U.S. Opioid Epidemic: Misconceptions and Prevention

Opioid use disorders (OUDs) are so prevalent in the United States that a national emergency to address this public health crisis was declared in 2017 (Broglio). While there is definitely a problem with opioids and opioid-related morbidity and mortality in America, one needs to delve into the numbers before an accurate assessment can be made.

A common expression used to describe the problem is “epidemic.” The term epidemic itself can be misleading and emotionally charged as it suggests a widespread disease that is usually highly contagious (Kroenke). As concern broadens and emotional intensity rises, data that are quoted to raise awareness and determine causes of the opioid epidemic can become clouded and statistics can become confusing or conflated (Oliver). Evaluating the facts and misconceptions about the opioid crisis can help uncover what is truth and what is error.

Complications in Interpreting Data

When a headline reports on prescription opioid deaths, it is assumed that opioids are the direct cause of death. The fact is that prescription opioid-related deaths are deaths where prescription opioids are present at the time of death but may not be the cause of the death (Oliver). The presence of an opioid may not be the cause of death but, unfortunately, if present will be listed as one or more of the causes of death (Schatman). This determinant increases the number of opioid deaths on paper when in reality it may not have been the ultimate cause. For example, a death may be caused by an overdose (OD) of acetaminophen, but if there was hydrocodone detected, even in minor amounts, and it had been used according to the prescribed directions, it would also be classified as a prescription opioid death (Oliver). The opioid wasn’t the cause, but it was present, so it’s listed as an opioid-related death.

Another problem with interpreting opioid data is that if a death occurs and multiple opioids are present, each drug is listed under its specific category, which increases the overall total by each specific opioid category, not just one. According to the National Institute on Drug Abuse (NIDA/2018), the sum of deaths involving specific types of opioids (synthetics, heroin, natural and semisynthetic, and methadone) was approximately 63,000 in the provisional data for 2017. However, the actual number of people who died with deaths classified as involving opioids for 2017 was much less—approximately 49,000 deaths (NIDA/2018). Multiple drugs detected at the time of death causes the total number of deaths attributed to specific opioids to be greater than the total number of deaths recorded (Oliver).

The emergence of highly potent and toxic synthetic opioid products (e.g. fentanyl and analogues) has been identified as the distinct contributing factor to recent spikes in opioid-related mortality in the United States and Canada (Lucyk). These illicitly produced and distributed opioid products have appeared and proliferated in North America only during recent years, with many distributed as counterfeit prescription (including prescription opioid) drugs or mixed in with other drug products (e.g. heroin or cocaine) which render ready detection, either by consumers or law enforcement, highly difficult (Armenian). In both countries, opioid-related mortality has led to discernable reductions in life expectancy across the general population (Case). The present opioid mortality crisis has been widely characterized as a “fentanyl” epidemic, consequently implicating synthetic opioid drugs as the primary culprit of the unprecedented death toll, although their predominant role and impact has been regionally inconsistent and heterogeneous across North America (Fischer).

Difficulties in Reporting Opioid-Related Deaths

It is difficult to provide numbers on opioid-related deaths and injuries because sources of that information all have different reports. Some published work list deaths per day, others give an annual total, while still others list the deaths per 100,000 people. Here are a few examples that show the difficulty of comparing and contrasting published information:

When reporting on the opioid epidemic prevention problem, the authors stated 115 overdose deaths occur per day from prescription and illicit opioid misuse (Fraser). The authors further stated the deaths in 2016 from drug overdose surpassed the total number of deaths that occurred in the Vietnam War. The publication did not state what that number was or clarify if it included only opioids or general drug overdose.
The Center for Disease Control (CDC) reported in 2018 there were 47,590 opioid-related deaths.
The National Institute of Drug Abuse reported in 2019 there were 21.7 deaths per 100,000 people from opioid overdose in the 2016 calendar year. It is impossible to know if this is the same number reported by Fraser et al. because they listed the cases per day.

It is difficult to compare different publications when the way they report the information is entirely different from others. Readers must be willing to take a more in-depth look on their own to get the answers they are looking for. Drug overdose, compared to opioid overdose, compared to opioid overdose involving prescriptions and/or illicit opioids are all very different and articles need to be vetted to ensure the wanted categories are being reviewed.

Preventing Opioid Abuse

No matter the ultimate finding, it is obvious there is an opioid problem on some level in the United States. Rectifying the opioid problem starts with educating the public to prevent them from misusing and abusing opioids on any level. Successful primary prevention is contingent on three critical prerequisites (Strand):

The disorder being prevented must have a detectable preclinical phase, during which individuals with elevated risk of the disorder can be identified and their progression stopped.
A tool for identifying individuals at risk who would benefit from primary prevention is required; frequently, this is a risk-stratification tool. The Opioid Risk Tool (ORT) is a tool used to stratify patients receiving an opioid prescription for risk of opioid misuse (Webster). Whatever tool is used, the main purpose is to be able to identify individuals who are at higher risk for OUD.
This risk-stratification tool needs to be used among a population with elevated prevalence of the condition seeking to be identified, which increases the overall accuracy of the results. Examples of that population are individuals being first exposed to opioid medications, those on chronic medication, and patients with chronic pain.

The National Academies of Science, Engineering, and Medicine developed a framework that groups prevention strategies into universal, selective, and indicated interventions (Springer).

