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Epidemiology of Substance Use Disorders: Opioid Use Disorder Epidemic 

Epidemiology of Substance Use Disorders: Opioid Use Disorder Epidemic
Chapter:
Epidemiology of Substance Use Disorders: Opioid Use Disorder Epidemic
Author(s):

L. Morgan Snell

, Andrew J. Barnes

, and Peter Cunningham

DOI:
10.1093/med/9780190920197.003.0001
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date: 28 June 2022

Introduction to Substance Use Disorders in the United States

Substance use disorders (SUDs) are defined by the World Health Organization to include both “harmful use” and “dependence syndrome” and constitute a pattern of substance use that harms health and creates “physiological, behavioral, and cognitive” effects “in which use of a substance . . . takes on a much higher priority for a given individual than other behaviors that once had greater value.”1 In 2015, 1.8 deaths per 100,000 globally were caused by alcohol use disorders, with 2.3 deaths per 100,000 due to other SUDs.1 Alcohol is the most prevalent substance of dependence worldwide2; however, the United States sees lower rates of “hazardous” use of alcohol than other member countries of the Organisation for Economic Cooperation and Development (OECD) such as Australia, England, France, and Germany.3 High-income North American countries such as the United States and Canada lead, however, in rates of drug dependence from substances such as cannabis, opioids, and cocaine.2 Globally, the annual disease burden of illicit drug dependence was 20 million disability adjusted life years (DALYs) in 2010, or 20 million years of healthy life lost due to SUDs.1,4 Opioid dependence represents almost half (9.2 million) of those DALYs,4 and, in the United States, almost 3 million individuals have a current or past opioid use disorder.5 The United States is experiencing historically high numbers of opioid overdoses, with approximately 115 fatal overdoses per day, and a rising incidence of neonatal abstinence syndrome, constituting a drug use epidemic. The age-adjusted rate of drug overdose deaths in the United States increased 9.6% from 2016 to 2017, contributing, in part, to a recent decline in life expectancy (0.1 years lower) in the United States for those born in 2017 compared to 2016.6,7,8 This epidemic appears largely unique to the United States, due in part to a fragmented healthcare system that exacerbates social and economic inequalities. In 2017, President Donald J. Trump’s administration declared the opioid epidemic in the United States a public health emergency, increasing emergency funding to combat this crisis.9 As of September 2018, eight state governors have implemented emergency declarations to address the opioid crisis, allowing them increased resources to combat growing mortalities due to this epidemic.10

In the United States, according to 2002–2016 data from the National Survey on Drug Use and Health (NSDUH) (see Box 1.1), alcohol remains the most prevalent substance in terms of lifetime use, with more than 80% of Americans reporting ever drinking (Table 1.1). Lifetime use of alcohol appears to have declined from 83.1% in 2002–2003 to 80.6% in 2016–2017. In contrast, lifetime use of cannabis has increased from 40.5% to 44.6% over the same period. Other illicit drugs such as cocaine and hallucinogens such as lysergic acid diethylamide (LSD) have remained steady in terms of the prevalence of lifetime use; however, nonmedical lifetime use of pain relievers and lifetime use of heroin has increased over this period. In the most recent survey year (2016–2017), 10.1% of adults had ever misused a pain reliever, even in the face of policy efforts to restrict supply and educate the public about dangers associated with use (discussed in more detail later in the chapter).11,12

Table 1.1 Ever use, selected substances and years

2002–2003

2004–2005

2006–2007

2008–2009

2010–2011

2012–2013

2014–2015

2015–2016

2016–2017

Alcohol

83.1%

82.6%

82.4%

82.5%

82.4%

81.9%

81.6%

80.7%

80.6%

(82.6, 83.5)

(82.2, 83.0)

(82.0, 82.9)

(82.1, 82.9)

(82.0, 82.8)

(81.5, 82.3)

(81.3, 82.0)

(80.3, 81.0)

(80.2, 81.0)

Cannabisa

40.5%

40.2%

40.2%

41.5%

42.0%

43.2%

44.1% (43.7, 44.6)

44.0% (43.5, 44.5)

