Prescription Opioid Addiction: What is Causing the Epidemic?
- Table of ContentsPrint
- What is Prescription Opioid Abuse?
- Why Are Opioid Analgesics Prescribed?
- Who is at Risk for Developing Prescription Opioid Addiction?
- Reasons for Prescription Opioid Abuse
- Prescription Opioids and Heroin
- The Problem of Pain
- Alternative Pain Management Approaches
- Conclusion/Concluding Thoughts
- View More Expert Guides
Read time: 30 minutes
Prescription opioids are semi-synthetic medications that derive from the active opiate alkaloids found in the opium poppy. In their numerous formulations, they are prescribed to relieve various levels of pain. With a similar method of action as heroin, they reduce the intensity of pain signals and are capable of producing positive, reinforcing effects in the user.
On a neurological level, prescription opioids work to dampen pain signals from the body, but the ensuing psychological effects—like euphoria and extreme relaxation—serve as the primary building blocks for the development of abuse and addiction. The summation of these effects prove intensely rewarding to those abusing them—eliciting persistent alterations in brain chemistry that may further compel an individual to use the drug, time and again.
In 2014, the United States alone saw nearly 4.3 million people age 12 or older using prescription painkillers non-medically, which accounts for almost 2% of the population in the country.1 Of these, roughly 2 million suffered from a substance use disorder related to their abuse of these medications.
The rates of non-medical prescription opioid abuse have remained relatively steady since 2002,1 and it is becoming clear that this is a problem that must be addressed.
Due to their status as drugs of medical value, the dangers of prescription opioid abuse are often overlooked. Many users disregard the risk of dependency in favor of the blissful high, unknowingly getting themselves started on a path toward opioid addiction.
At what point does prescription opioid use evolve into substance abuse, and why have prescription opioids become so widely abused?
To answer this question, we must consider all aspects of the problem, from:
- Individual motivations and constraints.
- Public health issues (like regulating physician guidelines).
- Psychological correlations between pain and drug abuse.
What is Prescription Opioid Abuse?
The cognitive effects of prescription opioids can be very alluring, as they extend beyond diminishing pain signals and into areas of the brain involved with emotional control and reward.2
When taken in higher doses, a user may experience pleasurable opioid side effects: euphoria, relaxation, and, in accordance with their intended effects, less bodily pain.
These gratifying sensations positively reinforce the drug use behavior that led to them. When persistently experienced, they serve to co-opt or otherwise alter reward pathways in the brain—a person is likely to want to keep using in order to experience the intensely pleasurable effects.
Essentially, this pattern of use tricks the brain into believing that taking high doses of these drugs is good for you. Because of the activation of reward pathways in the cortex, the user’s feelings with respect to opioids may slowly begin to change from simple enjoyment to anxious hunger as substance dependence develops.
To say that a person is dependent on opioid medications means that their pattern of use has a significant psychological and physiological component. Psychologically, they have begun to crave the drug and want to consume it despite being aware of the negative consequences. Physiologically, the body reacts poorly to the absence of opioids—a phenomenon known as acute opioid withdrawal syndrome.
The dual duress of craving opioids and fearing withdrawal often leads to escalating patterns of abuse, such as:
- Increase in doses.
- Rise in frequency of use.
- Changes in method of ingestion.
When a person takes more than the prescribed dose or uses an opioid medication without a prescription, patterns in their brain may begin to change. As a user progresses into opioid dependence, their brain becomes less responsive to the drugs—requiring ever-increasing doses in order to achieve the same desired effect.3 This is called tolerance.
Beyond escalating doses, abuse of prescription opioids can entail any number of use habits. For many, abuse involves taking the pills in a way that will hasten and enhance the euphoric effects. This can involve:
- Crushing pills into powder to be nasally insufflated (snorted).
- Dissolving pills into solution to be used via injection routes.
- Using them in combination with other substances, such as alcohol.
Prescription opioid abuse is a widespread issue, so distinguishing between opioid abuse, dependence and addiction is a vital part of understanding the scope of the problem.
Opioid abuse encompasses a pattern of use behaviors that indicate the drug is not being used as prescribed. This includes:
Opioid dependence reflects a physiologic state wherein the user begins to require the drug in order to avoid withdrawal.
Opioid addiction is characterized as persistent, compulsive drug-seeking behaviors and thoughts, despite the adverse consequences of the associated drug use.
Opioid abuse encompasses a pattern of use behaviors that indicate the drug is not being used as prescribed. This includes:
The lack of consensus on what constitutes opioid addiction is one of the reasons public health guidelines and physician education on this topic are so difficult to regulate.
Although physical dependence can indicate an addiction, it can also occur without the presence of psychological problems like craving and compulsive use—it may just be that a person has been using the drug therapeutically for a long time.
This occurs with many individuals who use opioids for pain—they develop a physical dependence on them but do not have the accompanying psychological symptoms that constitute an addiction. From a physician’s point of view, it is very difficult to discern who is experiencing a legitimate side effect of long-term use and who may be misusing opioids.
Both prescription opioid dependence and abuse are contributing factors to the development of an addiction, which can become intensely consuming. If a person begins using opioids for medical reasons, it is more likely that a dependency will develop first, potentially escalating into abuse behaviors. On the illicit market, abuse is generally the starting point for dependency. No matter how you cut it, opioid misuse is a dangerous habit with far-reaching consequences.
Why Are Opioid Analgesics Prescribed?
For many, prescription opioid abuse begins with a doctor’s recommendation. These medications get prescribed to treat moderate to severe pain, be it the result of injury, surgery, a chronic health condition (such as pain related to cancer) or a dental procedure.
When taken as prescribed, opioid medications can make a world of difference for a person in pain. They can markedly
improve quality of life—helping those otherwise consumed by their painful conditions to get through their daily life without experiencing constant agony.
Prescription opioid dosing is (or should be) carefully determined for each person in order to avoid the development of dependence.
Taking painkillers beyond the doctor-prescribed dose, or without a doctor’s prescription altogether, greatly increases the potential for abuse.
