Prescription opioid abuse

Sohaib Khaleel Mohammed, M.D., Angeline Prabhu, M.D., Samreen Fathima, M.D., Bilal Abaid, M.D., Steven Lippmann, M.D.

Introduction

Misuse of prescription opioids is a public health issue. In the United States (US), over two million adults annually abuse such drugs (1). By 2008, approximately 14 million people aged 12 years or older used oxycodone in their lifetime for non-medical purposes (2). Consumption of hydrocodone doubled and for oxycodone it increased by nearly 500% between 1999-2011 (3).  Prescription pain medications are easily accessible; some erroneous conceptions regarding their side effects and abuse potential, enhanced a dramatic increase in the non-medical use of prescription opioids (4). About two million Americans were dependent on and/or abused these drugs during 2014 (2).

Drug overdose deaths have increased in recent years. In 2010, 75% of fatalities due to pharmaceutical overdoses were caused by prescription-opioid analgesics (5). Such morbidity has dramatically escalated (6,7).

Clinical

The people using prescription opioids are have different characteristics than those abusing other opioid formulations, like heroin. These persons are commonly younger and Caucasian. Usage is less frequent and less often by the intravenous route. This community is more affluent, financially stable, and with less social concerns (1).

Clinical features of opioid toxicity include miosis, respiratory and central nervous system depression, bradycardia, coma, and death (8). Oxycodone can induce QT prolongation and/or Torsade de Pointes (9). Opioids often cause constipation with the bowel dysfunctions of abdominal pain, fullness, nausea, and ileus. Frequent falls occur among the older age individuals and a neonatal abstinence syndrome for new-borns. Human immunodeficiency and hepatitis viruses can co-present in anyone who utilizes non-sterile intravenous administrations (10,11).

Opioid dependence can follow long-term prescription narcotic use. The locus ceruleus (LC) is responsible for this effect; it activates sleep/wakefulness cycles and regulates blood pressure and breathing.  Mu receptor opioid actions on the LC, cause hypotension, somnolence, and decrease respiration. Constant exposure results in hyperfunction of LC neurons; therefore, opioid analgesia effect is diminished, resulting in tolerance. Opioid withdrawal occurs when there is an abruptly diminishing opioid effect and results in anxiety, diarrhea, glandular secretions, muscle spasms, and generalized pain (12).

Prevention

Legally prescribed opioids are sometimes misused for non-medical reasons (13). Substitutes like methadone, buprenorphine, and levo-alpha-acetylmethadol are available for the treatment of those who develop opioid addiction (1). A competitive opioid antagonist, naloxone, can be prescribed to reverse opioid overdose effects, especially respiratory suppression (14).

Safer opioid prescribing patterns are recommended by the Centers for Disease Control and Prevention (CDC) and other professional medical societies (15). Their guidelines proscribe high-dose opioids (e.g., ≥100 mg morphine equivalent daily doses) (13). They encourage carefully controlled physician prescribing patterns and compliance with federal and state narcotic prescribing rules. They also suggest drug monitoring programs, urine drug testing, patient/family education, and patient-clinician rapport (13).

Educating prescribers is an aid to control overuse. Various state laws and restrictive insurance policies about opioid prescribing dosage and duration can also help. Such systematic approaches hopefully will help prescribers provide safer care (13).

Conclusion

Abuse of prescription opioids has been rising. These analgesics are initially prescribed to patients for pain relieve. The number of deaths due to prescription opioid analgesics has been increasing. Misinterpretations about medication safety and easy availability have compounded this problem.

Life-saving respiratory depression is potentially reversed by naloxone administration.  In order to prevent and overcome the opioid abuse crisis, the recommended preventative plans should be beneficial.

References

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  2. US department of health and human services, substance abuse and mental health services administration. Available at https://www.samhsa.gov/sites/default/files/samhsa_cj2009.pdf Last accessed: August 28, 2017
  3. Jones CM. Trends in the distribution of selected opioids by state, US, 1999–2011. In National Meeting Safe State Alliance 2013. Last accessed: August 28, 2017
  4. Ling W, Mooney L, Hillhouse M. Prescription opioid abuse, pain and addiction: clinical issues and implications. Drug and Alcohol Review 2011; 30(3):300-305.
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  6. CDC. Wide-ranging online data for epidemiologic research (WONDER). Atlanta, GA: CDC. National Center for Health Statistics 2016. Available at http://wonder.cdc.gov.  Last accessed: August 28, 2017
  7. Rudd RA, Seth P, David F, et al. Increases in drug and opioid-involved overdose deaths – United States, 2010–2015. Morbidity Mortality Weekly Report. ePub 2016. Available at http://dx.doi.org/10.15585/mmwr.mm6550e1. Last accessed: August 28, 2017
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  11. Grunkemeier DM, Cassara JE, Dalton CB, et al. The narcotic bowel syndrome: clinical features, pathophysiology, and management. Clinical Gastroenterology and Hepatology 2007; 5(10):1126-1139.
  12. Kosten TR, George TP. The neurobiology of opioid dependence: implications for treatment. Science & Practice Perspectives 2002; 1(1):13.
  13. Liebschutz JM, Xuan Z, Shanahan CW, et al. Improving adherence to long-term opioid therapy guidelines to reduce opioid misuse in primary care: A cluster-randomized clinical trial. Journal of American Medical Association Internal Medicine 2017. doi:10.1001/jamainternmed.2017.2468. Last accessed: August 28, 2017
  14. Jeffery RM, Dickinson L, Ng ND, et al. Naloxone administration for suspected opioid overdose: an expanded scope of practice by a basic life support collegiate-based emergency medical services agency. Journal of American College Health 2017; 65(3):212-216.
  15. Dowell D, Haegerich TM, Chou R. CDC guideline for prescribing opioids for chronic pain—United States, 2016. Journal of American Medical Association 2016; 315(15):1624-1645.

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