44.6%

(39.9, 41.0)

(39.7, 40.7)

(39.6, 40.7)

(40.9, 42.0)

(41.4, 42.6)

(42.6, 43.8)

(44.1, 45.1)

Cocaine

14.6%

14.0%

14.4%

14.7%

14.5%

14.4%

14.6% (14.3, 15.0)

14.4% (14.1, 14.8)

14.7%

(14.2, 14.9)

(13.6, 14.3)

(14.1, 14.8)

(14.3, 15.0)

(14.1, 15.0)

(14.0, 14.8)

(14.3, 15.0)

Heroin

1.6%

1.4%

1.5%

1.5%

1.7%

1.8%

1.9%

1.9%

1.9%

(1.4, 1.7)

(1.3, 1.5)

(1.4, 1.7)

(1.4, 1.60)

(1.5, 1.8)

(1.6, 1.9)

(1.7, 2.0)

(1.8, 2.0)

(1.8, 2.0)

Methamphetamine

5.2%

4.5%

4.5%

4.0%

3.9%

1.5%

5.4%

5.4%

(5.0, 5.4)

(4.3, 4.7)

(4.3, 4.7)

(3.8, 4.2)

(3.7, 4.1)

(1.4, 1.6)

(5.2, 5.6)

(5.2, 5.6)

LSD (Hallucinogen)

10.3%

9.4%

9.4%

9.5%

9.1%

9.3%

9.5%

9.5%

9.6%

(10.0-10.7)

(9.1, 9.7)

(9.1, 9.7)

(9.1, 9.8)

(8.8, 9.4)

(9.0, 9.6)

(9.2, 9.8)

(9.3, 9.8)

(9.3, 9.9)

Pain relievers- nonmedical use (Nm)*

12.8%

13.3%

13.5%

14.0%

13.6%

13.9%

10.2%b (10.0, 10.4)

10.1%

(12.5, 13.1)

(13.0, 13.6)

(13.2, 13.8)

(13.6, 14.3)

(13.2, 13.9)

(13.5, 14.2)

(9.8, 10.3)

a National Survey on Drug Use and Health (NSDUH) asks participants about “marijuana” use; however, we use the scientific term “cannabis.”

b Beginning in the 2015–2016 survey, this measure was recorded as “Pain Relievers-Ever Misused,” rather than “Ever Used Pain Relievers Non-Medically” as it had been in previous survey periods.

* In the 2015–2016 survey, this measure was recorded as “Pain Relievers-Ever Misused,” rather than “Ever Used Pain Relievers Non-Medically” as it had been in previous survey periods.

Source: US Department of Health and Human Services, 2016.

Among the two most prevalent substances used by survey participants, past 30-day use of alcohol has consistently remained greater than 50%, with a slight gradual trend upward over time, and past 30-day use of cannabis has grown from 6.2% in 2002–2003 to 9.2% in 2016–2017 (Table 1.2). Trends in SUDs for both legal and illicit drugs over time have shown an overall decline since 2002, with opioids such as pain relievers and heroin remaining the exception to this trend (Table 1.3). As with lifetime use, while nationally representative estimates on opioid use disorders appear to represent a relatively low percentage of the population relative to other substances, they defy a general downward trend observed for other substances of abuse.13

Table 1.2 Past 30-day use, selected substances and years

2002–2003

2004–2005

2006–2007

2008–2009

2010–2011

2012–2013

2014–2015

2015–2016

2016–2017

Alcohol

50.5%

51.1%

51.1%

51.7%

51.8%

52.1%

52.2%

51.2%

51.2%

(49.9, 51.1)

(50.5, 51.6)

(50.5, 51.7)

(51.2, 52.3)

(51.2, 52.4)

(51.6, 52.7)

(51.7, 52.6)

(50.7, 51.7)

(50.7, 51.7)

Cannabisa

6.2%

6.0%

5.9%

6.4%

6.9%

7.4%

8.3%

8.6%

9.2%

(6.0, 6.4)

(5.8, 6.2)

(5.7, 6.2)

(6.2, 6.6)

(6.7, 7.2)

