Opioid Crisis in the USA
Currently, the United States of America is experiencing an opioid crisis. This paper focuses on the use of opioids as a pain management method and its adverse effects. Opioids are widely used by healthcare providers as acute and chronic pain treatments. Furthermore, opioid prescriptions started to increase after the 1970s. Nonetheless, the use of these drugs may result in addiction, misuse, and overdose. In general, opioid pain relievers are not harmful if they are used for short periods and strictly according to the healthcare prescriptions. However, they cause euphoria together with pain relief.
As a result, they can be injected incorrectly or in larger amounts than prescribed. The opioid misuse and abuse problem is very prevalent as supported by statistical data. The main reasons for opioid misuse include the desire to manage pain, experiencing euphoria, and the lack of readiness to speak about the problem. The government provides regulations at the federal and state levels. A comparison of relevant regulations in Connecticut and Massachusetts proves that there are many similarities between the situations. Therefore, opioids use is a great challenge for the US because it provokes overdoses, deaths, and addiction.
Opioids are a class of medication that includes heroin, synthetic opioids, such as fentanyl, and pain relievers that can be prescribed for medical treatment. They consist of naturally appearing substances taken from opium. The main application of opioids in managing pain among patients. They are capable of decreasing pain intensity signals that reach the brain. Nonetheless, there are many problems with the application of opioids in medical treatment. Nowadays, the US experiences an opioid epidemic due to increased use and potential negative health consequences. Opioids can lead to misuse, overdose, accidental death, and addiction. Cases of people becoming victims of accidental overdoses with lethal consequences are highly prevalent. Additionally, opioid use provokes increased violence and crime rates. Hence, healthcare providers must realize the scope of the problem to understand the victims and help them. Opioid misuse is a great challenge for American society because it leads to overdoses, deaths, and addiction.
Controlled Substance & Opioids
Controlled substances are illegal drugs that have a detrimental effect o the welfare and health of people. Consequently, the federal and state governments choose to regulate such substances. If a person uses controlled substances, they can be imprisoned or fined by federal, state, and local law enforcement (Swanson, n.d.). Nonetheless, not all controlled substances are illegal. Many of them can be prescribed to the general public and sold in dispensaries and pharmacies for legitimate medical use. The federal government defines which substances are controlled. They are listed in the Controlled Substances Act of 1970 (Swanson, n.d.). All such pharmaceuticals are divided into five categories or schedules. The first schedule involves substances that have a high potential for abuse, and are unsafe and unsuitable for medical treatment. This category includes ecstasy, peyote, marijuana, LSD, and heroin. The second schedule includes stimulants and narcotics that have high abuse potential and may lead to severe physical or psychological dependence.
Examples of such drugs are methamphetamine, amphetamine, codeine, opium, morphine, Percocet, OxyContin, Demerol, methadone, and Dilaudid (Swanson, n.d.). The third schedule provides substances that have lower abuse potential but can still lead to physical and psychological dependence. They include anabolic steroids, ketamine, Suboxone, Tylenol, and Vicodin. The fourth schedule involves substances that have lower abuse power than the previous one. Halcion, Restoril, Versed, Ativan, Valium, Klonopin, Soma, and Xanax belong to this category (Swanson, n.d.). The last schedule consists of medication with limited amounts of narcotics, such as cough syrups with codeine. Therefore, all controlled substances are regulated by the government.
In general, it is illegal to apply any of the aforementioned drugs without a prescription. Nonetheless, if the substance is properly prescribed and lawfully bought, there is no legal violation. The Controlled Substances Act is a federal law and many state laws that conflict with it will not be upheld by the federal court (Swanson, n.d.). The US Constitution Supremacy Clause insists that in the case of a conflict between federal and state laws, the first one is more relevant (Swanson, n.d.). Nonetheless, the states can be flexible in enforcing the Controlled Substances Act. Further, some states established stricter legislation. Most states simply apply the Controlled Substances Act provisions through the adoption of the Uniform Controlled Substances Act (Swanson, n.d.). Hence, controlled substances can be used by people, mostly for medical purposes, though the practice is strictly detected by the government.
