Mental Health Update | Understanding the Opioid Epidemic

 

When opioid abuse becomes serious and frequent, it can lead to addiction and death.

 

Opioids have become widely available, either via prescription or the black market, and this increasing availability is contributing to an escalation in the number of people who become addicted.

 

Users are finding it easy to access opioids that are very potent and therefore quite dangerous. High-potency opioids are some of the most, if not the most, addictive drugs in the world. They are flooding the market and people are overdosing on them at record levels.

 

Psychologists are on the frontlines of the crisis as they strive to help addicts recover and rebuild their lives. Psychologists also help families and individuals who struggle when their loved ones become addicted to opioids, and bachelor’s degree candidates in psychology are learning how opioids interact with the human brain in order to better understand how to intervene.

 

This article examines the opioid epidemic in detail and addresses the psychological underpinnings of the crisis. Here, you’ll discover the scope of the epidemic, the root of it, the psychology and physicality of opioid abuse, what to look for to spot someone who is using, as well as possible solutions.

 

 

Opioids are man-made painkillers. They mimic the effect of pain-relieving hormones the human body produces naturally. There are multiple types of opioids, but they’re all based on chemical compounds in the opium poppy plant, papaver somniferum. The chemical compounds themselves, in their natural form, are classified as opiates. These compounds include morphine and codeine.

 

When drug manufacturers further refine and concentrate opiates, or synthesize them, they create opioids. Opiates and opioids bind to receptors in the brain, causing the receptors to release signals that block pain. Since one of these receptors, the mu-opioid receptor, triggers reward systems in the brain, opioids are highly addictive.

 

 

Natural Opiates: These include morphine, thebaine, codeine, papaverine, and narcotine. Morphine and codeine are the most common opiates.

 

Semi-Synthetic Opioids: These are hybrid narcotics. To make them, manufacturers chemically modify opiates. Examples include heroin, oxycodone, hydrocodone, oxymorphone, and hydromorphone.

Synthetic Opioids: Manufacturers make synthetic opioids in a lab without using any naturally occurring opiates.

 

They can be extremely powerful. Examples include oxycontin, fentanyl, carfentanil, meperidine, and methadone.

What Is the Opioid Crisis?

 

In short, the opioid crisis is an epidemic of abuse, overdoses, and deaths in the United States. Opioids have long been a staple of medicine because they’re a highly effective painkiller, and people who suffer from chronic pain or overwhelming short-term pain need them to go about their daily lives. However, people have begun to abuse opioids in record numbers. Abuse often starts with a prescription, but should be distinguished from addiction (more on that soon).

 

Opioid abuse isn’t new. The opium dens of the 1800s were a precursor to today’s problems. However, only in recent years have high-potency synthetic opioids (such as fentanyl) become part of the picture. Synthetic opioids have brought abuse levels to a fever pitch, signalling an epidemic of epic proportions

 

 

The long and sordid history of the opioid crisis goes all the way back to the Civil War:

* Medics used morphine as an anaesthetic during the Civil War. Many soldiers became addicted to it after the war’s cessation.

* Bayer introduced heroin to the market in 1898. The medical community believed the semi-synthetic opioid was less addictive than morphine.

* The Harrison Narcotics Act of 1914 made a doctor’s prescription necessary to legally acquire opioids.

* Congress banned the production and sale of heroin in 1924.

* The Controlled Substances Act of 1970 made heroin a Schedule I drug, but lawmakers classified fentanyl, morphine, oxycodone, and methadone as Schedule II narcotics, meaning they are supposedly less addictive than heroin. Fentanyl, which figures prominently in today’s epidemic, is 80 to 100 times more powerful than morphine.

* Purdue Pharma began aggressively marketing Oxycontin in 1995.

* Between 1992 and 2012, the number of opioid prescriptions increased from 112 million to 282 million.

* The DEA conducted a sting operation called Operation Pilluted in 2015. The agency arrested 280 people, among them doctors and pharmacists, for dispensing opioids. It was the largest prescription drug sting in US history.

