One of the
most talked about topics when looking at the demographics of rural
communities—especially those in the regions of Kentucky, West Virginia,
Virginia, and Tennessee—is the growing epidemic of opioid addiction. A very
heavily debated topic centered around addiction being a choice or a disease has
sparked controversy over how to treat individuals who have opioid dependency.
So, what is it that makes opioid addiction so prominent in society? To answer
this question, we must first understand how opioids work.
Within the
central nervous system, there are three types of opioid receptors—mu, delta, and
kappa1. Of these 7-transmembrane G-protein coupled receptors (GCPRs),
the mu opioid receptor is the one that tends to have the higher affinity for
opioids such as morphine1. Once activated, a downstream inhibitory
process is activated by way of inactivating adenylate cyclases within the
affected cell2. Once this happens, the release of neurotransmitters
is inhibited which affects the transmission of pain to the thalamus at the
junction of the peripheral nerves and the central nerves within the dorsal horn2.
This decrease of sensation is what gives opioids their analgesic affects which may
lead to dependency and addiction.
The question
remains of how individuals become addicted to these substances if their sole
purpose is to manage pain. Social interactions are thought to be the underlying
cause for most addictions3. However, there are many other ways that
someone can become addicted to a substance. With opioids being used to treat
pain, there is always the chance that someone can become addicted without even
realizing it.
Often,
dependency can be seen when someone who has been treated with opioids for pain stops
receiving treatment. The seemingly immediate adenylate cyclase activity that
allows for neurotransmitter release will begin opioid withdrawal symptoms and
make the individual feel like they’re in pain1. With proper medical
intervention, the addiction from this point can be avoided. However, the easy
access to synthetic opioids such as fentanyl allows for individuals to continue
receiving “treatment” without prescriptions4.
 |
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Figure 1
shows a sharp increase in overdose death rates of opioids between 2000 and
2016. A sharp increase can also be seen for the other synthetic opioids such as
fentanyl4.
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With
dependency comes tolerance as well. This happens when an individual loses the
desired effect of a drug with administration of the normal dose. Continued use
of opioids, whether prescribed or obtained illegally, can lead to the
individual developing tolerance for the normal recommended dose for treatment
at which point they administer more to get the desired effect1. The
increase in dosage at this point is what eventually leads individuals to
overdose, which is why opioid related overdoses
have increased in recent years. According to the CDC, the number of deaths
related to opioid addiction increased to approximately 15 deaths per 100,000
people between 2000 and 20164. This increase in overdoses as well as
constant treatment of opioid withdrawals is what makes people question whether
this is a disease or just a choice.
Regardless
of one’s point of view, it is certain that the growing epidemic of overdoses by
use of opioids is cause for concern. Researchers are finding new substances
each day to help combat this crisis, such as AT-121 which was discovered to be
a dual action analgesic and opioid antagonist by the Wake Forest Baptist
Medical Center thus allowing an individual to receive the desired analgesic
effect without concern of addiction3. However, until
these types of drugs are approved for clinical use by the FDA, it is important
to recognize the impact that opioids can have on communities. Especially those
who may have easier access to them than most.
- Chahl, L. A. “Opioids- mechanism of action.” Australian Prescriber, 30 Jun. 1996, pp.63-65. Accessed 16 Sep. 2018. Web. https://www.nps.org.au/australian-prescriber/articles/opioids-mechanisms-of-action
- Pathan, H. and Williams, John. “Basic opioid pharmacology: an update.” British Journal of Pain. Feb 2012, 6(1): 11-16 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4590096/
- Mayo Clinic Staff. “Drug addiction (substance use disorder)” Web. Accessed 9/14/18. https://www.mayoclinic.org/diseases-conditions/drug-addiction/symptoms-causes/syc-20365112
- Center for Disease Control. “Opioid Data Analysis and Resources” Web. Accessed 9/14/2018. https://www.cdc.gov/drugoverdose/data/analysis.html
- Wake Forest Baptist Medical Center. “Scientists take big step toward finding non-addictive painkiller.” Science Daily, 29 August 2018. www.sciencedaily.com/releases/2018/08/180829143821.htm
By Dalton Hall, Master's of Medical Sciences Student, University of Kentucky
Another innovative approach to treating opioid addiction that I have read about is by vaccination. Researchers at the Walter Reed Army Institute of Research have developed a way to synthesize an opioid vaccine that will induce antibodies that bind to drugs such as heroin and prevent them from crossing the blood brain barrier and inducing their euphoric and addictive effects. Interestingly, the antibodies do not react with compounds like methadone and naltrexone that are used to treat opioid addiction and overdose, so the vaccine can be co-administered with these medications. So far, I believe this therapy has only been tested in mice, but maybe someday it will become another tool we can use to combat the opioid epidemic.