(7.2, 7.6)

(8.1, 8.6)

(8.4, 8.8)

(9.0, 9.5)

Pain relievers*

1.9%

1.9%

2.1%

2.0%

1.9%

1.8%

1.3%

1.2%

(1.8, 2.0)

(1.8, 2.0)

(2.0, 2.2)

(1.9, 2.1)

(1.8, 2.0)

(1.7, 1.9)

(1.2, 1.4)

(1.1, 1.3)

Heroin

0.1%

0.1%

0.1%

0.1%

0.1%

0.1%

0.1%

0.1%

0.2%

(0.0, 0.1)

(0.0, 0.1)

(0.1, 0.1)

(0.1, 0.1)

(0.1, 0.1)

(0.1, 0.1)

(0.1, 0.2)

(0.1, 0.2)

(0.1, 0.3)

a National Survey on Drug Use and Health (NSDUH) asks participants about “marijuana” use; however, we use the scientific term “cannabis.”

* In the 2015–2016 survey, this measure was recorded as “Pain Relievers-Ever Misused,” rather than “Ever Used Pain Relievers Non-Medically” as it had been in previous survey periods.

Source: US Department of Health and Human Services, 2016.

Table 1.3 Past-year substance use disordera selected substances and years

2002–2003

2004–2005

2006–2007

2008–2009

2010–2011

2012–2013

2014–2015

2015–2016

2016–2017

Alcohol

7.6%

7.7%

7.6%

7.4%

6.8%

6.7%

6.1%

5.7%

5.5%

(7.3, 7.8)

(7.5, 8.0)

(7.4, 7.8)

(7.2, 7.7)

(6.6, 7.0)

(6.5, 6.9)

(5.9, 6.3)

(5.6, 5.9)

(5.3, 5.7)

Any illicit substance

3.0%

2.9%

2.8%

2.8%

2.7%

2.7%

2.8%

2.8%

(2.8, 3.1)

(2.8, 3.0)

(2.7, 2.9)

(2.7, 2.9)

(2.6, 2.8)

(2.6, 2.8)

(2.7, 2.9)

(2.7, 2.9)

Cannabisb

1.8%

1.8%

1.6%

1.7%

1.7%

1.6%

1.5%

1.5%

1.5%

(1.7, 1.9)

(1.7, 1.9)

(1.6, 1.7)

(1.6, 1.8)

(1.6, 1.8)

(1.5, 1.7)

(1.5, 1.6)

(1.4, 1.6)

(1.4, 1.6)

Pain Relievers

0.6%

0.6%

0.7%

0.7%

0.7%

0.7%

0.7 %

0.6%

(0.5, 0.7)

(0.6, 0.7)

(0.6, 0.7)

(0.7, 0.8)

(0.7, 0.8)

(0.7, 0.8)

(0.6, 0.8)

(0.6, 0.7)

Heroin

0.1%

0.1%

0.1%

0.1%

0.2%

0.2%

0.2%

0.2%

0.2%

(0.1, 0.1)

(0.1, 0.1)

(0.1, 0.2)

(0.1, 0.2)

(0.1, 0.2)

(0.2, 0.2)

(0.2, 0.3)

(0.2, 0.3)

(0.2, 0.3)

a National Survey on Drug Use and Health (NSDUH) classifies past year “abuse or dependence”; however, the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) updates terminology to include both “abuse” and “dependence” under the larger category of “substance use disorders.”

b NSDUH asks participants about “marijuana” use; however, we use the scientific term “cannabis.”

