RUNNING HEAD: ADDRESSING THE EPIDEMIC OF OPIOID ABUSE
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Addressing the Epidemic of Opioid Abuse: Provider Role and Treatment and Prevention
Strategies
Audrey Kivlehan
Northeastern University
ADDRESSING THE EPIDEMIC OF OPIOID ABUSE
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Abstract
The abuse of opioids is highly prevalent in the United States and a serious threat to public
health. Health care professionals are in a valuable position to combat abuse through their
understanding of the risk-factors, reasons for abuse, as well as finding a balance between
prevention and necessary care. Furthermore, providers can use treatment and prevention
strategies. Certain pharmaceutical drugs can be used to prevent opioid overdose, prevent relapse,
treat overdose and wean patients off their dependence. In conjugation with abuse-deterrent
formulations provided by manufacturers, providers can prevent abuse through clinical
monitoring and education. Health care providers have the intellectual means and positions of
opportunity to make an impact on reduction of opioid abuse.
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Introduction
Prescription opioid abuse is a public health epidemic that is negatively impacting the
population of the United States. Prescription opioid abuse is defined as taking opioids without a
prescription, or taking them in ways not instructed by a clinician. (Rigg & Murphy, 2013) Opioid
analgesics are prescribed for treatment of severe pain. However, these drugs as a side effect
produce a euphoric effect, making them highly susceptible to abuse, and respiratory depression,
which is the reason for death by overdose.
Although opioid abuse is not a new concern to society, the incidence of abuse has been
rising dramatically. From 1990 to 2000, the incidence of painkiller abuse rose over 400% from
628,000 to 2.7 million. As a result, there was a 408% increase in opioid related emergency
department (ED) visits in that same decade. (Rigg & Murphy, 2013) In 2011, 420,040 ED visits
were related to opioid analgesics. Therefore, it is no surprise that the cost of opioid abuse on
society is hindering. The cost in 2007 was $55.7 billion, with 45% being attributed to healthcare
costs. (Prescription drug, 2014) It is estimated that two million people are expected to begin
abusing opioids each year, with the majority being young adults and adolescents. (Rigg &
Murphy,2013) These staggering numbers demonstrate the seriousness of the epidemic and the
need for immediate change.
Though the numbers are concerning, there is a way to combat opioid abuse through
treatment and prevention strategies. As the number of abusers have increased, so have the
number of people seeking treatment. From 1992 to 2002, there was a 350% increase in the
number of yearly admissions into opioid abuse treatment programs. (Rigg & Murphy,2013) This
demonstrates that there are members of this population that seek help and that these numbers can
rise with targeted strategies such as education. A crucial component to battling opioid abuse is
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the role of health care professionals. Clinicians and pharmacists play important roles in the lives
of their patients. These practitioners can treat their patients with prescription medications, and in
addition to efforts made by pharmaceutical companies, prevent misuse and abuse of opioids by
their patients. Providers can accomplish this through clinical monitoring and population targeted
education.
Role of Health Care Professionals
Health care professionals play a critical role in the battle against prescription opioid
abuse. There are a number of key components that professionals must be adept at. They need to
balance risk of misuse and benefit of medications, determine the reason for abuse and identify
risk-factors. Additionally, they can employ treatment with prescription medications and prevent
abuse through prescribing abuse-deterrent formulations, education and clinical monitoring.
These efforts will be explored in later sections.
Health care professionals must find a balance between risk of abuse and access to
medically necessary medications. Patients with chronic pain must not be denied access to their
medications. While 3.27-11.5% of patients may develop an addiction, the majority of patients
will not abuse their opioids. For those that do, their pain can be managed with medications with
lower abuse potential, such as buprenorphine. (Ling, Mooney, Hillhouse, 2011) Abuse does not
warrant end of medication treatment for pain. Each patient is unique, and so is their pain,
therefore the provider can weigh the benefits and downsides to prescribing an opioid and manage
the resulting outcome.
People abuse opioid medications for diverse reasons. The use is not always exclusively
recreational and initially accessed in an illicit manner. Many times, the patient’s first opioid high
was during use for a analgesia as the clinician had prescribed. Others use the medications to self-
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medicate for emotional or physical pain without a clinician’s direction. (Rigg & Murphy,2013)
This is something that needs to be segregated from the issue of abuse and treated by the
physician independently.
