The Opioid Epidemic: Complex Problems and Solutions

Do you know how many overdose-related deaths occurred in 2017? According to data that was collected by the Centers for Disease Control and Prevention (CDC) and graphs showing trends found on the National Institute on Drug Abuse (2019) 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 regulations to follow when it comes to prescribing opioid medications?

Before going any further with this issue of the opioid crisis, we must first understand what an opioid is. According to The Merriam-Webster Dictionary, opioids are “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 Dictionary also lists another definition that pertains more to 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, Shete, & Akbar, 2010). The opium alkaloids are opioids that are naturally derived from the opium plant, morphine being an example. Semi-synthetic opioids contain opium, but are modified in a lab and examples include oxycodone and hydrocodone. The final category of opioids are ones made in a lab, like fentanyl. One thing to keep in mind when talking about opioids is that they should not 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). Although it is good to know what opioids are, it is more important to know 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. An article in the Journal of Anaesthesiology Clinical Pharmacology, explains that the opioid receptors Mu, Delta, and Kappa are found 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 the respiratory, cardiac, and gastrointestinal tract. However, Pathan and Williams (2012) explain that out of these three receptors, the mu receptors have the most significance concerning how opioids affect the body. An article written by Hansan Pathan and John Williams found in the British Journal of Pain goes into more detail of how opioids interact at the cellular level.

Hansan Pathan and John Williams’ article entitled. “Basic opioid pharmacology: as update” explains that all of these receptors utilize 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. Pathan and Williams’ (2012), article goes even farther by laying out the sequence of what happens inside a cell after the opioid binds to its receptor. The following indicates 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 adenosine triphosphate (ATP). It is the phosphorylation, meaning adding another phosphate, of the GDP to form the GTP.

Normally, in a second messenger system like this, ATP is converted into cyclic adenosine monophosphate (cAMP) with the help of adenylate cyclase. The cAMP becomes the second messenger and helps drive other cellular processes. This is one of many second messenger systems that cells can utilize for different processes. For the opioid, after the subunit breaks away, it goes and blocks adenylate cyclase which in turn inhibits the production of cAMP. Pathan and Williams (2012) explain that by decreasing the amount of cAMP in the cell, there are closures of the Ca2+ channels and the opening of K+ channels. This leads to a hyperpolarization of a cell, and, if it happened in “neuronal cells, [it would have] reduced neurotransmitter release” (Pathan & Williams, 2012). So, as one can see, the mechanism of what causes an opioid to work 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? In the same article written by Pathan and Williams (2012), it explains 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, these pain receptors lessen the pain that we feel.

After a brief overview of how opioids block our pain and their mechanism of action, 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 opioid overdose deaths since 1999? The US Department of Health and Human Services displayed an 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, n.d.). This began the cascade effect of prescribing opioids for any type of pain. Two primary reasons played into the over-prescribing of opioids. First of all, doctors feared that “pain was going untreated” (Felter, 2019) and secondly, there was pressure from patients. An article written by Claire Felter entitled “The U.S. Opioid Epidemic”, mentions that pharmaceutical companies used false advertising with opioids by saying that “they posed little risk” to the people who took them.

The other side to this issue is that physicians are overprescribing opioid medications. The article, “The U.S. Opioid Epidemic”, gives insight into how healthcare providers feel pressured to give their patients opioids for their pain. Felter wrote that this is because “patients request them” (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 for the patient. However, something has to be done to make alternative pain treatments more affordable and accessible to patients.

However, besides being a cheaper treatment option, the risks of opioid use outweigh the benefits. To begin, let’s take a look at how opioids are beneficial. The most obvious answer to this is the fact that opioids are exceptional at treating pain that ranges for something short-term, like trauma, to a long-term illness, such as cancer. (Rosenblum et al., 2008). Chronic pain is a gray area when it comes to prescribing opioids because this is a long-term problem. However, it appears that the most popular chronic disease for opioid treatment is cancer. Relief from pain is the main and only benefit to using an opioid.

The most common risk of using an opioid that people have heard about is addiction. However, if one also looks at the side effects of opioids, one can see there are some other awful things that can happen. The more common side effects include “drowsiness, constipation, nausea, [and] vomiting…” (Gupta & Atcheson, 2013). Another major risk as mentioned earlier is that of 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 accustomed to a certain dose of a drug and you no longer get the benefit from it. That means that you need to keep increasing the dose of the drug in order to receive the reward. The best way to describe physical dependence is by saying that your body has grown so accustomed to the drug and 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.

As stated earlier, medical providers and the public did not become aware of the impact of opioids until overdose deaths began to skyrocket. However, some people may be asking what an overdose is. An overdose is when our bodies have an excess amount of a toxic substance, like opioids, that it begins to shut down. In the case of an opioid overdose, there are a three main signs to look for “coma, pinpoint pupils, and respiratory depression” (Limmer & O’ Keefe, 2016). These three signs are known as the opiate triad. Being on the lookout for these signs can help bystanders and emergency personnel give that person a fighting chance to receive 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 its mechanism to numb pain. Narcan is one tool that has become more available to the public to help fight against the opioid epidemic.