Importantly for healthcare providers and public health officials to be aware of, there is significant variation in past-year use disorders across individual characteristics and the substance used. For example, men are more likely than women to have an SUD across all substance categories (Table 1.4). Across substances, the highest proportion of use disorders tends to occur between 26 and 49 years of age, with cannabis a significant exception (the prevalence of abuse or dependence among those 18–25 years of age is 5.2% compared to 1.5% nationally). Non-Hispanic white adults reflect the highest prevalence of use disorders across all selected substances, with the exception of cannabis, where the prevalence of cannabis abuse or dependence was 2.3% among Non-Hispanic, African American adults. Achieving lower levels of educational attainment or income was generally associated with the highest prevalence of use disorders across substances, with alcohol being the exception to this trend. Although the prevalence of use disorders was higher across substances among those without health insurance coverage, the magnitude of that difference was greatest among heroin users, where three times as many individuals reporting past year heroin use disorder also report having no health insurance compared to those with insurance coverage. Despite the trends over the past decade or more that use of illicit drugs including cocaine, methamphetamine, and LSD have remained steady and more prevalent than use of heroin or nonmedical use of pain relievers, the opioid-related morbidity and mortality experienced in the United States has increased dramatically, becoming an epidemic and drawing attention from communities, providers, and policymakers. The remainder of this chapter focuses specifically on the origins of the US opioid crisis; recent trends in the use and abuse of opioids; the health, social, and economic costs associated with opioids; and changes under way in the healthcare delivery system to address opioid misuse.

Table 1.4 Past-year substance use disordera by selected demographic characteristics, 2016–2017

Alcohol

Marijuana

Any illicit drug use (other than cannabisb)

All opioids

Pain relievers

Heroin

Total % of population

5.5%

1.5%

1.5%

0.8%

0.6%

0.2%

Sex

Male

7.1%

2.1%

1.8%

0.9%

0.7%

0.3%

Female

4.0%

0.9%

1.3%

0.6%

0.5%

0.2%

Age

12–17

1.9%

2.3%

1.2%

0.5%

0.5%

0.0%

18–25

10.4%

5.2%

2.9%

1.2%

0.9%

0.5%

26–34

8.8%

2.0%

2.6%

1.4%

1.1%

0.6%

35–49

6.0%

1.0%

1.6%

0.9%

0.8%

0.3%

50–64

4.5%

0.5%

1.3%

0.7%

0.6%

65+

1.8%

0.0%

0.2%

0.1%

0.1%

Race/Ethnicity

White, Non-Hispanic

5.8%

1.3%

1.7%

0.9%

0.7%

0.3%

African American, Non-Hispanic

5.0%

2.3%

1.4%

0.7%

0.6%

0.1%

Other or multiple, Non-Hispanic

4.4%

1.4%

1.1%

0.5%

0.4%

0.1%

Hispanic

5.1%

1.7%

1.3%

0.5%

0.4%

0.2%

Adult educational attainment

Less than HS

5.1%

1.8%

2.4%

1.2%

0.9%

0.4%

HS or GED

5.4%

1.6%

1.8%

1.0%

0.8%

0.4%

Some college

6.3%

1.7%

1.9%

1.0%

0.8%

0.3%

Bachelor’s degree or higher

6.0%

0.9%

0.7%

0.3%

0.3%

0.1%

Annual household income

<$20,000

6.6%

2.5%

3.0%

1.4%

1.1%

0.5%

$20,000–$49,999

5.1%

1.5%

1.7%

0.8%

0.7%

0.3%

$50,000–$74,999

4.8%

1.3%

1.2%

0.6%

0.5%

0.2%

$75,000+

10.8%

2.2%

2.0%

1.0%

0.9%

0.2%

Covered by health insurance

Yes

5.3%

1.4%

1.4%

0.7%

0.6%

0.2%

No

7.6%

2.4%

3.3%

1.7%

1.3%

0.7%

Census region

Northeast

5.8%

1.7%

1.4%

0.9%

0.6%

0.3%

Midwest

5.9%

1.2%

1.5%

0.8%

0.6%

0.2%

South

4.9%

1.3%

1.5%

0.8%

0.6%

0.2%

West

5.9%

2.0%

1.6%

0.7%

0.6%

0.2%

There were statistically significant differences within each demographic group in the likelihood of abuse or dependence, by substance.

a National Survey on Drug Use and Health (NSDUH) classifies past year “abuse or dependence”; however, the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) updates terminology to include both “abuse” and “dependence” under the larger category of “substance use disorders.”

b NSDUH asks participants about “marijuana” use; however, we use the scientific term “cannabis.”

Source: US Department of Health and Human Services, 2016.