Universal Interventions

Limiting exposure to increasingly potent painkillers is an important part of current efforts to prevent addiction in the first place (Fraser). Larger social and environmental factors, such as lack of hope and purpose, are powerful drivers of addiction that require policies that prevent despair and support quality education, meaningful employment, stable housing, and justice reforms supportive of recovery (Fraser).

Selective Interventions

Selective prevention strategies are directed toward specific communities or subpopulations in which the risk of developing addiction may be higher than average (Fraser). Targeted, selective approaches to mitigating the impact of adverse community events include expanding life skills training in areas that are economically distressed, proactive screening and treatment of maternal depression, changing treatment and prevention services in jails and prisons, and creating a culture of trauma-informed care in health, social services, and law-enforcement worksites (Dasgupta).

Indicated Interventions

Indicated strategies can be used to screen and identify individuals who may already be in the early stages of addiction. In clinical settings, prescription drug monitoring programs allow clinicians to monitor individual patient use, to identify those seeking opioids inappropriately, and to counsel and refer patients to treatment and recovery programs when indicated (Fraser). In community settings, controversial but effective harm-reduction strategies such as syringe and needle exchange programs are saving lives and providing direct opportunities for public health and healthcare professionals to refer individuals to treatment and recovery programs (Fraser).

Summary

While this is not the first drug crisis in America, it is the deadliest and most costly in terms of lives lost, decreased life expectancy, lost productivity, crime, violence, and the devastating impact of addiction on families and communities (Neville).

Data must be presented to healthcare providers and to the public in factual and non-sensationalized ways, such as clearly separating prescription opioids from other opioids and drugs. Data also should not be cherry-picked to support a particular viewpoint, such as the amount of global opioids consumed in the United States, which may seem inflated if divorced from the knowledge of the lack of access to opioids in many countries and specific opioids that are simply not used in other developed countries (Oliver). With the development of a more detailed, accurate overview of the state of the opioid epidemic in the United States, we can better initiate practical steps to improve prevention and treatment early on.

References

Armenian P, Vo KT, Barr-Walker J, Lynch KL. Fentanyl, fentanyl analogs and novel synthetic opioids: A comprehensive review. Neuropharmacology. 2018;134(Pt A):121–32.

Broglio K, Matzo M. Perspectives on palliative nursing: Acute pain management for people with opioid use disorder. American Journal of Nursing. 2018;118(10), 42-56.

Case A, Deaton A. Rising morbidity and mortality in midlife among white non-Hispanic Americans in the 21st century. Proc Natl Acad Sci U S A. 2015; 112(49):15078–83.

Center for Disease Control and Prevention. National Center for Health Statistics: Provisional Opioid Overdose Death Counts. 2019. https://www.cdc.gov/nchs/nvss/vsrr/drug-overdose-data.htm.

Dasgupta N, Beletsky L, Ciccarone D. Opioid crisis: no easy fix to its social and economic determinants. Am J Public Health. 2018;108(2):182–186.

Fischer B, Vojtila L, Rehm J. The ‘fentanyl epidemic’ in Canada – some cautionary observations focusing on opioid-related mortality. Prev Med. 2018;107:109–13.

Fraser M, Plesacia M. The opioid epidemic’s prevention problem. AJPH. 2019; 109(2):215-217.

Kroenke K, Cheville A. Management of chronic pain in the aftermath of the opioid backlash. JAMA. 2017;317(23), 2365e2366.

Lucyk SN, Nelson LS. Novel synthetic opioids: an opioid epidemic within an opioid epidemic. Ann Emerg Med. 2017;69(1):91–3.

National Institute on Drug Abuse. Overdose death rates. 2018. https://www.drugabuse.gov/related-topics/trends-statistics/overdose-death-rates.

National Institute of Drug Abuse.Opioid-related overdose deaths. 2019. https://www.drugabuse.gov/opioid-summaries-bystate/new-jersey-opioid-summary.

Neville K, Foley M. The Economic Impact of the Opioid Use Disorder Epidemic in America: Nurses’ Call to Action. Nursing Economics. 2020;38(1):7-16.

Oliver JE, Carlson C. Misperceptions about the ‘Opioid Epidemic’: Exploring the facts. Pain Management Nursing. 2019;21,100-109.

Schatman ME, Ziegler SJ. Pain management, prescription opioid mortality, and the CDC: Is the devil in the data? Journal of Pain Research. 2017;10, 2489e2495.

Springer JF, Phillips J. The Institute of Medicine Framework and its implication for the advancement of prevention policy, programs and practice. Substance Abuse and Mental Health Services Administration. 2007. http://ca-sdfsc.org/docs/resources/SDFSC_IOM_Policy.pdf. Accessed November 26, 2018.

Strand MA, Eukel H. A primary prevention approach to the opioid epidemic. AJPH. 2019;109(6):861-863.

Webster LR, Webster RM. Predicting aberrant behaviors in opioid-treated patients: preliminary validation of the Opioid Risk Tool. Pain Med. 2005;6(6): 432–442.

Dan Bunker DNAP, MSNA, CRNA—Dan has worked in the healthcare industry for nearly 30 years. He worked as a registered nurse in the coronary care ICU for 7 years and was a flight nurse with Intermountain’s Life Flight for nearly 10 years. He has been a certified registered nurse anesthetist (CRNA) for 11 years, working in the hospital setting as well as maintaining his own private practice. In addition, he is a professor in the nurse anesthesia program at Westminster College in Salt Lake City, Utah. He has served in various leadership roles within the Utah Association of Nurse Anesthetists (UANA) and is currently the president-elect.