Non-medical users have a variety of reasons behind their opioid use. Some do not readily have access to the healthcare that they need, and so obtain these medications to self-treat pain, anxiety, loneliness, or even to temper the side effects of other drugs. Other users simply take them to achieve the blissful high.
No matter the motivation, prescription opioid abuse has undeniably swept the nation.
The epidemic of opioid abuse and dependency has even caught the attention of some government agencies. The Centers for Disease Control and Prevention (CDC) revised their opioid prescribing guidelines in 2016—now discouraging doctors from prescribing opioid medications for chronic, long-lasting pain.5
In 2012 alone, 259 million opioid prescriptions were doled out—that’s enough pills for every adult in the United States to have their own bottle!4
Even high government offices have taken steps to ease the prescription opioid abuse problem. In 2016, President Obama established a special budget to expand access to substance abuse treatment for opioid users, promote research on effective opioid abuse treatment, and increase the availability of naloxone, a drug used to treat opioid overdose.6
While opioids undeniably have their place in the medical world, the use of them is becoming increasingly more focused on recreational pleasure, perhaps due in part to the perception of these drugs as "safe" because of their doctor-prescribed origins. The more these drugs are viewed as medically safe, the riskier their abuse becomes.
Who is at Risk for Developing Prescription Opioid Addiction?
Some people begin using prescription opioids strictly to experience their psychoactive effects. Others follow a more protracted course, beginning with a legitimate medical need that devolves into recreational fun. Regardless of the user’s motivation to begin abusing the drugs, the results can be detrimental. Because the dangers can run so high, it is important to recognize risk factors for prescription opioid abuse.
A wide range of individuals—together representing a diverse cross-section of demographic variables—are bearing the brunt of the opioid abuse epidemic. A number of these differing individual characteristics may play a hand in the development of an opioid drug abuse problem.
The user’s gender, age, race, socioeconomic status, geographical area, and medical or clinical history can all factor in to the progression of opioid abuse. It is important to note that risk factors are correlational; they do not definitively predict that a person will develop an addiction to opioids.
Risk factors play an important role in the development of addiction; they are critical to understanding the different stages of addiction and relapse.
Genetics, for example, can underlie personality traits like impulsivity that lead to initiation of drug use. Furthermore, psychological predispositions can influence an individual’s specific stress-response, which may itself determine if and how that individual eventually develops problematic patterns of use.
Women are prescribed abuse-prone medications more often than men,7,8 yet men have been found to use opioid medications non-medically at significantly higher rates than women.9,10 Death from prescription drug overdose also occurs at higher rates in men than women.11
Despite these seemingly oppositional facts, men and women have been admitted to the emergency department at approximately equal rates for complications relating to opioid abuse.12
Death from prescription drug overdose occurs at higher rates in men than women. However, this gap is closing as overdose rates in women is increasing.
It may seem like women would have a higher risk of abusing opioid medications, but the data indicate that men report more problems associated with opioid use. The abuse gap between men and women has been closing up, however, as women have seen a 400% increase in overdose death rates from 1999 to 2013.13
Significantly fewer women have received substance abuse treatment than men,10 emphasizing the need for more substance abuse care outreach and education. Understanding gender specific trajectories of opioid addiction can help in the assessment of:
- Treatment utilization and success.
- Relapse prevention.
Rates of long-standing opioid medication use without a prescription are highest among younger users between the ages of 18 and 25,1,9 yet overdose rates are highest among users between 45 and 54 years old.11
The biggest increase in non-medical use of prescription pain relievers occurred in users 50 years and older—average rates of use in this group increased by 60% between 2003 and 2010.9
Younger people have a higher risk of abusing prescription opioids, but rates among older users are on the rise. Middle-aged users have the highest risk of overdose, which may reflect more frequent, higher dosing.
Studies into the age-related effects on prescription opioid addiction might aid in the prevention of over-prescribing by spotlighting the problems that cause it. Many providers have concerns about the effects of opioids in older adults or the potential for addiction or the diversion of medications. Clarification in this area can help develop proper sanctions and training interventions to improve the use of opioid analgesic therapy.
Rates of opioid prescriptions have been found to be highest among white patients, followed by black patients, Hispanic patients, and Asian or other race patients, regardless of socio-economic status.14,15
In addition, opioid overdose rates are nearly three times higher among American Indians/Alaska Natives and non-Hispanic whites than among blacks and Hispanic whites.11 These trends may reflect some underlying difference between races, but the more likely explanation is that they demonstrate the disparity between different races when it comes to health care.
Race has been shown to have a major impact on doctor-patient care,16,17 and the majority of physicians in the U.S. are white— only 6.4% identify as black or African American, 6.4% as Hispanic or Latino, and 18.4% as Asian.18
A white physician may be more likely to prescribe opioid pain medications to their white patients than patients of a racial background different than their own.
Racial disparities outline the need for a better understanding and education regarding the effect of race on health care and prescribing practices.
There is some preliminary evidence that socioeconomic status (SES), or what a person’s income and education level is, may be related to prescription opioid problems.
People from high SES areas suffering from moderate-to-severe pain are prescribed more opioid medications than those in the low SES neighborhoods.14
Education has also been associated with rates of opioid prescriptions. Patients with higher education levels are three times less likely to receive an opioid medication prescription than those with lower education levels.19,20
This means that the less schooling a person has, the more likely they are to be prescribed opioid medications to treat pain.
Socioeconomic status can affect substance abuse by:21
- Shaping drug use habits.
- Influencing the availability of health resources.
- Affecting adherence to medication.
While the association is not yet fully vetted, it is clear that socioeconomic status and opioid medication prescribing and abuse are intertwined.
Interestingly enough, abuse of prescription opioids has been found to have a regional component.
In the United States, abuse rates are highest in the Southeastern states, Appalachian area, and Northwest.11,22,14 Rural regions also tend to have higher rates of prescription opioid overdose than urban areas.23
These areas have the highest rates of opioid prescription problems, but interestingly, the higher rates do not reflect a higher incidence of injury, surgery, or chronic pain.
This discrepancy may reflect a lack of consensus among healthcare professionals as to the proper prescribing guidelines for opioid medications—a problem that the CDC’s new mandate hopes to address.