Opioids are among the substances that are included in the schedules. It is a drug class that consists of heroin, synthetic opioids, such as fentanyl, and pain relievers that can be prescribed for medical treatment (Cobaugh et al., 2014). In general, opioid pain relievers are safe when they are taken for short periods and the patients follow the prescriptions. At the same time, these drugs produce euphoria as well as pain relief. As a result, they can be misused or taken in larger than recommended doses. Regular use, even with an appropriate prescription, can provoke dependence and lead to overdoses or deaths. Pain is the most common complaint among patients who search for relief (Cobaugh et al., 2014). Efficient pain management methods have been developed within the last several years, but opioids still play an important role. Opioid medications are effective in terms of pain relief. However, the problem of pain and barriers to effective pain management contradict the nature of opioids and the risk of addiction (Cobaugh et al., 2014). Therefore, the abuse of this substance is a great challenge for healthcare personnel, because it is difficult to persuade patients to find a balance between pain management and addiction to opioids.
Opioids are a mixture of alkaloids extracted from poppy seeds. The term relates to all compounds that bind to opioid receptors. In 1806, morphine was isolated from opium. At the beginning of 1809, injectable morphine was applied for chorionic and acute pain treatment (Cobaugh et al., 2014). Opioids have pharmacological effects because they bind to opioid receptors both within and outside the central nervous system (Cobaugh et al., 2014). For the last twenty years, scientists have researched the possibility of the application of opioids for effective pain management. It was found that chronic and acute pain management is better accomplished through the multimodal approach that involved non-pharmacological treatments, as well as opioids and non-opioid analgesics. Opioids are applied for acute pain treatment when the pain cannot be handled through non-opioid therapy. For instance, acute pain after a dental procedure can be managed with the help of non-opioids, while patients that experienced major surgery will require parental opioid therapy for several days (Cobaugh et al., 2014). The most commonly applied opioids are fentanyl, hydromorphone, and morphine, but opioid prescription has to be individualized by the healthcare provider. Hence, opioids are widely used in medical treatment.
Hospitals must obtain the pain medication history of the patient that should include information about previous opioid therapy and adverse reactions. For instance, the patient may complain about itching from morphine but react to hydromorphone normally(Cobaugh et al., 2014). When opioids are a part of acute pain management regimens, they can be administrated through the neuraxial, parenteral, and oral routes. It was found that “small morphine doses administrated on the as-needed basis for the acute pain are superior to schedule design” (Cobaugh et al., 2014). When attempting to identify the correct opioid dose for acute pain, healthcare providers must consider whether the patient is opioid na? or tolerant. Opioid-tolerant patients are “people who have been taking opioids regularly scheduled prescribed opioids or have a substance abuse history related to illicit use of prescription opioids, illicit drug use or the participation in the opioid maintenance program” (Cobaugh et al., 2014). Therefore, opioid tolerance has to be considered to avoid underdosing the patient with acute pain and possible precipitating opioid withdrawal.
The ability to accurately calculate opioid doses is critical when converting the patient from one opioid to another. The most common mistake occurs when postoperative patients are moved from efficient parenteral hydromorphone dosage to nonequivalent and insufficient oral opioids (Cobaugh et al., 2014). Therefore, chronic pain management strategies are often based on opioids. In general, both pharmacological and nonpharmacological strategies are applied to chronic pain treatment and are often recommended for cancer-pain treatment. Nonetheless, long-term opioid therapy is related to increased healthcare utilization, higher depression rates, lower quality of life, persistent adverse effects, psychological and physical dependence, and opioid-induced hyperalgesia (Cobaugh et al., 2014). Therefore, there are many challenges related to opioid use despite their positive effect.
Opioid Misuse & Abuse
Prescribed opioid abuse and misuse in the US became a public health crisis that turned into an epidemic. It was found that abuse of prescription drugs and overdose are among the most common health threats (Volkow & McLellan, 2016). The main problem is the misuse of opioids. The misuse can be defined as the use of medications for any goals other than the ones indicated or directed medically. It is irrelevant whether the misuse was unintentional or willful and whether it resulted in harm. Opioid misuse is any illegal drug use, which is defined as intentional self-administration of the medication for nonmedical purposes, such as altering one’s state of consciousness (Volkow & McLellan, 2016). Hence, prescription opioids misuse is taking opioids in a dose or manner other than prescribed or taking the prescription of another person even if the reason for such actions is a legitimate medical complaint of pain. Since the early 1990s, there has been a rapid rise in prescription opioid misuse prevalence in the US (Volkow & McLellan, 2016). The main issue is that despite the opioids being prescribed often, their misuse can be fatal.
