January 01, 2018

Opioid Use Disorder: A Look Backward and a Path Forward

By Sarah E. Wakeman

Americans under age 50 are more likely to die from a drug overdose than from any other cause. The number of overdose deaths annually has now surpassed deaths due to car accidents, guns, or HIV. This public health crisis has been termed the “opioid epidemic” because the majority of these deaths are due to heroin, fentanyl, or prescription pain relievers. Some are now calling it a poisoning crisis as the drug supply is increasingly tainted with deadly synthetic fentanyl analogues. While an overdose can happen with any drug use, these deaths often occur in individuals with opioid use disorder, which we commonly refer to as addiction. This makes the tremendous loss of life all the more tragic; opioid addiction is a highly treatable illness, and nonfatal opioid overdose is a reversible condition.

While the current attention on the crisis of opioid-related deaths is recent, human use of opioids for pain relief and escape dates back thousands of years. Opioids are a class of drugs chemically similar to the opium poppy, Papaver somniferum. This includes naturally derived morphine and semi-synthetic and synthetic versions such as diacetylmorphine (better known as heroin) and prescription pain relievers like oxycodone. Sumerians called opium the “joy plant.” Homer wrote of it in The Odyssey, describing people who were overcome by a blissful forgetfulness after eating a mysterious plant. A renowned English physician in the 1600s, Thomas Sydenham, extolled the virtues of opium, stating, “Among the remedies which it has pleased Almighty God to give to man to relieve his sufferings, none is so universal and so efficacious as opium.”

Fast forward to the present. In 2015, an estimated 47.7 million people in the United States aged 12 years or older used illicit drugs or misused prescription drugs. Focusing on opioids specifically, in Massachusetts, it is estimated that 4.4 percent of the adult population has an opioid use disorder. In 2014, there were 92,262 emergency department visits and 53,000 hospitalizations for nonfatal opioid overdoses. In 2015, 52,404 people died from a drug overdose; 63 percent of these deaths involved an opioid. The burden of addiction is even higher in criminal justice–involved populations; an estimated 58 percent of state prisoners and 63 percent of sentenced jail inmates meet criteria for substance use disorder, and 26 percent and 28 percent, respectively, report a history of opioid use. The dramatic climb in rates of opioid overdose and opioid use disorder were correlated with accelerated physician prescribing of opioid pain relievers, driven in no small part by marketing techniques from pharmaceutical companies. Prescribed opioids fueled the current crisis; however, the details are more nuanced than popular narrative often suggests.

A common story we hear is a young person who was prescribed opioids for an injury or surgery and then developed an opioid use disorder. While this can certainly happen, the more common reality was a flood of excess opioid pills in the community, which led to nonmedical use and experimentation. The majority of people who misused opioid pain relievers reported getting them for free from a friend or relative, who, in turn, got them from one doctor. Greater access coupled with a lack of awareness about the risks of prescription opioids led to increased recreational use, and then for those vulnerable to addiction, the development of prescription opioid use disorder. From there, because of the cost of prescription opioids or because of decreased access, those individuals transitioned to illicit heroin, and now fentanyl. As one young man put it to me, “A few years ago OCs [referring to oxycodone] just disappeared and became harder and harder to get.” This highlights the complexity of the crisis. If all we do is make prescription opioids harder to access, those who have opioid addiction will simply transition earlier to illicit drugs. Given the current opioid supply, this really means an earlier switch to the Russian roulette of fentanyl, where any episode of use can result in death.

This timeline of opioid use is an external representation of the natural history of opioid use disorder. Early on, people use opioids to feel good or to feel relief. This may sound oversimplified, but it is worth remembering that people wouldn’t use opioids if there wasn’t some positive benefit. And for most people, opioid use doesn’t result in addiction. However, for a minority of vulnerable individuals, there is a gradual transition from using to feel good, to needing to use to feel normal, to needing to use just to keep from feeling sick. And this is the terrible cycle individuals get trapped in where changes in their body and brain mean that they can no longer function normally without an opioid in their system. We now know addiction is a chronic illness causally linked to genetics, which account for about half of a person’s risk, and environmental factors, such as early childhood trauma, co-occurring psychiatric illness, or exposure to peers who use drugs.

