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Opioids: Reflections on
the Impact of Policies and |
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Author:
Madeline M. Roberts MPH,
PhD The CDC and National Vital Statistics System mark three waves in U.S. opioid overdose deaths beginning in 1999 with prescription overdose deaths, moving into heroin overdose deaths in 2010, and synthetic opioid overdose deaths beginning in 2013. In 2016, deaths from opioid overdose reached over 42,000, a US record. In 2017, The Department of Health and Human services declared opioid misuse and related overdoses a public health emergency. The advent of COVID-19 and the corresponding challenges and disruptions to daily life has intensified the opioid crisis. In 2021, drug overdose deaths again reached record heights—this time over 107,000 deaths in one year. Currently, fentanyl and fentanyl-tainted synthetic opioids are driving opioid overdose deaths (here, here, and here). Evidence and common practice among physicians for most of the mid-20th century was that opioids were not appropriate for chronic pain treatment because they could lead to misuse and addiction. However, opioid prescribing gradually became more common for cancer patients and for acute pain. In the mid-1990s, the American Pain Society began advocating for pain as the 5th Vital Sign. In 1999, The Veteran’s Health Administration included pain as the 5th Vital Sign in their pain management strategy. This was shortly followed by the Joint Commission on Accreditation of Healthcare Organizations releasing standards for the assessment and treating of pain. The 1990s marked an increase in the prescription of opioids, which grew substantially in the early 2000s.Overdose deaths began to climb during this time. Hindsight of course offers the best vantage point, but perhaps the most striking part of this history is the overwhelming lack of quality evidence presented on long-term opioid use and dependence. The evidence base appears to have been repeated citation of relatively non-robust studies (one example here). An excellent, concise history of opioid use and related literature can be found here. Approximately 75% of opioid abusers reported their first opioid was a prescription drug, and individuals and state and local governments have demanded accountability from pharmaceutical corporations. Major settlements (here and here) totaling around $32 billion were reached in early 2022 between drug corporations and the majority of US state and local governments. Current strategies, approaches, resources Recent evidence from the Stanford-Lancet Commission on the North American Opioid Crisis projects 1,220,000 opioid-related deaths by 2029, and shows that increasing naloxone (an opioid antagonist, which rapidly reverses opioid overdose) availability by 30% could avert 25% of opioid deaths. Other helpful interventions include pharmacotherapy, syringe exchange, psychosocial treatment, and prescription monitoring programs (PMPs). One public health approach, harm reduction, acknowledges that some ways of using drugs are safer than others and therefore aims to mitigate the harmful consequences for people using drugs as opposed to focusing on drug use cessation. One such strategy is overdose prevention centers (OPCs), which provide a safe place to use pre-obtained drugs and trained staff prepared to intervene in the event of an overdose. This includes supervision of drug consumption as well as offering resources and services such as clean syringes, naloxone, and testing drugs for fentanyl. Importantly, people who use OPCs can receive or be linked to additional support services such as food and housing, medical support, and addiction treatment, among others. OPCs also emphasize social justice and dignity for people who use drugs who are often marginalized. New York opened the first OPCs in the United States on November 30, 2021, which saved dozens of lives within months of opening. This commentary offers a thoughtful summation of current evidence on OPCs, including their association with reduced public drug consumption and crime in the surrounding neighborhoods, as well as barriers and pushback in some areas. The authors also highlight the need for appropriate outcome measurements for OPCs so as to accurately reflect public health outcomes and objectives.
The opioid crisis is a multi-faceted, devastating story
with reflection points for everyone from physicians and epidemiologists to
policymakers, parents, and friends. Currently, evidence-based
interventions in this area do exist. We need all the bright minds and
hands to continue this research and carry forward this work. ■ |
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