Another problem is addiction. It develops slowly after months of use, but when the addiction has developed it can turn into a chronic disorder (Volkow & McLellan, 2016). Some people develop tolerance to opioids after a single dose, while in other cases the tolerance can evolve slowly. For instance, tolerance to the euphoric and analgesic opioid effects develops fast, while tolerance to respiratory depression is slow. To reach the latter effect, increased doses of opioids are required, which raises the risk of overdose (Volkow & McLellan, 2016). Physical dependence is related to psychological adaptation. It is responsible for the emergence of withdrawal symptoms after abrupt discontinuation. The withdrawal symptoms can be muscle ache, vomiting, nausea, diarrhea, insomnia, chills, etc. These symptoms vary in severity and duration based on the opioid prescribed, as well as duration, dose, and type (Volkow & McLellan, 2016). Hence, opioid misuse is a significant problem that can take the lives of patients due to the adverse influence of the substances.
It was found that the main reasons for prescription opioid drug misuse were pain relief, good feelings, and experimentation. 2.2% and 8.1% of people indicated that their reasons for opioid misuse were emotional or physical pain relief respectfully (Kenne et al., 2017). People who misused opioids for pain relief often did that because of a lack of financial and insurance resources. At the same time, the main reason for emotional pain-related misuse was fear and embarrassment (Kenne et al., 2017). Moreover, the reasons for prescription opioid misuse often depend on the drug type. It is important to note that determining the reasons for misuse can be a critical consideration in the attempt to prevent opioid misuse among college students (Kenne et al., 2017). Therefore, the challenges presented by opioids are great and have considerable adverse effects on society.
Opioid Epidemic - Current Problem
Nowadays, more the thirty percent of Americans suffer from some form of chronic or acute pain. Among the elderly, the prevalence of chronic pain is over forty percent. Such prevalence of chronic pain provokes active opioid use because such substances are commonly prescribed for pain management in the US (Volkow & McLellan, 2016). In 2013, US retail pharmacies dispensed 245 million prescriptions for opioid pain relievers (Volkow & McLellan, 2016). Moreover, while 65% were for short-term therapy, 3% to 4% of adults are prescribed with long-term opioid therapy (Volkow & McLellan, 2016). Even though opioids provide quick and efficient relief to different types of acute pain and improve the functioning of patients, such benefits are under question due to the great prevalence of misuse. Opioids are widely used in the wrong way, which has led to the national opioid epidemic of addiction, overdoses, and deaths. More than a third of 44000 drug overdose deaths in 2013 were related to pharmacological opioids (Volkow & McLellan, 2016). Additionally, a parallel increase in the opioid addiction rate was determined, influencing approximately 2.5 million people in 2014 (Volkow & McLellan, 2016). At the same time, the main sources of diverted opioids are prescriptions. Hence, healthcare providers started to question the practice of prescribing opioids.
The US experiences a significant overdose epidemic; the drug overdose rate rose since 1980. Prescription opioids have been increasingly included in drug overdose deaths statistics. Moreover, opioid analgesics were involved in thirty percent of drug overdose deaths in 1999, and the number later rose to 60% (Behavioral Health Coordinating Committee, n.d.). Additionally, the rate of opioid-related overdose deaths became higher in comparison to the overdose deaths from cocaine and heroin. Only in 2010, did opioid analgesics provoke 16651 deaths (Behavioral Health Coordinating Committee, n.d.). The prescription of such drugs likewise increased the morbidity level. The nonmedical use of chronic opioid analgesics rose to 75% between 2002-20003 and 2009-2010 (Behavioral Health Coordinating Committee, n.d.). Hence, the prevalence of overdose deaths is obvious.
Several factors have to be considered in analyzing opioid overdose deaths. One of them is the high volume of prescriptions. It was found that a small number of prescribers is responsible for most opioid prescriptions. In 2009, 82% of controlled substance prescriptions in Kentucky were provided by 20% of prescribers (Behavioral Health Coordinating Committee, n.d.). Another challenge is unethical pain clinics. For example, more than 1000 pain clinics operate in Florida (Behavioral Health Coordinating Committee, n.d.). Therefore, the problems with overdose deaths are critical and have to be researched and prevented.