Origins and Epidemiology of the US Opioid Crisis in the 21st Century

Globally, the burden of the opioid epidemic is estimated to be approximately 11 million life years lost when accounting for adverse health outcomes, disability related to opioid disorders, and opioid-related mortalities.5 Opioids are a class of drugs with high abuse potential that include (1) pain relievers legally available via prescription, such as codeine, morphine, oxycodone, and hydrocodone; (2) illegal drugs such as heroin; and (3) legally available and illegal synthetic opioids such as fentanyl.14,15 Opioids can be natural (derived from opium, such as morphine and heroin), semi-synthetic (hydrocodone), and synthetic (fentanyl and methadone).14,16 Many opioids users progress quickly to dependence upon initiation,17 and chronic use increases tolerance whereby increasing doses are required to produce the same effect. Tolerance and dependence work together to promote increased exposure to opioids through continued use, which can lead to addiction for a subset of users.18 In addition to the severe health consequences, there are also significant economic and social costs related to the opioid epidemic, each of which is discussed in this chapter.

In 2015, approximately 800,000 individuals in the United States were estimated to have used heroin within the past year, and 4 million have used prescription opioids for nonmedical use.5 In the United States, among those who use heroin, many had first used prescription opioids for nonmedical purposes.17,19 New medications combining opioids and non-opioid analgesics (e.g., acetaminophen) were developed and approved by the Food and Drug Administration (FDA) in the late 1970s and were thereafter marketed heavily by pharmaceutical companies who claimed the drugs were nonaddictive. This perception was bolstered by a 1980 Letter to the Editor published in the New England Journal of Medicine purporting to show that opioid prescriptions did not result in SUDs,20 a claim which has been “heavily and uncritically cited,” encouraging clinicians to prescribe opioids without fear of encouraging addiction.21 As large organizations such as the Veterans Health Administration, medical societies, and clinicians adopted pain as the “fifth vital sign,” short- and long-acting opioids came to be seen as a simple, effective, safe, and low-cost way to address many types of chronic pain.22 Since 1999, the United States has seen steadily increasing rates of opioid use disorders,14,23,24 prompting recent policy efforts to limit access to prescription opioids and expand access to opioid use disorder treatment.25,26

Symptoms of opioid use disorders include using opioids in increasing doses or for longer than intended, unsuccessful attempts to reduce or quit using opioids, strong desire to use opioids, substantial investment of time or resources obtaining opioids, interference of usual activities due to opioid use, use of opioids in hazardous situations, continued use of opioids even after suffering problems due to use, increasing dose over time, and withdrawal when not using opioids.5 As opioid use disorders have increased, there have been concurrent, sharp increases in opioid-related morbidity and mortality. Most notably, drug overdose deaths overall have increased threefold between 1999 and 2015 due to significant increases in prescription opioid-related overdose deaths. Additionally, there have been substantial increases in overdose deaths from nonprescription opioids such as heroin and synthetic opioids such as fentanyl (Figure 1.1).24 In 2015, prescription or illicit opioids were involved in nearly two-thirds (63%) of all drug overdose deaths in the United States.24

Figure 1.1 Age-adjusted overdose death rates, by opioid category: United States 1999–2016. Natural opioids (morphine, codeine, heroin) are derived from opium. Semi-synthetic opioids (hydrocodone, oxycodone) are produced by chemically modifying natural opioids. Synthetic opioids (fentanyl, methadone, some heroin) mimic the effects of natural opioids by binding to the same receptors.

Figure 1.1 Age-adjusted overdose death rates, by opioid category: United States 1999–2016. Natural opioids (morphine, codeine, heroin) are derived from opium. Semi-synthetic opioids (hydrocodone, oxycodone) are produced by chemically modifying natural opioids. Synthetic opioids (fentanyl, methadone, some heroin) mimic the effects of natural opioids by binding to the same receptors.

Source: US Centers for Disease Control (CDC) (2017).