Medical and Clinical History
Long-term medical use of prescription opioids to treat chronic pain is one of the leading risk factors for overdose.
People struggling with chronic pain at the same time as they are coping with a substance use or mental health disorder have the highest risk for misusing prescription opioids, especially with higher prescribed doses.24
In addition, long-term medical use of prescription opioids to treat chronic pain is one of the leading risk factors for overdose. Those with long-term medical need are actually at higher risk of experiencing an overdose than those “using without a prescription”.25
Common psychological disorders, such as mood disorders, have shown a clear link with the development of opioid abuse.26 Even the abuse of other substances, including alcohol, has been found related to opioid medication use problems.26
Any prescription opioid user who is dealing with these issues faces an increased risk of falling into a pattern of abuse.
One of the most dangerous problems with prescription opioids is that, all too often, they are viewed as a “safe” drugs due to their status as pharmaceutically manufactured substances with legitimate medical uses. Unfortunately, the underestimation of their dangers can lead people towards risky patterns of abuse and, ultimately, very harmful outcomes.
Reasons for Prescription Opioid Abuse
Prescription opioid abuse can occur for a multitude of reasons:
- Recreational highs.
- Compulsory habits due to dependence or addiction, or even for dealer profit.
No matter the root cause, there are numerous factors underlying the rise of prescription opioid problems, and a lot of them have to do with how these drugs are viewed in the social sphere. Once these perceptions are recognized, we can begin to understand how to address this escalating problem.
Social context may contribute to the structuring of prescription opioid use norms and acceptability.27
In fact, non-medical prescription drug users are more likely to have positive expectations about the effects of use,28,29,30 and many younger users do not recognize the extent of risks associated with abuse of opioid medications.31
Viewing prescription opioid abuse as a socially acceptable practice has a particularly potent impact on adolescents.
Young people may gain their understanding of prescription opioid use by observing older people in their lives taking pills on a frequent basis.32 In addition, social media has expanded the scope of community connection, allowing for substance-using teens to develop a network of like-minded peers.32
The use and abuse of prescription drugs may be viewed as more socially acceptable than use and abuse of illicit substances like cocaine.
A surprising majority of college students underestimate the prevalence of non-medical use of prescription drugs.33
College students may prefer prescription medications for:
- Recreational highs, because they are easy to hide.
- Producing effects that last longer than other substances.
- Enhancing the feeling of drunkenness.
- Potentially less severe repercussions if caught using them.31
When people believe that their peers are engaging in a particular behavior, such as opioid medication abuse, they often normalize it, which only serves to expand the problem’s scope.
If we can gain a better understanding of how prescription opioids are rationalized as a socially acceptable drug of abuse, we may begin to find ways to counteract this misunderstanding and reduce the high rates of abuse.
Perceptions of Safety
Prescription drugs have become an accepted, sometimes medically necessary part of society. Some of the factors that contribute to their widespread acceptance, and further their perception as “safe” drugs include:
- Authoritative source.
- Easy consumption.
- Easy accessibility.
- Frequency of prescription.
Because these medications often come recommended by a trusted authority source (a doctor), the risks associated with abuse can be easily overlooked. Some users may not realize that they have a problem until something drastic happens, such as overdose.
Opioid medication abuse doesn’t necessarily involve routes of administration that are highly stigmatized or associated with negative health effects such as smoking or injecting,34,35 which may contribute to the widely-held assumption that they are safe.36
On top of this, prescription opioids can be obtained through safer outlets—getting a prescription from a doctor or pills for a friend is probably safer than going to a dealer.
Frequency of Prescription
The staggering number of opioid prescriptions being written sends the wrong message to consumers regarding the dangers of opioid abuse. Not only has the number of opioid prescriptions nearly quadrupled since 1999, the average dose prescribed has risen dramatically.38
In fact, the most damage is seen in users who are taking these medications exactly as their doctor recommends: 60% of deaths related to opioid use occur in those who were given a prescription based on physician guidelines, and the other 40% occur in people who get their opioids through diverted prescriptions, doctor shopping, or multiple prescriptions.38,39
A major contributing factor to the perceived halo of safety is the aggressive marketing by major pharmaceutical companies.
The amount of money these companies have spent promoting their drugs has increased dramatically in recent years,40 and this type of direct-to-consumer marketing may communicate the message that opioid medications, like all prescription pharmaceuticals, are not only good for you, but safe to use and without negative consequence.41
Fortunately, the new CDC guidelines for opioid prescribing practices are a step in the right direction. Encouraging as the changes may be, fewer prescriptions cannot guarantee lower rates of abuse. Further steps will need to be taken in order to improve the safety of users.
Ensuring that all opioid prescriptions are accompanied by education regarding the risks and dangers of misuse may help to curb the high rate of health problems associated with these medications.
Both physicians and consumers should be well-informed in order to ensure the medications are rightfully prescribed, properly dosed, and taken according to specific guidelines in order to avoid adverse consequences.
The mere fact that these potent drugs are so readily available poses a danger to opioid users. Some drug abusers take advantage of their legal status as substances with legitimate medical value. They may fake symptoms or otherwise find a way to obtain opioid prescriptions from their doctors will the sole intent of recreational use.
Some users may even resort to “doctor shopping” wherein they visit different doctors in order to get multiple prescriptions for opioids.
While not common, this practice has been found to skew prescribing rates, with average patients that are presumed to be doctor shoppers encompassing 0.7% of the opioid prescription populace but obtaining almost 4% of the weighted opioid medication amounts.41
On average, extreme doctor shoppers were able to get 32 opioid prescriptions acquired through 10 different prescribers in 2008 alone.42 There is a good chance that many of these people are selling the drugs to people without a medical need for them.
Practitioners need a better system for tracking and accessing patient medication monitoring to watch for suspicious prescription acquisition patterns.
Surprisingly, while these types of misrepresentation and doctor shopping techniques do take place, most who abuse opioid medications do not obtain their drugs this way. Most non-medical users get the drugs from a friend or relative, often for free but occasionally buying or stealing them.1
Only 22.1% of non-medical users “legitimately” got their drugs from a doctor in 2014, indicating that diversion of these medications is a major concern.1
Friends and relatives are unlikely to have a full understanding of the dangers associated with opioid medications. When users get the drugs from their peers and family, they may unknowingly be taking an unsafe dose for their body and health status.
