Making Sense of the Opioid Crisis

Sadly, we've all heard about the opioid crisis far too often on the news, but what does it actually mean? There are several elements of the issue that are worth digging into a little further.

How Opioids Work

Opioids are a class of substances that work on natural opioid receptors in the nervous system. The body actually makes some of its own opioids, such as endorphins. Opioid medications are also used as painkillers, including codeine and morphine. Heroin is an illegal opioid, but diverted prescription opioids are also used to feed opioid addictions.

And yes, opioids are addictive. That means a couple of things. One, people tend to develop a tolerance, so higher and higher doses are required to achieve the same effect. People also become both psychologically and physiologically dependent on them, and will experience a withdrawal syndrome if they start using them.

Sometimes illicit opioids are the starting point for abuse, often for people who are trying to numb out trauma they may be struggling to cope with. In other cases, people will be started on prescription opioids for a legitimate reason, but because of various factors that make them susceptible, they end up developing an addiction.

Finding the right balance in the use of opioids for pain can be difficult. Doctors have a responsibility to warn patients about the addictive potential, and this is probably not happening as often as it should. Systems-level interventions should be in place so that if someone is beginning to engage in abuse by practices like multi-doctoring, it is somehow flagged so involved treatment providers can intervene.

However, it's also important to realize that not all prescription opioid users are going to develop a psychological dependence on their medication. Opioids may be the only way that they are able to achieve adequate pain control, and until we have better alternatives, across-the-board restrictions on opioid prescribing are likely to result in worsened pain control for some of the people that need these medications the most.

Fentanyl

Fentanyl isn't something new. It's been used for years, both in intravenous form in hospital and in long-acting transdermal patch form in the community. In the past, the street market for fentanyl was mostly fed by diverted prescription fentanyl patches. What has changed in recent years is that a supply of ultra-cheap powdered fentanyl from China has flooded the North American market. This can end up making its way into almost anything, and not just opioids. Often, users have no idea what's actually in the drugs they're getting.

Fentanyl is incredibly potent. It only takes a very small amount to saturate opioid receptors in the body, and not only that, it also binds those receptors tightly and doesn't want to let go. Even more frightening is carfentanil. It's a super-powered version of fentanyl that's used to tranquilize elephants... and it also kills humans.

Respiratory Depression

The reflex of breathing is driven by an area in the brainstem. When too many opioid receptors are activated in the brainstem, it shuts down the drive to breathe. This is referred to as respiratory depression. The only way to restart breathing is to temporarily block those opioid receptors, and this is done with the medication nalaxone, also known as Narcan. It occupies opioid receptors, kind of like putting up a sign for any opioids floating around saying "sorry, we're closed for lunch." The brain can then get back to its normal work of telling the lungs to breathe.

Chances are the user isn't going to be very happy about it, since this will knock them straight into withdrawal, but at least they'll be breathing. Increasingly, users and those in their lives are being trained to administer naloxone, which is given as an intramuscular injection, so they can intervene right away without waiting for paramedics to show up.

The large number of opioid overdoses has led to the use of terms like opioid epidemic, opioid crisis, and public health emergency. In the Netflix documentary Heroin(e), the city of Huntington, West Virginia, is presented as the "overdose capital of America," with five to seven overdoses per day. This is putting a huge strain on emergency services as they are witnessing so many deaths.

The city of Vancouver is referred to as the overdose capital of Canada, with more than 1420 drug overdose deaths in 2017. It's estimated that approximately 80 percent of these were due to fentanyl. There are supervised injection facilities in the city, and these have saved many lives.

Saving Lives

This is not a simple problem and there are no simple solutions. While overdoses are the main outcome of concern, there are multiple ways that people can end up getting to that endpoint, and to truly address the problem, interventions must target all of those pathways.

While harm reduction measures like naloxone training or supervised injection sites may be unpalatable to some who might think they encourage drug use, they save lives. On their own they're not enough, but it's gotten to the point that we as a society need to do whatever we can to slow down this freight train of death.