At the same time, it was found that opioid addiction is strongly related to criminal activity. In particular, in 2010 1.5 million people aged 18 and older who were on supervised release from jail had a higher dependence rate on the aforementioned substances in comparison to the people that were not involved in criminal activity (Manchikanti et al., 2012). The substance dependence rate was 29.9% among the people on probation. That is higher in comparison to the same rate among the people that were not on probation, which was 8.3% (Manchikanti et al., 2012). Additionally, New Mexico’s experience with the opioid epidemics and related crimes is a good example. In particular, there is a great problem with heroin. People prefer to move from painkillers to heroin because it is very similar but cheaper and easier to access. The Drug Enforcement Administration stated that “from 2015 to 2017 were arrested 133 people for heroin trafficking and 38 people for pharmaceutical trafficking on the NE Mexico state” (Holt & Klarer, 2017). At the same time, they seized 136 kilograms of heroin and 110000 dosage units of pharmaceuticals (Holt & Klarer, 2017). Therefore, it is easy to see a strong relationship between opioid abuse to the increase in the level of crimes and violation cases.
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At the same time, there are many medical emergency cases caused by opioid abuse. In particular, in 2009 around 4.6 million drug-related emergency cases were recorded (National Institute on Drug Abuse [NIDA], 2011). In 50% of the cases, the patients had problems with adverse reactions to the prescribed pharmaceuticals, while 45% were related to drug abuse (NIDA, 2011). In particular, heroin was involved in 213 118 emergency cases (NIDA, 2011). Rates for heroin abuse was the highest among people aged 21 to 24. Hence, the opioid crisis is an urgent problem in the US, which is supported by the provided statistical data.
Opioids use is regulated by the federal Controlled Substance Act established in 1970. It regulates the disposing, distribution, importing, use, processing, and manufacturing of specific drugs, including the opioids approved by medical applications. Another regulatory document is the Secure and Responsible Drug Disposal Act created in 2010. It authorized the DEA to expand the methods of controlled substances disposal and collection (Swanson, n.d.).In 2014, the rules were expanded and included regulations on the disposal of opioids through registered pharmacies, hospitals with on-site pharmacies, narcotic treatment programs distributors, and manufacturers with the ability to represent collection receptacles for a controlled substance (Swanson, n.d.). Furthermore, the Drug Addiction Treatment Act was created in 2010. It shaped the system for some physicians to gain waivers to prescribe schedule III, IV, and V drugs, including buprenorphine and naloxone for opioid dependence treatment (Swanson, n.d.). In general, almost all states implemented some form of the prescription drug monitoring program. Not all states mandate the application of the programs. However, most require the use of prescriptions for gaining access to the drugs under any circumstance. In particular, Tennessee and Main require prescribers and dispensers to check the program when prescribing opioids and then continue doing so at set intervals for as long as the prescription is being renewed (Swanson, n.d.). Hence, the regulations are provided by the federal government and state law legislation.
Importance for Healthcare Providers
The main goal of this paper is to explain the complexity of the opioid use situation. Nowadays, it is critical to understand the US experience with the opioid crisis due to a lot of cases of misuse, addiction, overdose, violence, and death. Hence, one must understand the nature of opioids and how to apply them appropriately. In particular, healthcare providers are obligated to understand these issues to save patients from making mistakes. Healthcare providers have the leading role in managing opioid abuse among patients. In particular, physicians have to realize that the opioid crisis can be managed through collaborating closely with community initiatives, detecting and treating opioid-dependent individuals, increasing awareness of the risk of opioid addiction, and limiting the prescription of opioids. Without realizing the seriousness of the problem, it is impossible to help the victims of drug abuse. Additionally, there is a great need for a coordinated approach to the issue on the state, regional, and local levels, because effective solutions would include different sectors within communities, such as social services, law enforcement, government regulators, and public health professionals. It is critical to increase awareness among healthcare providers because the negative effects of opioid misuse can lead to lethal consequences. Therefore, without knowing about the existence of the opioid epidemic, it is impossible to prevent emergency cases or the patients’ deaths.
It is possible to compare and contrast the opioid regulations in two states, particularly Connecticut and Massachusetts. Connecticut regulations allow veterinarians, nurse-midwives, advanced practice registered nurses, physician assistants, optometrists, podiatrists, dentists, and physicians to prescribe opioid antagonists within their practice scope (Dube, 2017). Additionally, the legislation after 2015 provides pharmacists with
the ability to prescribe medication in case they refrain from directing or delegating the other person to prescribe the medication or provide the training to the recipient, maintain training and dispensing records under the law’s recordkeeping requirements, train recipient of the opioid antagonists on how to administrate it, and act in good faith. (Dube, 2017)
Similarly, in Massachusetts, opioids can be prescribed by nurse anesthetists, nurse-midwives, nurse practitioners, optometrists, veterinarians, dentists, podiatrists, and physicians (Massachusetts Medical Society, 2016). Hence, the parties involved in the regulation are approximately the same, though more access is provided by nurses in Massachusetts.