The availability of opioid medications has contributed greatly to the abuse problem. The widespread overprescribing of opioids has led to the diversion and exploitation of these medications, and unfortunate abusers suffer the consequences.
Motivations (Self-treatment Vs. Recreational)
While it may be true that prescription opioids are viewed as more safe and more socially acceptable than other substances, it is important to understand why people are abusing these drugs in the first place.
Some users may be taking these opioids, with or without a prescription, to treat a variety of problems. Managing acute pain, chronic pain, stress, and emotional problems are common motivations behind this self-treatment.43,44,45 This type of use is especially common among athletes coping with both short and long term sports injuries.46
Coping with psychological distress may also play a large role in the abuse of opioid medications. The specific psychological issues being “medicated” differ across gender lines.
Women are more likely to take these medications to deal with stress, conflict, and anxiety relating to their social circle,47 while men are more likely to be using them to cope with depression.48
Perhaps the most obvious motivation for prescription opioid abuse is recreational pleasure. Opioids can produce a euphoric high where the user feels relaxed and at peace.49 Different methods of consumption can enhance this high by producing faster and more intense effects. Snorting, for example, produces a rapid and intense high followed by a faster comedown. Many opioid abusers take the medications in a way other than the intended method of ingestion in order to achieve the desired recreational gratification.
Understanding why people are abusing prescription opioid medications can help professionals take better preventative measures to reduce the harm that these drugs can cause.
For users that are taking opioids to cope with emotional or psychological distress, increased availability of behavioral interventions may help to preclude their use.
Stricter guidelines for prescribing opioids (such as those offered by the new CDC recommendations) as well as lowering the available doses of these prescriptions may help decrease rates of recreational abuse, as these practices may ultimately reduce the supply of (and average dose of) opioid medications available on the illicit market.
Mental Health Correlations
There have been strong correlations found between prescription opioid abuse and mental health issues.
In fact, nearly 45% of people struggling with an opioid medication use disorder meet the DSM-IV criteria for either depression or anxiety.50 Depression and anxiety are even more strongly associated with prescription opioid use than other substance use disorders,50 and almost 80% of non-medical opioid medication users have a history of depression and anxiety.51
People who struggle with the issues of severe anxiety or depression are more likely to underestimate the dangers of prescription opioid abuse,52 and it has been suggested that adolescents with acute anxiety may be at particular risk for prescription drug abuse.53
In some cases, problematic drug use may “uncover” or lead to the development of these mental health issues. In other instances, it may be that pre-existing psychological disorders predispose a person to later develop substance abuse problems.
Ensuring that all doctors consider a person’s mental health history when prescribing medications, especially opioids, may be an effective strategy in reducing non-medical prescription drug abuse. As part of their patient assessment, physicians must consider all the risk factors associated with prescription opioid abuse so that they may make more carefully considered decisions to administer these potent medications.
Other Substance Use Disorder
Poly-substance abuse in association with the prescription opioids is not uncommon. Problem drug use in general, including that of alcohol abuse, has been associated with higher rates of prescription opioid use.50
In 2011, more emergency department visits involved people using prescription opioids in combination with other substances than using them on their own.12Benzodiazepines are a particularly dangerous part of this mix, and account for nearly 30% of the drug combination emergency room complications. This alarming percentage indicates more ER complications than those seen in association with the next two culprit substances combined—with alcohol at nearly 15% and marijuana at 10%.12
Teens are also showing patterns of problematic multi-substance abuse. Nearly 7 out of 10 teens that use prescription opioids non-medically take them with another substance.54 Marijuana is the most popular addition, followed closely by alcohol—both of which are co-abused with opioids in more than 50% of reported cases.
Co-abuse of opioid medications with central nervous system depressants such as alcohol and benzodiazepines is especially dangerous. Depressant drugs like these can slow a person’s breathing and heart rate to lethal levels, as well as compounding other physical effects that dangerously compromise a user’s health.55,56,57
Considering how many opioid-using individuals are combining the drugs with other substances, education regarding the effects of co-use should be emphasized to physicians and patients alike. Adolescent substance education is of particular importance, as rates of co-abuse are alarmingly high among this population.
Prescription Opioids and Heroin
Prescription opioids and heroin are in the same class of drugs. While they exhibit some pharmacodynamic differences, they all act on the same sub-population of opioid receptors and are capable of eliciting similar neurological effects. Furthermore, the cascade of molecular events that they initiate in the brain impacts a characteristic set of neurotransmitters systems.58 All of these substances have a high abuse and addiction potential in part because they influence areas of the brain related to processing and reward regulation.
Some of the prescription opioids—such as oxycodone and fentanyl—have abuse potential that rivals (or exceeds) that of heroin due to their sheer potency and pharmaceutical purity.59,60
It has even been theorized that prescription opioid abuse is leading some users into heroin use because heroin is cheaper to buy, sometimes easier to obtain and, via an injectable route, is capable of providing relatively quicker and more intense highs than its prescription opioid counterparts.
User reports corroborate these assumptions.58 In fact, the majority of current heroin users abused prescription opioids before initiating heroin use. It is important to note that the reverse is not necessarily true—rates of heroin abuse among those who abuse prescription opioids are low.58 This indicates that prescription opioid abuse is a major risk factor for heroin use. To clarify, not all individuals with an addiction to prescription opioids will develop an addiction to heroin, but prescription opioid abuse creates physiological and psychological vulnerabilities that may make heroin seem desirable.
Considering that these medications may not only be more abuse-prone than heroin, but may even lead some users into heroin use, it is a wonder that are perceived as a safer, alternative high. In fact, overdose rates for prescription opioids were nearly twice the overdose rates for heroin in 2014.61
There is widespread misunderstanding regarding the relationship and similarities between opioid medications and heroin, leading to the incorrect assumption that prescription opioids are safe to use and abuse. As evidenced by these reports, this is simply not the case.
