Gateway Prescriptions: America's Opioid Problem

Opioid-related deaths in the United States have seen an exponential rise in the past two decades. Whether synthetic (eg, fentanyl or heroin) or natural (eg, opium), the addictive potential of opioids can lead to psychological dependence and drastically decrease life expectancy.

For the first time since the early 1960s, the United States has seen a 2-year drop in life expectancy. A major reason for this is the rise in opioid use. The adverse events resulting from opioid use are not limited to street use. Prescribed opioid medications are more accessible and cheaper.

From 2006, and peaking in 2012, there was an alarming increase in opioid prescriptions. In 2012, 255 million prescriptions were made at a rate of 81.3 prescriptions per 100 persons. The United States has more opioid-related deaths and prescriptions per capita than any other country. The statistics are clear. The United States has an opioid problem.

However, the problem is more complicated than simply decreasing the number of opioid prescriptions. In fact, in 2020, the opioid dispensing rate was the lowest it had been in 15 years. But opioid-related deaths remained high and topped 100,000 in the same year. This was a 28.5% increase from the year prior. This may be explained by compulsive use, withdrawal syndrome, and psychological dependence that may lead to a number of mental health disorders, including depression and suicidal behavior.

Opioid Use, Depression and Suicide

Opioid misuse and opioid-related death have been a major disease burden for the United States in the past decade. The addictive potential of opioid painkillers makes the current crisis extremely tough to combat.

A reduction in opioids that are prescribed may lead the patient to seek the same interventions by illicit means. A 2014 study discovered that three quarters of heroin users in substance abuse treatment programs began with using painkillers, and a 2015 analysis by the Centers for Disease Control and Prevention found that individuals who are addicted to painkillers are at a 40-fold risk for heroin addiction.

Illicit use of opioids are associated with a higher risk for adverse events and mortality. The pronounced effects of opioids are a key risk factor for addiction and dependence. Poor mental health care access and high rates of unemployment among people with opioid use disorder are key contributors to addiction, and the socioeconomic effects of the coronavirus pandemic has likely worsened the situation.

A plan in place is required when transitioning patients from opioids, specifically for patients with prolonged use who may have developed dependence.

However, according to data from the Surgeon General's Report on Alcohol, Drugs, and Health, only one tenth of individuals struggling with a substance use disorder get specialized treatment. Prolonged opioid use increases the risk for depression and contributes to the chronic course of illness.

In addition, 2014 data from the National Survey of Drug Use and Health found that people with opioid use disorder have a 40%-60% elevated risk for suicidal ideation compared with people who reported no opioid use disorder. Observational data have also reported an elevated rate of completed suicide in populations with prolonged opioid use. It is clear that the prevention and focus should not be to simply reduce opioid dispensing. Interventional methods should focus on improving patient quality of life by targeting addiction and dependence behaviors after the discontinuation of opioid use.

Patients experiencing substance use disorders are a vulnerable yet often overlooked patient population. The high rates of suicidal behavior among opioid users and chronic pain patients warrants further research on evaluating the mechanisms underlying this association and effective intervention measures to prevent the progression of psychiatric comorbidities.

Shedding light on these interactions may help guide the development of novel prevention and treatment strategies. Treatments that specifically target individuals with substance use disorders who are at an increased risk for suicide are also imperative. The overlap in suicidality and substance misuse may arise from motivational deficits.

As such, interventions that target risk factors for low motivation must continue to be further investigated. Finally, the field would benefit from the development of tools to screen for risk for suicide to identify individuals who may benefit from targeted intervention.

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About Hartej Gill

Hartej Gill is a PhD candidate and researcher at the Canadian Rapid Treatment Center of Excellence and the Institute of Medical Science at the University of Toronto. He has expertise in mood disorders, investigating the etiology and pathophysiology of mental health disorders from both a clinical study and population health perspective, with over 50 peer-reviewed publications.

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