ReplyDeletehttps://www.genengnews.com/gen-news-highlights/opioid-abuse-may-be-curbed-by-new-vaccine/81255284
With increasing data demonstrating the negative effects of opioid use, more research and studies are looking into the effects of other pain management treatment options. Some of these alternatives include the use of nerve blockers, modified opioids (as Cassie mentioned), physical therapy and other types of therapy, as well as acupuncture as other means to coincide with or potentially eliminate the need to use opioids, especially for chronic pain circumstances. The central idea behind this is that pain management and treatment should be patient-centered on an individual basis, with the combination of multiple routes of pain relief rather than using opioids as the first/only treatment option. As more data emerges, I believe the future of pain management will migrate towards new approaches to work towards resolving the opioid epidemic in this country.
ReplyDeletehttps://www.webmd.com/special-reports/opioids-pain/20180314/opioid-alternatives
The opioid crisis is a serious public health emergency, roughly 90 people die everyday from opioid overdose. AT-121 appears to be a promising alternative to our current pain medications and to combat the opioid epidemic. AT-121 works by binding to both mu opioid receptors and nociceptin opioid receptors, compared to conventional opioids which primarily bind to mu receptors. The bifunctional property of AT-121 allows it to provide a strong analgesic effect without the undesired affects such as respiratory depression and physical dependence. It’s efficacy, however, was only tested in rhesus monkeys and not yet ready for human use. It is possible that these results may not translate well to humans and should be taken with a grain of salt. It would be wishful thinking to pin our hopes of fixing this crisis on a single “addiction-free drug”. Like Caitlin mentioned, we will need a multi-faceted or combination approach, i.e. physical therapy, counseling, along with prescription drugs to combat the opioid crisis.
ReplyDeleteScientists take big step toward finding non-addictive painkiller
https://www.sciencedaily.com/releases/2018/08/180829143821.htm
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ReplyDeleteWe're so worried about people, the poor animals are caught in the middle which is hardly fair to them. Although the FDA and DEA will deny their direct involvement in the decreased supply and and availability of opioids to veterinary clinics, it is clear their current policies and limits on production are having an outreaching effect on which opioids and how much is readily available to veterinarians. I have witnessed first hand in a couple of the veterinary clinics I have either shadowed or actively worked in. This is mostly an issue at emergency clinics because of the larger supply required to keep them stocked. Opioids are routinely used in an emergency situation to stabilize patients, perform other treatments and procedures and then continued therapy after the patient is discharged just as in humans. Any veterinarian with half a brain can figure out if their human is trying to abuse opioid medication prescribed for their pets so that should hardly be a concern. If alternative non-addictive pain meds become available to humans, hopefully this would free up supply and decrease costs for veterinarians and their clients.
ReplyDeletehttp://news.vin.com/vinnews.aspx?articleId=49484
This opioid epidemic is such an unfortunate issue. I find it even more heartbreaking that it has hit here, in our home state of Kentucky. I have come across people I have gone to high school with or heard stories of people in Lexington whom are my age, struggling to keep away from these toxic drugs, which had led them to overdosing. With the overdosing numbers rising and people turning to synthetic opioids such as fentanyl, there is some sort of comfort knowing that researchers are finding new substances to steer away from opioids. I came across an article from WebMD stating that a team of researchers from both Wake Forest University and the University of Bath in the U.K. are exploring a new drug that will alleviate pain without disrupting the patient’s breathing or influence them to abuse it (Collins, 2018). The new drug for now is called by its chemical compound, BU08028 and was tested on rhesus macaque monkeys (Collins, 2018). Researchers gave the monkeys an opportunity to collect as much of the drug that they wanted, however they did not abuse this offer (Collins, 2018). Researchers also found that once they had stopped administering the drug, the rhesus macaque monkeys did not show symptoms of painful withdrawals (Collins, 2018). Experimenting on this species of monkeys and seeing a successful outcome, gives optimism to hopefully gravitate towards starting clinical trials in humans (Collins, 2018).
ReplyDeleteReferences:
Collins, S. (2018, March 14). Beyond Opioids: The Future of Pain Management. Retrieved October 18, 2018, from https://www.webmd.com/special-reports/opioids-pain/20180314/opioid-alternatives
Opioid usage is a very frightening, and real, threat to our community. Just 2 years ago, a young man who lived near me and rode the same bus died of an opioid overdose. Like Satya and Caitlin touched on, I believe the strict use of opioids for pain management should be tweaked. Physicians should employ more combined and diverse treatment techniques, instead of strictly prescription narcotics, in an effort to reduce addiction risk. In 2015, Kentucky providers wrote 97 opioid prescriptions per 100 people, compared to the national average of 70/100 (NIDA, 2018). The over-prescription of these highly dangerous medications is concerning and will definitely need to be altered, as the trend of age-adjusted opioid death continues to rise in the state to nearly twice the national average. (NIDA, 2018) The death toll will continue to climb in the state, and across the country if the mass prescription of opioids continues like it has.
