Opioid Use Disorders and Opioid Overdose Epidemics

Updated: Sep 26, 2020

By Dr. Mark Gold

Cries for help have been increasing since the coronavirus quarantine. EMTs have been busy with COVID 19, as have community emergency departments and general hospitals. The overdose-reversal support system (Naloxone and other MATs) that we patched together to respond to the opioid use epidemic had become broken.

Suspected overdoses nationally jumped 18 percent in March, 29 percent in April and 42 percent in May, data from ambulance teams, hospitals, and police reported July 1 by the Washington Post shows [1]. We have previously discussed [2] the disruptions to the heroin and cocaine importation and distribution networks.

They have been replaced by synthetic drugs like fentanyl and methamphetamine, manufacture in China, India, Southeast Asia, and Mexico. Being stuck at home, isolated, unable to see their counselor or go to their treatment meetings in person have created the perfect storm for a re-emergence of opioid use, opioid use disorder, and opioid overdose epidemics.

We had thought we peaked when data from the Centers for Disease Control shows a marginal decline in fatal overdoses in 2018, from 70,237 to 68,557, it also reveals that fentanyl is still the primary cause of fatal overdoses. 2018 data shows that every day, 128 people in the United States die after overdosing on opioids.

At least 47,600 people died in the USA from drug overdoses involving opioids in 2017, and estimates suggest 500,000 deaths due to opioid overdoses may occur over the next five years. Synthetic opioids, fentanyl, manufactured in China, India, or Mexico are a big part of this overdose problem.

Between 2012 and 2018, the number of fentanyl-induced fatal overdoses rose dramatically, accounting for a majority of overdose deaths. As described by many experts like Rummans [3], Cicero [4], and Gold [5], the number of prescriptions written for pain increased and accumulated in the medicine cabinet only to find new users in the family and others.

In 2017, health care providers across the US wrote more than 191 million prescriptions for opioid pain medication—a rate of 58.7 prescriptions per 100 people. The prescription opioid crisis was quickly followed by a heroin use epidemic and is now a fentanyl and synthetic opioid crisis where we see more primary fentanyl use disorders [6]. This trend toward fentanyl has only increased in the COVID19 epidemic.

The unprecedented increase in opioid-related overdoses and mortality has escalated exponentially, infiltrating all segments and strata of American society while concurrently overwhelming our healthcare system and befuddling policymakers. The three waves of the current opioid crisis followed: prescription opioids, heroin, and synthetic opioids.

Now, we have a synthetic or even a primary fentanyl use epidemic. It is not likely to just go away. Drug cartels can make fentanyl all over the world at little cost. One of the key findings from the report by Pardo and colleagues is that fentanyl’s death toll doesn’t grow because of new consumers, but because it replaces less deadly opioids among individuals with OUD.

Opioid use disorder and opioid addiction continue at epidemic levels in the US and worldwide. Three million US citizens and 16 million citizens worldwide have opioid use disorder. More than 500,000 in the United States are dependent on heroin.

In a recent publication in Science [7], researchers examined drug overdose deaths and unintentional drug poisonings in the United States. They demonstrated that while drug overdoses may look like they come and go, in reality, they grow year after year.

From 1979 through 2016, they grew exponentially along a remarkably smooth trajectory. Reversing opioid overdoses with Naloxone or Narcan was a crucial part of the harm reduction strategy of the ‘70s and even more critical today.

Overdose Reversal in Hospitals, by EMTs, in the Home, and the Community

N-allyl- noroxymorphone, better known today as naloxone, is a derivative of the synthetic opioid oxymorphone. Naloxone or Narcan has been called everything from a wonder drug to the single most useful and vital intervention in reducing the impact of opioid use and overdose epidemics [8].

First patented in 1961, naloxone was approved by the FDA

in 1971 under the name Narcan. Most people refer to it by that name, Narcan. While an old medication, it is more critical today than ever before. It is the subject of a recent pharmacological review [9].

While most medications are prescribed after an office visit and examination, naloxone is most often administered by non-health professionals, EMTs, friends, and others as well are given by Emergency Room health providers in hospitals. Naloxone is safe, so safe that it is often administered when the diagnosis is in question, almost like a diagnostic test.

If the coma or low pulse low respiration crisis isn’t reversed by naloxone, then it must not be an opioid overdose the saying goes. In the emergency room, most anyone taking opioids who are having an emergency with pinpoint pupils or decreased pulse, respirations, or consciousness with a history of any new prescription opioids or illicit drug use is given Narcan.

Just giving Narcan is possible, because it is very fast-acting, safe, and has remarkably few side effects. Narcan can not get a person high, and you can not tell the difference between getting an injection of naloxone intravenously and saltwater. The main side effect is the desired effect, producing acute withdrawal from opioids.

Naloxone has been in use in the United States for more than 50 years. It is the go-to or a mainstay in medical settings for reversing opioid effects, opioid toxicity, and overdose.

I gave it during my internship in the Yale Emergency Room in the ‘70s. At that time, naloxone was approved only for intravenous (IV), intramuscular (IM), and subcutaneous (SQ) administration. Narcan has saved and treated tens of thousands of opioid overdoses. Rescuing, resuscitating, and reviving overdose victims are critical steps in helping people with opioid use disorders(OUD).

When Pitt [10] and her colleagues at Stanford looked at what would make the most impact in reducing OUD deaths, it was Narcan. No other prevention or treatment or public health intervention was close to as effective. Prescribing naloxone to opioid users and encouraging those patients with an OUD to have Narcan with them, while providing MATs and appropriate counseling, is the essence of the harm reduction component of a comprehensive treatment model for OUD.

Not only OUD patients, non-prescription opioid users, pain patients given Narcan prescriptions, older patients, and others should be counseled regarding the signs and symptoms of opioid overdose, including pinpoint pupils, shallow or absent breathing, and unresponsiveness. If an overdose is suspected, naloxone should be administered by anyone who has it, as soon as possible. Then, call 911.