In 2008, I had the opportunity to join a biotech company that responded to NIH's request to develop a medication for the treatment of alcohol dependency and opioid dependency. After 30 years working with medications for severe mental health illnesses, this new opportunity not only taught me a great deal about the brain and addictions, but helped explain to me the debilitating and personal struggles that eventually took the life of my father.
The purpose of this review is to join the national conversation on the devastation caused by chronic dependency on opioid drugs, including right here in Florida. Since it is at the level of an epidemic, local, county, state and federal officials, alongside regulatory agencies, must work together in finding solutions to help opioid-dependent individuals. Critical steps must also be taken to safeguard communities. It is important to understand that the impact of opioid dependency goes beyond the addicted individual, often resulting in devastating consequences with families and children, newborns, education, employment, crime and health factors. Opioid addiction also has a negative impact in our communities -- policing, first responders and crime.
Natural and Synthetic Opioids
The flowering plant papaver somniferum (opium poppies) is the source for naturally-occurring opium. Opium, extracted from the plant as sap then dried, is classified as a narcotic and is very addictive. Morphine is a derivative of opium, whereas heroin is a derivative of morphine. Synthetically-manufactured opioids, are also narcotics, highly addictive and are manufactured for legal distribution via a physician's prescription (typically for pain management). Examples of synthetic opioids are fentanyl, dilaudid, methadone, demerol and oxycodone. Most opioids are Schedule II narcotics.
Addiction and the Brain
The National Institute of Drug Abuse (NIDA) defines addiction as "a chronic, relapsing brain disease that is characterized by compulsive drug seeking and use...considered a brain disease because drugs change the brain..." Without going into great and technical details regarding what occurs in the brain from initial use to prolong use of opioids, the brain undergoes changes and will eventually crave and need more and more of the opioid to maintain pleasurable feelings. Over time, the intake of the opioid becomes more frequent, often at higher doses. Brain images in clinical studies show how the brain undergoes changes after prolong use of opioids.
Opioids are chemicals that mimic naturally-occurring chemicals in the brain called neurotransmitters, and they can actually interfere with a healthy brain's functioning. In the illustration below (from NIDA), normally-occurring neurotransmitters, in this case dopamine, exist in the brain to enable pleasure sensations. However, opioids (like the cocaine example below) will trick the brain and take the place of (block) the dopamine, preventing it from attaching to a brain receptor (essentially a communication system). Dopamine now saturates the brain in excessive amounts (abnormal state).
Government and other research organizations track and report on the appropriate use and misuse of prescription drugs, including opioid medications. Increasingly, data shows that physicians may be over-prescribing opioid medications, as well as recommending use for prolong periods of time. By not curtailing and monitoring the over-prescribing of opioids, patients risk using them beyond the original therapeutic need (e.g., pain management), potentially building tolerance and becoming addicted. NIDA cites that "more than 90 Americans die after overdosing on opioids" every day in the U.S.
The illustrations below, from the Substance Abuse and Mental Health Services Administration, charts "misuse of prescription drugs among adults aged 18 or older and the primary reason for misusing these drugs among adults who misused them." In one year alone, 91.8 million individuals were prescribed opioid-based pain relievers in 2015, with 12.5% reported as misuse. Of the 12.5% misusers (chart on the right), the majority misused opioids that were originally prescribed for pain. Other ways individuals misuse opioid medications include using someone else's prescription, taking more units and higher doses then prescribed, and self-prescribing for other uses.
The treatment for opioid dependence begins with detoxification under medical supervision, sometimes lasting several days or weeks. The difficult process monitors withdrawal symptoms (e.g., cravings and urges), as well as associated physical, physiological and psychological symptoms. Medications used in the detox process, to slow withdrawal symptoms, are methadone or buprenorphine. Some patients may require sedation. Counseling is critical to helping individuals deal with stress, avoid temptations, maintaining abstinence and integrating back into the community. Lastly, FDA-approved prescription medications (methadone, buprenorphine and naltrexone) are also effective for the treatment of opioid dependence and may help reduce relapse.
