The Opioid Epidemic across the World: Introduction
With more than 27 million people suffering from substance use disorders, the opioid crisis is a global health problem. In 2016, for example, 275 million people admitted to taking drugs (34 million used opioids, while 19 million took opiates).
Note that although the terms opiates and opioids are often used interchangeably, there’s a subtle difference: opioids refer to all drugs that affect the opioid receptors in the human brain. Opioids can be semi-synthetic (e.g., hydrocodone) and synthetic (e.g., fentanyl). Opiates, on the other hand, are opioids that are naturally derived from the opium poppy plant (e.g., codeine). Opioids can be divided according to their potency and pharmacological effects: agonists (e.g., morphine), partial agonists (e.g., buprenorphine), agonists-antagonists (e.g., nalorphine), and pure antagonists (e.g., naloxone) (Trivedi, Shaikh & Gwinnut, 2007).
Info 1: Opiates vs. Opioids
Evidence shows that taking opioids for a long time leads to physical dependence and symptoms of tolerance and withdrawal. However, substance use does not always result in addiction; addiction is characterized by psychological dependence and compulsive substance abuse despite harmful consequences.
Although drug addiction is often associated with illicit drugs, such as heroin, prescription opioids are among the most misused substances across the globe. In the US, more than two million people started using opioids in 2017. Additionally, according to data provided by the Centers for Disease Control and Prevention, opioids accounted for 67.8% of all 70,237 drug overdose deaths in America in 2017. In Australia, prescription opioids are the leading cause of premature death in two-thirds of all drug-related fatalities. According to the United Nations Office on Drugs and Crime, the highest rates of prescription abuse in Europe are across Northern Ireland, Denmark, Germany, Estonia, and Finland, while the highest mortality rates are in Ukraine, Ireland, Iceland, and Luxembourg.
The Drug Epidemic in the US
The prescription opioid crisis in the US, in particular, has reached pandemic levels. The US accounts for 5% of the global population and 80% of the global opioid supply. Every year doctors issue approximately 200,000,000 opioid prescriptions; consequently, the sale of painkillers across the States has increased by 300% since 1999.
Data shows that 20-30% of people who use prescription drugs misuse them, 8-12% become addicted, and 4-6% of all people with an opioid use disorder will take heroin. Moreover, between 2002 and 2011, more than 25 million Americans started nonmedical use of prescription pain killers. In 2015, there were more than 91.8 million people who used prescription opioids and out of them, 11 million misused the drugs (Huecker, Azadfard & Leaming, 2019).
Today, more than 2.1 million people in the US are living with an opioid use disorder. Alarmingly, 130 people die from an opioid overdose every day. In fact, opioid overdoses increased by 30% from July 2016 to September 2017 in 45 states. The Midwestern region, in particular, saw an opioid overdoses increase of 70% during this period.
Info 2: The Drug Epidemic in the US
While there are effective medication-assisted treatments for opioid addiction, data shows that only 10% of users receive adequate care. Of all residential programs, only 36% offered medication-assisted treatment in 2016. So, why are effective medication-assisted treatments limited and treated as a further cause of addiction?
Understanding Medication-Assisted Treatments
Medication-assisted treatment (MAT) is defined as a combination of medications and behavioral therapies for the treatment of drug addiction in safe settings. Globally, medication-assisted treatments are the gold standard in opioid addiction care. Medication-assisted therapies prove to be highly effective methods, with methadone, buprenorphine, and naltrexone being the three FDA-approved medications for opioid use disorder (Medication-Assisted Treatment for Opioid Use Disorder, 2018). Evidence shows that medication-assisted treatments lead to a variety of physiological, mental, social, and financial benefits. For example, medication-assisted treatments result in reductions in factors, such as morbidity and mortality rates, overdose deaths, infectious diseases, treatment dropout rates, and criminal activity. Interestingly, demographics have shifted significantly; while in the 1960s, 80% of patients entering treatment were men, living in inner-city areas and using heroin, by 2010, the majority of patients were middle-class women living in less urban areas.
- Methadone: Methadone is a potent opioid agonist. Evidence shows that methadone is efficacious in treating addictions and has high retention rates. The drug blocks the pleasurable experiences produced by other opioids and reveals the highest analgesic potential. Moreover, methadone has both slow onset and offset, which decreases the prevalence of withdrawal symptoms and cravings. Initially introduced in treatment in 1964, methadone is now widely used in approved Opioid Treatment Programs and accepted as first and foremost effective medication, which reduces drug-related morbidity and mortality rates. Note that the Opioid Treatment Programs in the US are regulated by the Substance Abuse and Mental Health Services Administration (SAMHSA). Data shows that between 2003 and 2015, the number of clients receiving methadone increased from about 227,000 to 350,000. Although methadone is an effective evidence-based treatment, the drug is still highly stigmatized, and patients lack access to treatment or take-home dosing privileges.
- Buprenorphine: Buprenorphine is a partial agonist and a Schedule III controlled substance with a terminal half-life of three-four hours and duration of action of up to eight hours. The main benefit of buprenorphine is that the medication can be used in office-based settings. In fact, the number of Opioid Treatment Programs offering buprenorphine increased from 11% to 58% between 2003 and 2015, while the number of clinics without Opioid Treatment Programs offering buprenorphine increased from 5% to 21% for the same period. As of 2013, data shows that the medication has the largest coverage across state Medicaid programs. Buprenorphine is available in a stand-alone formulation or in combination with naloxone. Note that Suboxone is the common name for the combination of buprenorphine and naloxone in a 4:1 ratio. Despite its evidence-based benefits, buprenorphine also sparks controvers