About the Epidemic
The opioid epidemic is one of the largest public health challenges facing the United States. In 2016, more than 63,000 people died from drug overdoses, more than in any other time in history.1 Drug overdose is the leading cause of accidental death in the country and is now responsible for more deaths than motor vehicle accidents and gun homicides combined.2 Today, at least 2 million Americans are suffering from substance use disorders related to prescription opioids and 591,000 are dependent on heroin, costing the United States $78.5 billion per year in healthcare and treatment costs, criminal justice costs, and lost productivity.3
One of the most important causes of the epidemic is the rising prescribing rate of opiate pain relievers. The United States consumes more opioids than any other country, with some states reporting more opioid prescriptions than there are people.4 This is a rapidly growing threat, with the rate of opioid prescribing nearly quadrupling from 1999-2014, even while reported levels of pain remained constant.4
The emergence of extremely potent new synthetic opioid pain relievers is fueling greater rates of drug abuse and overdose. One of these, fentanyl, is more than eighty times more potent than morphine and contributes to the dramatic tripling of synthetic opioid overdose rates in the United States from 2014 to 2015.3
Although not all people who abuse opioids inject drugs, people who do inject drugs are at higher risk of transmission of blood-borne pathogens such as HIV or hepatitis C (HCV). Sharing needles, syringes, or other materials is an efficient route of viral transmission that allows the direct transfer of virus into the bloodstream. Sharing syringes is especially common among younger, newer, and white people who inject drugs.5 Other risk factors associated with drug use, including sex without a condom, sex with multiple partners, and transactional sex also place people who inject drugs at high risk for HIV or HCV infection.5 In the United States, injection drug use is the most common transmission route of HCV and is one of the most effective routes of HIV transmission.6,7
Rising rates of opioid use may contribute to outbreaks of HIV and HCV. As people seek cheaper and more efficient means of drug consumption, the use of heroin and other illicit substances increases. According to SAMHSA, nearly 80% of persons initiating heroin use previously used nonmedical pain relievers.8 In 2015, a small community in Scott County, Indiana, experienced an historic outbreak of HIV concentrated in people who injected opioids and shared needles. Within four months of initiating its investigation, the Indiana State Department of Health identified 135 people diagnosed with HIV, of whom 80% reported injecting drugs and 84% of whom were co-infected with HCV.9 The outbreak was declared a public health emergency and by the end of 2015, 181 people were diagnosed with HIV.10 Rising rates of opioid abuse are likely to contribute to more outbreaks like this one.
There are several evidence-based public health responses to reduce opioid abuse and new HIV or HCV infections. Drug abuse can be successfully treated through the use of opioid substitution treatment, in which patients substitute the use of heroin or prescription opioids with long-acting, but less psychotropic, opioids such as buprenorphine or methadone. This form of treatment is supported by several clinical trials and studies, yet the accessibility of these treatment programs is limited by a lack of facilities able to provide treatment, financial barriers to access, and legal restrictions on the number of patients that can receive office-based prescribing.11
In addition, otherwise fatal overdoses of opioids can be reversed by the administration of medications like naloxone, an opioid antagonist that rapidly reverses the effect of opioids during an overdose. Since naloxone must be administered quickly in order to be effective, in recent years community-based programs, substance use treatment facilities, public health departments, and pharmacies have begun offering naloxone to emergency health workers and laypersons that are likely to witness an overdose.12 However, the legality of naloxone use is variable by state.
People who inject drugs can dramatically reduce the risk of infection with HIV and HCV by using new syringes and materials every time they inject. Syringe exchange programs (SEPs) are an effective public health approach to reducing the spread of blood borne diseases by providing new syringes and connecting clients to HIV testing, substance abuse treatment programs, and other healthcare services.13 Although these programs are effective in reducing needle sharing and do not increase crime or injection drug use in communities, SEPs are not legal in every state.14 Although federal dollars can in some cases be used to fund SEPs, no federal money can be used in purchasing the syringes themselves.
Supervised consumption services (SCS) are an additional public health intervention designed to provide a safe space for drug consumption, increase the use of clean injection equipment, and link drug users with medical services and addiction treatment.15 There are more than 100 SCS operating worldwide, including one in Vancouver, Canada,16 and several communities in the United States are now considering opening SCSs.
