The Centers for Disease Control and Prevention (CDC) has declared the overuse and abuse of opioids an epidemic (Hedegaard et al., 2018; Rudd et al., 2016). On average, 130 Americans die every day from an opioid overdose (CDC, 2019a). The United States consumes 99% of all the world’s hydrocodone, 80% of the world’s oxycodone, and 65% of the world’s hydromorphone prescription opiate supply. Twenty-five percent of all workers’ compensation costs relate to opioids, and $56 billion per year is spent on opioid abuse costs.
Trends of opioid overdose–related deaths have increased 5.5% annually, from 6 deaths per 100,000 people in the United States in 1999 to 16.3 in 2015. Rates of drug overdose deaths continued to increase. In 2017 the age-adjusted rate of drug overdose deaths (21.7 per 100,000) was 3.6 times the rate in 1999 (6.1 per 100,000).
The rate of drug overdose deaths involving synthetic opioids other than methadone, which include drugs such as fentanyl, fentanyl analogs, and tramadol, increased from 0.3 per 100,000 in 1999 to 1.0 in 2013, 1.8 in 2014, 3.1 in 2015, 6.2 in 2016, and was 9.0 in 2017. That is an increase of 45% from 2016 to 2017. The rate increased on average by 8% per year from 1999 through 2013 and by 71% per year from 2013 through 2017 (Hedegaard et al., 2018).
In 2017 the number of overdose deaths involving opioids (including prescription opioids and illegal opioids like heroin and illicitly manufactured fentanyl) was 6 times higher than in 1999 (CDC, 2019a). Clearly, America has an opioid epidemic that is claiming lives and lifestyles. Additional statistics, not as easily identified but very real, are the lost productive work hours and loss of meaningful lives, families, and marriages due to opioid abuse (ASAM, 2016).
Opioid drugs include:
- Codeine (only available in generic form)
- Hydrocodone (Hysingla ER, Zohydro ER)
- Hydrocodone/acetaminophen (Lorcet, Lortab, Norco, Vicodin)
- Hydromorphone (Dilaudid, Exalgo)
- Oxycodone (OxyContin)
- Fentanyl (Actiq, Duragesic, Fentora)
- Meperidine (Demerol)
- Methadone (Dolophine, Methadose)
Whereas natural opiates come from the opium plant and the active ingredient is morphine, semi-synthetic opioids are those created in laboratories and include hydromorphone, hydrocodone, and oxycodone as well as the illegal drug heroin. All of these are called narcotics and are schedule II drugs, except for heroin, which is an illegal schedule I drug and hasn’t been approved for any medical use.
Substance abuse is global in scale and claims millions of lives worldwide. According to the World Drug Report 2019, published by United Nations Office on Drugs and Crime (UNODC) in 2017, some 53.4 million people worldwide had used opioids in the previous year, 56% higher than the estimate for 2016. Among those people, 29.2 million had used opiates such as heroin and opium, 50% higher than the 2016 estimate of 19.4 million.
North America continues to be the subregion with the highest annual prevalence of opioid use, with 4.0% of the population using opioids. North America has seen a rising number of overdose deaths resulting from the use of opioids. More than 47,000 opioid overdose deaths were recorded in the United States in 2017, an increase of 13% from the previous year. Those deaths were largely attributed to synthetic opioids such as fentanyl and its analogues, which were involved in nearly 50% more deaths than in 2016. In Canada, nearly 4,000 opioid-related deaths were reported in 2017, a 33% increase from the 3,000 overdose deaths reported in 2016. Fentanyl or fentanyl analogues were involved in 69% of those deaths in 2017, compared with 50% in 2016 (UNODC, 2019)
In 2017 the states with the highest rates of death due to drug overdose were West Virginia (57.8 per 100,000), Ohio (46.3 per 100,000), Pennsylvania (44.3 per 100,000), the District of Columbia (44.0 per 100,000), and Kentucky (37.2 per 100,000).
States with statistically significant increases in drug overdose death rates from 2016 to 2017 included Alabama, Arizona, California, Connecticut, Delaware, Florida, Georgia, Illinois, Indiana, Kentucky, Louisiana, Maine, Maryland, Michigan, New Jersey, New York, North Carolina, Ohio, Pennsylvania, South Carolina, Tennessee, West Virginia, and Wisconsin (CDC, 2019a).
You are a medical/surgical nurse and a patient who has orders for hydrocodone is complaining of pain rated at 5 out of 10. What nonpharmacologic options do you have to help with pain reduction? How often do you offer those to your patients? Is your healthcare facility supportive of your efforts to offer nonpharmacologic options for pain control?
Defining Use and Abuse
Clarifying the difference between dependence and addiction is important to better understanding of the issues in opioid use and abuse. Dependence is the physical tolerance of the drug that requires increased amounts of the drug to achieve the desired response. Withdrawal of the drug will result in physical symptoms such as shaking, tremors, nausea, and vomiting. Addiction/substance use disorder, is a behavioral disorder that refers to the emotional desire for the drug and the desired effects it brings, which often creates strong drug-seeking behaviors.
The DSM-5 defines opioid use disorder (OUD), as a disorder characterized by loss of control of opioid use, risky opioid use, impaired social functioning, tolerance, and withdrawal. Tolerance and withdrawal do not count toward the diagnosis in people experiencing these symptoms when using opioids under appropriate medical supervision. OUD covers a range of severity and replaces what DSM-IV termed “opioid abuse” and “opioid dependence.”
An OUD diagnosis is applicable to a person who uses opioids and experiences at least 2 of the 11 symptoms in a 12-month period (SAMHSA, 2018). Generally, those who are dependent on opioids will vary between feeling sick without the drug and the desired high after taking the drug. Being addicted to the drug (having OUD) will motivate a person to do whatever it takes to get and take the drug to avoid the dreaded withdrawal symptoms.
Withdrawal symptoms include the following:
- Intense drug cravings
- Depression, withdrawal fears, anxiety
- Sweating, watery eyes, runny nose
- Restlessness, irritability
- Dilated pupils
- Diarrhea, abdominal cramps
- Fever and chills
- Muscle spasms
- Tremors and joint pain
- Nausea and vomiting
- Elevated heart rate and blood pressure (ASAM, 2015)
People at risk for opioid dependence and addiction are seen in every age, gender, ethnicity, and culture. Physical dependence varies. A genetic component has been identified that influences how quickly a person may slide from occasional use to physical need and addiction to the drug (Kreek et al., 2005). Susceptible populations have typically included the homeless, alcoholics, and those with personality or mental health disorders who look for a way to block the emotional pain of life stressors. Healthcare professionals, who experience great work stress, have a higher risk of becoming dependent or addicted to opiates following back or other injuries and having easier access to narcotics in their work setting (NCSBN, 2014, 2011).
- A drug user who wants the drug for a party.
- The drug user who depends on his dealer for a steady supply.
- A person who uses the drug regularly and now physically depends on an increase of the drug.
- The person who takes opioids occasionally for entertainment and to feel pleasure.
A: Change in level of consciousness and pinpoint pupils.