The defining hallmark of opioid addiction is compulsive drug use despite negative consequences. This is a crucial point to sit with and truly understand. Addiction is not a rational behavior. No person says, “When I grow up, I want to be addicted to heroin,” or “Today is the day I want to die from an overdose.” Those of us with prefrontal cortices not affected by drug use can examine the risks and benefits of a behavior and think about consequences and delayed gratification and make a choice to stop a behavior that leads to harm. However, for people with active drug use and addiction, that part of the brain stops functioning normally; we can actually see these changes on functional MRI images of the brain. So, expecting a person with active addiction to make a willful choice to simply stop using drugs would be akin to asking a person with diabetes and an under-functioning pancreas to simply will his blood sugar under control. Both illnesses are affected by behaviors and “choices,” yet they also are characterized by changes to biology. For most people, willpower alone will never be enough to get well.

The diabetes comparison is also useful when we look at effective treatment for opioid use disorder. Just as for diabetes, opioid use disorder is a chronic illness where the goal is not cure but rather successful treatment and remission. With diabetes, we use a combination of medication treatments, such as insulin; behavioral change, like diet and exercise; and ongoing support and monitoring. A similar set of strategies is most effective for opioid use disorder, with medication with behavioral support resulting in the best likelihood of remission and recovery. While some people are able to successfully manage their diabetes with behavior change alone, many aren’t. We don’t shame those who need insulin or hear people say they “believe” in dietary management but not in diabetes medication. Unfortunately, this is how people talk about addiction treatment, particularly when it comes to medications like buprenorphine or methadone.

One of the most common misperceptions about medications like buprenorphine or methadone is that you are replacing one drug with another or that people are “addicted” to these medications. Yet if you think about the definition of addiction—compulsive use of a drug despite harm—taking a daily medication allowing a person to feel normal, to work and parent and have relationships, to not get incarcerated or overdose does not meet the criteria of addiction. Taking a daily medication that improves health and quality of life is what we do for most chronic illnesses, yet we don’t say people are addicted to their blood pressure medication.

The misunderstanding about the importance of medications in treating opioid addiction is not only incorrect; it is incredibly unwise if our hope is to end the crisis of opioid addiction and related death. Methadone and buprenorphine have been extensively examined in rigorous scientific studies for decades. These medications activate the same receptor in the brain that all opioids do; however, they do so in a slow, stable way that restores normal functioning by relieving craving and withdrawal. This approach of using a chemically similar medication to manage a chronic illness where homeostasis has gotten disturbed is what we do for diabetes with insulin, hypothyroidism with thyroid hormone, or adrenal insufficiency with steroids. Methadone and buprenorphine are impressively effective. Both reduce the likelihood of relapse and ongoing drug use, health care costs, infectious complications like HIV or hepatitis C, and importantly the risk of death by more than 50 percent. In fact, a study published last year found that the risk of dying from overdose decreases nearly sixfold for people when they are in methadone treatment compared to no treatment. A third medication option is naltrexone, an opioid blocker. It also sticks to the opioid receptor, but instead of causing some opioid effect to relieve craving and withdrawal, it simply functions like a bodyguard, blocking other opioids. A long-acting injectable formulation of naltrexone is an effective relapse prevention tool for selected individuals after detoxification; however, existing research suggests it is less effective for all comers with opioid use disorder.

What about detox? How did we get this far without mentioning residential treatment and the “beds” that we hear so much talk about needing? Despite what policymakers and even some clinicians might say, detoxification or residential “rehab” has never been shown to be an effective treatment to keep people off of opioids. Studies have repeatedly shown that regardless of the duration of the detoxification process, a majority of individuals will relapse to opioid use unless they are started on medication treatment. It is astonishing that we continue to spend so much money on revolving doors of detoxification and residential stays despite minimal effectiveness and tremendous costs. In addition, these approaches can actually be harmful as the risk of overdose and death after leaving detoxification increases dramatically. However, the magical notion that one can go away for 30 days and get rid of this challenging chronic illness continues to sway public opinion and bankrupt families desperate to help their children and loved ones.

A last point to make is that people need to be alive to ultimately recover. If our goal as a society is to help people with this terrible illness get well, we also have to address how to keep them alive long enough for treatment and recovery to happen. A number of interventions have been proven to keep people who use drugs safe from overdose death or life-limiting infections. These include naloxone prescription, a medication that reverses an overdose; syringe exchanges, which offer sterile equipment to prevent infection; and safe consumption sites, which are medically supervised settings where people who use drugs can do so in a monitored way. These interventions have historically been made controversial, as if there is a conflict between reducing harm on the one hand and promoting treatment on the other. In fact, they are complementary and rooted in a patient-centered approach that recognizes people who use drugs are deserving of compassion and dignity. They are also evidence based, with research clearly demonstrating they save lives, increase the likelihood of addiction treatment entry, improve public safety, and advance public health. In the past, we referred to kindness and compassion for people who use drugs as being enabling. It is time to think instead about how to enable health and enable people to stay alive and get well.