In light of the dramatic rise in opioid-related deaths in the United States, state and federal policies and professional society guidelines have been implemented to monitor and limit access to opioids while allowing for their use as effective pain relievers for many patient needs. Perhaps as an unintended consequence of limiting access to prescription opioids for individuals already dependent on them through policy efforts such as prescription drug monitoring programs (PDMPs), use of illicit alternatives has increased, as have deaths due to these substances.24,27 Contributing, in part, to the rising rates of mortality attributable to illicit opioids is the use (intentional and unintentional) of synthetic opioids such as fentanyl. Contact with even small doses of fentanyl through either recreational substitution, combination of fentanyl with heroin, or accidental exposure through contamination of purchased heroin with fentanyl greatly increases the risk of adverse health outcomes, including mortality.28 Overdose deaths due to heroin have increased from approximately 0.7 in 100,000 persons in 1999 to 4.9 per 100,000 by 2016, with a sharp increase around 2010 (Figure 1.1). Deaths due to synthetic opioids other than methadone reached 6.2 per 100,000 in 2016, again seeing a sharp increase in recent years. By contrast, increases in overdose deaths due to commonly prescribed opioids other than methadone have slowed since 2010. As of 2015, the number of overdose deaths due to heroin surpassed those due to prescription opioids, and heroin and synthetic opioids are now the primary drivers of the continued increase in the rate of opioid-related overdose deaths.

In addition to the sharp rise in mortality due to opioid-related overdose, increases in opioid use disorders have created a significant burden on the healthcare system, including increases in admissions and treatment for nonfatal poisoning and other opioid-related adverse health events. In 2014, there were 92,262 emergency room visits for opioid poisonings, a rate of 28.9 per 100,000 population. More than half of these opioid poisonings were due to heroin use (17.1 per 100,000 population, Table 1.5). In addition to emergency room visits, nearly 53,000 inpatient admissions occurred in 2014 related to opioid poisonings.24

Table 1.5 Estimated number and age-adjusted rate of healthcare visits due to opioid poisonings per 100,000 population, 2014

All opioid poisonings

Heroin poisonings

Rate

Number

Rate

Number

Emergency room visits

28.9

92,262

17.1

53,9300

Inpatient admissionsa

15.6

53,000

3.6

11,474

a This number excludes patients who died due to poisonings.

Source: Centers for Disease Control, 2017.

Adding complexity to understanding and addressing the current opioid crisis, many adults with opioid use disorder also have a comorbid mental health condition, a risk factor for continued opioid abuse.29,30 In 2017, 8.5 million US adults were estimated to have a mental illness and at least one SUD in the previous year, and 3.1 million were estimated to have both an SUD and a serious mental illness in the previous year.30 Importantly, the prevalence of certain mental health comorbidities varies significantly by type of opioid abused. The magnitude of the prevalence of reporting having a major depressive episode in the past year among those with use disorders for heroin, pain relievers, and all opioids was similar across substances (31.0–31.7%) and significantly higher than the likelihood of such an episode among the general population (6.9%) (Table 1.6). Serious psychological distress, a less diagnosis-specific measure, was reported by more than half of those with heroin use disorder (54.9%), higher than the prevalence among those who abused or were dependent on pain relievers (42.5%, p<0.001) and significantly higher than the prevalence among the general population (10.9%).

Table 1.6 Additional risk factors associated with opioid use disorders,a 2016–2017

General population

Pain reliever use disorder

Heroin use disorder

All opioids-use disorder

Past-year major depressive episode

Yes

6.9%

31.7%

31.4%

31.0%

No

93.1%

68.3%

68.6%

69.0%

Past-year serious psychological distress

Yes

10.9%

42.5%

54.9%

52.5%

No

89.1%

47.5%

45.1%

47.5%

a National Survey on Drug Use and Health (NSDUH) classifies past year “abuse or dependence”; however, the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) updates terminology to include both “abuse” and “dependence” under the larger category of “substance use disorders.”

Note: There are statistically significant differences in the likelihood of use disorders among risk factor categories, by substance.

Source: US Department of Health and Human Services, 2017.

