Tackling Opioid Overdose Epidemic Demands Multiple Approaches

The opioid crisis owes much of its origins to the health care system, and so the health care system must take up the cause to end it, said Nora Volkow, M.D., director of the National Institute on Drug Abuse (NIDA), at APA’s 2017 Annual Meeting in San Diego.

Opioid abuse has a “devastating impact,” Volkow told an overflow crowd. “There were 33,000 opioid overdose deaths in 2016, and the epidemic has touched everyone, which is what we have stressed—that addiction can happen to anyone.”

How bad is the epidemic? Volkow recounted a meeting she attended at the Vatican, where an American surgeon remarked: “For the first time, we don’t have a lack of organs for donation.”

Psychiatry has a greater role to play in resolving the addiction crisis, Volkow said.

“Psychiatrists need to get more involved in the management of chronic pain conditions,” she said. “Psychiatry’s presence reinforces the point that addiction is a disease and thus a responsibility of the health care system.”

NIDA is now working with APA to develop a curriculum for psychiatry residents built on the premise that patients with nonaddictive mental illnesses must get treatment for addictions, given that comorbidity of mental illness with substance abuse is extremely common.

The epidemic was shaped in part by good intentions gone wrong, fueled in the 1990s by a rising concern for pain treatment (“pain as the fifth vital sign”) and a mistaken belief that opioids taken for pain would not induce addiction, said Volkow. Policies to reduce pain had unexpected consequences.

“Our prescription practices went completely awry,” she said. “From 1991 to 2011, the number of prescriptions for oxycodone and hydrocodone rose from 76 million to 219 million. In 2013, doctors wrote about 260 million prescriptions for opioids, enough for one month’s use for every adult in the U.S.”

Opioids work well for acute pain, but the body develops tolerance within days, requiring higher and higher levels of the drug to achieve the same levels of analgesia, she said. However, the tolerance in the brain’s pain network rises faster than tolerance in the brainstem’s breathing centers, ultimately slowing or stopping breathing and leading to death by overdose.

Development of different interventions are already under way, said Volkow. Last year the Centers for Disease Control and Prevention issued prescribing guidelines for acute pain, urging providers to prescribe no more than a three-day supply of opioids, use nonopioid therapies, choose immediate-release formulations, and follow up to reevaluate risk of harm. Volkow noted that sometimes emergency department physicians and dentists send patients home with prescriptions for a 30-day supply of painkillers, most of which can be diverted or misused.

“We all face the challenge of seeing that patients with pain—particularly chronic pain—are properly treated,” she said. “Throughout education and training, med students, doctors, nurses, pharmacists, and dentists must learn when to use opioids and then use them carefully with close monitoring.”

The Drug Enforcement Administration pushed manufacturers to reduce production by 15 percent in 2016. Data from 2015 show that the number of prescriptions for opioids decreased, but opioid overdoses still rose. As prescription opioids become harder to obtain, users shift to illegal and often more lethal variants. They transition first to relatively cheap heroin but eventually move on to synthetic opioids like fentanyl.

“Fentanyl is a good anesthetic in the operating room because it’s rapid acting and can be stopped rapidly,” said Volkow. “But it is 50 times more potent than heroin, so only a tiny dose is needed for effect, and addicts often overdose before they finish injecting.”

Worse yet is carfentanyl, which packs 5,000 times the punch of heroin.

Science has more work to do, as well, starting with increasing knowledge about brain pathways and the role of genetics in addiction.

“We also need to develop more treatments for managing chronic pain that are less addictive and not based on opioid receptors,” she said. For instance, inflammatory mediators prevent the production of pain, and cannabinoids regulate stress reactions to it. Targeted opioid analgesics with less addiction and overdose potential were explored in the past without success, but more is known today, and those alternatives may be worth another look.

More treatment options are needed, too. Naloxone has proven its value in reversing overdoses, and reductions in costs make it more widely available. Fentanyl requires multiple doses of naloxone, so there is a need to find other drugs to prevent respiratory depression, said Volkow. “I would like to see a longer-acting version to protect users from overdosing again while offering a chance for longer-term postoverdose interventions.”

Medication-assisted treatment is a promising approach to treating opioid addiction, but 60 percent of addicts are not receiving such care, largely because of the stigma attached to the treatment, she said. Methadone, buprenorphine, naloxone, and naltrexone are currently available.

“This is not ‘exchanging one drug for another,’ ” she said. “That argument betrays a lack of understanding of how these drugs work.”

A more significant problem is that there are not enough trained providers and treatment sites to meet the demand. Other barriers exist as well. Making a daily trip to a methadone clinic requires making a decision about treatment once a day, and addiction erodes free will and self-control, so NIDA is working with pharmaceutical companies to develop extended-release versions that would likely increase compliance. In rural areas with few doctors, such treatment could be monitored by nurses or other providers.

An even higher-risk avenue of research lies in the development of vaccines that would make antibodies to capture drugs. So far vaccines have not produced enough antibodies to capture enough drug, but research continues.

Nonetheless, research and policy solutions can go only so far, added Volkow in an interview with Psychiatric News following her talk.

“The epidemic is most acute in parts of our country where people have experienced a loss of hope and opportunity and culturally meaningful beliefs,” she said. “We have to tackle this as a social problem along with the biological issues.” ■

The CDC’s Guideline for Prescribing Opioids for Chronic Pain can be accessed here. The NIDA research report titled “Medications to Treat Opioid Addiction” is available here.