Narcotics, or prescription opioids, are a class of drugs that are medically utilized most often for pain relief when the pain is severe and does not respond to other types of treatment. Opioids are used often in their medicinal form due to the chemicals they contain that can relieve pain and relax the body. In the United States, prescription opioid medications are considered to be controlled substances and require a prescription from a physician to fill. Most opioids are taken by mouth, but occasionally, the opioid fentanyl is administered through a patch on the skin.
The most prevalent natural opiates include codeine, morphine, and thebaine. These types of opiates are made from a naturally occurring gummy substance from the seed pods of plants like the opium poppy. Natural opiates are base chemical compounds that contain nitrogen or are sometimes referred to as alkaloids.
The most prescribed opioids, semi-synthetics, are developed in a laboratory from naturally occurring opiates by altering the chemical-molecular structure of them. These types of opioids include the medications hydrocodone, oxycodone, hydromorphone and oxymorphone.
Fully synthetic opioids are entirely manufactured in a laboratory without any type of naturally occurring opioid as a foundation or starting point. This includes medications such as fentanyl, methadone, tramadol, pethidine, levorphanol, and dextropropoxyphene.
Short-term Medical Uses of Prescription Opioids
The primary purpose of most opioid prescriptions is to reduce a patient’s pain. They can be used for short-term pain reduction after sudden injuries such as broken bones and severe burns, or they can be used to treat long-term chronic pain that occurs from a number of diseases and conditions.
Opioids are often prescribed after having a surgical procedure done to reduce pain during the time of recovery. Examples of procedures that warrant an opioid prescription include a cesarean section, organ removal or transplant, removal of any type of bowel or urinary obstruction, any type of orthopedic surgeries to replace joints and repair broken bones, tumor removal, oral surgeries and many more.
Because the nature of almost all surgical procedures involves the cutting of multiple tissues, prescription opioids are often the only way to relieve that type of deep pain after the procedure. When used for this purpose, the prescription will be very short term. Often, it is only for a week post-procedure to get the patient through the most critical part of recovery.
Long-term Medical Uses of Prescription Opioids
Conditions and diseases that result in severe chronic pain are highly diverse and may be non-terminal or terminal. Disorders of the blood, disorders of the bones, nerve-related disorders, all types of cancers and autoimmune disorders can produce the type of pain that warrants a prescription for an opioid painkiller.
Hematologic conditions are characterized by disorders of the blood-forming organs and the blood such as cancers of the blood and bleeding disorders. Sickle cell disease is known to cause widespread avascular necrosis, otherwise known as bone tissue death, due to a lack of oxygen supply. Avascular necrosis due to any condition will be extremely painful and is often treated with prescription opioids.
Cancers of the blood including any type of leukemias, myelomas, lymphomas, myelodysplastic syndromes, and myeloproliferative neoplasms result in chronic pain because the proteins that the cancer cells excrete can cause extensive damage to the nerves. This type of pain is another situation that opioid prescriptions are commonly written out for. Prescriptions for opioid painkillers are given to cancer patients who are in active treatment or terminal.
Hemophilia is a bleeding disorder that causes chronic bleeding into muscles and joints. This results in severe inflammation and joint pain on a regular basis. Prescription opioids are effective for patients to manage pain from hemophilia and other bleeding disorders.
Thrombophilia is a blood clotting disorder that causes an abnormal buildup of platelets and red blood cells inside of the blood vessels. This can easily result in oxygen deprivation to any tissues throughout the body. Without sufficient amounts of oxygen, these tissues begin to die; necrosis, or death of tissue, can result in excruciating pain that opioid prescriptions will help treat.
Cryoglobulinemia is a condition that is characterized by an excess of abnormal proteins in the blood. At low temperatures, these proteins become gel-like and solid enough to block up blood vessels and cause vasculitis. This mechanism results in chronic pain throughout the entire body that opioids are often prescribed to treat.
Systemic lupus, inflammatory bowel disease, rheumatoid arthritis, multiple sclerosis, type 1 diabetes mellitus, Guillain-Barre syndrome, chronic inflammatory demyelinating polyneuropathy and vasculitis are all considered to be inflammatory autoimmune disorders. This group of disorders involves the body’s own immune system targeting and attacking a certain type or types of healthy cells in the body.
The mechanism of the immune system attacking substances is called inflammation, and inflammation in many forms results in chronic and severe pain that manifests differently in each disorder variation. Opioids are commonly prescribed to patients who have a confirmed diagnosis for one or more of these and where other treatment methods have not been successful.
Other conditions that do not fit a category but are commonly associated with the prescription use of opioids are acquired immune deficiency syndrome or AIDS, chronic pancreatitis, fibromyalgia, musculoskeletal deformities, atrophy, asymmetry and other conditions of the musculoskeletal system.
How Opioids Work in the Body
Prescription opioid medications take their action on certain transmembrane neurotransmitter receptors including mu, kappa and delta receptors in the brain. These receptors couple with molecular intermediaries or G proteins, which start the communication process between cells. Once the opioid binds to these receptors, they intercept normal nerve signals and their messages. Instead of sending signals that they should send, they instead transmit a signal to the brain that inhibits pain, decreases the rate of breathing and has a general tranquilizing effect.
There are opioids that exist naturally in the brain and body; however, the body is not able to produce the amount of these natural opioids that it would take to stop severe pain sensations. Natural opioids also do not have the same extent of dopamine flooding effects that opioid medications do. The receptors in the brain are not able to distinguish the difference between the naturally occurring opioids and the opioids that come from medication. Because the chemical and molecular structure is similar, the opioids from the medication are able to easily trick the receptors that they attach to in the brain. They are then able to activate those receptors to send the pain-blocking messages to the brain.
