Do you know how many overdose-related deaths occurred in 2017? According to data that was collected by the CDC, and graphs showing trends found on the National Institute on Drug Abuse (2019) showed that the number is 70,237. Out of the 70,237 drug overdoses 47,600 were caused by opioids of any kind. Out of the 47,600 opioid-related overdoses, 17,029 were caused by prescription opioids.
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If we unpack that data we see that nearly 68% of the overdoses are caused by opioids, and around 36% of the opioid overdoses were caused by prescription opioids. Many things may be to blame, but seeing that prescription opioids made the list, one question should be asked. Should physicians have restrictions when it comes to prescribing opioid medications?
Before beginning any further with this issue of the opioid crisis, we must first understand what an opioid is. According to Merriam-Webster dictionary, it stats that it is “any of a group of endogenous neural polypeptides that bind especially to opiate receptors and mimic some of the pharmacological properties of opiates.” (Opioid, 2019) The Merriam-Webster also listed another definition that pertains to more the synthetic opioids that have the same properties as opioids but aren’t derived from nature. There are three main classes that opioids can fall into, they can be either “opium alkaloids, semi-synthetic, [or] fully synthetic” (Kumar, Manish, & Zafar, 2010). The Opium alkaloids are opioids that are naturally derived from the opium plant which an example is morphine. Semi-synthetic opioids contain opium, but are modified in a lab and examples include oxycodone, hydrocodone, etc. The final category of opioids are made in a lab and include fentanyl. One thing that we must keep straight when talking about opioids is that they shouldn’t be called narcotics. Narcotics is a term used in the legal world that “refers to opioids and a few other drugs that are grouped with opioids” (Rosenblum, Marsch, Joseph, & Portenoy, 2008). However, it doesn’t help to know what opioids are, but rather how they work within the body.
The whole mechanism of how opioids work can be quite complicated. There are a number of different receptors that are receptors for opioids. According to an article in the Journal of Anaesthesiology Clinical Pharmacology it talks about the Mu, Delta, and Kappa receptors within the nervous system. Each of these receptors affects a different area of the body. For example, the Delta receptor can “cause spinal and supraspinal analgesia” (Pathan & Williams, 2012) or the Mu can affect respiratory, cardiac, and the GI tract. However, the article does state that out of all the receptors, “the most important is [the] mu receptor” (Gupta & Atcheson, 2013). The British Journal of Pain goes into more detail of how opioid interact at the cellular level.
The British Journal of Pain says that all of these receptors utilized G-proteins. That means that inside the cell, there is a production of a second messenger that is needed to create the opioid effect on the body. An article written by Hansan Pathan and John Williams (2012), published in the British Journal of Pain, lays out a sequence of what goes on inside a cell after the opioid binds to its receptor. Here are how the events unfold starting with the binding of the opioid to the receptor. Once the opioid binds to the receptor it activates the subunits of G-proteins attached to the receptor. The article mentions that the “ subunit…exchange[s] its bound guanosine diphosphate (GDP) molecule with intercellular guanosine triphosphate (GTP)” (Pathan & Williams, 2012). What that means is that there is a creation of another energy molecule within the cell that isn’t ATP. It is the phosphorylation, meaning adding another phosphate, of the GDP to form the GTP.
We see that the subunit is bound to GTP, but there is also another subunit that is free to interact inside the cell, called the subunit. These don’t really matter since in this second messenger system turns ATP into cAMP with the help of adenylate cyclase. This is one of many different second messenger systems that cells can utilize for different processes. For the opioid, after the subunit breaks away, it goes and blocks adenyl cyclase which in turn inhibits the production of cAMP. Pathan and Williams (2012) also tell us that by decreasing the amount of cAMP in the cell, there are closures of the Ca2+ channels and the opening of K+ channels. This would cause what is known as a hyperpolarization of a cell and if it happened in “neuronal cells, [it would have] reduced neurotransmitter release” (Pathan & Williams, 2012).
So, you can see that the mechanism of how an opioid works can be complicated. However, we know that opioids reduce the pain that we feel. The question then becomes; how do opioids block or numb our pain? Well, in the same article written by Pathan and Williams (2012), there is a brief section that talks about this. It talks about how an opioid can cause an inhibitory effect that disrupts “nociceptive transmission” (Pathan & Williams, 2012). Nociceptors are what are known as pain receptors that are spread throughout the body. By blocking or reducing their transmission to the brain, causes the lessening of the pain that we feel. That is how the opioid works to help us reduce the pain that we feel.