* The Department of Health and Human Services reported that over 130 people in the US died from opioid overdoses every day in 2016 and 2017. Synthetic opioids, such as  fentanyl, caused 46 percent of deaths in 2016, compared with 14 percent in 2010.

* On October 24th, 2018, President Donald Trump signed a law promoting research on alternatives to opioids, and expanding treatment-access to Medicaid patients with substance use disorders.

* On January 14th, 2019, the National Safety Council declared that death by opioid overdose is more likely than death by car crash.

 

 

* According to the CDC, fentanyl is the most common opioid contributing to drug overdose deaths. Between 2013 and 2016, the number of fentanyl overdoses went up by 113 percent each year.

* Over a period of 14 years, the number of heroin overdose deaths spiked by 533 percent. In 2016, about 13,219 people died from heroin overdose, compared with 2002, when 2,089 people died.

* Of the 70,200 drug overdose deaths in 2017, about 68 percent involved an opioid.

* According to the CDC, in 2017 the number of opioid overdose deaths was 6 times higher than it was in 1999.

* According to the National Institute on Drug Abuse, about 50 percent of young people who abuse heroin started off by abusing prescription opioids. Overall, prescriptions were the gateway for around 80 percent of new heroin users.

* According to the Department of Health and Human Services, in 2016 and ‘17 an estimated 11.4 million people misused prescription opioids, which led to over 17,000 deaths from common prescriptions; synthetic opioids other than methadone contribute to over 19,000 deaths.

* Americans make up 5 percent of the global population but consume 80 percent of the opioids.

* According to Dr. Sanjay Gupta, every 19 minutes someone dies of a drug overdose in America. All told, the CDC reports that over 130 people die of an opioid overdose daily.

 

 

There are many causal determinants for where we are now with the opioid crisis. Researchers have long known that users develop a tolerance. What this means is that, although the recommended prescription dosage may continue killing pain, it will not continue triggering the same dopamine release, therefore pleasure increase, to the brain. Users need to up their dosage to experience pleasure. This is why opioids are so addictive.

 

Besides the physiological factor, there are multiple other causes of the opioid epidemic:

 

 

Many observers point to pharmaceutical companies’ aggressive marketing of opioids to the medical community in the 1990s. In 1995, Purdue Pharma began an aggressive marketing campaign asserting that Oxycontin, a brand of oxycodone painkiller, was not addictive. The company targeted doctors who had a record of prescribing the most opioids. Purdue faced federal charges in 2007 for “misleading and defrauding physicians and consumers.” The company subsequently paid $634.5 million in criminal and civil fines.

 

 

Purdue’s success in marketing Oxycontin as non-addictive may have stemmed from confusion about the addictive qualities of opioids in general. In 1980, Jane Porter and Dr. Hershel Jick of Boston University published a letter in the New England Journal of Medicine claiming, “Addiction Rare in Patients Treated with Narcotics.” The letter didn’t cite a study, it was merely an observational account of hospitalized patients (who can’t possibly increase their dosage). After Purdue began its marketing campaign, researchers and physicians began citing this letter more than ever, even though they hadn’t conducted the proper research to back it up.

 

 

Starting in 1992, doctors began prescribing opioids at an increasing rate. By 2012, there were more than two and a half times the number of opioid prescriptions than there were in ‘92. This was enough to get many users hooked. When prescriptions ran out, users began turning to heroin, which can be laced with deadly fentanyl. Between 2013 and 2017, the number of prescriptions decreased by 22 percent. However, a chart from the CDC shows that deaths caused by synthetic opioids, either prescribed or illicit, began to skyrocket in 2013:

 

 

People can misuse prescriptions in multiple ways: they sell or give their pills to others; or, they take more than the recommended daily dosage and appeal to doctors for another prescription; or, they lie about their pain from the outset to get a prescription. Prescription misuse often leads to addiction, and addicted users often turn to the black market. In turn, black market opioids are more likely to be laced with deadly fentanyl.