There are many risk-factors for those who may be likely to become opioid abusers. One
risk-factor is prior illicit drug abuse. There is a high correlation between use of cocaine, heroin or
marijuana and opioid abuse. Secondly, mental health conditions may contribute to a higher
likelihood of abuse. Those with conditions such as depression are twice as likely to abuse opioids
as those without. (Rigg & Murphy,2013) Additionally, patient exposure can lead to abuse. There
is a correlation between regional areas that commonly use a certain drug for therapeutic uses and
a high incidence of abuse. (Cicero, Surratt, etc.,2007) An understanding of these risk-factors help
providers to make the best decision for their patient’s treatment.
To highlight one profession, pharmacists in particular have a unique role in addressing
the epidemic. These providers are the last health care professionals that a patient interacts with,
before returning home with their opioids. There are three major tasks that the pharmacist can
implement to address abuse. First, the pharmacist can analyze the prescription to make sure that
it is in fact valid and prescribed for a necessary and legitimate purpose. Second, the pharmacist
should counsel the patient on their opioid medication to ensure complete understanding. Third,
the pharmacist can follow-up when abuse or misuse has been recognized, with the patient, the
physician or with other pharmacies. (Journal of, 2014)
Opioid Abuse Treatment
There are many drugs on the market that can assist in prevention of overdose and
treatment of addiction. These drugs have remarkable abilities to reverse an overdose, assist a
patient in addiction recovery and prevent relapse. They should be used in order to benefit the
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patient’s well-being, as well as combat the national epidemic of abuse. Three drugs for these
uses are naloxone, naltrexone, methadone and buprenorphine.
Naloxone, an opioid antagonist, is a drug that is widely used to treat opioid overdose. It
can be found on the person who has overdosed, in the hands of police officers and emergency
responders. In small doses, this drug is able to completely reverse the life-threatening effects
such as respiratory depression and sedation that can lead to death. It has a short duration of
action, so within a few hours the overdose symptoms are likely to return. However, with medical
treatment the person can make a full recovery. Family members, law enforcement and medical
personnel should be encouraged to have access to this drug in order to save lives of those who
are experiencing an overdose.
A drug similar in its pharmacology to naloxone is naltrexone. However this drug is
reserved for patients who have already completed withdrawal from opioid analgesics. This
medication has a longer duration of action and can last for around ten hours. It is typically
administered three times a week, post detoxification, to patients who have a high likelihood of
opioid abuse relapse. It can also be used to prevent relapse with alcohol and heroin addicts.
The two drugs indicated to treat opioid addiction are methadone and buprenorphine. They
are used to wean addicted patients off opioids so that they are able to return to living productive
lives. With methadone treatment, patients will receive a daily dose between 60 to 120 mg of the
drug with a minimum of 12 months of treatment. There are many benefits of methadone
treatment including: lower risk of overdose, lower rate of injectable drug use, reduced rate of
disease transmission (such as HIV), and reduced rate of mortality. (Methadone, 2002) One major
downside to methadone is that it has similar side effects as morphine such as respiratory
depression. Methadone receives a great deal of negative feedback from critics claiming that it is
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simply an addiction substitution and criticism of the high risk of methadone diversion. Though
negative situations may arise from this medication, methadone has been able to help countless
people recover from their addiction. Buprenorphine and methadone operate in similar ways,
however buprenorphine is typically reserved for milder cases. It does produce respiratory
depression, but has a ceiling effect. It is available in an abuse deterrent formulation, Suboxone,
that combines naloxone to prevent the euphoric effect of opioids.
Opioid Abuse Prevention
Health care professionals and pharmaceutical companies can implement a multitude of
prevention strategies to combat opioid abuse. First, pharmaceutical manufacturers can
incorporate abuse-deterrent properties in all high risk medications as encouraged by the FDA.
Second, providers can implement targeted opioid abuse education within high risk populations.
Finally, practitioners can use clinical strategies to monitor their patients for abuse characteristics
in order to intervene appropriately.
A major preventative measure against opioid abuse is the use of abuse-deterrent
formulations. These drugs can be abused through swallowing, crushing and snorting, smoking or
injection. Abuse-deterrent formulations, such as physical/chemical barriers, agonist/antagonist
combinations, aversion, delivery system and the use of a pro-drug, can prevent these
manipulations. (Guidance, 2013) Manufacturers may add ingredients to deter abuse such as
naloxone and niacin. These additives cause unfavorable effects when used by injection or
snorting. Others may not be active at all in the body unless they are metabolized in the liver,
requiring the drugs to be taken orally. To highlight some examples, the formulations of Zohydro
ER, and Targiniq ER, with an abuse-deterrent formulation, can be compared.
