_________________________________________________________________________ Opioid Use Disorder
The increase in opioid analgesic abuse is particularly troubling because respiratory depression and death can result from the doses at which these agents are frequently abused, especially when mixed with other central nervous system depressants [29]. The two populations for whom prescription opioid abuse is especially problematic are adolescents, due to the uncertain implication of future dependence, and the elderly, due to the increased vulnerability to toxicity. Early exposure to opioids in adolescent users may cause neurobiologic changes and behavioral consequences that differ from adults [29]. GEOGRAPHIC PATTERNS OF MISUSE Nonmedical use of opioid analgesics has been observed in both rural and urban areas. Among people 18 years of age and older, the highest percentage of past-year illicit pain medication users live in small metro (3.5%) areas followed by completely rural (3.2%), less urbanized (3.2%), urbanized nonmetro (3.2%), and large metro (3.1%) areas [12]. Research data also suggest a problem with injecting among rural opioid users, a problem more typically associated with urban drug users [10]. The West (3.4%) and the South (3.3%) areas have the highest percentage of past-year users, followed by and the Northeast (3.2%) and Midwest (3.0%) [12]. RISK FACTORS FOR OPIOID USE DISORDER Persons at heightened risk for heroin experimentation include those who abuse alcohol or marijuana, those with first-degree relatives addicted to alcohol or other drugs, and those with friends and associates addicted to heroin or at high risk of heroin experimentation [8]. Of course, not all persons who use drugs regarded as having a high liability of misuse end up becoming addicted to the drug. Among persons who try heroin, an estimated 23% develop heroin dependence, a rate comparable to cocaine but greater than marijuana [30]. The expected drug effect and the setting of use (context of administration) play important roles in the social learning of drug use. Because opioids, like other drugs that increase dopa- mine turnover, lead to conditional responses, the use of opioids may become conditioned to the activities of daily living. As a result, environmental stimuli become powerfully associated with opioid use, which can trigger cravings for the drug [29]. The visibility of pharmaceutical marketing and advertising of medications may also play a role by changing the attitudes toward ingestion of these agents [29]. For youth, a social learning aspect to drug use is likely, based on the modeling of drug use by adults in their families and social networks [29]. Individuals who use nonmedical prescription opioids before 13 years of age are more likely to become addicts than those who initiate use at 21 years of age or older. The odds of becoming an addict are reduced 5% each year after 13 years of age [31]. Additionally, it is a commonly held view among adolescents (27%) that prescription drugs are “much safer” than street drugs [32]. This belief is undoubtedly shared with much of the adult population and has led to the extraordinary rise in recreational prescription drug users.
Marked increases in prescriptions written for opioids in the United States and Internet access to prescription drugs may explain a portion of the increase in opioid use disorder. How- ever, although Internet access is a major problem and accounts for some of the increase in opioid drug abuse, the same rate of increase has not been observed for other prescription drugs, such as stimulants, suggesting that other factors are involved [29]. Changes in the way medicine is practiced also influence prescription practices. Primary care physicians provide a greater proportion of care for pain patients rather than pain specialists, increasing the potential of diversion and misuse [29]. The Institute for Clinical Systems Improvement recommends considering screening patients for substance use disorders when there is an unclear etiology of pain. (https://www.icsi.org/wp-content/ uploads/2019/10/Pain-Interactive-7th-V2-Ed-8.17.pdf. Last accessed March 21, 2024.) Level of Evidence : Expert Opinion/Consensus Statement The increase in emergency department mentions is not solely accounted for by an increase in prescriptions; for example, from 1994–2002, fentanyl mentions increased more than 50-fold while the number of prescriptions increased only 7.2- fold. This is now clearly known to be the result of increases in illicitly manufactured formulations. Similar excessive increases in emergency department mentions relative to prescriptions have been observed with oxycodone but not morphine or hydrocodone [29]. Risk Factors for Prescription Opioid Abuse Among Pain Patients Long-term use of prescription opioids for chronic pain results in abuse or dependence in 2.8% to 18.9% of patients [29]. Predictors of dependence on opioid medications among pain patients include substance abuse-related diagnoses, positive toxicology for opioids, and other medical diagnoses, includ- ing diagnosis of comorbid psychiatric conditions [33]. Other patients at risk include those with idiopathic pain (no clear etiology) or high levels of psychologic distress or disability [7]. Alcoholism and other drug dependence are often viewed as contraindications for opioid medications in chronic noncan- cer pain. EPIDEMIOLOGY OF OVERDOSE Overdose is a major cause of premature death among opioid drug users. Nonfatal overdoses (defined as instances in which loss of consciousness and respiratory depression occur but are not fatal) are highly prevalent among heroin users, occurring in 50% to 70% of this population [34]. As noted, the Cen- ters for Disease Control and Prevention (CDC) reported the
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MDRI2026
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