 

 

In a study of 653 people with or without chronic pain, those with chronic pain identified coping with physical pain as their main reason for using opioids. Those without chronic pain reported that they were primarily using them to avoid symptoms of withdrawal — this was the main reason for current opioid use among both groups. In other words, whether someone is continually using opioids to treat pain or to get high, it’s easy to develop a habit, and quitting cold turkey causes withdrawal symptoms.

 

This study reflects the complexity of opioid use. Many people begin using opioids because doctors prescribe a painkiller to help them manage until they can eliminate the cause of pain. Others begin using recreationally. Recreational users may begin using for the same reasons they would use other substances. These triggers are similar to those that lead to binge drinking and alcohol abuse. High-risk users may be using opioids as a coping mechanism, for social reasons, or simply because they want to get high and also want to avoid withdrawal symptoms.

 

Both recreational and medical users can develop opioid use disorder (OUD) through continuous use. OUD differs from non-abusive opioid use — OUD is problematic, while opioid use in and of itself is not. The DSM-5 defines OUD as a “problematic pattern of opioid use leading to clinically significant impairment or distress.” Users who develop OUD often take more than they should for extended periods of time. They develop physical and psychological dependency.

At-Risk Populations

 

 

Seniors are at risk of becoming addicted because they are more likely to experience chronic pain than other segments of the population. As noted, many people begin using opioids because of chronic pain, and continue using to avoid withdrawal symptoms.

 

 

Veterans face a number of challenges after service discharge. Like seniors, veterans are more likely to experience chronic pain due to injury. Moreover, veterans who are diagnosed with post-traumatic stress disorder (PTSD) may seek to self-medicate with opioids. Veterans who suffer from chronic pain often must cope with co-occurring PTSD stemming from physical and mental trauma.

 

 

Members of the LGBTQ community face their own set of challenges. A study of nearly 35,000 people found that “non-heterosexual orientation was generally associated with a higher risk of substance use and substance dependence.” While the majority of study participants who identified as LGBTQ weren’t opioid users or addicts, statistically speaking there was a higher rate of substance use for them than there was for those who did not identify as LGBTQ, possibly due to societal and cultural factors.

 

 

In 2016, 3.5 percent of adolescents reported misusing opioids within the past year. The rate of misuse doubled for older adolescents and young adults aged 18-25. At that time, the rate of abuse for adolescents had gone down compared to past years; however, adolescents are still at risk due to the prevalence of substance abuse among cohorts, the social pressures of the age, and the relative ease-of-access.

Native Americans

 

In Washington State, a study found that “the overdose rate for American Indians and Alaska Natives was 2.7 times higher for opioids and 4.1 times higher for heroin than white residents.” Native Americans are at risk because of high rates of co-occurring mental and substance use disorders — 8.8 percent of adults had such disorders in 2014, compared with the national average of 3.3 percent.

 

 

In 2017, a survey found that “74 percent of farmers have been directly impacted by the opioid crisis.” People in rural communities are at risk of developing OUD because of socioeconomic factors and a lack of adequate access to mental health services. The Substance Abuse and Mental Health Services Administration (SAMHSA) discovered that poverty can increase a person’s likelihood of abusing drugs, and today’s rural communities are increasingly poor.

 

 

There are many factors that influence the likelihood of individual opioid abuse. Categorically speaking, there are individual factors — such as pain, mental health issues, genetic determinants — factors related to relationships — such as peer pressure — factors related to communities — including community norms — and factors related to societies — including socioeconomic status.

 

At the individual level, methamphetamine use is an example of a risk factor influencing opioid abuse. Many opioid abusers have a co-occuring substance abuse problem, and meth users may seek a “downer” like heroin to balance out an “upper” like meth — a sedative to mask a stimulant.

