United States Opioid Crisis

United States Opioid CrisisCharleen TorresLewis University College of Nursing and Health ProfessionsUnited States Opioid CrisisOn October 26, 2017 President Donald J. Trump declared the opioid crisis a public health emergency (“The Opioid Crisis,” n.d.). This announcement shed light on the staggering number of deaths claimed by opioids. The Centers for Disease Control and Prevention (2018) report that an estimated 130 Americans die every day from an opioid overdose. The President’s Commission on Combating Drug Addiction and the Opioid Crisis chaired by New Jersey’s Governor, Chris Christie, later submitted a 138-page report that offered a more in-depth look and potential solutions for the opioid crisis. The Commission reported that the largest opioid-related deaths were linked to people who have recently been released from prison, those who combine prescription opioids with other scheduled medications, and those who receive opioid prescriptions from multiple doctors and pharmacies (“The Opioid Crisis,” n.d.). Opioid misuse is more prevalent in young adults ages 18 to 25 years old. A study conducted by the National Survey on Drug Use and Health (NSDUH) revealed that opioid use disease (OUD) was 72.29% among whites, 13.82% among Hispanics, 9.23% among African-Americans, and 4.66% among others (“The Opioid Crisis,” n.d.). Other factors also contributed to OUD. These include: people in low income communities making less than $50,000 annually, those living in large metropolitan areas, and those who are male. Deaths resulting from opioid overdoses have surpassed traffic fatalities and deaths related to other drugs. It is estimated that overdose deaths, drug addiction, and prescription opioid misuse have cost the United States approximately $111 billion dollars (“The Opioid Crisis,” n.d.). Along with this amount, comes an inestimable burden; the pain and suffering of friends and family members of those who keep fighting or have lost the battle to opioid addiction. In an effort to make these stories known and raise awareness, the White House launched a new website, CrisisNextDoor.gov (“The Opioid Crisis,” n.d.). This website created a safe space for people to tell their personal stories of how the opioid epidemic has affected them, and also provides resources for those seeking help. In its opening letter, the President’s Commission on Combating Drug Addiction and the Opioid Crisis (2017) compared opioid abuse to a terrorist organization. They pleaded, “If a terrorist organization was killing 175 Americans a day on American soil, what would we do to stop them? We would do anything and everything. We must do the same to stop the dying caused from within.” In order to prepare for the fight, the administration and other agencies began by taking a closer look at where the problem began. Causes of Prescription Opioid Epidemic in the United StatesIn order to better understand the causes of opioid use disease (OUD), it is important to define two terms that are often mistakenly used interchangeably: opiate and opioid. Opiates are drugs that come from the opium poppy plant, such as codeine, heroin, and morphine. In order to avoid reliance on the poppy plant, scientists in the 1800’s synthesized variations of opiates and created opioids. Opioids come in different forms such as tablets, injections, and capsules. Opioids are either entirely or partially synthetic. Some of the most common synthetic opioids include: butorphanol, diphenoxylate, fentanyl, meperidine, methadone, pentazocine, propoxyphene. Common semi-synthetic opioids include: buprenorphine, hydrocodone, hydromorphone, nalbuphine, oxycodone, oxymorphone (Liu, Pei, & Soto, n.d.). The first opioid crisisThe United States experienced its first opioid crisis in mid-to-late-19th century as a result of unrestricted opioid prescriptions by physicians in an effort to treat injuries and ailments tormenting Civil War combatants and veterans. Unregulated production and shipments of opium along with clandestine distributors exacerbated the crisis. Opioid addiction made its way to urban and rural areas, and left its imprint with heroin addiction in large cities during the 20th century. Medical professionals began to recognize and openly discuss the adverse side effects of these drugs. Local and federal agencies began by taxing opium and passing regulations like the Controlled Substances Act of 1970. The United States Drug Enforcement Agency (DEA) was put in charge of enforcing the Controlled Substances Act of 1970, which established policies to regulate the manufacturing, importation, possession, distribution, and use of narcotics (“The Opioid Crisis,” n.d.). OxyContin paves the way for addictionDr. Lockwood’s (2018) piece describes how