At the same time, in Connecticut, the law prevents healthcare providers from prescribing opioids for more than seven days for grown people during their first-time outpatient use. The 2017 legislation reduces that amount to a five-day supply in cases of minors under 18 (Dube, 2017). In the case of prescribing an opioid drug to a minor, the law demands the healthcare provider to discuss the risks related to the opioid use with the minor and their legal custodian, guardian, or parent (Dube, 2017). The 2017 laws demand healthcare providers have such a conversation with adult patients. The discussion must include the reason why a prescription is needed, the dangers of taking opioids with benzodiazepines, alcohol, and other central nervous system depressants, and related risks of overdose and addiction.
The rule in Massachusetts is not the same. For adults, a first-time opioid prescription has to be limited to a seven-day supply. However, until there is further DPH guidance, the regulation applies to any opioids that belong to Schedule II-VI. Even Schedule IV and V prescriptions that have low abuse potential are covered (Massachusetts Medical Society, 2016). This cannot be used in case the prescription is necessary for the treatment of opioid dependence. Providers have to “document in medical record every time the outpatient opiate prescription is provided to the patient for such treatments to demonstrate that the prescription qualifies for a general exception to the prescribing limits” (Massachusetts Medical Society, 2016). The same requirements apply to minors.
At the same time, there are certain differences. In particular, it is possible to get a supply for longer than seven days in cases of acute pain management, palliative care, pain related to the cancer diagnosis, and chronic pain management if the patient is getting an opiate prescription for the first time (Massachusetts Medical Society, 2016). If the first time prescription is
provided for more than a seven-day supply under the exception, the prescriber has to indicate if there were known and available non-opiate alternatives, provide information about the actual condition or treatment that needs more than seven days, and document in the medical records the specific expectations for which the opiate is prescribed. (Massachusetts Medical Society, 2016)
In the case of minors, if the opiate prescription is provided for more than a seven-day supply, the healthcare provider has to document the conversation performed with the guardian or parent about the possible risks, detect whether the person utilized available non-opiate alternatives, present information regarding the treatment that requires more than seven days, and document the prescribed opioid palliative care, pain related to cancer, chronic pain management, or an acute medical condition (Massachusetts Medical Society, 2016). Hence, the procedure for minors is very similar to the regulations in Connecticut.
In conclusion, controlled substances in general and opioids, in particular, have a great influence on the state of health in the US. The situation is very complicated because opioids are a critical part of effective pain management. Nonetheless, there is another side to these drugs, because people can misuse opioids, which often leads to overdoses, deaths, and addiction. According to the analyzed statistical data, it is clear that the US is experiencing a great opioid crisis. It is possible to see that accidental deaths are prevalent due to opioids and it is extremely high, just as the prevalence of emergency cases. Additionally, opioid addiction relates directly to increased violence and crimes. The main reasons for opioid misuse are the desire to manage pain, experience euphoria, and the lack of readiness to speak about the problem. Therefore, the situation is critical and it is important to realize the great scale of the challenge. The government regulates opioid use in the states through federal and state legislation. In particular, it is possible to compare opioid legislation in Connecticut and Massachusetts. The legislation is quite similar in the two states. Healthcare providers play a great role in the opioid epidemic challenge. It is critical to promote awareness regarding this problem among healthcare providers because it is impossible to detect whether a person has problems with opioids or to prevent negative health consequences without realizing the nature of opioids and their effect on the psychological and physical state of the patients.
The paper helps to realize that it is critical to pay attention to the opioid-related complications and challenges to be ready to face them in practice with real patients who may be harmed due to the lack of awareness among healthcare providers. Further ignorance regarding the problem may lead to even more challenging consequences. Hence, it is important to act, and healthcare providers and legislators have to assume the leading roles in any such initiatives. Nowadays, there are a lot of legal regulations related to this problem, but they do not have the desired effect. It is critical to promote education programs that will raise the awareness level among patients and healthcare providers because both sides have made some efforts to reduce the prevalence of addiction, overdose, and deaths due to opioid abuse. This information will have a great influence on my future career because it will help me to realize the obstacle to providing patients with efficient assistance. After conducting the research, I gained an understanding of the scope of the problem, which will help me be more attentive to the patients taking opioids and more responsible in explaining the consequences of opioid abuse. Additionally, it will help me inspire other colleagues to be more active and efficient in combating opioid abuse.