Opioids are the most powerful pain relievers known. When taken as prescribed, they help manage pain safely and effectively. But the rising tide of opioid abuse has become an unbridled public health issue. Opioids can be highly addictive. They block pain sensations by binding to opioid receptors in the central nervous system (CNS)—the same receptors to which heroin binds. Opioid abuse may depress the CNS and lead to death.
Use and abuse of prescription opioids have grown dramatically in the United States. Americans account for 4.6% of the world’s population but consume approximately 80% of the world’s opioid supply. They consume 99% of the world’s supply of hydrocodone, a commonly used opioid.
According to the Centers for Disease Control and Prevention (CDC), more than 12 million people used prescription painkillers for nonmedical reasons in 2010. Opioid abuse has led to increases in emergency-department visits (more than 475,000 in 2009), hospitalizations, and admissions to substance-abuse treatment centers at a time when our healthcare system is already strained.
Prescription drug abuse accounts for the greatest percentage of drug-overdose deaths. The CDC reports that in 2008, opioids were involved in 14,800 overdose deaths—more than heroin and cocaine. Unintentional overdose deaths from prescription opioids have quadrupled since 1999 and now outnumber those from heroin and cocaine combined.
Some experts believe prescription opioids are important “gateway” drugs. Also, the fact that healthcare practitioners prescribe them may lull users into believing they’re safe. Yet opioids pose not just the risk of abuse but additional risks as well. (See the box below.)
How opioids increase other risks
Although oral opioids can’t transmit human immunodeficiency virus (HIV), their use may increase the risk of HIV transmission through altered judgment and poor decision-making while under the influence. Also, some people inject opioids to intensify their effect, posing the risk of HIV and other infectious diseases from unsterile paraphernalia or sharing injection equipment.
Risk factors for substance abuse include a family history of addiction, a history of emotional illness, and peer pressure. In the healthcare setting, it’s hard to determine the addiction rate among long-term opioid users. Nonetheless, a 2007 study of 800 primary-care patients taking opioids found approximately 4% were addicted. In other research on patients with various pain complaints, the addiction rate was less than 1% for those who’d never used opioids and approximately 4% for those who’d taken opioids previously. Although opioid use in treating acute pain generally appears benign, long-term opioid use has been linked to clinically meaningful abuse rates.
Opioid abuse and addiction in infants and the elderly
In 2012, the first national study of its kind found the number of infants born addicted to prescription opioids had tripled over the previous 10 years; 3.4 of every 1,000 infants born in hospitals in 2009 suffered from drug withdrawal. The number of pregnant women who used or abused opioids rose fivefold from 2000 to 2009; many of them said they didn’t know opioids could harm their babies. Some women who are addicted to opioids when they become pregnant are unable to quit.
Elderly adults abuse opioids, too. With age comes loss—of a spouse, friends, relatives, home, job, or health. Living alone (and longer) and feeling lonely and depressed can place the elderly at greater risk for substance abuse. Many elderly persons also lose their social and emotional support systems; for some, going to the doctor may be their only social activity. Also, older adults who abuse substances may be overlooked or misdiagnosed, placing them at greater risk for continued misuse. A 2011 literature review found a high rate of prescription drug misuse among older adults and projected that the number of elderly persons who abuse substances will double by 2020.
In the current epidemic of opioid use and misuse, the supply chain is short, running from the prescribing physician to the patient and the prescription drug abuser (who may be the same person). The vast majority of illicitly used prescription opioids are obtained from physicians, not drug dealers. Between 1991 and 2010, opioid prescriptions rose from about 75.5 million to 209.5 million. In 2011-2012, among persons aged 12 and older who’d used prescription pain relievers nonmedically in the previous 12 months:
- 54% said they obtained the drugs free from a relative or friend
- 15% bought or stole the drugs from a relative or friend
- 19% obtained the drugs from a single doctor
- only 1.8% got the drugs from more than one doctor
- just 4.3% bought the drugs from a dealer or stranger.
As these data indicate, many opioid users get the drugs from diversion through family and friends or from their primary care physician. Drug dealers are a relatively insignificant source.
