Understanding the Opioid Epidemic: Diagnosis, Risk Factors, Treatment Options, and Addiction Reduction Strategies

A comprehensive opioid addiction summary discusses the diagnosis, risk factors, physical manifestations, treatment options, and measures implemented to combat the opioid epidemic, emphasizing the need for health care providers to limit opioid prescriptions and prioritize evidence-based addiction treatment.  

The diagnosis of opioid use disorder (OUD) involves meeting at least 2 of 11 specified criteria within a one-year period. Factors contributing to the increase in OUD include the overprescribing of opioid medications by health care providers, the downplaying of their abuse potential, and aggressive marketing of drugs like Oxycontin and Opana. Several risk factors for misuse of these medications have been identified, including early initiation, previous substance abuse history, family history of substance abuse, adverse childhood experiences, and psychological comorbidities. 

While most people misuse opioids for pain relief or to prevent withdrawal symptoms, increasing evidence shows that opioids are not effective as long-term pain medications. Withdrawal symptoms can manifest when opioids are abruptly discontinued or tapered and include both acute and chronic phases with symptoms like nausea, vomiting, insomnia, muscle pain, and tachycardia. However, many providers do not have experience with the prolonged subacute chronic phases. 

“Chronic opioid use causes alterations in receptor sensitivity, leading to medication tolerance and changes in pain perception,” said researchers. “Opioid-induced hyperalgesia (OIH) causes pain perception out of proportion to the stimulus (hyperalgesia) in those who use or misuse opioids long-term.”  

Opioids have varying toxicokinetics and exhibit different half-lives and potencies, with synthetic drugs like fentanyl and carfentanil being more potent and posing a higher risk of overdose and requiring higher doses of naloxone for reversal. These drugs are also lipophilic and metabolized in the liver through phase 1 and phase 2 reactions. 

The history and physical examination of patients with OUD can vary depending on the duration and intensity of their opioid use. Those who sporadically misuse small doses may show no physical abnormalities or clear historical findings. On the other hand, patients with chronic oral opioid use may exhibit sedation while actively using the drug, as well as miosis and a hyperactive response to pain. Patients who are dependent on intravenous heroin may present with various effects of injection drug abuse, such as bacteremia, endocarditis, track marks, scarring, poor dentition, lack of IV access sites, abscesses or cellulitis, and signs of hepatitis or cirrhosis. Although patients may be hesitant to discuss their substance abuse patterns, obtaining a detailed history is crucial when OUD is suspected. 

Providers should start by taking a detailed history and physical exam for patients suspected of having OUD, as some patients may withhold information or be openly deceptive and manipulative.  

Practitioners should provide inpatient or outpatient substance use disorder treatment for patients with OUD. Short-term opioid prescriptions do not offer long-term benefits, and regulations to limit opioid prescriptions are increasingly being implemented in the US. Patients experiencing opioid withdrawal often need antiemetic/antidiarrheal therapy and IV hydration. Medications for OUD, such as buprenorphine and methadone, can be effective in medically supervised withdrawal. Naloxone should be promptly administered to reverse opioid overdose, and all at-risk patients should have naloxone kits available.  

The Mainstreaming Addiction Treatment (MAT) Act expands the availability of evidence-based treatment and allows all health care providers to prescribe buprenorphine for OUD. With the elimination of the DATA-Waiver program, practitioners with Schedule III authority can now prescribe buprenorphine without patient limits. Pharmacy staff can fill buprenorphine prescriptions using the prescriber's DEA number, though some dispensing software may still require X-Waiver information. Practitioners must still adhere to state limits for treating patients with OUD. 

Known differential diagnoses include acute pancreatitis, bacterial gastroenteritis, barbiturate toxicity, benzodiazepine toxicity, chronic pancreatitis, influenza, peptic ulcer disease, and viral gastroenteritis. Heroin abuse is linked to increased rates of motor vehicle accidents, while medication-assisted treatment has not been found to significantly impact driving performance.  

The opioid epidemic has become widespread in the US and worldwide, leading to the implementation of measures such as prescription drug monitoring programs, good samaritan laws, naloxone distribution, and increased funding for rehabilitation. Given the highly addictive nature of opioids, health care providers should limit their prescription to severe pain cases and discontinue their use as soon as possible. 

Reference 

Azadfard M, Huecker MR, Leaming JM. Opioid addiction. Nih.gov. Published February 28, 2019. Updated January 2023. Accessed November 22, 2023. https://www.ncbi.nlm.nih.gov/books/NBK448203/