The misuse and abuse of illicit and prescription opiates is a growing problem in the United States. Even though Americans make up less than 5 percent of the world’s population, we consume close to 100% of the world’s supply of hydrocodone and nearly 80% of the world’s supply of legal and illegal opiates .
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Because of the vast availability of drugs and its impact on many facets of healthcare and the economy, it is imperative that health care providers and policy makers understand what drugs are being abused, who uses these drugs, where the drugs come from, and the health and economic burden on the United States. It is becoming exceedingly important for those directly involved with substance abusers to understand the physiological consequences, psychosocial consequences and withdrawal consequences of drugs. Opiates and opiate derivatives in particular, whether illicit (such as heroin) or prescription (such as Oxycontin) are being heavily abused across the country. These drugs can have serious health implications during use and during abrupt cessation (detoxification or withdrawal).
This paper will present a review of the literature on the epidemic of heroin and prescription opiate abuse. Through a critical review, concepts such as the prevalence of the problem, the physiologic consequences of abuse, the current trends in management of the problem and implications for nursing and healthcare will be explored.
Before proceeding, it is important to briefly discuss the basic pharmacology of opiate drugs. Opiates, otherwise known as narcotics, include the drugs heroin, morphine, codeine, oxycontin, hydrocodone, methadone and other chemically-related derivatives. All opiates are considered dispensable only by prescription in the United States with the exception of heroin, which is illegal in all circumstances. Opiates wield their effects by activating pleasure centers in the brain. The neurobiochemical model of addiction suggests that over time, the brain’s chemistry changes so that it yearns for the substance when it is not there and can produce physiologic effects of withdrawal when stopped. Heroin for example, which is chemically-related to morphine (the chemical name for heroin is diamorphine) readily crosses the blood-brain barrier to cause a rapid spilling of dopamine into the dopaminergic receptors of the brain’s neurons. For this reason, the drug is easily addictive and absence of the drug causes a sensation of craving and can cause feelings of illness, such as nausea and diarrhea, when stopped abruptly. .
Prevalence of the Problem
Several researchers in the nursing, allied health and economics disciplines have explored and discussed the prevalence of prescription opiate abuse and hypotheses of the origin of the problem. However, there is a large gap in the literature related to the prevalence of illicit drug abuse (heroin) among different populations. The prevalence data for heroin abuse in the US is largely reported by national survey trends, such as the National Institute of Drug Abuse (part of the National Institutes of Health) Survey on Drug Use and Health (NSDUH). Even so, the massive survey document pays little attention to the problem of heroin abuse and reports only two percent of the 67,500 survey respondents using heroin in the month preceding the survey (National Survey on Drug Use and Health, 2009).
The etiology of prescription drug misuse and abuse is discussed more heavily in the literature than is heroin abuse. According to the NSDUH, in 2009 4.8% of the survey respondents aged 12 and older reported using prescription opiates for non-medical reasons. Of those, over 55% reported obtaining the drug for free from a friend or relative, and 4.8% reported purchasing the drug from a dealer on the streets (National Survey on Drug Use and Health, 2009).
Researchers at Columbia University surveyed adolescents aged 12 to 17 in 2005 and found that 9.3% reported the misuse of prescription opiates over the past month. In exploring the adolescents’ motives for abuse, the researchers found that the most commonly reported motives were ease of attainment and affordability . Among young adult college students, prevalence of non-medical prescription opiate abuse has been reported between seven and nine percent in the past month to twelve to fourteen percent lifetime prevalence .
One of the most at-risk groups for misuse of and addiction to prescription opiates is the chronic pain population. When used appropriately, opiate pain medications are a gold standard of care for serious pain-related conditions (such as post-operative pain, neuropathic pain and so on). In an effort to better manage pain, the number of prescriptions for opiate medications increased 154% in the ten-year period from 1992 to 2002, even though the population of the United States increased by only 13% .
Although prescription opiates have been used to treat pain and improve the quality of life among acute and chronic pain patients, the advent of the drugs’ misuse has led to a wide body of literature on prescriptive practices and monitoring of opiate drugs. There delicate balance between managing pain adequately and the risk for misuse, addiction and diversion has been discussed in the literature recently, largely among the adolescent/young adult and chronic pain populations.
Although there is a general lack in the literature of the number of people prescribed opiates for chronic pain . There is a large body of literature which suggests that the increased number of prescription opiates for chronic pain patients has contributed significantly to the drug abuse problem. In studies to investigate the use of prescription opiates for chronic pain, it has been found that pain treatment plans are sparse, good documentation on the patient’s health history and history of substance abuse is rare, and opiates are sometimes improperly utilized or not indicated at all .
Health Consequences of Opiate Abuse
Both prescription and illicit opiates have the potential to exert a myriad of acute and chronic negative health effects for the user. Neurological decline, vision changes, cardiac abnormalities, vascular complications, pulmonary disorders and mortality have been studied and reported.
In a study of over 500 opiate addicts, electrocardiographic changes were documented in 61% of the sample. These ECG changes included ST-segment elevation, which may indicate ischemic heart damage (or lack of oxygen-rich blood to the myocardium) and QTc prolongation (seen mostly with methadone addicts). Prolonged QTc intervals may lead to inappropriate triggering of the ventricles and may lead to potentially lethal ventricular tachycardia .
The use of heroin and other drugs by injection with non-sterile or reused needles may produce powerful toxins in the bloodstream leading to endocarditis, left ventricular hemorrhage and death. Researchers in Ireland reviewed the autopsy findings from eight cases of heroin users and found rapid fatal illness caused by the endotoxin Clostridium novyi which caused fatal subendocardial hemorrhage, spleen enlargement and pulmonary edema in all of the subjects studied .