people became obsessed with treating chronic pain. This led to labeling pain assessment as the fifth vital sign. Purdue Pharma, a privately-owned company by the Sackler family in North Carolina, saw a big opportunity in this new approach to treat pain. In 1996, Purdue Pharma introduced OxyContin to the market. OxyContin was marketed as a sustained-release opioid whose properties would reduce peaks and troughs of narcotic levels that created addiction (Lockwood, 2018). This marketing campaign quickly became popular, and physicians began prescribing OxyContin at exponential rates. Purdue Pharma began courting doctors with conferences at resorts, gifts, and paid speakers. Oxycodone sales increased 287.3% between the years 2000 and 2010. As demand for OxyContin grew, so did unemployment rates with the collapse of the economy. Pill mills gained popularity, and Medicare recipients turned to them for OxyContin and then sold it for high dollar amounts (Lockwood, 2018). Soon, overdose deaths soared, and communities were at the mercy of opioids. Ohio’s Governor John Kasich was one of the first to tackle the problem in his home state. Other agencies, including The Joint Commission joined the fight, and took legal action against Purdue Pharma for misbranding OxyContin. Purdue Pharma pled guilty and paid over $600 million dollars in fines (Lockwood, 2018).Contributors to the crisisThe President’s Commission on Combating Drug Addiction and the Opioid Crisis included a section in their final report listing other factors that aggravated the opioid crisis (“The Opioid Crisis,” n.d.). The list included the following: unsubstantiated claims that falsely disassociated opioids from addictive tendencies, pain patient advocacy, the opioid pharmaceutical manufacturing and supply chain industry, rogue pharmacies, and unethical physician prescribing. Pain assessment labeled as the fifth vital sign, lack of regulation by the Food and Drug Administration (FDA), and reimbursement for prescription opioids by health care insurers also contributed to the crisis. Last, they blamed the lack of physician and patient education, the lack of national prevention strategies, and the unintended consequences no one predicted. When all these factors converged and OUD dramatically increased, the appropriate treatment and workforce did not grow with it, and the shortage of adequate resources was too significant to keep up (“The Opioid Crisis,” n.d.). Legal ActionNational legislationOn October 24, 2018, the Substance Use Disorder Prevention that Promotes Opioid Recovery and Treatment for Patients and Communities Act, or the SUPPORT for Patients and Communities Act became a public law. This law intends to focus on evidenced-based treatment and follow-up-care mainly for pregnant women, young adults, people living in rural areas, and those who are in the process of recovery from a substance use disorder. Only an estimated 20% of Americans battling opioid addiction reported receiving treatment in the last year (Davis, 2019). The SUPPORT for Patients and Communities Act plans to increase the access to opioid-agonist therapy and rehabilitation resources. Pregnant women and children are one of the main focuses of this law because women who use opioids during the gestational period are more likely to deliver a child suffering from Neonatal Abstinence Syndrome (NAS). The law makes it clear that states can now use Medicaid funds to pay for services to treat children suffering Neonatal Abstinence Syndrome. These services include counseling for mothers and caretakers. It will also allows former foster care youth to receive Medicaid coverage until age 26 inside and outside of the state where they aged out of the foster-care system (Davis, 2019).The law then turns its attention to older Americans by implementing screening methods for substance abuse. It mandates Medicare to cover treatment programs, including counseling and opioid-agonist therapy. Contrary to previous regulations, states can now use Medicaid funds to cover treatment in certain Institutions for Mental Disease (IMD) for up to 30 days for people 21 to 64 years of age who suffer from substance use disease. Those IMDs who are covered under Medicaid must comply with following evidence-based practices, and offer opioid-agonist medications and buprenorphine, a partial opioid agonist that can be given in low doses to produce sufficient agonist effects without producing withdrawal symptoms in opioid-addicted individuals. Those states who expand their Institutions for Mental Disease are prohibited from cutting back on spending for outpatient and community-based substance abuse services (Davis, 2019).State of Illinois legislationIllinois stands next to 30 other states that offers a strict medical