Now that we know pretty well how an opioid works within the body, we must take a step back to look at how this crisis came to be. The graphs that I alluded to earlier, kept track of all the opioid overdose deaths since 1999 up to 2017. Why have they kept track of the overdose opioid deaths since 1999? The US Department of Health and Human Services had a little infographic that talked about this problem briefly. It mentioned that it wasn’t until the late 1990s that this crisis began. The infographic talked about pharmaceutical companies telling medical professionals that opioids were completely safe to use (Public Affairs, 2019). This began the cascade effect of prescribing opioids for any type of pain. This was brought about because it was the fear of doctors that “pain was going untreated” (Felter, 2019) and the pressure from patients. From the article talking about The U.S. Opioid Epidemic, it mentions that pharmaceutical companies did false advertising with opioids by saying that “they posed little risk” to the people who took them.
The flip side to this issue are the physicians that are prescribing the opioid medication. According to the article. The U.S. Opioid Epidemic, it talks about how healthcare providers feel pressured to give their patients opioids for pain. The article stated that this is because “patients request them” (Felter, 2019) over other treatments like acupuncture because opioids are cheaper than the alternative pain treatments. This is where the problem really lies when it comes to physicians prescribing opioids. It boils down to doing what is beneficial to the patient. However, there is something that has to be done to make alternative pain treatments more affordable and accessible to patients.
Now, we can weigh the benefits that come with using opioids and the risks that come from opioid usage. To begin, let’s take a look at how opioids are beneficial to someone. The most obvious answer to this is the fact that opioids are great for managing “acute severe pain and chronic pain related to advanced medical illness” (Rosenblum et al., 2008). Chronic pain is a gray area when it comes to prescribing opioids because this is a longer-term problem. However, with what this quote is saying in regards to chronic pain with an advanced medical illness, it is referring to a chronic disease like cancer. That is basically the main and only benefit to using an opioid.
The most common risk of using an opioid that everyone knows about is the addiction. However, if you also look at the side effects of opioids, there are some pretty nasty things that can happen. The more common side effects include “drowsiness, constipation, nausea, vomiting…” (Gupta & Atcheson, 2013). Another major risk that I mentioned earlier is the risk of addiction or death. There is a difference between addiction, tolerance, and physical dependence for the drug. Addiction can be thought of as the “inability to stop using a drug” (National Institute, 2018). Tolerance is when your body becomes acquired to a certain dose of a drug and you no longer get the benefit from it. That means that you need to have a higher dose of the drug for the body to receive the reward. The best way to describe physical dependence is by saying that your body has grown accustomed to the drug that it needs it to stay in normal working order. Out of these three, addiction is the most common and is the riskiest outcome for anyone who takes an opioid medication.
I have mentioned earlier that medical providers and the rest of the public didn’t become aware of the impact that opioids had until overdose deaths began to skyrocket. Some people may be asking what an overdose is? An overdose is when our bodies have an excess amount of a toxic substance, like a bunch of opioids, that it begins to shut down. In the case of an opioid overdose, there are a few signs to look out for. These signs all fall under what is known as the opiate triad and include “coma, pinpoint pupils, and respiratory depression” (Limmer & O’ Keefe, 2016). Being on the lookout for these signs can help bystanders and emergency personnel give a person a fighting chance to get help and to see another day. The main drug that is used to counteract an opioid overdose is called naloxone, more commonly known as Narcan. This binds to the opioid receptor preventing the opioid from carrying out their mechanism to numb pain. This is one tool that has become more available to the public to help fight against this epidemic.
After reading about the overview of this crisis and what the risks and benefits are to using opioids, the question remains what is being done to limit the prescribing of opioids? The stance that I take when it comes to answering this question is that I am for putting limits on physicians prescribing opioids for chronic pain. I am alright with prescribing and administering opioids in the case for the severe chronic and acute pain. However, I see that this crisis deals more with prescribing opioids to treat chronic pain that isn’t associated with any aggressive medical condition, like cancer. From what I have researched about solutions to this problem, I came across something that the Centers for Disease Control (CDC) put out. They came up with a guideline that has 12 recommendations to help “primary care clinicians treating adult patients with chronic pain outside of active cancer treatment, palliative care, and end-of-life care.” (Dowell, Haegerich, & Chou, 2016).