The Problem of Pain
The fact that opioid medications provide unparalleled benefits for people suffering from extreme pain makes addressing the prescription abuse problem a tricky endeavor.
On the one hand, the number of opioid prescriptions has skyrocketed,38 which runs directly counter to allegations that pain has been largely undertreated by the medical community.62 On the other hand, the over-prescribing of opioid medications to treat chronic pain has proven to be a major societal concern.63
How can these seemingly opposing problems be reconciled?
Many believe we need alternative options for treating chronic, non-cancer related pain. This may involve:
- Decreasing or stopping the effectiveness of higher doses.
- Producing negative effects if the drug is taken outside of doctor-recommended parameters.
- Developing a physical or chemical barrier to methods of abuse.
These deterrent efforts might include the development of crush-resistant pills, adding a gelatin chemical so that the pills cannot be dissolved in water, or including an agent that may react negatively in the presence of alcohol or other substances.
One such formulation, extended-release oxycodone, was made to be tamper-resistant so that users could not abuse the drug by crushing or dissolving the pills. It has shown very promising results after its release on the market in 2010, reducing abuse rates by 41% (65).
The creation of abuse-resistant medications may help curb the problem by maintaining the availability of effective pain treatment while at the same time drastically reducing the potential for alternative use or increasing doses.
The CDC revised their opioid prescription screening guidelines in 2016, no longer promoting opioids as a treatment for chronic non-cancer pain.5
These new recommendations discourage using opioids as a first line of defense against painful conditions, especially long-lasting pain. They encourage frequent doctor-patient check-ins to ensure that the drugs are being taken only as prescribed, as well as the promotion of substance abuse treatment in the event that a patient develops an abuse problem.
By revising patient screening, the medical community can more effectively prescribe and dose these potent medications to the people that will derive the most benefit with the least amount of risk.
These new guidelines may help reduce the amount of prescription opioids available for non-medical use in addition to exposing more treatment options for patients struggling with opioid abuse and addiction.
When medical practitioners are provided adequate, up-to-date information on the risks associated with opioid medications, they can more judiciously administer these medications and clearly communicate concerns to their patients regarding appropriate and safe opioid use.
Because painful conditions can be so debilitating, it is imperative that all aspects of prescription opioid medications be analyzed and considered before being prescribed to a patient.
The balance between pain management and a substance abuse problem relies on the delicate scale of medical necessity. Alternative options for pain management may be a less risky option for most patients, and physicians must be provided the information and education necessary to determine whether or not a patient should be prescribed such a potent drug. Fortunately, locales that have taken pivotal action to reduce prescription opioid abuse have seen very promising results, including fewer opioid prescriptions being given and lower rates of overdose deaths.58
Alternative Pain Management Approaches
Managing pain is a necessary part of life for many people. Because opioid medications come with such high risks, finding alternate methods to cope with and treat painful conditions can help alleviate the opioid epidemic. There are many alternative options for pain management that have shown promising results.
The insertion of very thin needles into certain points on the body. Has demonstrated positive results in back pain and headache issues.66
Pain conditions can cause a lot of stress in a person’s life. Stress reduction practices can help alleviate the sense of pain through a variety of methods: mindfulness meditation,74,75 Yoga,76,77,78 music therapy,79,80,81 massage,82,83,84 and biofeedback85 have all shown positive results in the management of pain.
Regular physical activity can provide major benefits for people suffering with painful conditions. Physical activity regimens that are tailored to the particular condition have shown the best results.6,68,697
Nearly one half of chronic pain patients develops depression.70 Engaging in therapy, especially cognitive-behavioral therapy, has been shown to help patients minimize the impact that pain has on their life, including thoughts and emotions, which can result in reduced perceptions of pain.71,72,73
A state of concentration that is very focused. Has been found to help with pain related to post-surgery, arthritis, cancer, headaches, and fibromyalgia.66
There is a lot of controversy surrounding the medical use of marijuana. This substance has been found to help many people cope with pain,86,87,88 but may have adverse health effects so it is important to consult with a medical professional.
Efforts to curb the prescription opioid abuse problem are challenged by numerous factors that all relate to the way that these medications are perceived in the public sphere. Despite their legal status, opioid medications have a very high potential for abuse and addiction and are being overprescribed at alarming rates.
Fortunately, the steps that are being taken have shown promising results. With a better understanding of the underlying causes of this epidemic, both professionals and consumers will be better equipped to address the major public health concerns arising from opioid abuse. Continued determined efforts to educate society, prevent abuse and diversion, and acknowledge factors that play into opioid abuse will help expose the truth behind these powerful drugs.
1. Center for Behavioral Health Statistics and Quality. (2015). Behavioral health trends in the United States: Results from the 2014 National Survey on Drug Use and Health (HHS Publication No. SMA 15-4927, NSDUH Series H-50).
2. Merrer, J.L., Becker, J.A., Befort, K., & Kieffer, B.L. (2009). Reward processing by the opioid system in the brain. Physiological Review, 89(4). 1379-1412.
3. Kosten, T.R. & George, T.P. (2002). The neurobiology of opioid dependence: Implications for treatment. Science and Practice Perspectives, 1(1). 13-20.
4. Centers for Disease Control and Prevention. (2014). Opioid Painkiller Prescribing, Where You Live Makes a Difference. Atlanta, GA: Centers for Disease Control and Prevention.
5. Centers for Disease Control and Prevention. (2016). Guideline for prescribing opioids for chronic pain. Atlanta, GA: Centers for Disease Control and Prevention.
6. The White House. (2016). Fact sheet: President Obama proposes $1.1 billion in new funding to address the prescription opioid abuse and heroin use epidemic. Office of the Press Secretary.
7. Raofi, S. & Schappert, S.M. (2006). Medication therapy in ambulatory medical care; United States, 2003-2004. Vital Health Statistics, 13(163). 1-40.
8. Simoni-Wastila, L., Ritter, G., & Strickler, G. (2004). Gender and other factors associated with the nonmedical use of abusable prescription drugs. Substance Use and Misuse, 39(1). 1-23.
9. Jones, C.M. (2012). Frequency of prescription pain reliever nonmedical use: 2002-2003 and 2009-2010. Archives of Internal Medicine, 172(16). 1265-1267.