After reading about the overview of this crisis and the risks and benefits 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 there should be limits on physicians prescribing opioids for chronic pain. I am all right with prescribing and administering opioids for cases of 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 conditions, like cancer. From researching solutions to this problem, I discovered something that the CDC put out. They published a guideline that has 12 recommendations to help doctors treat “adult patients with chronic pain outside of active cancer treatment, palliative care, and end-of-life care.” (Dowell, Haegerich, & Chou, 2016).

I will discuss a few of these recommendations starting with the use of non-opioid medications to help treat chronic pain that do not fall into the categories laid out in the above paragraph. Physicians need to realize that opioids should not be the first drug of choice in treating this type of chronic pain because of the risks that are involved with them. They should prescribe something like a nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen or a stronger non-opioid drug. Also, if healthcare providers have 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.

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 are prescribed opioids. By doing so, it can help to limit the number of prescriptions that are being written for opioids. If physicians see 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 make sure to slowly wean the patient off the opioid, as there could be some serious side effects if they stop suddenly. I admire how the CDC suggested that clinicians need to offer treatment to people who are already addicted to opioid medications. (Dowell et al., 2016).

I also believe that in order to reduce the number of opioid prescriptions that physicians write, both current and future medical providers need to be educated on the risks associated with overprescribing opioids. This can be as simple as a continuing education course that educates healthcare providers on new ways to treating pain, such as using “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 inform patients with alternative treatments for their 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 for research into using opioids for treating chronic pain. The article, “A Proactive Response to Prescription Opioid Abuse” explains how the side-effects of using opioids to treat a patient with chronic pain, long-term, is unknown because of the relatively few studies that have been done. (Califf, Woodcock & Ostroff, 2016). By creating more funding for this research, we would be able to have more evidence for healthcare providers to make better-informed decisions regarding the prescribing of opioids. This would allow physicians to see what can occur with the prolonged use of opioids for chronic pain not associated with cancer or end-of-life care. It will also help to expand the evidence-based treatments that physicians can give to patients struggling with chronic pain and to educate them on the risks associated with overprescribing opioids.

Looking at this problem from a biblical perspective can be quite challenging. One sees that it deals with addiction. There are a lot of biblical passages that talk about addiction. An example being 1 Corinthians 6:19-20 which states:

“Do you not know that your bodies are temples of the Holy Spirit, who is in you, whom you have received from God? You are not your owe; you were bought at a price. Therefore honor God with your bodies.” (I Cor. 6:19-20, New International Version) This passage is talking about how are bodies are the temple where the Holy Spirit dwells. That means that we must not desecrate or harm our bodies with any sort of addiction, like opioids, that it destroys the dwelling place of God. Many biblical passages that address the issue of drunkenness can also be applied to other addictions, like opioids. An example being Proverbs 23:29-35: “Who has woe? Who has sorrow? Who has strife? Who has complaints? Who has needless bruises? Who has bloodshot eyes? Those who linger over wine, who go to sample bowls of mixed wine. Do not gaze at wine when it is red, when it sparkles in the cup, when it goes down smoothly! In the end it bites like a snake and poisons like a viper. Your eyes will see strange sights, and your mind will imagine confusing things. You will be like one sleeping on the high seas, lying on top of the rigging. “They hit me,” you will say, “but I’m not hurt! They beat me, but I don’t feel it! When will I wake up so wake up so I can find another drink?”

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.

“Love the Lord your God with all your heart and with all your soul and with all your and with all your strength. The second is this: Love your neighbor mind as yourself. There is no commandment greater than these.” (Mark 12:30-31) We need to learn the importance of what Jesus teaches in Matthew 25:34-36 and verse 40. “Then the King will say to those on his right, ‘Come, you are blessed by my Father, take your inheritance, the kingdom prepared for you since the creation of the world. For I was hungry and you gave me something to eat, I was thirsty and you gave me something to drink, I was a stranger and you invited me in, I needed clothes and you clothed me, I was sick and you looked after me, I was in prison and you came to visit me.’ The King will reply, Truly, I tell you, whatever you did for one or the least of these brothers and sisters of mine, you did for me.” (Matthew 25:34-36, 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. We must be willing to step out and come alongside people who are struggling with using drugs, like opioids.

By showing individuals addicted to opioids that people actually care for them in a personal way may help them see that there are other ways to overcome the pain they are feeling. Helping someone who is less fortunate or needing to get out of a situation is what Christ demonstrated when he was on this earth. 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. Showing the love of Christ may be all that is needed for them to abandon their opioid addiction and find true inner peace. It is by demonstrating 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 the amount of pain that we feel. We have also talked a little about the onset of this crisis and the risks and benefits of using opioids. I have laid out a few solutions that could 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 opioids 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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