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Heroin can cause significant acute peripheral and central nervous system complications such as neuropathy and hearing loss. In a study six of intravenous and intranasal heroin users admitted to the hospital for acute illness, five had documented rhabdomyolysis between three and 36 hours after administration of the drug. In each of the five cases, there was no documented trauma. Typically rhabdomyolysis occurs after a traumatic, compression-type injury where enzymes spill into the musculature and cause rapid neurological decline, loss of muscle tone and coma. In each of the subjects studied, no trauma or compression injury occurred . In a group of patients with a reported history of “speedballing” (or mixing heroin and cocaine), 2 of the 16 studied experienced sudden, bilateral sensorineural hearing loss four hours after “speedballing” which resolved within three days. One additional participant experienced sudden hearing loss after “speedballing” but unilaterally. The mechanism by which the hearing loss occurred was described as a possible cochlear toxicity or autoimmune reaction related directly to the drugs .
Injection of drugs of any type can cause vascular complications, skin and soft tissue infections and infectious diseases such as hepatitis and HIV . In the most severe cases, opiate abuse may lead to death, generally from overdose. Heroin has been related to 1.65 deaths per 100,000 people in the Florida population alone over the last decade and in Alabama between 1986 and 2003, a review of medical examiner’s reports revealed those who’s cause of sudden death was undermined were 5.3 times more likely to have a history of drug abuse . Researchers in the United Kingdom have further investigated heroin deaths and concluded that overdose related to heroin rarely occurs after the use of heroin alone- in 50% of the cases they reviewed, alcohol was also involved .
Although studies have been published on the health effects of abuse itself, a review of nursing, medical and allied health literature shows a significant lack of studies on the health consequences of withdrawal (abrupt cessation) of opiate drugs. Several studies have been found relating to the use of pharmacotherapy to treat opiate addiction (such as methadone and similar programs) but no studies have explored the physiologic effects of withdrawal without medication assistance. Searching online databases for relevant articles on opiate withdrawal does not yield any studies other than those using medication-assisted withdrawal therapies (such as methadone and buprenorphine). This is important to populations such as inmates in a correctional facility where pharmacotherapy is not generally used during detoxification and requires further attention .
In sum, the potential health-related consequences of opiate abuse can negatively affect a myriad of body systems. The risk of potentially fatal infectious disease, neurological and cardiovascular complications and death by overdose creates a public health problem that demands attention. Health care providers in all arenas must be able to rapidly and appropriately identify those at risk.
Implications for Advanced Nursing Practice
Nurse practitioners are allowed prescriptive authority in almost any state across the country. Depending on the practice setting, they may prescribe opiates to treat pain. Opiates are the gold standard for treating moderate to severe pain in both acute and chronic pain syndromes . There has been some discourse in the literature on the dilemma to treat or not to treat pain with opiates. On the one hand, effective pain management is not only ethical but also opiates are effective for many patients for pain management – and on the other hand there is a fear of misuse, dependence and addiction issues . The ability for advanced practice nurses to identify drug-seeking behavior, issues with addiction and possible diversion of opiates is crucial to the problem of opiate abuse. As it has been documented in the literature, diversion of prescription opiates generally occurs with the patient selling, trading or giving away the medication to another. According to Annie Gerhardt, emergency room nurse practitioner, “drug seekers become victims of their own disease”, becoming involved in a tangled web of addiction, drug-seeking, drug diversion and criminal behavior that escalates over time with increased drug use . Gerhardt (2004) suggests monitoring patients treated with opiates for refilling meds before their follow up appointments, patient reports of “losing” medications, attempting to see different providers for pain medications (which can usually be identified by pharmacies), and “scamming” providers for more medications by complimenting the provider or the office staff or displaying increased levels of pain in order to procure more medication. When prescribing opiates to treat pain in patients already known to have addiction issues, using sustained-released formulations may reduce dependency while adequately treating pain. Sustained-release formulations usually have a reduced street value and are less likely to be sold and diverted, and the withdrawal from sustained-release opiates is typically not as severe .
In terms of advanced practice nursing, prescribers have the unique ability to screen for potential addiction issues, monitor those who are prescribed addictive medications and potentially control diversion of those medications to others for whom they are not prescribed. Ultimately, the knowledge of drugs of abuse and health-related consequences is important for nurses at all levels to possess.
Implications for Research
To further add to the body of literature on the subject of opiate drug abuse, addiction and withdrawal, several areas still need to be explored.
First, patterns of drug use in individual populations and communities should be investigated. The types of drugs most commonly used, the routes of administration of these drugs and their negative health-related consequences should be studied in a variety of communities, both urban and rural, to gain a better understanding of the patterns of use across the country. More research is needed beyond simple prevalence studies on the number of people who use to expand on the actual patterns of abuse. Similarly, the psychosocial consequence of drug use across different populations needs further investigation in order to articulate the negative impact on individuals and communities.
Because the abrupt cessation of opiate drugs without medication assistance occurs frequently in specific settings, more research needs to be done on the physiological effects of non-assisted detoxification. The patterns of symptoms of withdrawal and negative health effects among populations such as the incarcerated and the hospitalized need to be explored. The potential for the development of evidence-based protocols for the management of abuse and withdrawal in these settings can occur once the patterns of symptoms and health consequences are documented.
In sum, the problem of drug abuse (which extends far beyond even opiate drugs) has been reported in multiple sources, and prevalence studies seem rampant in the literature. However, much more work needs to be done on the consequences of drug abuse from a healthcare perspective across a variety of populations in different settings to begin to understand the impact of drugs on communities.
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