At the same time, opioid medications cause the flooding of the brain’s reward system with the neurotransmitter called dopamine. The brain is naturally wired to encourage a human to repeat life-sustaining activities by correlating them with feelings of reward or pleasure. That reward or feeling of pleasure is caused by the flooding of dopamine from taking the opioid medication rather than by stimulation due to natural behavior. This is the reason that opioid medications are notorious for having euphoric effects.
The Prevalence of Medical Opioid Prescriptions
Early on in the 1990s, the number of prescriptions for opioid medications began to rapidly increase. As synthetic opioids were further developed and opioid pain relief was discovered in a more diverse range of diseases and conditions, the number of scripts for it skyrocketed. About 223.7 million prescriptions for opioid medications were filled annually between the years of 2006 and 2017 according to the Journal Of the American Medical Association.
In general, the rate of opioid medications prescribed hit a peak in the United States in 2010 and remained steady to the year 2012. Ever since 2012, the prescribing rate has marginally declined. From the year 2006 to the year 2017, there was a 19 percent decrease in the number of annual opioid medication prescriptions that were written in the U.S.
In 2017, there were over 58 opioid prescriptions written for every 100 Americans in the U.S. In addition, during 2017, over 17 percent of Americans obtained at least one opioid medication and had it filled. Upon doing the math, this breaks down to 3.4 dispensed opioid medication prescriptions for each patient.
In the U.S., legal regulations have been implemented to tighten the rules on prescribing opioid medications and awareness has risen about the dangers of it. Even with the trivial decrease, the Economic Survey of the United States that was released in 2018 reports that the opioid prescription rates per capita in the United States were considerably higher than the rates in other OECD countries.
How Duration of Opioid Medication Treatment Influences the Risk of Developing a Substance Use Disorder
Any individual who takes an opioid medication, even taking it as directed by their physician, is still at risk for developing an opioid use disorder. Due to the way that the opioids flood the reward centers in the brain, prescription opioid medications are highly addictive. Whether an individual intends for it to happen or not, opioid medications essentially teach the brain through its reward system to crave and take the medication again.
When opioid medications are taken over a period of time, the body reduces the speed of endorphin production because the opioid medication is providing it already. This results in an overall decrease in endorphins because the opioid is no longer compounded by the normal amount of endorphins in the brain. Because of this, the pain-relieving effects and euphoric effects of the medication are not as strong as they were when first starting on that dosage.
When this occurs, it means that the individual has developed a tolerance to the opioid medication. Because of how easy it is to develop a tolerance to opioids, a five-day treatment with a strong dose of opioid medication is going to pose less of a risk than a 20-day treatment with a low dose of the opioid medication. Once a tolerance to the opioid has developed, a substance use disorder begins to form.
This happens because the individual will continue taking the opioid and increasing their doses to feel the same amount of relief from pain or euphoria that they felt when they started taking it. The brain chemistry begins to change, and the brain forgets how to produce its own source of dopamine. When the individual stops taking the opioid, they will experience symptoms of withdrawal that occur because their brain is trying to adjust and learn how to work without the opioid again. This is also referred to as having a mental and physical dependence on opioid medications.
In recent years, data has estimated that 2 million individuals have an opioid use disorder from prescription opioid medications in the United States annually.
Treating acute pain with prescription opioids leads to long-term use, and long-term use leads to the individual developing a tolerance. A tolerance then develops into a dependence on the opioids that results in addiction. Opioid addictions are the leading cause of prescription overdose fatalities.
Dangers of Opioid Medication Prescriptions by Numbers
Awareness and national regulations are most likely the reasons for the decrease in the number of new opioid medication prescriptions being written each year. Prescription opioid medications are extremely dangerous when overdosed on and are the leading overdose fatality drug category.
The most common prescription opioid medications that are involved in overdose deaths in the United States include:
There are 46 lives taken every day in the United States from overdoses that involve prescription opioids. Between the years of 1999 and 2017, there were over 218,000 fatalities in the U.S. attributed to prescription opioid overdoses. There were over five times more prescription opioid overdose fatalities in 2017 then there were in 1999.
The Duration of Opioid Medication Prescriptions Is Increasing
Recent data shows that fewer patients have been initiating new prescription opioid medication use. However, the data also shows that patients who have already been prescribed opioids are proceeding with long-term use of the medications.
In the United States in 2017, the average duration in days per opioid prescription was 18. This statistic continues to increase. From the year 2006 to the year of 2015, opioid prescription average duration increased by over 33 percent from 13.3 days to 17.7 days.
According to recent data, it appears that physicians are writing fewer new opioid prescriptions but keeping their patients on the opioid medications for longer periods of time. Prescriptions of shorter duration, or defined by less than 30 days, made an increase in average duration between 2006 and 2017. Long-duration prescriptions, or prescriptions defined by more than 30 days in length, increased from 18.3 percent of all opioid prescriptions to 24.9 percent of all the opioid medication prescriptions.
According to the Centers for Disease Control and Prevention, the likeliness of long-term opioid medication use increases depending on the duration of the initial prescription given. After the fifth day of taking an opioid medication, the likeliness of long-term use sharply increases. Another spike in the likeliness of long-term use also occurs after the 31st day of taking the opioid medication. Long-term use increases when the initial supply is 10 or 30 days and with every subsequent opioid prescription refill.
In other words, physicians are heeding the warnings regarding opioid medication prescriptions in one way but not in another. In order to collectively combat the issue of the opioid crisis in the U.S., physicians and lawmakers alike need to both reduce the frequency of new opioid medication prescriptions and the duration of existing and new opioid prescriptions.