marijuana program. On August 28, 2018, former Illinois Governor Bruce Rauner signed the Alternative to Opioids Act into law. The law aimed at reducing the recent surge of opioid overdose deaths, which showed an increase of 15.3 per 100,000 persons in 2016 from 3.9 per 100,000 persons in 1999 (Barnas, 2019). Illinois hopes that those who receive or qualify for opioid prescriptions will turn to medical marijuana instead of OxyContin, Percocet and Vicodin (Barnas, 2019). This law introduced major changes to medical marijuana regulation already in place. Before, providers were required to fingerprint and perform criminal background checks on all participants. This often led to patients being turned down. Just in the year 2017, the Illinois Department of Health denied 635 qualifying participants based only on their failed background checks. Shortly after Illinois introduced the Alternative to Opioids Act, the state of New York introduced a similar bill. A study conducted by the Journal of Pain Research in 2016 found a 64% drop in the use of opioids when replaced with medical marijuana. The medical marijuana program in Illinois is due to expire in July of 2020. However, the increasing movement of Illinois lawmakers to legalize marijuana statewide is predicted to gain support from the new Governor J.B. Pritzker (Barnas, 2019).There are those who argue that marijuana might not be the best alternative to opioid abuse. Marijuana continues to be classified as a Schedule 1 drug and this means that it has the same addictive tendencies as heroin. Adolescents who have experimented with marijuana often develop use of illicit and prescription drugs for nonmedical reasons. Marijuana has shown evidence of affecting physical and mental health, loss of memory, and respiratory diseases. There is also concern that medical marijuana may not address the underlying cause of an individual’s addictive behavior but will only worsen it. Last, people suffering from cancer, AIDS, or other immunocompromised conditions may experience harmful effects from medical marijuana. Doctors say that substituting opioids with medical marijuana will require years of extensive follow-up to prove its efficacy (Beach House, 2017). Solutions to Resolving the ProblemPreventionIn its final report, the President’s Commission on Combating Drug Addiction and the Opioid Crisis recommended that one of the first steps to fighting the epidemic is raise awareness. They stressed the need for a national public education campaign similar to the AIDS campaign in the 1980s. Their main targets are youth, their parents, and those who are 16 to 34 years old; a prime time for pregnancy, parenting, and addiction. While this is an approach that was effective in the 1980s, some worry that it may not be so easy to achieve with the opioid crisis. This is because consistency, cultural sensitivity, reinforcement in the home, schools, community, and workplaces, and delivery by influential adults and peers are all needed in unison for the message to reach its full potential (“The Opioid Crisis,” n.d.). Prescription drug monitoring programsThe CDC (2017) reports that states have begun to implement prescription drug monitoring programs (PDMP) by using electronic databases to keep track of statewide controlled substance prescriptions. PDMPs gives access to healthcare providers and pharmacists to patient’s prescribing history. This program not only aids in identifying patients who may be misusing prescription opioids, but it also identifies prescribers and distributors with patterns of inappropriate prescribing. However, the President’s Commission reported that only an estimated 35% of prescribers are registered with PDMPs. A study by the John Hopkins Bloomberg School of Public Health revealed that a staggering 86% of prescriptions for opioids written in the year 2015 were dispensed without analyzing the patient’s history via a PDMP database first (“The Opioid Crisis,” n.d.). Its is essential that healthcare providers make maximum use of PDMPs for it to be an effective measure against OUD. Expanded access and administration of naloxoneNaloxone is an opioid antagonist that can be administered intravenously, subcutaneously, or via an intranasal atomization device. This medication has been available for over forty years, and all 50 states and the District of Columbia, Guam, and Puerto Rico allow paramedics to administer it. The National Institute of Drug Abuse reports that only 12 out of these 53 jurisdictions allow emergency medical technicians (EMTs) to administer naloxone. This has become problematic because EMTs are usually the first on scene and sometimes the only ones. EMTs should be given the training and accessibility to naloxone to reduce overdose deaths, especially in