The United States is currently facing the opioid crisis. This crisis effects opioid users while destroying families at the same time. Opioid misuse/abuse is an ongoing battle our society is fighting with and it will take a systematic change in order to achieve opioid reduction. The system of supply and demand forms a relationship between opioids and pain that influenced the current epidemic. Sadly, the epidemic plagues our country and the probability of overdosing/death is very common. To address this epidemic, this literature will review finding different ways to reduce opioid misuse/abuse, opioid availability, and reforming current policies and procedures.
Most researchers studying opioid use focus on opioid misuse/substance use disorder. Beaudoin et al (2014) defines opioid misuse as patients using opioids more often or in higher amounts than prescribed by a physician or used for reasons other than pain in her article, “Prescription opioid misuse among ED patients discharged with opioids” (p. 580). People are misusing opioids at an alarming rate within our society. Choi et al (2019) states in the article, “Adults who misuse opioids: Substance abuse treatment use and perceived treatment need”, “11.8 million US residents misused opioids (prescription pain reliever and/or heroin) and 2.1 million of them had opioid use disorder (OUD)” (p.247).
Even though the information from this study was found back in 2016 the statistics behind opioid misuse continues to increase and the exact percentage is unknown but disorders have been created. Grossbard et al (2014) states that, “Substance use disorders are among the most common medical conditions and are associated with significant morbidity and mortality”, in his article, “Clinical monitoring and high-risk conditions among patients with SUD newly prescribed opioids and benzodiazepines” (p.24). This disorder is mainly fueled by addiction and the desire to treat pain which can develop into using unethical approaches when taking opioids. This desire for opioids has created the current epidemic and it comes with deadly consequences within society.
Cicero et al (2017) discusses that reducing opioid access carries its level of importance but we should focus on why opioids carry such a significate level of demand from users in his article, “Understanding the demand side of the prescription opioid epidemic: Does the initial source of opioids matter?” (p. 1). The demand aspect of opioids has the power to emotionally, mentally, and physically control its users. Opioids can alter personal morals and ethics over life itself and lead to overdosing causing death. Henningfield et al (2019) states in his article, “The nexus of opioids, pain, and addiction: Challenges and solutions”, “The 21st century opioid epidemic has evolved to the point that overall life expectancy is declining as opioid overdose deaths escalate” (p.1).
Understanding why users are so impacted by opioids holds crucial information towards the possibility of finding treatment that may lead to reducing opioid misuse/abuse. Yarborough et al (2016) states in his article, “Understanding opioid overdose characteristics involving prescription and illicit opioids: A mixed methods analysis”, “to reduce risk of opioid overdose, efforts should focus on screening for impaired cognition and motor skills, prescribed and illicit polysubstance use, and changes in life circumstances, psychosocial risks/supports, and pain control” (p. 55).
Focusing on the main important intersections and life circumstances an individual is going through before writing prescriptions of highly abusive and deadly opioids can possibly reduce opioid misuse/abuse within society. Overdose is heavily influenced by opioid misuse and substance use disorders but there are many other factors that should be held accountable for the horrible consequences of opioids.
This research reviews pain management and clinical practices as current factors for reducing opioids. Marie et al (2018) states in her article, “Pain and opioids: Call for policy action”, “this dual crises of opioid abuse and chronic pain provide a unique opportunity to advance practice, research, and policy in a way that supports a targeted research agenda and more comprehensive assessment and treatment for chronic pain and/or substance use disorders” (p. 41). This opportunity of advancement that Marie discusses starts with awareness towards the issue and follows with education on the current opioid epidemic that our society is facing.
Marie et al (2018) discusses that President Trump declared the opioid epidemic a national emergency for the US and after the announcement the executive branch directed funds toward treating facilities and training for naloxone (a drug that blocks opiate receptors) administration (p. 41). Marie et al (2018) then relates the funding towards the facilities and training to the “Comprehensive Addiction and Recovery Act legislation” that President Obama signed to expand funding for addiction treatment (p. 41). This funding generates the opportunity for highly significant decisions to be made for our health care system in order to reduce opioids. Marie et al (2018) states that nurse practitioners hold important responsibilities for creating change for opioid misuse treatment within the clinical practice field by influencing state and federal health policies (p. 41).