 

At the relationship level, adolescents may face peer pressure increasing the likelihood of abuse, while people in relationships with opioid abusers face a similar type of social pressure.

 

At the community level, neighborhoods can influence the likelihood of opioid abuse for individuals. According to SAMHSA, youths who move more than three times in a year in urban environments are more at risk of opioid abuse.

 

At the societal level, SAMHSA found that groups who face discrimination are more likely to abuse prescription opioids.

 

 

Addiction begins with abuse. Users who abuse opioids take them regularly for an extended period of time, and daily use is common. The use period normally lasts longer than recommended by a physician. It doesn’t take long to develop dependence: According to the Mayo Clinic, “The odds you’ll still be on opioids a year after starting a short course increase after only five days on opioids.”

The other precipitating factor for addiction is quantity. As a user continues to abuse opioids, they develop a tolerance, meaning they have to keep increasing the dosage to achieve the same high.

 

When the brain becomes inured to opioids, it stops releasing the same amount of dopamine. This also applies to chronic pain. If the pain level remains severe for longer than expected, then the regular dosage no longer has the same effect after regular use. Many chronic pain sufferers have to increase the dosage to get relief. After a while, they may keep using so as to avoid pain and the symptoms of withdrawal.

WebMD cautions not to “confuse tolerance and physical dependence with addiction.” According to WebMD, only about 5 percent of people become addicted after taking opioids “as directed” for a year. This means a prescribed regimen will not necessarily lead to addiction. 

 

 

* Compulsive behavior — lying, stealing, and exhausting financial resources to get more of the drug.

* Marked changes in mood and behavior —  depression and anxiety; lack of interest in work, family, friends; change in appetite and appearance; slurred speech.

 

When an opioid abuser becomes addicted, most of their activities center around getting the next fix.

Effects of Opioid Use

 

Opioids have short-term and long-term effects. Like any drug, opioids have side-effects besides their intended use as painkillers.

 

 

* Pain relief

* Euphoria

* Drowsiness and sedation

* Constipation

* Nausea

* Clouded thinking

* Respiratory depression (slow and ineffective breathing)

 

 

* Gradual overdose

* Paranoia

* Sexual dysfunction

* Sleep-disordered breathing

* Nausea and vomiting

* Constipation

* Tolerance and dependence

* Abdominal distention and bloating

* Liver damage

* Brain damage due to respiratory depression

 

 

There are clear signals when it comes to opioid use and abuse. If you’re trying to determine whether someone is using, look for the following physical, behavioral, and psychological symptoms, as well as withdrawal symptoms.

Physical Signs

 

The physical signs of opioid abuse include frequent drowsiness and a lack of energy, as well as a change in appearance. Addicts tend to look emaciated due to a lack of appetite. Additionally, even if not addicted, an opioid user tends to exhibit the following:

* Constricted “pinpoint” pupils, even in a room with low light

* Drooping eyes

* Flushed face and neck

 

 

An opioid user may exhibit the following behaviors:

* Frequent and sudden scratching of arms, stomach, or legs

* Intense calm

* Disconnected, blunted affect during social interaction; disinterest in social interaction (except with other users)

* Secretive; prone to avoiding conversations with non-users about activities

 

 

An opioid user may experience the following psychological issues:

* Lack of motivation

* Lack of ability to concentrate

* Paranoia

* Hallucinations

* Thoughts constantly revolve around next fix

 

 

When an opioid abuser stops using, the body goes into a kind of shock as it tries to cope with the lack of opioids. It’s extremely important to look for symptoms of withdrawal. Spot these signs and you’ll know if someone has been using. Users experiencing withdrawal symptoms are likely to relapse to avoid further symptoms. Moreover, if withdrawal is severe, the user may require hospitalization.