The Impact of Opioid Dependency
Perhaps the most painful outcome of the opioid dependency crisis in the U.S. are the growing number of opioid-related deaths. This chart (from the Centers for Disease Control shows deaths with "any opioid" skyrocketing in the last 15 years. Note the growth of "other synthetic opioids." Nevertheless, overdoses are at an all-time high with prescription opioids overall.
The CDC also estimates that the "economic burden of prescription opioid misuse alone in the United States is [estimated at] $78.5 billion a year, including the costs of healthcare, lost productivity, addiction treatment, and criminal justice involvement."
The table on the right, from the U.S. Department of Health & Human Services, does a good job to further illustrate the impact of opiod dependence in a variety of areas.
Each year, the Florida Department of Law Enforcement publishes a comprehensive report by the Medical Examiners Office on "Drugs Identified In Deceased Persons By Medical Examiners." The illustration below is from the 2016 report (published May 2017) and compares 2015 to 2016 drug-related deaths, sorted by type of drugs. Note the 14 "opioids" on the right table, associated with 4,515 Florida deaths where opioids were present in the body. Two other important points: 1) the increases in the numbers in 2016 v. 2015 associated deaths; and 2) the much higher numbers when compared to other drug classes. The pie chart ranks morphine, fentanyl, oxycodone, heroin and hydrocodone as the top five opioids present in recorded Florida deaths.
The Florida Behavioral Health Association (www.myfbha.org) has a "Media Publication and Public Information Resource" guide titled "Florida's Opioid Crisis." It highlights many data sources specific to Florida and the impact of opioids. Among the resources in the guide are some of the economic costs of opioid dependence. For example, in 2015, Florida hospital costs associated with opioids was in access of $1.1 billion. Public payer hospital costs in 2015, for 919 opioid-related cases, was in access of $66 million. General hospitals reported 2,038 cases at costs in access of $112 million. Sadly, 49 cases are also reported for involving infants going through withdrawal due to exposure to opioids prior to birth.
Governor Scott Executive Order on Opioid Epidemic in Florida
On May 3, 2017, Governor Rick Scott signed Executive Order 17-146 stating the "opioid epidemic threatens the State of Florida with an emergency, and that as a consequence of this danger a state of emergency exists in the State of Florida." The Order provides direction to various agencies and departments to reorganize, seek funds and suspending necessary rules in order to respond to the opioid emergency in a timely manner. The Order also incorporates, by reference, a declaration for improved statewide access to naloxone, enabling immediate and emergency administration by first responders and emergency health care providers to patients suspected of overdosing on an opioid.
Governor Scott has also proposed to add $50 million dollars to the 2018-2019 state budget for drug treatment programs, as well as proposing specific legislation to address opioid abuse in Florida. The legislation proposes to: 1) limit prescribed opioids to three days (seven under strict protocol; 2) mandate that all physicians that prescribe opioids participate in the Florida Prescription Drug Monitoring Program; 3) tightly manage pain management clinics; and 4) seek additional federal funds.
On a positive note, Florida is one a very few states that took aggressive action against unregulated prescribing of opioids by pain clinics. As such, the CDC posted this slide showing the positive impact the regulations have had on over-prescribing of opioids.
Prescription opioids clearly have a role in treatment when appropriately prescribed by physicians for appropriate pain management (typically severe pain conditions). However, it is unfortunate that U.S. trends continue to rise where opioid prescription drugs are misused, abused and are associated with numerous overdoses and deaths. The misuse of opioids, which leads to addiction and changes in the brain, is a chronic and debilitating disease. Individuals should have access to treatment providers, comprehensive and long term care, medications that work and behavioral health therapy to help with community reintegration.
This is a call to communities, elected officials, advocates and others to stay abreast of the opioid epidemic right here in Florida. We need to actively support legislative bills designed to reduce inappropriate prescribing of opioids, as well as increase funding for treatment and services. We need to applaud and support the Governor's emergency declaration. More importantly, we thank law enforcement, first responders and emergency health care professionals that see the impact of opioid drug abuse first hand every day. Working together we can make a difference.