Exploring the Opioid Epidemic: A Three-Act Tragedy

Opioid use disorder (OUD) is a substance use disorder characterized by cravings for opioids, continued use despite physical and/or psychological deterioration, increased tolerance with use, and withdrawal symptoms after discontinuing opioids. Opioid withdrawal symptoms include nausea, muscle aches, diarrhea, trouble sleeping, agitation, and a low mood.[12] Addiction and dependence are important components of opioid use disorder.[13]

Risk factors include a history of opioid misuse, current opioid misuse, young age, socioeconomic status, race, untreated psychiatric disorders, and environments that promote misuse (social, family, professional, etc.).[14][15] Complications may include opioid overdose, suicide, HIV/AIDS, hepatitis C, and problems meeting social or professional responsibilities.[16][17] Diagnosis may be based on criteria by the American Psychiatric Association in the DSM-5.[17]

Opioids include substances such as heroin, morphine, fentanyl, codeine, dihydrocodeine, oxycodone, and hydrocodone.[5][6] A useful standard for the relative strength of different opioids is morphine milligram equivalents (MME).[18] It is recommended for clinicians to refer to daily MMEs when prescribing opioids to decrease the risk of misuse and adverse effects.[19] Long-term opioid use occurs in about 4% of people following their use for trauma or surgery-related pain.[20] In the United States, most heroin users begin by using prescription opioids that may also be bought illegally.[21][22]

People with opioid use disorder are often treated with opioid replacement therapy using methadone or buprenorphine.[23] Such treatment reduces the risk of death.[23] Additionally, they may benefit from cognitive behavioral therapy, other forms of support from mental health professionals such as individual or group therapy, twelve-step programs, and other peer support programs.[24] The medication naltrexone may also be useful to prevent relapse.[10][8] Naloxone is useful for treating an opioid overdose and giving those at risk naloxone to take home is beneficial.[25]

This disorder is much more prevalent than first realized.[26] In 2020, the CDC estimated that nearly 3 million people in the U.S. were living with OUD and more than 65,000 people died by opioid overdose, of whom more than 15,000 overdosed on heroin.[27][28] In 2022, the U.S. reported 81,806 deaths caused by opioid-related overdoses. Canada reported 32,632 opioid-related deaths between January 2016 and June 2022.[29][30]

History

2D structure of semi-synthetic opiate buprenorphine.

Historical misuse

Opiate misuse has been recorded at least since 300 BC. Greek mythology describes Nepenthe ("free from sorrow") and its use by the hero of the Odyssey. Opioids have been used in the Near East for centuries. The purification and isolation of opiates occurred in the early 19th century.[31] In the early 2000s, buprenorphine was one of the first opioid dependence drugs approved in the U.S. to combat opioid abuse, after decades of research led to the development of drugs to fight opioid use disorder.[32]

Historical treatment

Levacetylmethadol (LAAM) was formerly used to treat opioid dependence. In 2003, its manufacturer discontinued production. There are no available generic versions. LAAM produced long-lasting effects, which allowed the person receiving treatment to visit a clinic only three times per week, as opposed to daily as with methadone.[33] In 2001, LAAM was removed from the European market due to reports of life-threatening ventricular rhythm disorders.[34] In 2003, Roxane Laboratories, Inc. discontinued it in the U.S.[35]

Diagnosis

The DSM-5 guidelines for the diagnosis of opioid use disorder require that the individual has a significant impairment or distress related to opioid uses.[4] To make the diagnosis two or more of 11 criteria must be present in a given year:[4]

More opioids are taken than intended

The individual is unable to decrease the number of opioids used

Large amounts of time are spent trying to obtain opioids, use opioids, or recover from taking them

The individual has cravings for opioids

Difficulty fulfilling professional duties at work or school

Continued use of opioids leading to social and interpersonal consequences

Decreased social or recreational activities

Using opioids despite being in physically dangerous settings

Continued use despite opioids worsening physical or psychological health (i.e. depression, constipation)

Tolerance

Withdrawal

The severity can be classified as mild, moderate, or severe based on the number of criteria present.[6] The tolerance and withdrawal criteria are not considered to be met for individuals taking opioids solely under appropriate medical supervision.[4] Addiction and dependence are components of a substance use disorder; addiction is the more severe form.[36]