What is it?
The Diagnostic and Statistical Manual for Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR) defines opioid abuse as a maladaptive pattern of opioid use leading to clinically significant impairment or distress in personal, social, or job-related responsibilities within a 12-month period, including:
- Failure to fulfill major job obligations at work, school, or home
- Recurrent opioid use in hazardous situations, such as driving or operating heavy machines while impaired
- Opioid-related legal problems
- Social and interpersonal problems caused by or exacerbated by opioid use
Most individuals who meet the criteria of opioid abuse and continue to use eventually meet the criteria of opioid dependence.
The Rise of Prescription Opioid Abuse in North America
Opioid use and abuse has increased markedly in the North America starting in the 1990s and continuing to the present. The increase in opioid abuse coincides with the availability of high-purity heroin, which allows users to begin use by snorting or smoking, rather than by IV. Moreover, increased opioid abuse coincides with the enormous increase in opioid prescriptions since the 1990s through to today. During this period of time, abuse of prescription opioids has grown at a particularly fast rate. A few statistics dramatically illustrate this problem:
- Americans consume approximately 80% of the world's opioid supply though they only constitute 4.6% of the world's population.
- Americans consume 99% of the world's supply of hydrocodone (the opioid in Vicodin).
- Between 1997 and 2006, retail sales of oxycodone have increased by 588%, while retail sales of methadone have increased by 933%.
The statistics below are drawn from data from the 2006 National Survey on Drug Use and Health (NSDUH), sponsored by the Substance Abuse and Mental health Services Administration (SAMHSA), and illustrate the increase in prescription opioid abuse over the previous decade.
The number of persons aged 12 and older illicitly using prescription pain relievers doubled from 2.6 to 5.2 million between 1999 and 2006. In 2006, 2.2 million persons aged 12 or older used prescription pain relievers illicitly for the first time. This is more than any other illicit drug, including marijuana, with 2.1 million new users aged 12 or older in 2006. The fact that opioids are prescribed by doctors has led many people to believe they are safe, one of the reasons for the large spike in new users.
So where are all these pills coming from?
The 2006 NSDUH Survey also showed that the great majority of illicitly used prescription opioids are obtained not from drug dealers, but rather from a single physician. In 2006, among those aged 12 and older who have used prescription pain relievers non-medically in the past 12 months:
- 55.7% reported they obtained drugs free of charge from a relative or friend.
- 14.8% reported they bought or stole drugs from a relative or friend.
- 19.1% reported they obtained drugs from one doctor.
- Only 1.6% reported getting drugs from more than one doctor.
- Only 3.9% reported buying drugs from a dealer or stranger.
- Only 0.1% reported purchasing drugs on the internet.
- In cases involving non-medical users obtaining their drugs from a friend or relative, 80.7% reported that their friend or relative had obtained the drug from just one doctor.
So these numbers suggest that in reality drug dealers are a relatively small source of illicitly used prescription opioids. The greatest source of illicit opioids comes from diversion through family and friends, and the majority of these opioids are obtained from a single physician rather than from "doctor shopping."
The human cost
Moving from illicit use of opioids to opioid dependence carries some dire consequences. The yearly mortality rate for those who are opioid dependent is approximately 2%. As sustained remission from opioid dependence is difficult to achieve, most users will continue to struggle with dependency for their whole lives. There has been a large increase in drug poisoning related mortality since 1990. This increase is in large part the result of unintentional drug overdoses attributed either to opioid pain relievers or unspecified drugs.
- From 1979-1990, unintentional drug overdoses increased on average 5.3% per year.
- From 1990-2002, unintentional drug overdoses increased on average 18.1% per year. This also happens to correspond with an increase in opioids prescribed for pain during the same period.
- From 1999-2002, opioid analgesic poisonings on death certificates increased 91%. Fatal heroin and cocaine poisonings increased 12.4% and 22.8%, respectively during the same period.
- In 2002, 5,528 deaths were reported from prescription opioid overdoses, more than either heroin or cocaine. The increase in mortality corresponds with an increase in retail sales of opioids.
The US Centers for Disease Control and Prevention (CDC) reported that methadone contributed to 31.4% of opioid-related deaths in the US from 1999-2010, while Methadone alone also accounted for 39.8% of all single-drug opioid-related deaths. Methadone is associated with a significantly higher overdose death rate than that of other opioid drugs.
Increases in accidental heroin overdoses may be due in part from both a decrease in cost and increase in purity. According to the DEA, average heroin purity increased from 7% in 1980, to 48% in 2000, to 70% in 2003. This allows first-time users to get high by snorting or smoking heroin, both of which may be perceived as being much less dangerous than IV use. Many users also believe that risk of overdose is minimal when snorting or smoking heroin, though the risk of overdose remains substantial regardless of route of administration. The increase in purity also means that mistakes in dosing are potentially more lethal.
Treatment of patients with methadone or buprenorphine (Suboxone) maintenance therapy results in substantially reduced mortality rates.
Many users who are dependent on opioid also have significant medical and psychiatric issues. Also associated with opioid dependency are adverse social, familial, and vocational consequences. The risk of criminal activity and legal consequences also increases as dependence becomes more severe. Increased risk of blood-borne infections such as hepatitis B, C, and HIV is associated with intravenous injection of opioids.
Just as with mortality rates, many of these comorbidities are reduced by opioid substitution therapies (e.g. methadone maintenance). This has been confirmed in studies such as in a 12-month controlled trial involving various German treatment centers which examined over 1,000 patients who were severely opioid dependent and treated them with supervised oral methadone or intravenous heroin.
Who is abusing?
Overall, males abuse opioids more commonly than females. For heroin users, the male-to-female ratio is approximately 3:1. However, the male-to-female ratio is much closer for prescription opioids at 1.5:1.
Most commonly, illicit use of opioids begins in late adolescence or early adulthood. Generally, experimentation with tobacco, alcohol, and other drugs precedes experimentation with opioids. The period of time from initial use to dependency is extremely variable, ranging from a few weeks to several years, with a percentage of individuals never progressing past the abuse phase.
- ^ American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision. Washington DC: American Psychiatric Association. 2000. [Link]
- ^ Wang J, Christo PJ. The influence of prescription monitoring programs on chronic pain management. Pain Physician May-Jun 2009; 12(3):507-15. [PubMed] [PDF]
- ^ SAMHSA, Office of Applied Studies. Results from the 2006 National Survey on Drug Use and National Findings. 2007. [Link] [PDF]
- ^ Centers for Disease Control and Prevention (CDC). Vital Signs: Risk for overdose from methadone used for pain relief – United States, 1999-2010. Morbidity and Mortality Weekly Report (MMWR) Jul 2012; 3;61. [PubMed] [PDF]
- ^ Reimer J, Verthein U, Karow A, et al. Physical and mental health in severe opioid-dependent patients within a randomized controlled maintenance treatment trial. Addiction Sep 2011; 106(9):1647-55. [PubMed]