FOREWORD: The Long-Term Effects of Opiate Use on Patients with Chronic Illness
In this foreword to observation articles by Barnette, Chandler, Joyner, and Luterman, Camilla Manning covers the rise in prescription opiate addictions and how emergency departments have responded.
For the past 70 years, emergency departments have served to provide medical care to citizens suffering from emergency conditions. The rapid increase in visits to the emergency room in the 1960s led to the establishment of spaces for the population to remedy their needs in a short span. As physicians began to recognize the rise in immediate care, they sought emergency training and became full time emergency specialists. The University Association for Emergency Medical Services (UAEMS) was founded in 1970 to provide physicians with a facility to practice emergency medicine (American). This facility initiated a habitat for physicians to improve patient health in an efficient environment. Although emergency departments have become widespread, beneficial services for the American public, overall health in the population has declined. More than 100 million people in the United States suffer from chronic illnesses. These conditions require continuous medical attention and often limit the mobility and productiveness of individuals due to severe pain. The conventional response to pain is to relieve the symptoms via pain medications. Remedies for pain have existed for centuries such as opiates given to patients in the 1600s. Opioids are natural, semisynthetic, or synthetic substances that act on opioid receptors in the central nervous system (Parthvi). Medicines such as morphine and heroin were introduced by the 19th century, and doctors prescribed chloroform as an anesthetic for surgery in the 20th century. Furthermore, advanced medications improved healing and became more available for patients with severe pain. However, doctors worried that the intensity of these medications would cause addictions, and their apprehensions eventually came true. The use of opiates has influenced a “corresponding increase in addiction, illicit use, overdose deaths and disability, without improvement in overall perception of pain” in the United States that is only worsening.
In 2016, health care providers wrote more than 214 million prescriptions for opioid pain medication in the United States. Those medications were then abused by more than 11 million people in that same year (Seven). This finding reflects how opiates are widely used to decrease pain, yet they become addictive and can potentially lead to death. The opiate epidemic depicts a system of medicine that instantaneously relieves symptoms without any long-term benefits. Thus, people continue to take medicines that become addictive. To understand how we can overcome this crisis, we must understand patients’ needs. There are two main types of pain: chronic and acute. Chronic pain affects the pain signals within one’s nervous system, causing injured tissues to not repair because of this signal disruption (Murray). It can last for several months to years, whereas acute pain is sharper and has a shorter duration. Therefore, doctors have to address both forms of pain in varying ways. However, the research needed to resolve chronic pain is much more extensive and costly, so patients with chronic illnesses are often given medications aimed for acute pain. Those patients then develop addictions to medications that are merely masking their pain, not resolving it.
Due to the severity and danger associated with addictions, physicians have worked to implement laws that limit the amount of prescriptions given out annually. Even with these actions, patients with chronic illness continue to suffer the consequences of ambiguity in medical research, and those already dependent on opiates have inaccessibility to them.
The rise in opiate use began when a 1980 letter responded to “inadequate pain control in palliative cancer care and postoperative pain” (Murray). Doctors used this argument to increase pain prescriptions for treatment. According to the New England Journal of Medicine, only four patients developed addictions to opiates out of the 11,882 patients prescribed medicine. A paper published in 1986 suggested that “chronic opiate therapy was safe for non-cancer pain in a case series of 38 patients.” These claims prompted a radical shift in medical practice although they were merely observations. In 1997, the American Academy of Pain Medicine and the American Pain Society (APS) suggested further increase in opiate prescriptions in a consensus statement that failed to cite any studies. Accidental opiate-related deaths increased to one per 100,000 individuals. Physicians were pardoned further in a 1998 recommendation from the Federation of State Medical Boards. The boards suggested that “physicians not be subject to regulatory action for prescribing opiates, even for adverse effects or death from chronic high-dose therapy.” The number of accidental opiate-related deaths increased to more than five per 100,000 patients by 2011 as the amount of prescribed medications quadrupled.