ReplyDeleteReference:
Kentucky Opioid Summary
https://www.drugabuse.gov/drugs-abuse/opioids/opioid-summaries-by-state/kentucky-opioid-summary
Most (if not all) opioids on the market today target mu opioid receptors. They provide pain relief, but also produce euphoric effects that lead many people to become addicted. I have been wondering, what would happen if we instead targeted kappa or delta opioid receptors? These three types of receptors are all inhibitory g-protein coupled receptors, albeit with different subjective effects. It has been shown that targeting delta and kappa opioid receptors have produced some efficacy in the treatment of pain, without producing euphoric effects (Vanderah, 2010). I really hope more research goes into these types of drugs. Chronic pain does exist, and opioids have been a life-changer for many people. It is a shame that chronic pain patients are also suffering because of the opioid epidemic, not just addicts.
ReplyDeleteReference:
Vanderah, T. (2010). Delta and kappa opioid receptors as suitable drug targets for pain. The Clinical Journal of Pain, 26(10).
Clearly we are all aware about how prevalent this issue is in our state. I am from northern Kentucky, and the "NKY Hates Heroin" campaign started in 2014. It is a nonprofit that provides education, support, and resources to those suffering from addiction and their families. It is not uncommon to see their signs posted in people's front yards. A few years ago, someone from my high school passed after an overdose. I still see posts for him on social media; it truly can happen to anyone and the impact is widespread.
ReplyDeleteAlthough opioid prescription rates have decreased over the past few years, they are still certainly overprescribed. During my gap year, I worked at an integrative health clinic that combined chiropractic care with medical massage therapy. Research has shown success with massage therapy in cases of chronic pain, especially lower back pain (Tsao, 2007). A lot of patients came in after car accidents and many came in a few times a week for maintenance care. It seemed to be a common theme that these people did not want to go to other offices where they would be prescribed medication and they really appreciated the care they received. When success would plateau with massage, the chiropractor would suggest physical therapy. This approach may not be for all patient cases, but I definitely witnessed it help people and believe it could be a strong alternative substitute for opioid medication.
Tsao, J. C. I. (2007). Effectiveness of Massage Therapy for Chronic, Non-malignant Pain: A Review. Evidence-Based Complementary and Alternative Medicine, 4(2), 165-179.
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ReplyDeleteThe opioid abuse & dependency is a worldwide problem now a days. This nasty epidemic is slowly killing the society. It even hit a very small, developing & peace loving country like Bangladesh (where I am from). Since there is a lot of discussion on the physical & chemical aspects of opioid dependency, I would like to focus on the emotional & social side of it.
ReplyDeleteOpioid dependency does not just destroy a person's life, it affects the families of the abusers too. Through different real life stories of people which were reported over time, I was shocked to find out how terrible a nice person can become after the opioid dependency engulfs him/her. Domestic violence can be connected to opioid abuse. About 80% of domestic violence is the result of some drug abuse. There were instances where addicted son or daughter killed mom. There are also incidents where addicted mom killed newborn child either from overdose in breast-milk or from negligence / not being able to care for the baby. Also, not every addicted person dies, but it is their morals which die first. As a result families has to go through unending cycle of suffering & trying to get rid of this curse. These cases are extremely terrifying themselves, making us to think about how as a society, we're loosing the emotional & social values because of opioid abuse.
https://www.cnn.com/2018/08/29/health/breastfeeding-drugs-homicide-charge-samantha-jones/index.html
https://www.nytimes.com/2018/01/21/us/opioid-addiction-treatment-families.html
Living in Kentucky, the topic of opioid addiction is very important and hits home. Kentucky is among the top ten states with the highest opioid related overdose deaths (NIH, 2018). In 2015 alone, Kentucky providers wrote 97 opioid prescriptions per 100 people (NIH, 2018). Addiction is a disease that starts out as pleasure and then results in something you cannot live without (MayoClinic, 2018). Medical professionals define drug addiction as an irresistible craving for a substance and compulsive usage of the drug, leading to harmful consequences (MayoClinic, 2018).
ReplyDeleteAs you mentioned, opioids trigger release of endorphins (the brain’s feel-good neurotransmitters). These endorphins are responsible for altering our perception of pain and boosting our sense of pleasure (MayoClinic, 2018). This is what makes them so dangerous and highly addictive. When opioids are taken repeatedly over time, the body slows production of endorphins, and the body then builds up a tolerance (MayoClinic, 2018). Therefore, the dosage must be increased each time in order to achieve the same pleasurable feeling. It’s important that you mentioned the various types of opioid receptors and their affinity for opioids.
