Opioid crisis update: What's changed and where are we?

Opioid addiction has gone from a relic of bygone eras to an epidemic raging in American homes and communities. No spot on the US map is untouched by the addiction crisis, and it's common to know someone who has been struck by this tragedy.

But much has changed in the fight against opioid addiction. New diagnostic approaches and treatments, as well as shifting attitudes, are hopefully poised to lay this problem to rest.

How we got here

Chart out the pattern of opioid overdose deaths in the US, beginning in 1999, and you get a hockey-stick graph.^[]

Between 1999 and 2020, an estimated 546,000 people died from opioid overdoses.

The CDC charts the rise of opioid addiction and its deadly wake in three distinct waves. Wave 1 began to crest in the 1990s with the wide distribution of prescription opioids. Wave 2 marked a shift toward fatal heroin overdoses beginning in 2010.

Clinicians find themselves struggling to stay afloat as Wave 3 pummels the US healthcare system. Driving this surge are synthetic opioids such as fentanyl. Increasingly, fentanyl and its synthetic analogs (acetylfentanyl, furanylfentanyl, and carfentanil) have made their way into combinations with heroin, cocaine, and counterfeit pills—all with deadly implications, including accidental overdose.

Where we are now

Overdose is still one of the leading causes of injury-related deaths in the US.^[]

In 2020, unintentional injury—which includes poisoning by overdose—was the leading cause of death for people aged 15–44 years according to CDC data. In the 25–34 cohort, poisoning accounted for 66.9% (20,938) of unintentional injury fatalities, based on further CDC findings. Among the 35–44 cohort, 70.7% of deaths (21,943) stemmed from poisoning.

Compare that with 2010, when unintentional injury was the leading cause of death in people aged 15–44 years. But among the 25–34 cohort, poisoning accounted for 46.4% of deaths (6,767), while among the 35–44 cohort, poisoning stood at 50.5% of deaths (7,476).

Although there are many treatment modalities, including medications and therapy approaches for opioid use disorder (OUD), it is important that healthcare professionals educate the general public on how addiction is a disease that can affect anyone in an effort to destigmatize addiction.

Naloxone and fentanyl test strips are two readily available, affordable ways to help curb the third wave of the opioid epidemic. Naloxone can be given either intranasally or via injectable form to anyone suspected to be experiencing an opioid overdose.

Therefore, it is important that healthcare professionals counsel and educate the public on signs and symptoms associated with opioid overdose. Fentanyl test strips are used to test for laced fentanyl in illicit substances for individuals who engage in recreational drug use.

Looking ahead

Treatments to thwart overdose and addiction are evolving. As with many areas of medicine, the COVID-19 pandemic transformed care delivery for OUD.

For example, a Current Psychiatry Reports review published in 2022 assessed existing research on the efficacy of telehealth used in conjunction with medication-assisted treatment for OUD.^[]

While the researchers identified areas needing further training, development, and study, their assessment was generally positive. They noted that the majority of studies under consideration reported improved abstinence and retention rates.

“It can also serve as a vehicle to implement more innovative approaches to healthcare delivery that overcome the clinician shortage,” the authors wrote.

Overall, however, research seems to suggest that there is still ground to be gained with medication for OUD (MOUD). A JAMA Network Open study published in 2022 sought to determine MOUD use rates among people who may have benefitted from the treatment.^[]

The study included 2019 data on a nationally representative sample of 2,206,169 people who may have benefitted from this treatment. Inclusion criteria were OUD in the past year, reporting MOUD use in the past year, or receiving specialty treatment for opioid use in the last year.

The researchers determined that of this group, only 27.8% actually received MOUD in the past year. No qualifying adolescents received MOUD, and only 13.2% of those over the age of 50 received it.

Shifting attitudes

On a clinical and societal level, attitudes toward OUD may help shape the response to the crisis in the future.

Research found that the American public is polarized. According to a Journal of Public Policy study published in 2022, people are more likely to favor punitive policies to fight opioid addiction if they attribute addiction to personal choices, are conservative, or “high in racial resentment.”^[] However, people with a personal connection to OUD are more likely to favor supportive policies.

OUD remains a real medical condition—not a personal choice—and can affect anyone regardless of age, gender, race or social class. Opioid use disorder comes with life-and-death consequences. As such, the attitudes of clinicians are significant here as well.

According to a Substance Abuse review published in 2021, clinicians' attitudes on MOUD affect prescribing practices, referrals, adoption, access and utilization.^[] Treatment orientation, knowledge, and exposure appeared to shape attitudes toward MOUD among various types of professionals.

In other words, what clinicians think, feel, and believe can make a difference for patients. The physician-patient therapeutic alliance is an incredibly important component of successful addiction treatment. Therefore, it is important that clinicians adopt a de-stigmatizing, empathetic, and educational mindset with patients when counseling about addiction treatment services.

“Findings indicate that interventions should seek to increase knowledge about MOUD and foster interprofessional communication related to MOUD, especially between prescribers and behavioral health providers,” the Substance Abuse author wrote.