I will talk about a few of these recommendations starting with the use of non-opioid medications to help treat chronic pain that doesn’t fall into the categories laid out in the above paragraph. Physicians need to realize that opioids shouldn’t be the first drug of choice in treating chronic pain because of the risks that are involved with them. They should prescribe something like and nonsteroidal anti-inflammatory drugs (NSAIDs) like ibuprofen or a stronger non-opioid drug. Also, if a healthcare provider has to prescribe an opioid, they should prescribe it at “the lowest effective dosage [and] carefully reassess benefits and risks when considering increasing the dose…” (Dowell et al., 2016). Along the lines of prescribing at the lowest effective dose, medical providers should also avoid a lengthy prescription period. What I mean by this is that opioids should be used for the shortest amount of time and not for a lengthy period of time.
There are a few more things that are beneficial to help improve the communication of the risks of giving opioids for chronic pain. The main thing that physicians need to do is to consistently be reevaluating and reassessing the patients that they are prescribing opioids too. By doing so, it can help to limit the number of prescriptions that are being written for opioids. If a physician sees that a patient is improving after using opioids for a period of time, they should begin to decrease the dosage and give the patient a few alternative ways to manage their pain. They need to makes sure to slowly lean the patient off the opioid as there could be some serious side effects if they stop it suddenly. I really like how the CDC put in that clinicians need to offer treatment “for patients with opioid use disorder” (Dowell et al., 2016).
I also believe that in order to reduce the number of opioid prescriptions that physicians write is by educating both current and future medical providers on the risks associated with overprescribing opioids. This can be as simple as a continuing education course that educates healthcare providers “on the appropriate use of these products” (Califf, Woodcock, & Ostroff, 2016) that manufacturers make called “extended-release or long-acting (ER/LA) opioids” (Califf et al., 2016). By doing this, medical professionals will become better equipped at being able to handle writing opioid prescriptions for patients with chronic pain. When one goes into any field of medicine, one is a life-long learner and needs to be continually refreshed on new techniques or protocols that have been implemented in the medical community.
We need to also create funding to allow for research into using opioids for treating chronic pain. It is as the article entitled A Proactive Response to Prescription Opioid Abuse states “that there is very little research on the long-term benefits of opioids for treating chronic pain” (Califf et al., 2016). By creating more funding for this research, we would be able to have more evidence for healthcare providers to make better-informed decisions in regards to prescribing opioids. This will allow physicians to see what can occur with the prolonged use of opioids for chronic pain that doesn’t associate with cancer or end-of-life care. This will help to expand the evidence-based treatment that physicians can give to patients struggling with chronic pain and to educate them with facts and not possibilities of things going wrong.
Looking at this problem for a biblical perspective can be quite challenging. One sees that it deals with addiction, in which there are a lot of biblical passages that talk about addiction. Some include 1 Corinthians 6:19-20 with talking about the body being a temple or passages that speak about being drunk. However, I feel that if we look at this problem from a biblical view, we should see that love is the best way to approach this problem. We are commanded by Jesus in Mark 12:30-31 to love both God and our neighbors. We need to learn the importance of what Jesus teaches in Matthew 25:34-40. It is in this passage that we see love and compassion being played out for everyone ranging from the sick to the hungry. As Christians, we have been commanded to love our neighbors no matter what and to take care of people in need. So, we have to be willing to step out and walk alongside people who are struggling with using drugs, like opioids.
By showing them that people actually care for them in a personal way, it may help them see that there are other ways to overcome the pain that they are feeling. Helping someone who is less fortunate or is in need of getting out of a situation is what Christ did when he was on this Earth up to his death. He was willing to heal people and drive out demons. We should look to him as an example in order to help people see that there is another more powerful drug that has a great side effect, Jesus. If we are able to show the love of Christ to them, that may be all that is needed for them to give up their opioid addiction and find true inner peace in Jesus Christ. It is through showing the love of Christ that we may be able to turn the tide against the opioid epidemic.
The opioid crisis is a very complex problem that will take a lot of time and resources to overcome. You have seen that opioids work in the nervous system by causing an inhibitory effect on the transmission of pain receptors. Thus blocking or lowering the amount of pain that we feel. We have also talked a little bit about the onset of this crisis and the risks and benefits of using opioids. I have laid out a few solutions that need to be done in order to help reverse the trends of overdose deaths that are due to prescription opioids. It is my personal belief as I have stated earlier, that physicians need to limit prescribing opioid medications for chronic pain. I am perfectly fine with them still prescribing them for severe chronic and acute pain. I would also like to add that spreading the love of Christ is something that all Christians need to do. By incorporating love and the suggested solutions to this problem, hopefully, one day we will begin to see the number of deaths caused by opioid prescriptions begin to head back to zero.
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