One of the most common drugs being abused these days is Fentanyl. Fentanyl is an opioid analgesic and interacts primarily with the opioid mu receptor (DrugBank, 2016). Fentanyl may increase the patient’s tolerance for pain and decrease the perception of any discomfort (DrugBank, 2016). This is why drugs like fentanyl are at a high risk for abuse and must be highly controlled. Personally, I believe those living with chronic pain should not be prescribed opioids because they are not a safe and effective long-term treatment option. There are many other less addictive pain medication options and therapeutic rehab techniques available. While their will never be a way to eliminate drug addiction/illegal distribution, are there more restrictions the government can place on the usage of these drugs? What other treatment options are available for those suffering from chronic pain?
References:
Drug Bank. Fentanyl. https://www.drugbank.ca/drugs/DB00813. Published 2016. Accessed November 1, 2018.
How Opioid Addiction Occurs. Mayo Clinic. https://www.mayoclinic.org/diseases-conditions/prescription-drug-abuse/in-depth/how-opioid-addiction-occurs/art-20360372. Published February 16, 2018. Accessed November 1, 2018.
Kentucky Opioid Summary. National Institute on Drug Abuse. https://www.drugabuse.gov/drugs-abuse/opioids/opioid-summaries-by-state/kentucky-opioid-summary. Published February 2018. Accessed November 1, 2018.
When looking at any public health crisis, it is clear that early prevention usually goes a lot further than simply treating symptoms. However, we currently face the daunting task of treating a growing population of opioid-dependent users while finding more effective chronic pain-management strategies to prevent future opioid-dependence. Such a complex problem clearly requires a multi-faceted, comprehensive solution. At the National Rx Drug Abuse and Heroin Summit in 2017 the U.S. Department of Health and Human Services (HHS) publicly listed five priorities in addressing this epidemic: "improving access to treatment and recovery services; promoting use of overdose-reversing drugs; strengthening our understanding of the epidemic through better public health surveillance; providing support for cutting-edge research on pain and addiction; and advancing better practices for pain management." (1) While we are a long way from the end, clearly some notable progress has been made. The Kentucky Office of Drug Control Policy now provides an active online registry that allows patients to locate pharmacies that can dispense naloxone without a prescription. (2) Funding from the NIH and NIDA is finding innovative alternatives to opioids in drugs like AT-121 (as Satya mentioned) and pain management devices such as spinal cord stimulators (3). Stricter legislature with respect to the schedule of narcotics, such as the 2014 ruling that rescheduled hydrocodone from schedule III to II, (4) remains another helpful step towards fighting this epidemic.
ReplyDelete1. https://www.hhs.gov/about/leadership/secretary/speeches/2017-speeches/secretary-price-announces-hhs-strategy-for-fighting-opioid-crisis/index.html
2. https://www.pharmacytimes.com/publications/issue/2017/
january2017/increasing-national-naloxone-access-kentucky-is-first-to-open-online-naloxone-registry
3. http://news.bostonscientific.com/2018-01-11-Boston-Scientific-Receives-U-S-FDA-Approval-for-Spectra-WaveWriter-TM-Spinal-Cord-Stimulator-System
4. https://www.deadiversion.usdoj.gov/fed_regs/rules/2014/
fr0822.htm
The opioid epidemic has become a devastating topic that has become far too familiar, especially in our state of Kentucky. I have witnessed this opioid epidemic take the lives of many of my peers, family friends, and idols. Each time I am left wondering "why hasn't our public health system done more?", "why aren't there better rehabilitation strategies?", "what more can be done to end this epidemic?", better yet, "how can physicians more accurately prescribe opioids?" Coming from someone who has recently suffered an injury with a very painful recovery process, I sympathize with those who are in honest need for pain management. I find it very frustrating that I live in a society where I am too scared to ask for additional pain medications in fear of coming off as an addict, forcing me to continue on the harmful Ibuprofen/Tylenol switch-off path. The CDC published a guideline for prescribing opioids for chronic pain, which could potentially help patients and physicians, like myself, find a healthy balance in pain management. The first step to the guideline explains the initiation or continuation of prescription opioids. This step describes treatment goals and potential risks and benefits of treatment. The second step explains the process of prescribing. This includes the opioid selection (immediate/extended release versus long-acting), the dosage, duration, follow-up, and discontinuation. I think this step is extremely, if not most, important in the pain management therapy. There should be plenty of follow-up appointments AND drug tests and there should also be a planned date of discontinuation. The third step basically reiterates the first but is equally as important, this addresses the harms and potential benefits of opioid use. There should be some kind of "counseling", if you will, when someone is prescribed pain medication, to make sure their head is in the correct place and to make sure this is the only option for treatment. The fight against the opioid epidemic will not be an easy one, but it will be worth it for the betterment of our society and for our health care system.
ReplyDeletehttps://www.cdc.gov/drugoverdose/prescribing/guideline.html