Researchers and authors have partly blamed Purdue Pharmaceuticals for enforcing the use of OxyContin. OxyContin is a slow-release form of Oxycodone: a semisynthetic opioid similar to morphine that reduces moderate to severe pain (Murray). The company utilized programs that promoted OxyContin as first-line treatment for non-cancerous patients. Primary care physicians who prescribed an abundance of OxyContin received bonuses and coupons for their work, which resulted in Purdue paying approximately $635 million in a criminal prosecution. Moreover, they sparked a significant spread of opiate pain medication. The Center for Medicare and Medicaid Services (CMS) faced a similar issue in 2012 as they endorsed a scheme that reimbursed emergency departments for patient satisfaction surveys. Physicians surveyed the satisfaction of their patients through questions that asked about their pain, physician care, and medicines prescribed. Physicians were compensated for prescribing the most opiates. In 2016, a study detailed that 40% of emergency department physicians were disciplined for not prescribing opiates and 71% were pressured to do so from administration. Moreover, physicians gained personal compensation at the expense of their patients’ needs.
In the Journal of Psychopharmacology, the authors of Neuropsychological Performance of Methadone-Maintained Opiate Users explore the effect of treatment on opiate dependencies. Methadone maintenance treatment (MMT) was first used in the 1960s and “has been shown to effectively reduce the use of other drugs, criminal activity, mortality, and the transmission of HIV and other blood-borne pathogens, such as hepatitis” (Wang). It is the most commonly used treatment for opiate addiction in many countries, including the United States, yet neuropsychological studies suggest that it has negative effects on cognition. Some studies, however, propose that there is no effect. Cognitive impairment is an issue for patients because it contributes to addiction relapses. Therefore, authors Wang, Wouldes, Kydd, Jensen, and Russell conducted research to explore the effects of MMT on cognitive function.
The researchers compared the performances from 32 MMT patients, 17 opiate-dependent subjects, and 25 healthy control subjects using “computerized neuropsychological test batter[ies]” (Wang). The participants used these tests to measure their intelligence quotient as well as “memory, sensory-motor function, information processing, attention, verbal function, executive function and emotional identification.” The authors suggested that cognitive impairment is related to factors associated with a history of substance abuse rather than methadone because some of the patients previously had heroin and morphine addictions. The results of the tests showed that MMT and opiate users displayed deficient information processing skills. They also concluded that methadone “does not alter hippocampal plasticity by decreasing the number of…neurons,” as a damaged hippocampus can alter memory and learning (Wang). Those who utilize MMT have an opportunity to strengthen their cognition while battling opiate dependence. The authors suggest that patients continue to use MMT as well as implement eating habits that improve and sustain a healthy lifestyle.
In another journal article, Donald Wesson discusses the effects of an alternative to Methadone Maintenance Treatment: buprenorphine. Wesson worried that in an effort to face the opiate crisis, physicians wrongfully restricted opioids for those who needed them and that methadone treatments were being condoned in medical practice. He claimed that buprenorphine is a safer and efficient drug than methadone.
According to Wesson’s research, the Drug Abuse Treatment Act of 2000 (DATA) and the Food and Drug Administration (FDA) approved of prescribing two forms of buprenorphine in 2000 and 2005. Wesson found that 12 to 24 mg/day of buprenorphine has the same effect as 80 mg/day of methadone and continued to research the impacts of this treatment by observing the brain’s mu and kappa opiate receptors (Wesson). He also noted that the opiate antagonist naltrexone is accessible to U.S. patients. Naltrexone was proven to be useful for opioid abusers who were determined to overcome their addiction. However, an FDA approved form of the drug is not on the market. Overall, Wesson believes that opiate agonist maintenance and “sublingual buprenorphine” should become the first-line of defense for patients with chronic illness. Because buprenorphine is provided at opiate maintenance clinics and office-based practices, those who are unable to access clinics have a better opportunity to receive pharmacotherapy.