New strict policies and practices that educate patients more about the dangers of opioids may lead to influencing a foundation for creating change toward opioid reduction. Lipman (2013) states in his article, “We can make opioids safer”, that governmental regulation is required but more support is needed in order to serve opioid users within society (p.113). Lipman’s (2013) research argues that opioids obviously are overused and misused but they still benefit patients when taken properly and our health professionals must advocate for patients and educate them (p. 113).
Opioids and pain definitely have a complex relationship and Covvey (2015) states in his article, “Recent developments toward the safer use of opioids, with a focus on hydrocodone”, “the use and availability of opioids is a delicate balance between the provision of effective pain management and protection against the harms associated with use/misuse” (p. 906). Reforming the current system in order for standards to be changed and new policies put in place is only the beginning towards trying to reduce opioids in our society and Covvey (2015) states, “the key message regarding recent regulation/policy is that there is significant work left to be done in the fight against opioid-related harms” (p. 906).
The issue regarding opioid reduction is multi-layered and it’ll take more than policies changing; certain laws need to be revised in order to create change and there have been some signs of positive growth during the epidemic. Burris (2018) states in his article, “Where next for opioids and the law? Despair, harm reduction, lawsuits, and regulatory reform”, that “research in the past few years shows positive effects for some law: PDMP laws (prescription drug monitoring programs), pill mill laws, and hard-to-evaluate good Samaritan and naloxone laws” (p. 29).The system is in need of change from the policies and pain management currently in place now but it’ll take a national effort in order to reduce opioid use/misuse. Different attempts have been made in order to create this change and possibly the next effort requires new strategies and technology.
This research will review different strategies and technologies behind reducing opioid misuse/abuse. While reforming policies and practices are imperative toward reducing opioid misuse/abuse, creating new ideas and methods using technology are equally as important in order to curve the epidemic. Opioid reduction can come from many different methods but this research will review some different approaches. Maincent et al (2016) lists different “abuse-deterrent formulation approaches” in her article, “Recent advances in abuse-deterrent technologies for the delivery of opioids”, these different approaches are listed as “physical barriers, chemical barriers, antagonist, aversive agent, and prodrugs” (p.58).
These approaches were made by the FDA in order to create a diverse system where the different approaches can conduct an abuse-deterrent formulation. Maincent et al (2016) states that the physical barrier approach increases mechanical strength and/or viscosity preventing dosage from crushing and/or opioid extraction (p. 58). This increase in strength will help prevent the attempt to abuse the opioid thus reducing opioid misuse/abuse. Maincent et al (2016) then states that the chemical barrier approach creates a complexation or salt formation preventing opioid extraction by altering drug release rate or solubility (p.58).
If the possibility of misusing an opioid by changing the chemical factors is taken away and the negative intentions are no longer available then opioid reduction can generate. The aversive agent approach is the only approach I don’t fully agree with, Maincent et al (2016) states that this approach has “Undesired pharmacological/unpleasant effect if released and/or if excessive dose administered” (p.58). The aversive agent approach is an idea that I believe is outdated and Maincent et al (2016) states that even the FDA prefers other abuse-deterrent technologies rather than aversion technology (p.69). While I understand the reasoning behind this approach is to achieve less opioid abuse it has the potential to be harsh.
Maincent et al (2016) describes the actions that each of these different approaches have the potential to prevent as in “chewing/crushing, snorting/inhaling, injecting, and multiple dosing” (p.58). This section of research is clearly the fastest and most effective way in order to reduce opioid misuse/abuse. These macro level different approaches toward reducing the probability of users to abuse the opioid through current technology could be considered the most vital step in order to curve the epidemic. Reforming policies and clinical practices require time in order to see a difference but this approach effects the epidemic instantly by changing the actual physical drug properties thus reducing misuse/abuse.
Herry et al (2013) states in the article, “Reducing abuse of orally administered prescription opioids using formulation technologies”, that prodrugs are a very effective but costly abuse-deterrent formulation (p.106). The reason behind why this approach is so effective is definitely recognizable. Herry et al (2013) states that “when the product is abused via the intra-nasal or intravenous route the prodrug cannot bind to the opioid receptors, no euphoric effect is obtained and abuse becomes ineffective” (p. 106). If the substance abuser doesn’t have the ability to abuse the drug then reduction is achieved with this formulation but the idea is still being developed.
