In the beginning, it killed the pain and it didn’t bother me. I didn’t have cravings for it or anything like that. When I couldn’t stand the pain, I would take a pill. And then one day, I woke up and took a pill; there was no pain though… It sneaks up on you, it grabs you without notice… I didn’t know I was becoming addicted when I became addicted.”


This story is unfortunately becoming more and more common each year. Prescription opioid abuse has been on the rise in the US and Canada for the past 20 years; however, there has recently been a dramatic increase in reported opioid abuse and opioid use-related fatalities. According to the Public Health Agency of Canada, 2,923 people are believed to have died from opioid-related overdoses between January and September 2017 – a 45% increase over the same period the previous year. In this issue of IMMpress, we will take a closer look at the opioid crisis to better understand what it is and why it is on the rise, as well as examine some of the preventative measures enacted by governmental and medical authorities.

What are Opioids?

Opioids are a class of substances that contain potent analgesic properties. For centuries, they have been used as painkillers and anesthetics all over the world. Opioids dampen nerve signalling by binding to opioid receptors, which are widely expressed on neurons of the central and peripheral nervous system. While opioids have the beneficial ability to relieve pain in users, one of their major side effects is inducing the feeling of euphoria. This ability to induce a “high” creates the potential for compulsive drug use and addiction, making the abuse of medicinal opioids a persistent issue. The abuse of opioids poses a real threat to users. Opioids function as respiratory depressants; therefore, a high enough dose can lead to respiratory arrest and ultimately death. The combination of high prescription rates, addictiveness, and potential of fatal overdose has made the “opioid crisis” a significant public health concern.

Prescription Pressure

While the opioid crisis represents a complex issue consisting of social, healthcare, and legislative factors, certain events can be pinpointed as critical to the overall development of the crisis. One of the major events thought to have greatly contributed to the early development of the opioid crisis was the campaigning led by pharmaceutical companies in the late 1990s. Massive campaigns were initiated by pharmaceutical companies to advertise newly developed analgesic drugs and advocate for better treatment of pain by medical professionals. These campaigns ultimately led to a report by the Joint Commission on the Accreditation of Healthcare Organizations (JCAHO), which criticized medical professionals in the US for under-treating pain even though many effective analgesics were on the market and insisted that these drugs should be more widely used. Although the medical community at the time was still divided over the potential addictiveness of these drugs, the report made national headlines and appeared on the front page of newspapers and magazines across the US. This put a tremendous amount of pressure on the medical community, which resulted in a significant increase in the prescription of opioids. In response to this, more pharmaceutical companies quickly pushed their own analgesics to market to meet the new demand, thus further increasing access to these drugs. Altogether, this inevitably led to record rises in opioid abuse as more and more individuals became exposed to these addictive substances.

I sort of knew it was wrong, but at the same time I didn’t think it was such a bad thing. My head was telling me, “Dude, the doctor prescribed this to you. How bad can it be?” I thought me catching a little buzz was harmless.”

A shortsighted solution

The second major factor thought to have contributed to the opioid crisis was the introduction of OxyContin, a highly potent sustained-release opioid that could provide pain relief over a 12 hour period. OxyContin contained a built-in release mechanism that slowly released the drug from the capsule over a period of 8 to 12 hours. Due to the slow-release properties of the drug, the US Food and Drug Administration (FDA) concluded that OxyContin would dissuade abuse because it would not provide users with an immediate reward, a hallmark of many addictive substances. This erroneous decision allowed the sponsoring company to place a label on the package stating that the drug had “low abuse potential”, leading to its widespread prescription across the country. By 2001, it became the best-selling narcotic in the US. Opioid abusers quickly realized that they could simply crush or dissolve the capsules to obtain a large amount of OxyContin for immediate ingestion or injection. The reason why the introduction of OxyContin was such a significant milestone in the development of the opioid crisis was its dose. While the standard immediate-acting opioid tablets at the time had doses of around 5 to 10 milligrams, OxyContin had a dose of 80 milligrams. As a result, OxyContin became an extremely popular substance on the drug market.