The International Journal of Drug Policy includes an article written by Jessica De Maeyer who explores the difference between quality of life (QoL) and health-related quality of life. QoL addiction research has grown intensely among opiate users since 2000 due to the high risk of relapse (De Mayer). The research is used to influence drug policy and drug treatment. For this reason, De Maeyer conducts studies to assess the QoL of opiate users. The first study compares opiate users to the general public, and the second study examines substitute treatment on QoL. 15 instruments were used to determine QoL, and the results of 38 studies were recorded. They showed that the quality of life for opiate users is typically lower than the general population before and during treatment. Compared to patients with psychiatric issues, opiate users scored similarly. However, in physical health and social functioning, they scored lower. Overall, QoL research has been limited to studying drug addiction and has become more subjective rather than objective. Even so, De Maeyer’s studies emphasize the significance of QoL on future opiate and addiction research.
One of the many factors influencing the opiate epidemic in the United States is the inability of medical departments to create long-term recovery programs for patients with chronic illness. The articles written by Joyner, Barnette, Chandler, and Luterman show how doctors and patients struggle with the consequences of opiate addictions in emergency departments. Physicians have taken short cuts by prescribing these patients addictive pain medications. However, because research on chronic illnesses is limited and expensive, physicians are restricted in how they can treat patients. The opiate crisis will only continue, as the number of people with chronic illnesses increases in America. Thus, a change in the structure of America’s healthcare system is essential in treating citizens. Physicians alongside pharmacists and other scientists must collectively focus on the needs of people. Many scientists and physicians have already provided other researchers with information on the impacts of opiate addictions on quality of life and potential treatments that reduce dependence: methadone, buprenorphine, and naltrexone. Some proclaim that buprenorphine is a better alternative for detoxification of opiates than methadone and specifically entail how the drug works throughout the nervous system. De Maeyer’s studies show the long term effect of opiate use on quality of life for the patients tested. Doctors and scientists who conduct future research on these subjects must work to evaluate the safety and effect of each drug, noting its benefits and shortcomings. Incoming physicians should be trained to serve patients who require continual rehabilitation and utilize treatments such as MMT and buprenorphine to reduce opiate addiction. Such an implementation within health facilities would tremendously impact the progression of medical practice over time.
American Academy of Emergency Medicine. (n.d.). Retrieved from: https://www.aaem.org/about-us/our-values/history
De Maeyer, J. (2010). Quality of life among opiate-dependent individuals: A review of the literature. The International Journal of Drug Policy, 21(5), 364-380. Retrieved from: www.ncbi.nlm.nih.gov/pubmed/20172706
Murray, M., Stone, A., Pearson, V., & Treisman, G. (2019). Clinical solutions to chronic pain and the opiate epidemic. Preventive Medicine, 118, 171-175. Retrieved from: www.ncbi.nlm.nih.gov/pubmed/30315848
Parthvi, R., Agrawal, A., Khanijo, S., Tsegaye, A., & Talwar, A. (2017). Acute opiate overdose. American Journal of Therapeutics, 1. doi:10.1097/mjt.0000000000000681
Seven Staggering Statistics About America’s Opioid Epidemic. (2018, August 07). Retrieved from: https://www.choosept.com/Resources/Detail/7-staggering-statistics-about-%C2%A0%C2%A0%C2%A0
Wang, G. Y., Wouldes, T. A., Kydd, R., Jensen, M., & Russell, B. R. (2014). Neuropsychological performance of methadone-maintained opiate users. Journal of Psychopharmacology. Retrieved from: journals.sagepub.com/doi/abs/10.1177/0269881114538541
Wesson, D. R., & Smith, D. E. (2010). Buprenorphine in the treatment of opiate dependence. Journal of Psychoactive Drugs, 42(2). Retrieved from: www.tandfonline.com
Wesson, D. R. (2004). Buprenorphine in the treatment of opiate dependence: Its pharmacology and social context of use in the U.S. Journal of Psychoactive Drugs, 36(Sup2), 119-128. Retrieved from www.tandfonline.com