Furthermore, there is significant variation in opioid dependence and abuse by US census region. The Northeast, the census region which accounts for 17.2% of the total US population,26,31 suffered from the highest prevalence of past-year opioid use disorders in 2016–2017 (0.9% of residents) and the highest prevalence of heroin use disorders at 0.3% (Table 1.4). Past-year use of heroin among persons 12 years of age and older also varies substantially by state (Figure 1.2), with states in the Northeast seeing percentages from 0.47% to 0.84%, in contrast to states in the West such as California, where the percentage of past-year heroin use was as low as 0.19–0.25%.

Figure 1.2 Past-year heroin use by state, ages 12 and up, 2016–2017.

Figure 1.2 Past-year heroin use by state, ages 12 and up, 2016–2017.

Source: SAMHSA Center for Behavioral Health Statistics and Quality, NSDUH, 2016 and 2017.

Surveillance data, including the substance use prevalence estimates highlighted in Tables 1.1–1.3, illustrate an interesting juxtaposition between decreasing or stable rates of lifetime use and past 30-day use of pain relievers and heroin among individuals 12 years of age and older but increasing rates of abuse or dependence on opioids. Looking to prescribing rates over time helps illustrate how prescription opioid prescribing practices have changed over the previous decade and influenced the number of prescription opioids to which patients have access. For example, the overall rate of prescriptions for opioids written per 100,000 persons increased annually from 2006 to 2008 (4.1% annual percent change [APC]) and 2008 to 2012 (1.1% APC), until it began decreasing between 2012 and 2016 (−4.9% APC, Table 1.7).24 Healthcare providers have likely responded to policy strategies to monitor opioid prescriptions, discussed in more detail later in this chapter.12 However, despite fewer opioid prescriptions being written, over the same period of time, the rate of prescribing for a supply of prescription opioids for fewer than 30 days decreased (−3.2% APC 2006–2016) while the rate of prescribing for a supply of drugs for greater than or equal to 30 days increased (4.3% APC 2006–2016). Similarly, the average number of days of supply per prescription increased from 13.3 days in 2006 to 18.1 in 2016, an overall annual percentage increase of 3.1%. These trends in longer supply of opioids per prescription may contribute to the likelihood of abuse or dependence among patients prescribed these drugs, even though measures of lifetime use or past 30-day use appear to have remained stable over the same period.

Table 1.7 Trends in prescribing patterns for opioids, selected years

Prescribing rate per 100 persons

2006–2016

2006–2008

2008–2012

2012–2016

2006

2016

APCa

APC

APC

APC

All opioid prescriptions

72.4

66.5

−0.8

4.1

1.1

−4.9

(−1.1, −0.4)

(2.8, 5.4)

(0.5, 1.7)

(−5.3, −4.5)

Days of supply <30

54.7

39.2

−3.2

1.3

−1.2

−7.3

(−3.6, −2.8)

(−0.1, 2.7)

(−1.9, −0.5)

(−7.7, −6.8)

Days of supply >30

17.6

27.3

4.3

9.9b

2.9c

−1.3d

(3.8, 4.9)

(9.2, 10.5)

(1.3, 4.6)

(−2.1, −0.5)

Average days of supply per Rx

13.3

18.1

3.1

4.4e

3.4f

2.5g

(3.0, 3.3)

(4.0, 4.8)

(3.0, 3.7)

(2.4, 2.6)

a APC refers to annual percentage change.

b Trend is 2006–2010.

c Trend is 2010–2013.

d Trend is 2013–2016.

e Trend is 2006–2008,

f Trend is 2008–2011,

g Trend is 2011–2016.

Source: Centers for Disease Control, 2017.

Prescribing rates for opioids also vary nearly twofold by state (Figure 1.3), mirroring variation in trends in heroin use by state (Figure 1.2) and opioid abuse or dependence by region (Table 1.6). Notably, states in the Midwest and Southeastern United States had the highest rates of opioid prescriptions per 100 people in 2012 (96–143 prescriptions per 100 people). States and regions facing higher rates of opioid-related morbidity and mortality are under increasing pressure to combat the significant costs associated with this epidemic. The economic and social costs of SUDs generally, and opioid use disorders specifically, are discussed next.