Synthetic killers

The widespread prescription of opioids throughout the late 1990s and early 2000s, combined with the increased availability of high-dose opioids such as OxyContin, certainly played a significant role in the spread of the opioid epidemic; however, the recent spike in opioid-related fatalities across the US and Canada is due to a relatively new player in the opioid crisis: synthetic opioids. Synthetic opioids are novel derivatives of opioids that have similar bioactive effects (analgesia, euphoria). These drugs have recently become increasingly available on unregulated drug markets due to reduced supply and prescription of natural opioids. They are more dangerous due to their extreme potency. Fentanyl, a well known synthetic opioid, is 50 times more potent than heroin and 100 times more potent than morphine. As little as 2 milligrams of fentanyl are enough to kill most people. As effort is made to reduce access to opioids, more users are turning to illegal markets to obtain the drugs; as a result, they are at risk of obtaining opioids contaminated with fentanyl or other synthetics. In Canada alone, 53% of opioid-related deaths in 2016 involved fentanyl contamination. In 2017, this number grew to 75%. Fentanyl contamination is not just a danger to users – it also places first responders at risk of overdosing due to accidental or involuntary contact with the drug.

Combatting the crisis

While the opioid crisis remains a major problem in the US and Canada, government and health officials are attempting to address the issue. Naloxone is a medication capable of reversing the effects of opioids. Administration of naloxone can be lifesaving to someone who has been exposed to fentanyl. Due to the inherent risk of synthetic opioids to opioid users, the government of Ontario has made naloxone kits freely available to anyone who may be at risk. Friends and families of users, or even users themselves, can now pick up a free kit from pharmacies across Ontario. Recently, all frontline police officers in Hamilton were equipped with naloxone kits, helping to not only save the lives of users but also any first responders exposed to these drugs.

When combatting the opioid crisis, it is important to remember that many users are incredibly dependent on these substances and may go to extremes to obtain them. A lesson that can be learned from the many substance battles in the past, such as Prohibition or the battle against methamphetamine and heroin, is that cutting off the supply is not feasible and in many cases can actually worsen the problem. Drugs will continue to flow into the US and Canada from illegal sources, which inadvertently increases the danger of synthetic-contaminated opioids. A more effective approach to battling a substance-abuse problem is to scale up public health solutions. This includes programmes such as harm-reduction therapy, behavioural therapy, and supervised injection sites. Recently, Health Canada approved three injection sites in Toronto, where users can inject illegal drugs while under the supervision of medical professionals. Despite sponsorship from Health Canada and many medical professionals, supervised injection sites in Toronto have been the centre of much controversy. Some believe these sites go against illegal drug trafficking laws, while others state that they only enable further drug use. While they face scrutiny from the public, injection sites have proven to be quite effective internationally. In Switzerland and the Netherlands, drug-related deaths dropped significantly following the introduction of medically-supervised injection sites. Similar results were seen in other areas of Europe and the UK. Programmes such as this, which address the needs of users, are much more likely to be successful in reducing substance abuse. While we are not there yet, as evidenced by the continued increase in reports of opioid-abuse, significant strides have been made to lessen the epidemic. Going forward, public health policy and legislation should continue to put the needs of dependent users first as we battle the opioid crisis.


References:

  1. Back SE, Lawson K, Singleton L, Brady KT. Characteristics and Correlates of Men and Women with Prescription Opioid Dependence. Addictive behaviors. 2011;36(8):829-834. doi:10.1016/j.addbeh.2011.03.013.  
  2. Cicero TJ, Ellis MS. The prescription opioid epidemic: a review of qualitative studies on the progression from initial use to abuse. Dialogues in Clinical Neuroscience. 2017;19(3):259-269. 
  3. Eugenia Socias, M. Epidemic of deaths from fentanyl overdose. BMJ 2017; 358 doi: https://doi.org/10.1136/bmj.j4355 (Published 28 September 2017) 
  4. Wright, N, Tompkins, C. Supervised injecting centres. BMJ 2004; 328 doi: https://doi.org/10.1136/bmj.328.7431.100 (Published 09 January 2004) 
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Dario Ferri

Dario is a MSc student at the University of Toronto pursuing a project related to defining new mechanisms by which the immune system is altered in patients with systemic lupus erythematosus.
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