races, ethnicities, ages, genders and socioeconomic status. Instead of criminalization we need to increase funding and change the conversation from judgment and stigma to care and compassion.
Where Can I Get More Information?