You've heard me rail on Healthcare Triage about how accidents and guns are huge killers of children, but when it comes to adults, drug overdoses are a much bigger problem.  In 2014, about 34,000 adults died in car crashes and about the same number of deaths resulted from gun violence, but more than 47,000 people died from drug overdoses.

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This episode is brought to you in part by generous support from the National Institute of Healthcare Management.

As we discussed in our last episode, opioids work to alleviate pain.  In the 1990s, when Oxycontin, vicodin, and percocet arrived, they quickly became popular choices for the treatment of chronic pain.  We shouldn't minimize the pain problem in America.  A 2011 report from the Institute of Medicine argued that about 100 million people in the United States suffer from chronic pain, almost 1/3 of Americans.

Pain is real and a lot of people are experiencing it, but treatment of pain with opioids can be more harmful in the long run than living with the pain.  Worldwise, somewhere between 26 and 34 million people abuse opioids.  More than 2 million of them are Americans who are abusing prescription opioids and nearly half a million more are abusing heroin.  

Research shows prescription opioid abuse is associated with heroin abuse.  In 1991, about 76 million prescriptions were dispensed for opioids in the United States.  By 2011, this number had peaked to 219 million, pretty much a tripling of prescriptions.  With this massive increase in prescriptions, the number of bad outcomes increased as well.   Emergency room visits for abuse of prescription opioids went from 145,000 in 2004 to almost 306,000 just four years later.  Admissions for the treatment of of abuses of prescription opioids constituted about 1% of admissions in 1997 and they made up 5% of admissions a decade later.

In 1999, about 2000 people died from heroin, and about 4000 people died from prescription opioid painkillers.  By 2013, the numbers had increased to more than 10,000 for heroin and almost 19,000 for opioids.  The problem, of course, is that the same thing that makes opioids powerful is the same thing that makes them so dangerous: they act on the same parts of the brain as heroin and morphine, and if used improperly, i.e. snorting or injecting, the euphoric effects are significantly increased.  

The numbers are a problem, too.  If the estimates of 100 million people suffering from chronic pain in the United States are accurate and we treat many of them with opioids, as was the case, then even if a small percentage of these people became dependent on them, we're talking about a lot of people.

In the last episode, we discussed how opioids worked to reduce pain, but they also produce a sense of pleasure and well-being.  People who experience this sensation tend to like it and want to experience it again.  Some formulations of opioids, especially extended release forms, try to minimize this effect.  Unfortunately, some people try to get around that by using the drugs in inappropriate ways, again, crushing, snorting, injecting.  Because the extended release forms contain higher doses, this places people at even higher risks of complications.

Tolerance is a problem as well.  With repeated use, opioids use potency and users are tempted to increase the dose.  This increases the euphoric effect and leaves them more likely to become addicted.   Addiction is defined as the compulsive seeking and using of drugs in spite of terrible consequences.  Why someone people succumb to addiction and others do not is still a point of debate.  Some believe that about half of this variability is due to genetic factors.  The other half of determinants are more environmental, including mental health, socioeconomic status, and stressors. 

Although it was debated for some time, it seems to be more and more clear that the increase in the use of opioids has also resulted in an increased use of heroin, especially among young adults, there's been a significant increase in the use of heroin nationwide.  Heroin is cheaper than opioids in general and easier to buy in some communities.  The number of heroin users in the United States almost doubled between 2005, when 380,000 people used it and 2012, when 670,000 did, and of course, with heroin being illegal and unregulated, it can be contaminated with other drugs and it's much easier to overdose.  When it's used intravenously, it also leaves users at risk for HIV, hepatitis, and other bloodborne diseases.  

We've been very liberal with our use of opioids.  Some reports in pain management settings show that more than 90% of patients treated were given opioids for their chronic pain, but pain management clinics account for a small number of total prescriptions.  About 20% of patients in primary care settings were long-time users and more than 60% received opioids from their primary care provider.  

Many chronic users were prescribed at least two different opioids from at least three different providers.  Even safer prescriptions carry significant risk.  Data from the CDC show that about 80% of prescribed "low doses" of opioids from a single provider still accounted for about 20% of overdoses in the United States.  Patients receiving high dose prescriptions, still from a single provider, still account for an additional 40% of overdoses.

The typical drug-seeking patient who sees multiple doctors and tries to fool them in order to get more drugs accounts for only 40% of overdoses in the United States.  There appears to be little evidence that long-acting opioids are better for pain control with less risk for abuse.  Many people believe this, though.  There's a growing sense that their use leads to quicker escalation to high dose therapy.  

It appears that the world is waking up to the problem, though.  Recent studies highlight a recognition that opioid abuse is associated with a significant increase in mortality in people in the United States.  More and more policymakers are focused on the problem and trying to find solutions, but in the meantime, we need to focus on how to treat those who already have a problem.  That's the topic of next week's Healthcare Triage.

Healthcare Triage is supported in part by viewers like you through patreon.com, a service that allows you to support the show through a monthly donation.  We'd especially like to thank our research associates Joe Sevits and M.T. and our surgeon admiral Sam.  Thanks, Joe, M.T., and Sam!  More information can be found at patreon.com/healthcaretriage.