Factors contributing to opioid abuse
One factor that contributes to opioid abuse is the perception that these drugs are safe and legal because doctors prescribe them. What’s more, some people seem to believe the prescribing healthcare provider should in some way be accountable for opioid abuse. Also, society doesn’t frown as much on opioid misuse as much as it does on heroin or crack abuse. In one survey, almost 50% of teens said they thought prescription drugs are much safer than illegal street drugs and that their misuse doesn’t warrant the same retribution from their parents as heroin or crack use. Also, opioids are easy to conceal and unlike alcohol, can’t be smelled on the user.
Another contributing factor is ease of access. Prescription opioids have become much easier to get, not just from friends and relatives but on the Internet. Anyone with access to a computer can obtain opioids online, even without a prescriber’s supervision. Many websites that sell opioids lack quality-control standards, increasing the risk of drug toxicity.
The new pattern of opioid prescribing contributes to abuse by making it easy to obtain opioids. Many patients now see their primary care physician to manage pain instead of a pain-management specialist, leaving the physician’s office with an opioid prescription.
Treating opioid abuse
People who abuse opioids may encounter many real or perceived barriers to treatment. Perhaps the greatest is the stigma of being treated for drug abuse.
Various therapies and treatment protocols for substance abuse exist, but no single optimal treatment approach exists. Some experts believe the most effective approach is to incorporate treatment into primary care on an individual basis, treating opioid abuse like other chronic illnesses. Identifying those at risk can be done at the primary-care level and may help abusers get treatment earlier.
Nurses must become proficient in identifying opioid abuse and implementing evidence-based practices to provide appropriate care. Familiarize yourself with both the obvious and not-so-obvious signs and symptoms of opioid abuse, as well as available resources and treatment options.
As a professor of nursing, I assign my students to attend a meeting of a self-help group, such as Narcotics Anonymous or Alcoholics Anonymous. After completing the assignment, students come back to class expressing amazement at what they’ve experienced. Most state they weren’t aware of what really goes on in self-help groups, and say they have a new respect and firsthand knowledge of existing resources for people struggling with substance abuse.
Briggs WP, Magnus VA, Lassiter P, et al. Substance use, misuse, and abuse among older adults: implications for clinical mental health counselors. J Ment Health Couns. 2011:33(2):112-27.
Centers for Disease Control and Prevention. Vital signs: Overdoses of prescription opioid pain relievers; United States, 1999—2008. www.cdc.gov/mmwr/preview/mmwrhtml/mm6043a4.htm?s_cid=mm6043a4_w. Accessed September 25, 2013.
Fishbain DA, Cole B, Lewis J, et al. What percentage of chronic nonmalignant pain patients exposed to chronic opioid analgesic therapy develop abused/addiction and/or aberrant drug-related behaviors? A structured evidence-based review. Pain Med. 2008;9(4):444-59.
Fleming MF, Balousek SL, Klessig CL, et al. Substance use disorders in a primary care sample receiving daily opioid therapy. J Pain. 2007;8(7):573-82.
Foundation for a Drug-Free World. The truth about prescription drug abuse: International statistics.
www.drugfreeworld.org/drugfacts/prescription/abuse-international-statistics.html Accessed September 25, 2013.
Gordon AJ, Kunins HV, Rastegar DA, et al. Update in addiction medicine for the generalist. J Gen Intern Med. 2011;26(1):77-82.
Johnston LD, O’Malley PM, Bachman JG, et al. Monitoring the future: national results on adolescent drug use; overview of key findings. Bethesda, MD: National Institute on Drug Abuse; 2008
Patrick SW, Schumacher RE, Benneyworth BD, et al. Neonatal abstinence syndrome and associated health care expenditures: United States, 2000-2009. JAMA. 2012;307(18):1934-40.
U.S. Department of Health and Human Services. Results from the 2010 NSDUH: Summary of national findings.
www.samhsa.gov/data/NSDUH/2k10NSDUH/2k10Results.htm. Accessed September 26, 2013.
Barbara B. Blozen is an associate professor in the College of Professional Studies at New Jersey City University in Jersey City, New Jersey.