areas that have paramedic shortages. Those who oppose the distribution of naloxone argue that making it more accessible will lead to risky opioid use. However, a study in Massachusetts showed no significant difference in the emergency department visits in communities with high or low overdose education and naloxone distribution programs (National Institute of Drug Abuse, 2018).The Nurses’ RoleNurses have the ability to play an essential role in reducing opioid addiction. It is important that they recognize the importance of patient and family education when opioids form part of patient’s treatment. Nurses need to stress the importance of avoiding opioid diversion by thoroughly explaining proper administration, proper safekeeping, and adequate disposal when the opioid is no longer needed (Manworren & Gilson, 2015). Patients should be reminded not to share opioids with friends and family, and to only take the opioid for symptoms it has been prescribed for. Nurses also need to carefully and systematically document when a patient is administered an opioid and how the patient responded to it. This is where quality patient assessment is vital because the patient might not always have the ability to communicate their symptoms. Careful documentation helps ensure that patients are not over or under medicated, and provides safe continuity of care. Nurses must also strive to stay informed in alternative and new ways to treat pain so that patients have options. Last, with the administration of opioids comes great responsibility. The nurse must be well educated in recognizing a patient who is in distress or in a life-threatening opioid reaction, and have naloxone readily available (Manworren & Gilson, 2015).ConclusionThe United States took a big step toward rehabilitation when President Trump declared the opioid crisis a national emergency. This mobilized the government to dig up the root of the problem in order to see just how deep opioids had cut through the nation. With a solid description of the birth of the opioid crisis in hand, officials and agencies across the country implemented programs and launched a massive opioid prevention campaign to stop overdose deaths and addiction. Healthcare professionals soon recognized the importance of evidence-based treatments, and just how bad false claims like those of Purdue Pharma can put a nation at the mercy of opioids. States have pushed for the implementation of prescription drug monitoring programs to monitor opioid use and prescriber tendencies. Time will determine if national and state legislation have been effective, or if any amendments need to be made. Those at the forefront of patient care, such as nurses, must recognize what a vital role they play in the fight against the opioid crisis and stay abreast of new developments. There is no telling when “opioid” and “crisis” will stop being in the same sentence, but for now the fight continues. ReferencesBarnas, J., (2019). Pilot program for medical marijuana as alternative to opioids goes into effect. Retrieved March 13, 2019, from https://www.illinoispolicy.org/pilot-program-for-medical-marijuana-as-alternative-to-opioids-goes-into-effect/ Beach House. (2017). Medical marijuana as an opiate treatment? Pros & cons of this eyebrow-raising method. Retrieved March 13, 2019, from https://www.beachhouserehabcenter.com/learning-center/medical-marijuana-as-an-opiate-treatment-pros-cons-of-this-eyebrow-raising-method/Davis, C., (2019). The SUPPORT for Patients and Communities Act: What will it mean for the opioid-overdose crisis? The New England Journal of Medicine, 380, 3-5. Retrieved from https://www.nejm.org/doi/full/10.1056/NEJMp1813961Liu, L., Pei, D., & Soto, P. (n.d.). Introduction to the Opioid Epidemic. Retrieved March 13, 2019, from https://www.poison.org/articles/introduction-to-the-opioid-epidemic-182Lockwood, Charles J,M.D., M.H.C.M. (2018). Why is there an opioid crisis? Contemporary OB/GYN, 63(2), 6-8,10. http://ezproxy.lewisu.edu/login?url=https://search-proquest-com.ezproxy.lewisu.edu/docview/2025302719?accountid=12073Manworren, R., & Gilson, A. (2015). CE: Nurses’ role in preventing prescription opioid diversion. American Journal of Nursing, 115(8), 34-40. https://ovidsp-tx-ovid-com.ezproxy.lewisu.edu/sp3.33.0b/ovidweb.cgi?QS2=434f4e1a73d37e8c6114a63cc85fea09cfcd755b663c246278ed7bcfafeNational Institute of Drug Abuse. (2018). Is naloxone accessible? Retrieved March 13, 2019, from https://www.drugabuse.gov/publications/medications-to-treat-opioid-addiction/naloxone-accessibleThe Opioid Crisis. (n.d.). Retrieved March 13, 2019, from https://www.whitehouse.gov/opioids/Understanding the Epidemic. (2018, December 19). Retrieved March 13, 2019, from https://www.cdc.gov/drugoverdose/epidemic/index.html