Immediate withdrawal symptoms include:

 

* Watery eyes

* Muscle aches and pains

* Anxiety and restlessness

* Runny nose

* Excessive sweating

* Insomnia

* Frequent yawning

Delayed withdrawal symptoms, which occur after the first day of cessation, include:

* Diarrhea

* Stomach cramps

* Goosebumps

* Nausea and vomiting

* Racing heartbeat

* High blood pressure

* Dilated pupils

* Tremors

 

Clinicians use the Clinical Opiate Withdrawal Scale to rate the severity of withdrawal.

 

 

Solving the opioid epidemic will take a concerted effort from everyone involved. While there’s no single solution, there are a number of steps we can take to diminish the intensity of the crisis.

 

 

There’s an ongoing debate among psychologists, epigeneticists, sociologists, and neuroscientists about whether addiction is a brain disease. According to Dr. Stanton Peele, who is an expert on addiction, “Research repeatedly demonstrates that those addicted to drugs regularly solve their addictions given supportive life conditions.” He contradicts the notion of addiction as a genetically inherited brain disease and cites research on opioid addicts who have gone into remission, meaning they’ve stopped using.

 

Yet according to the National Institutes of Drug Abuse (NIDA), “Scientists estimate that genes, including the effects environmental factors have on a person’s gene expression, called epigenetics, account for between 40 and 60 percent of a person’s risk of addiction.”

 

Viewing opioid addiction as a disease and trying to stifle the supply of opioids to a hopelessly addicted population has not worked. The NIDA is undertaking an ambitious research plan to “address addiction in new ways” because the previous ways have failed.

 

More research will need to go towards treating addiction as a socially and societally determined disorder.  Psychologists and sociologists with social science degrees will be essential to furthering research in this respect.

 

 

Legislation should ideally work to seek intervention methods beyond criminalization. According to the British Medical Journal, “A thorough review of the international evidence concluded that governments should decriminalize minor drug offenses, strengthen health and social sector approaches, move cautiously towards regulated drug markets where possible.”

 

To this end, the state of Oregon has already passed legislation decriminalizing first-time heroin possession, because the state found that prison time for first-time offenders was exacerbating the problem. Oregon is mandating addiction treatment for first-time offenders.

 

Federal legislation can also seek to prioritize addiction treatment and, as Peele puts it, “emphasize harm reduction” by equipping at-risk communities with naloxone (a drug that counteracts opioid overdose), in addition to other prevention approaches.

 

 

Interestingly, SAMHSA found that people who obtain bachelor’s degrees are less likely to misuse prescription drugs. Conversely, even if they go to college, people with a mental illness are more likely to misuse prescriptions. Professors and administrators in institutes of higher education can provide college students with mental health resources to help prevent prescription drug abuse.

 

People in impoverished communities could also benefit from more community-based education and psychological counseling on how to prevent the pitfalls of opioid prescription misuse. Furthermore, at-risk communities can benefit from safe syringes and monitored spaces where they can wean themselves off of opioids.

 

As mentioned, heroin and other opioids laced with fentanyl and fentanyl analogs are causing the most overdose deaths. Prevention measures should seek to keep users from taking dirty heroin by providing a safe alternative such as methadone and involving users in social support groups with the express aim of helping them quit opioids. Naloxone must be made widely available to prevent drug overdose deaths.

 

 

To treat opioid use disorder (OUD) it’s necessary to address the issue of chronic pain, because chronic pain, combined with opioid use, often leads to OUD. The number of prescriptions doctors write for chronic pain patients also increases the amount of opioids in circulation.

 

Psychologists are particularly well-equipped to help the 100 million people suffering from chronic pain in the US. According to the American Psychological Association, psychological treatment emphasizes “understanding and managing the thoughts, emotions and behaviors that accompany” chronic pain.

 

Chronic pain management techniques can be part of a comprehensive strategy. In Wilkes County, North Carolina, a program called Project Lazarus helped lower overdose deaths by 38 percent. Project Lazarus taught primary care providers about chronic pain management and safe opioid prescribing, focused on building community coalitions, and used rescue medications such as naloxone to treat people who were overdosing.