10. Back, S.E., Payne, R. L., Simpson, A.N., & Brady, K.T. (2010). Gender and prescription opioids: findings from the National Survey on Drug Use and Health. Addiction and Behavior, 35(11). 1001-1007.
11. Paulozzi, L.J., Jones, C., Mack, K., & Rudd, R. (2011). Centers for Disease Control and Prevention (CDC). Vital signs: overdoses of prescription opioid pain relievers—United States, 1999-2008. MMWR Morbidity and Mortality Weekly Report, 60(43). 1487- 1492.
12. Substance Abuse and Mental Health Services Administration. (2015). Emergency department visits involving narcotic pain relievers. Drug Abuse Warning Network: The CBHSQ Report.
13. Centers for Disease Control and Prevention. (2013). Prescription Painkiller Overdoses. Atlanta, GA: Centers for Disease Control and Prevention.
14. Joynt, M., Train, M.K., Robbins, B.W., Halterman, J.S., Caiola, E., & Fortuna, R.J. (2013). The impact of neighborhood socioeconomic status and race on the prescribing of opioids in emergency departments throughout the United States. Journal of General Internal Medicine, 28(12). 1604-1610.
15. Pletcher, M.J., Kertesz, S.G., Kohn, M.A., & Gonzales, R. (2008). Trends in opioid prescribing by race/ethnicity for patients seeking care in US emergency departments. JAMA, 299(1). 70-78.
16. Berger, J.T. (2008). The influence of physicians’ demographic characteristics and their patients’ demographic characteristics on physician practice: implications for education and research. Journal Association of American Medical Colleges, 83(1). 100–105.
17. Komaromy, M., Grumbach, K., Drake, M., Vranizan, K., Lurie, N., Keane, D., & Bindman, A.B. (1996). The role of black and Hispanic physicians in providing health care for underserved populations. New England Journal of Medicine, 334(20). 1305–1310.
18. U.S. Bureau of Labor Statistics. (2015). Labor force statistics from the current population survey.
19. Platts-Mills, T.F., Hunold, K.M., Bortsov, A.V., Soward, A.C., Peak, D.A., Jones, J.S., … McLean, S.A. (2012). More educated emergency department patients are less likely to receive opioids for acute pain. Pain, 153(5). 967-973.
20. Krebs, E.E., Lurie, J.D., Fanciullo, G., Tosteson, T.D., Blood, E.A., Carey, T.S., & Weinstein, J.N. (2010). Predictors of long-term opioid use among patients with painful lumbar spine conditions. The Journal of Pain, 11(1). 44–52.
21. Galea, S. & Vlahov, D. (2002). Social determinants and the health of drug users: socioeconomic status, homelessness, and incarceration. Public Health Report, 117(1). S135-S145.
22. McDonald, D.C., Carlson, K., & Izrael, D. (2012). Geographic variation in opioid prescribing in the U.S. Journal of Pain, 13(10). 988-996.
23. Centers for Disease Control and Prevention. (2013). Addressing prescription drug abuse in the United States: current activities and future opportunities. Washington, DC: U.S. Department of Health and Human Services.
24. Sehgal, N., Manchikanti, L., & Smith, H.S. (2012). Prescription opioid abuse in chronic pain: a review of opioid abuse predictors and strategies to curb opioid abuse. Pain Physician, 15(3). ES67-ES92.
25. Centers for Disease Control and Prevention. (2012). CDC grand rounds: prescription drug overdoses – a U.S. epidemic. MMWR Morbidity and Mortality Weekly Report, 61(1). 10- 13.
26. Sullivan, M.D., Edlund, M.J., Zhang, L., Unutzer, J., & Wells, K.B. (2006). Association between mental health disorders, problem drug use, and regular prescription opioid use. Archives of Internal Medicine, 166(19). 2087-2093.
27. Galea, S., Nandi, A., & Vlahov, D. (2004). The social epidemiology of substance use. Epidemiological Review, 26. 36-52.
28. Boyd, C.J., Teter, C.J., West, B.T., Morales, M., & McCabe, S.E. (2009). Non-medical use of prescription analgesics: a three-year national longitudinal study. Journal of Addictive Diseases, 28(3). 232-242.
29. McCabe, S.E., Boyd, C.J., & Young, A. (2007). Medical and non- medical use of prescription drugs among secondary school students. Journal of Adolescent Health, 40(1). 76-83.
30. McCabe, S.E., Teter, C.J., Boyd, C.J., Knight, J.R., & Wechsler, H. (2005). Nonmedical use of prescription opioids among U.S. college students: prevalence and correlates from a national survey. Addictive Behaviors, 30(4). 789-805.
31. Lord, S., Brevard, J., & Budman, S. (2011). Connecting to young adults: an online social network survey of beliefs and attitudes associated with prescription opioid misuse among college students. Substance Use and Misuse, 46(1). 66-76.
31. Compton, W.M. & Volkow, N.D. (2006). Abuse of prescription drugs and the risk of addiction. Drug and Alcohol Dependence, 83(1). S4-S7.
32. Hanson, C.L., Cannon, B., Burton, S., & Giraud-Carrier, C. (2013). An exploration of social circles and prescription drug abuse through twitter. Journal of Medical Internet Research, 15(9). E189.
33. McCabe, S.E. (2008). Misperceptions of non-medical prescription drug use: a web survey of college students. Addictive Behaviors, 33. 713–724.
34. Foltin, R.W. & Fischman, M.W. (1992). Self-administration of cocaine by humans: choice between smoked and intravenous cocaine. Journal of Pharmacology and Experimental Therapeutics, 261(3). 841-849.
35. Des Jarlais, D.C., Arasteh, K., Perlis, T., Hagan, H., Heckathorn, D.D., McKnight, C., Bramson, H., & Friedman, S.R. (2007). The transition from injection to non-injection drug use: long- term outcomes among heroin and cocaine users in New York City. Addiction, 102(5). 778-785.
36. Keyes, K.M., Cerda, M., Brady, J.E., Havens, J.R., & Galea, S. (2014). Understanding the rural-urban differences in nonmedical prescription opioid use and abuse in the United States. American Journal of Public Health, 104(2). E52-E59.