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Zohydro ER is a hydrocodone tartrate extended-release drug with no abuse-deterrent
features. It is the first drug that is approved as a single-entity product of extended-release
hydrocodone that is indicated for patients with severe pain. Prior to this medication,
hydrocodone had been formulated with acetaminophen, which is contraindicated for patients
with liver damage. Since its approval in October, 2013, this medication has been the center of
much controversy. The medication was approved by the FDA against a recommendation from its
advisory committee. (Young, 2013) Without these abuse deterrent properties, it is extremely
susceptible to abuse and overdose. After recognizing these concerns, the manufacturer, Zogenix,
Inc., will be filing a supplemental new drug application by October 2014 to introduce abuse
deterrent formulations of Zohydro. This updated formula would be available to patients in early
2015. (Zogenix, 2014) Following its initial release of the drug,this pharmaceutical company
recognized the importance of abuse deterrent formulations to the public and for patient safety.
Targiniq ER is oxycodone hydrochloride and naloxone hydrochloride extended-release
approved by the FDA in July 2014. This drug is meant for the exclusive treatment of severe pain
that requires around the clock long-term analgesic treatment when there are no other options
suitable for the patient’s needs. The formulation deters abuse through the incorporation of
naloxone. When one tries to abuse this drug by crushing and snorting it or injecting it, the
naloxone will block the euphoric effects and the ability for the user to get high. One downside to
this formulation is that it can still be abused by the oral route since naloxone does not work
orally. (Liscinsky, 2014) Although this formulation is not impervious to abuse, its deterrent
features will without a doubt limit the extent that it can be used for illicit means. Therefore, it is
crucial that manufacturers require their drugs to have abuse-deterrent properties and that
practitioners support these efforts through prescribing abuse-deterrent formula drugs.
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Education regarding opioid abuse prevention can be targeted towards specific populations
to have the most effective results. One example is through targeting cocaine addicts. A study
published in 2013 by Khary K. Rigg and John W. Murphy at the Philadelphia Veterans Affairs
Medical Center, analyzed patients participating in an opioid abuse rehabilitation program in
South Florida. One of their major findings was on the relationship between cocaine and opioid
abuse. They found that the two have a strong correlation of use and when a person abuses both,
one cannot be treated without addressing the other. Rigg and Murphy recommend opioid abuse
preventative measures to be directed at cocaine users. They suggest education on lethal
consequences of using cocaine and opioids in conjunction and offer advice on how to improve
“crash symptoms” and prevent overdoses. (Rigg & Murphy, 2013)
Health care providers can implement clinical monitoring to prevent abuse of prescription
opioids. One clinical monitoring program providers can use is the Screener and Opioid
Assessment for Patients with Pain (SOAPP). This is a questionnaire given to patients who are
taking or are being considered to take pain medication. This will inquire about the patient’s
mood, living environment, drug history, personal relationships and legal issues. Through these
results, clinicians can determine which way to proceed with a patient’s treatment. An additional
clinical monitoring strategy is urine toxicology screening. Patients who are taking opioid
medications in the long-term may undergo testing if the physician orders it.
Conclusion
Opioid abuse is the misuse of prescription painkillers to achieve a euphoric effect in the
body and brain. It is endangering lives at astronomical numbers and continues to kill more and
more each year. This epidemic needs to be recognized by all members of the population.
However, health care professionals should be called on to play a role in prevention because of
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their scholar within medicine and powerful positions as health resources. Practitioners are a
source of information and guidance for many where they can receive accurate and personalized
medical information.
Providers can prevent and treat opioid abuse by improving on skills they already have
and enhancing awareness of the epidemic. They can identify those at risk for drug abuse and take
precautions in prescribing and dispensing opioids. Additionally, there are many medications that
can assist in treating opioid abuse related issues such as overdose and prevention of relapse.
Prevention can be implemented through education and clinical monitoring. Furthermore, abuse
prevention can be addressed by pharmaceutical companies through abuse-deterrent formulations.
With the numbers of opioid abusers rising, health care professionals must use their power and
abilities to combat this epidemic.
Reflective Note:
I would include this piece in my portfolio because it demonstrates my ability to research and
argue a position on a medically relevant topic. In addition, it shows my understanding of and
demonstrates interest in an important and current public health topic. This paper shows that I
have an understanding of a pharmacist’s role in opioid abuse prevention.
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