An Evidence-Based Road Map to Navigating the Opioid Epidemic

Opioid use disorder (OUD), which is “often secondary to non-medical use of prescription opioids” is a major public health issue in the United States to the extent that it has been called an epidemic.¹ In October 2018, President Trump announced that his administration was declaring the opioid crisis a national public health emergency under federal law and directing all executive agencies to “use every appropriate emergency authority to fight the opioid crisis.”² Opioid-related overdoses have risen “exponentially,” increasing at a rate of 9% annually.³ According to US Department of Health and Human Services, in 2016 and 2017, 11.4 million people misused prescription opioids, 2.1 million people had an OUD, and 42,249 people died of opioid-related overdoses.⁴

The authors of a review article sought to conceptualize the complexity of the OUD epidemic, “using a conceptual model grounded in the disease continuum and corresponding levels of prevention” and examined studies and reviews conducted during the last 15 years to formulate evidence-based interventions for the treatment of OUD.¹ Senior review author Robert Pack, PhD, MPH, professor of Community Behavioral Health, associate dean for Academic Affairs, and executive director of the Center for Prescription Drug Abuse Prevention and Treatment, East Tennessee State University, Johnson City, told Clinical Pain Advisor: “Many of my colleagues have been personally affected by the opioid problem, and it has touched my life as well.”

He added: “[The article] is an exposition on the fact that there are a number of different interventional approaches to address the opioid crisis, and no single approach will be sufficient.”

Drivers of Nonmedical Use of Prescription Opioids

Nonmedical use of prescription opioids “results from a complex, cumulative interaction of multiple drivers,” which include “market forces, misguided policy, perceptions of risk, and stigma,” the authors note. One of the key drivers is a “copious supply of prescription opioids,” which are used for  the treatment both of pain and of opioid addiction (eg, with buprenorphine). Prescription opioid sales have quadrupled since 1999, a rise that is accompanied by increases in hospital admissions related to prescription opioids and in overdose deaths. States with the highest rates of nonmedical use of prescription opioids and overdose deaths were found to have the highest rates of opioid prescribing. “We really have to do better at prescribing,” Dr Pack remarked. “In Tennessee, where I live, we have a serious overprescribing problem. In fact, according to the Drug Enforcement Agency’s 2017 data, Tennessee had a record number of opioid overdoses.”

This rise in prescribing of prescription opioids in the last 2 decades of the 20th century occurred at a time during which medical professionals were urged to resort to prescription opioids to manage untreated and chronic noncancer pain. In 1996, the American Pain Society proposed that pain be regarded as the “fifth vital sign,” thereby “elevating the importance of pain assessment to equal that of established vital signs,” and urging physicians to respond to or proactively treat patients’ pain. “Highly intertwined with this shift toward more aggressive use of prescription opioids” was aggressive marketing on the part of pharmaceutical companies, understating addictive risk and overstating advantages of prescription opioids. This led to a low perception of risk/harm on the part of the medical and lay communities.

In addition, there is considerable stigma toward individuals with addiction, which can “hinder help-seeking behaviors, the availability of treatment and other support, and perhaps the implementation of interventions across all levels of prevention,” noted the review authors. Individuals who have become addicted are often regarded as morally weak or enacting a choice, rather than suffering from a “chronic, relapsing disease,” with additional stigma surrounding evidence-based strategies that address the condition. “Thus, stigma, whether toward addiction or toward strategies aimed at alleviating its harms, can foster a socio-cultural environment unsupportive of responding to [nonmedical use of prescription opioids], thereby perpetuating the problem,” according to the authors.

Potential Interventions

The conceptual model suggested in the review is predicated on the “continuum of the disease of addiction, from non-use to dependence, addiction, and ultimately, premature death.” Targeted public health strategies “need to be brought to bear against different points all along the disease continuum for measurable progress to be made against the epidemic.”

Primary prevention “aims to prevent the development of a disease, and addiction is a preventable disease”; therefore, “[p]reventing the initiation of [nonmedical use of prescription opioids] or any illicit opioid should be the highest goal.” Primary interventions can be delivered in an array of settings and target diverse populations. Making them culturally relevant and tailored to each population can facilitate their acceptance and sustainability in community settings. Primary prevention also includes training and continuing education for healthcare professionals.

Secondary prevention “involves the early detection of a disease to decrease its severity and consequences.” In the case of OUD, this can involve “identifying non-medical use and diversion as a means of averting progression to addiction and the sequelae of untreated addiction.”