37. Johnston, L.D., O’Malley, P.M., Bachman, J.G., & Schulenberg, J.E. (2010). Monitoring the Future. National Survey Results on Drug Use, 1975---2009. Vol. 2: College Students and Adults Ages 19-50. Bethesda, MD: National Institute on Drug Abuse; 2010. NIH Publication 10-7585.
38. Manchikanti, L., Helm II, S., Fellows, B., Janata, J.W., Pampati, V., Grider, J.S., & Boswell, M.V. (2012). Opioid epidemic in the United States. Pain Physician, 15. ES9-ES38.
39. Letter to Janet Woodcock, MD, Director, Center for Drug Evaluation and Research, U.S Food and Drug Administration, from Physicians for Responsible Opioid Prescribing RE Docket No. FDA- 2011-D-0771, Draft Blueprint for Prescriber Education for Long Acting/Extended Release Opioid Class-Wide Risk Evaluation and Mitigation Strategies. 2 December, 2011.
40. Ventola, C.L. (2011). Direct to Consumer Pharmaceutical Advertising: Therapeutic or Toxic? Pharmacy and Therapeutics, 36(10). 669-684.
41. Netemeyer, R., Burton, S., Delaney, B., & Hijjawi, G. (2015). The legal high: factors affecting young consumers’ risk perceptions and abuse of prescription drugs. Journal of Public Policy and Marketing, 34(1). 103-118.
42. McDonald, D.C. & Carlson, K.E. (2013). Estimating the prevalence of opioid diversion by “doctor shoppers” in the United States. PLOS ONE 8(7). e69241.
43. Young, A., McCabe, S.E., Cranford, J.A., Ross-Durow, P., & Boyd, CJ. (2012). Nonmedical use of prescription opioids among adolescents: subtypes based on motivation for use. Journal of Addictive Disorders, 31(4). 332-341.
44. Garland, E.L., Hanley, A.W., Thomas, E.A., Knoll, P., & Ferraro, J. (2015). Low dispositional mindfulness predicts self-medication of negative emotion with prescription opioids. Journal of Addiction Medicine, 9(1). 61-67.
45. Merlo, L.J., Singhakant, S., Cummings, S.M., & Cottler, L.B. (2013). Reasons for misuse of prescription medication among physicians undergoing monitoring by a physician health program. Journal of Addiction Medicine, 7(5). 349–353.
46. King, S. (2014). Beyond the war on drugs? Notes on prescription opioids and the NFL. Journal of Sport and Social Issues, 38. 184-193.
47. Back, S.E., Lawson, K.M., Singleton, L.M., & Brady, K.T. (2011). Characteristics and correlates of men and women with prescription opioid dependence. Addictive Behaviors, 36(8). 829-834.
48. Green, T.C., Grimes Serrano, J.M., Licari, A., Budman, S.H., & Butler, S.F. (2009). Women who abuse prescription opioids: Findings from the Addiction Severity Index-Multimedia Version Connect prescription opioid database. Drug and Alcohol Dependence, 103. 65-73.
49. National Institute on Drug Abuse. (2014). Prescription drug abuse: how do opioids affect the brain and body?
50. Sullivan, M.D., Edlund, M.J., Steffick, D., & Unützer, J. (2005). Regular use of prescribed opioids: association with common psychiatric disorders. Pain, 119(1). 95–103.
51. Green, T.C., Black, R., Serrano, J.M.G., Budman, S.H., & Butler, S.F. (2011). Typologies of prescription opioid use in a large sample of adults assessed for substance abuse treatment. PloS one, 6(11). e27244.
52. Viana, A.G., Trent, L., Tull, M.T., Heiden, L., Damon, J.D., Hight, T.L., & Young, J. (2012). Non-medical use of prescription drugs among Mississippi youth: constitutional, psychological, and family factors. Addictive Behaviors, 37(12). 1382-1388.
53. McCabe, S.E. & Cranford, J.A. (2012). Motivational subtypes of nonmedical use of prescription medications: results from a national study. Journal of Adolescent Health, 51(5). 445-452.
54. McCabe, S.E., West, B.T., Teter, C.J., & Boyd, C.J. (2012). Co-ingestion of prescription opioids and other drugs among high school seniors: results from a national study. Drug and Alcohol Dependence, 126(1-2). 65-70.
55. Cone, E.J., Fant, R.V., Rohay, J.M., Caplan, Y.H., Ballina, M., Reder, R.F., & Haddox, J.D. (2004). Oxycodone involvement in drug abuse deaths. II Evidence for toxic multiple drug-drug interactions. Journal of Analytical Toxicology, 28. 217–225.
56. Kreek, M.J. (1984). Opioid interactions with alcohol. Advances in Alcohol and Substance Abuse, 3(4). 35-46.
57. Jones, J.D., Mogali, S., & Comer, S.D. (2012). Polydrug abuse: a review of opioid and benzodiazepine combination use. Drug and Alcohol Dependence, 125(1-2). 8-18.
58. Compton, W.M., Jones, C.M., & Baldwin, G.T. (2016). Relationship between nonmedical prescription-opioid use and heroin use. The New England Journal of Medicine, 374. 154-163.
59. Ternes, J.W. & O’Brien, C.P. (1990). The opioids: abuse liability and treatments for dependence. Advances in Alcohol and Substance Abuse, 9. 27-45.
60. Comer, S.D., Sullivan, M.A., Whittington, R.A., Vosburg, S.K., & Kowalczyk, W.J. (2008). Abuse liability of prescription opioids compared to heroin in morphine-maintained heroin abusers. Neuropsychopharmacology, 33. 1179-1191.
61. National Institute on Drug Abuse. (2015). Overdose Death Rates.
62. National Academy of Sciences. (2011). Relieving pain in America: a blueprint for transforming prevention, care, education, and research. Washington DC: Institute of Medicine (US) Committee on Advancing Pain Research, Care, and Education.
63. Volkow, N.D. (2014). America’s addiction to opioids: heroin and prescription drug abuse. National Institute on Drug Abuse, Senate Caucus on International Narcotics Control.