Finally, in an effort to stem the overprescribing of opioid pain relievers, several states in the United States have created prescription drug monitoring programs (PDMPs) to monitor prescribing patterns of controlled substances, combat fraud, facilitate interventions and create opportunities for real-time interventions.17
Seth P, Scholl L, Rudd RA, Bacon S. Overdose Deaths Involving Opioids, Cocaine, and Psychostimulants — United States, 2015–2016. MMWR Morb Mortal Wkly Rep 2018;67:349–358. Available at: http://dx.doi.org/10.15585/mmwr.mm6712a1.
United States Department of Justice Drug Enforcement Administration. 2015 National Drug Threat Assessment Summary. DEA-DCT-DIR-008-16. Oct 2015. Available at: https://www.dea.gov/docs/2015%20NDTA%20Report.pdf.
Compton WM. Research on the use and misuse of Fentanyl and other synthetic opioids. Mar 31, 2017. Report to Congress: House Committee on Energy and Commerce, Subcommittee on Oversight and Investigations. National Institute of Drug Abuse. Available at: https://www.drugabuse.gov/about-nida/legislative-activities/testimony-to-congress/2017/research-use-misuse-fentanyl-other-synthetic-opioids.
Centers for Disease Control and Prevention. Prescribing Data. Dec 20, 2016. Available at: https://www.cdc.gov/drugoverdose/data/prescribing.html.
Centers for Disease Control and Prevention. HIV and Injection Drug Use. Nov 29, 2016. Available at: https://www.cdc.gov/vitalsigns/hiv-drug-use/.
Centers for Disease Control and Prevention. Viral Hepatitis and Young Persons Who Inject Drugs. Apr 17, 2017. Available at: https://www.cdc.gov/hepatitis/featuredtopics/youngpwid.htm..
Centers for Disease Control and Prevention. HIV Risk Behaviors. Dec 4, 2015. Available at: https://www.cdc.gov/hiv/risk/estimates/riskbehaviors.html.
Muhuri PK, Gfroerer JC, Davies MC. Associations of Nonmedical Pain Reliever Use and Initiation of Heroin Use in the United States. CBHSQ Data Review August, 2013. Available at: http://archive.samhsa.gov/data/2k13/DataReview/DR006/nonmedical-pain-reliever-use-2013.pdf.
Conrad C, Bradley HM, Broz D, Buddha S, Chapman EL, et al. Community Outbreak of HIV Infection Linked to Injection Drug Use of Oxymorphone — Indiana, 2015. MMWR May 1, 2015; 64(16):443-4. Available at: https://www.cdc.gov/mmwr/preview/mmwrhtml/mm6416a4.htm.
Peters PJ, Pontones P, Hoover KW, Patel MR, Galang RR, et al. HIV Infection Linked to Injection Use of Oxymorphone in Indiana, 2014-2015. NEJM 2016; 375:229-39. Available at: https://www.ncbi.nlm.nih.gov/pubmed/27468059.
Nosyk B, Anglin MD, Brissette S, Kerr T, Marsh DC, et al. A call for evidence-based medical treatment of opioid dependence in the United states and Canada. Health Aff 2013 Aug; 32(8):1462-9. Available at: https://www.ncbi.nlm.nih.gov/pubmed/23918492.
Wheeler E, Jones TS, Gilbert MK, Davidson PJ. Opioid overdose prevention programs providing naloxone to layersons – United States, 2014. MMWR Jun 19, 2015; 64(23):631-5. Available at: https://www.cdc.gov/mmwr/preview/mmwrhtml/mm6423a2.htm?s_cid=mm6423a2_w.
Wodak A, Cooney A. Do needle syringe programs reduce HIV infection among injecting drug users: A comprehensive review of the international evidence. Subst Use Misuse 2006;41:(6) 777-813. Available at: https://www.ncbi.nlm.nih.gov/pubmed/16809167.
Marx MA, Crape B, Brookmeyer RS, Junge B, Latkin C, Vlahov D, Strathdee SA. Trends in crime and the introduction of a needle exchange program. Am J Public Health 2000;90(12):1933–6. Available at: https://www.ncbi.nlm.nih.gov/pubmed/11111271.
Drug Policy Alliance. Supervised injection facilities. Available at: http://www.drugpolicy.org/supervised-injection-facilities..
Vancouver Coastal Health. Insite. Available at: http://www.vch.ca/public-health/harm-reduction/supervised-injection-sites..
Islam MM, McRae IS. An inevitable wave of prescription drug monitoring programs in the context of prescription opioids: pros, cons and tensions. BMC Pharmacol Toxicol 2014;15:46. Available at: https://www.ncbi.nlm.nih.gov/pubmed/25127880.