Tamper-resistant formulations are definitely another factor that can reduce opioid misuse/abuse. Herry et al (2013) states that the four main strategies for tamper resistant approaches are “gelling formulations, hot-melt processed formulations, highly resistant tablets, and resin-based formulations” (p. 107). These formulations can eliminate the ability to physically change and abuse prescription medications in the future. Herry et al (2013) states that gelling formulations limit extraction and the abuse through the nasal and intravenous ways (p. 107).
Hot-melt processed formulations are highly tamper-resistant because crushing the products into powder for snorting or extraction are very difficult (Herry et al 2013, p 107). These two formulations of tamper-resistant approaches are very similar in effectiveness and they both have a possibility to reduce opioid misuse in our society. Focusing on clinical practices and policy reform are the first initial steps toward creating systematic change; but developing new formulations using current technology is vital in order to curve the opioid epidemic.
This section will review research focusing on the availability of opioids within society. The focus on opioid availability is very debatable, and I can relate my personal experiences to this topic because I work at a pharmacy and sell prescription opioids to customers everyday but recently all class two narcotics (opioids) have been unavailable to order for stock and I thought that was worth adding because it’s never happened in the five years I’ve worked there. Beaudoin et al (2014) states, “Hydrocodone is now the most commonly prescribed medication in the United States, more than any blood pressure, cholesterol, or diabetes medication” (p. 580).
After considering the statistics behind people with blood pressure (1 out of 3) and diabetes complications and the total deaths per year that those two health issues have, it’s astonishing to learn that hydrocodone is still being prescribed more often than the other medications. Covvey states that “Hydrocodone in particular has been touted as a primary driver behind opioid-related abuse and misuse due to its widespread availability and use” (p. 902). The availability of hydrocodone is being prescribed at such a high rate it could be considered a key influencer in the opioid epidemic. Opioid availability stems from a fundamental framework set forth in 1961 called “The Single Convention on Narcotic Drugs” (Maurer, 2013).
Maurer et al (2013) states in her article, “Examining influences on the availability of and access to opioids for pain management and palliative care”, that the framework is “meant to ensure appropriate availability of controlled medicines such as opioid analgesics for medical purposes and to prevent diversion, illicit trafficking, and abuse” (2014). Stricter laws have been made for narcotics since 1961, but while this framework has good intentions it had to be rewritten in order to reduce the current opioid epidemic. Brooks (2014) states in her article, “Mitigating the safety ricks of drugs with a focus on opioids: Are risk evaluation and mitigation strategies the answer”, “more than 50% of respondents regard opioid drug addiction as a major US health problem and believe that doctors should face limits on their prescribing abilities for addictive pain medication” (p. 1684).
Even though the research was found back in 2013 the current epidemic that America is facing still reveals that doctors are prescribing these opioids far too often and the probability for opioid addicts or someone with SUD to have these drugs accessible are too dangerous. Wang et al (2013) states in her article, “Prevalence and correlates for nonmedical use of prescription opioids among urban and rural residents”, “there are several national efforts to address nonmedical use of prescription opioids including efforts to dispose of unused medications, expand access to medication assisted therapy, and inform physician prescribing patterns through prescription drug monitoring programs and risk evaluation and mitigation strategies” (p. 157).
Opioid availability obviously fuels the epidemic and opioid misuse/abuse will decrease with fewer opioids being prescribed but there will need to be a balance between the amount of prescriptions written and the amount of prescriptions that are restrained in order for opioids to maintain a positive effect within society. Even though there are many different aspects and approaches involved with opioid reduction, opioid availability will go down as the final research examined in this literature review.
This literature review was written in order to find different approaches that reduces opioid misuse/abuse in America. These different approaches were reviewed in order as listed: understanding opioid misuse/substance use disorder and how it affects the users and leads to overdosing/death, reforming the current pain management system and clinical practices in order to create a systematic change, using different strategies and technology that show signs of efficiency in reducing opioid abuse, and focusing on opioid availability within America.
These different approaches are imperative in order to curve the epidemic and create systematic change that potentially can help millions of Americans. One of social workers main purpose is to enhance the quality of life for those who are most vulnerable and oppressed within society. Advocating to change the current opioid epidemic will help bring awareness to the issue and hopefully positively impact the system.
Research on correlating the racial aspects involved with the opioid epidemic could be done in order to find which populations are currently the most at risk during the crisis. The opioid epidemic will still continue to grow and many lives will be lost but society must become more aware and educated in order to reduce and create a systematic change.