64. U.S. Department of Health and Human Services, Food and Drug Administration. (2015). Abuse-deterrent opioids – evaluation and labeling: Guidance for industry. Center for Drug Evaluation and Research (CDER).
65. Butler, S.F., Cassidy, T.A., Chilcoat, H., Black, R.A., Landau, C., Budman, S.H., & Coplan, P.M. (2013). Abuse rates and routes of administration of reformulated extended-release oxycodone: initial findings from a sentinel surveillance sample of individuals assessed for substance abuse treatment. The Journal of Pain, 14(4). 351-358.
66. U.S. National Library of Medicine. (2013). Alternative medicine – pain relief. Medline Plus.
67. Nija, J., Kosek, E., Van Oosterwijck, J., & Meesus, M. (2012). Dysfunctional endogenous analgesia during exercise in patients with chronic pain: to exercise or not to exercise? Pain Physician, 15. ES205-ES213.
68. Hayden, J.A., van Tulder, M.W., & Tomlinson, G. (2005). Systematic review: strategies for using exercise therapy to improve outcomes in chronic low back pain. Annals of Internal Medicine, 142(9). 776-785.
69. Silvano, M. (2001). Exercise in the treatment of chronic pain. Clinical Journal of Pain, 17(4). S77-S85.
70. Flor, H. & Turk, D.C. (2011). Chronic pain: An integrated biobehavioral approach. Seattle: IASP Press.
71. Wilson, J.J. & Gil, K.M. (1996). The efficacy of psychological and pharmacological interventions for the treatment of chronic disease-related and non-disease-related pain. Clinical Psychology Review, 16. 573-597.
72. Morley, S., Eccleston, C., & Williams, A. (1999). Systematic review and meta-analysis of randomized controlled trials of cognitive behaviour therapy and behaviour therapy for chronic pain in adults, excluding headache. Pain, 80. 1-13.
73. Turner, J.A. & Jensen, M.P. (1993). Efficacy of cognitive therapy for chronic low back pain. Pain, 52(2). 169-177.
74. Rosenzweig, S., Greeson, J.M., Reibel, D.K., Green, J.S., Jasser, S.A., & Beasley, D. (2010). Mindfulness-based stress reduction for chronic pain conditions: variation in treatment outcomes and role of home meditation practice. Journal of Psychosomatic Research, 68. 29-36.
75. Kabat-Zinn, J. (1982). An outpatient program in behavioral medicine for chronic pain patients based on the practice of mindfulness meditation: theoretical considerations and preliminary results. General Hospital Psychiatry, 4. 33-47.
76. Tilbrook, H.E., Cox, H., Hewitt, C.E., Kang’ombe, A.R., Chuang, L., Jayakody, S., Aplin, J.D., … Torgerson, D.J. (2011). Yoga for chronic low back pain: a randomized trial. Annals of Internal Medicine,155(9). 569-578.
77. Williams, K.A., Petronis, J., Smith, D., Goodrich, D., Wu, J., Ravi, N., Doyle Jr, E.J., … Steinberg, L. (2005). Effect of Iyengar yoga therapy for chronic low back pain. Pain, 115. 107-117.
78. Galantino, M.L., Bzdewka, T.M., Eissler-Russo, J.L., Holbrook, M.L., Mogck, E.P., Geigle, P., Farrar, J.T. (2004). The impact of modified hatha yoga on chronic low back pain: a pilot study. Therapies in Health and Medicine, 10(2). 56-59.
79. Guetin, S., Coudeyre, E., Picot, M.C., Ginies, P., Graber-Duvernay, B., Ratsimba, D., Vanbiervliet, W., … Herisson, C. (2005). Effect of music therapy among hospitalized patients with chronic low back pain: a controlled, randomized trial. Annales de Readaptation et de Medecine Physique, 48(5). 217-224.
80. Magill, L. (2001). The use of music therapy to address the suffering in advanced cancer pain. Journal of Palliative Care, 17(3). 167-172.
81. Schorr, J.A. (1993). Music and pattern change in chronic pain. Advances in Nursing Science, 15(4). 27-36.
82. Plews-Ogan, M., Owens, J.E., Goodman, M., Wolfe, P., & Schorling, J. (2005). Brief report: A pilot study evaluating mindfulness-based stress reduction and massage for the management of chronic pain. Journal of General Internal Medicine, 20(12). 1136-1138.
83. Walach, H., Guthlin, C., & Konig, M. (2003). Efficacy of massage therapy in chronic pain: a pragmatic randomized trial. The Journal of Alternative and Complementary Medicine, 9(6). 837-846.
84. Hernandez-reif, M., Field, T., Krasnegor, J., & Theakston, H. (2001). Lower back pain is reduced and range of motion increased after massage therapy. International Journal of Neuroscience, 106(3-4). 131-145.
85. Turner, J.A. & Chapman, C.R. (1982). Psychological interventions for chronic pain: a critical review. I. Relaxation training and biofeedback. Pain, 12(1). 1-21.
86. Hill, K.P. (2015). Medical marijuana for treatment of chronic pain and other medical and psychiatric problems: a clinical review. JAMA, 313(24). 2474-2483.
87. Ware, M.A., Wang, T., Shapiro, S., Robinson, A., Ducruet, T., Huynh, T., Gamsa, A., Bennett, G.J., & Collet, J. (2010). Smoked cannabis for chronic neuropathic pain: a randomized controlled trial. CMAJ, 182(14). E694-E701.
88. Martin, B.R. & Lichtman, A.H. (1998). Cannabinoid transmission and pain perception. Neurobiology of Disease, 5. 447-461.
89. Turk, D.C., Swanson, K.S., & Tunks, E.R. (2008). Psychological approaches in the treatment of chronic pain patients- when pills, scalpels, and needles are not enough. The Canadian Journal of Psychiatry, 53(4). 213-223.
90. Turk, D.C., Zaki, H.S., & Rudy, T.E. (1993). Effects of intraoral appliance and biofeedback/stress management alone and in combination in treating pain and depression in patients with temporomandibular disorders. The Journal of Prosthetic Dentistry, 70(23). 158-164.