Figure 1.3 Opioid prescribing rate per 100 people, by state, 2012.15

Figure 1.3 Opioid prescribing rate per 100 people, by state, 2012.15

Economic and Social Costs of Substance Use Disorders

The annual cost of SUDs in the United States is approximately $740 billion,16 representing a combination of economic costs and social costs associated with use of tobacco ($300 billion), alcohol ($249 billion), illicit drugs ($193 billion), and prescription opioids ($78 billion). Economic costs to society are accumulated through lost wages and forgone economic opportunities resulting from dependence or addiction, as well as health sector and other government spending to prevent and control substance use. Social costs associated with SUDs include family and community disruption and trauma, including movement of children into social services and foster care, and increased contact with the criminal justice system for substance-related crime. Each of these types of substance use-related costs is discussed in more detail next.

Economic Costs Associated with Opioid Use Disorders

The economic costs of SUDs have increased in recent years (Figure 1.4), primarily due to the rising costs associated with opioid use disorders and the attendant opioid crisis.32 These costs are both borne by individuals and aggregated at the local, state, and federal levels. Federal drug control spending increased from $21.7 billion in fiscal year 2007 to $30.6 billion in fiscal year 2016. While some of the increased spending is due to additional law enforcement costs, spending on drug treatment has also increased. The economic cost of opioid use disorders is comprised of both fatal and nonfatal costs. Fatal costs are those such as forgone earnings arising from early mortality of working-age individuals and healthcare costs incurred due to fatal overdose and poisoning mortalities. These fatal costs ($21.5 billion, Figure 1.5) represented 27% of the total burden of prescription opioid use in the United States in 2013. Nonfatal economic costs ($57 billion) include lost productivity (26% of total costs, or $20 billion), healthcare costs to insurers and individuals (33%, $26 billion), costs to the criminal justice system (10%, $7.6 billion), and costs related to substance abuse treatment (4%, $2.8 billion). Among health insurance-related prescription opioid costs, private insurance payments represent 18% of total costs, followed by 7% paid by Medicaid.

Figure 1.4 Federal drug control spending growth, 2007–2016.16

Figure 1.4 Federal drug control spending growth, 2007–2016.16

Figure 1.5 Distribution of the economic burden of prescription opioid overdose, abuse, and dependence.18

Figure 1.5 Distribution of the economic burden of prescription opioid overdose, abuse, and dependence.18

There is also significant variation by opioid in which payers face the highest cost burden. From 2002 to 2012, the average annual excess health costs for opioid abuse covered by private insurance (i.e., the difference in private insurer spending between enrollees with opioid abuse and matched controls) ranged from $14,000 to $20,000, and from $6,000 to $15,000 for Medicaid enrollees.33 Out of 53,000 opioid poisoning admissions to hospital inpatient wards in 2014 reported earlier in this chapter, 18.4% of patients were privately insured.24 There were 92,262 emergency department visits for opioid poisonings, and 20.3% of patients were privately insured, 13% covered by Medicare, 37% by Medicaid, and 25% were uninsured. When inpatient admissions and emergency department visits are combined, public forms of insurance (Medicare and Medicaid) account for more than half of all hospital-related payments for opioid poisonings. For heroin poisoning visits specifically, the economic burden falls even more disproportionately on the Medicaid program, with 44% of hospital admissions due to heroin poisoning hospitalizations covered by Medicaid. Likewise, 40% of heroin poisoning emergency department visits were paid for by Medicaid. In addition to the burden of heroin-related hospital utilization falling on public coverage programs, those without any insurance represent a substantial number of inpatient admissions (21%) and emergency department visits (29%) related to heroin poisoning.

Like opioid prescription rates, heroin use, and opioid use and dependence, the economic burden of opioid use disorders also varies significantly by state (Figure 1.6). States in the Midwest, Southeast, and Northeast regions of the United States face economic costs ranging from 3.7% to 14.6% of state gross domestic product (GDP) in 2016, with states such as Ohio, Kentucky, and West Virginia facing among the highest costs as a share of their state’s economy.

Figure 1.6 Economic cost of opioid use disorder as a percent of state gross domestic product (GDP) in 2016.19

Figure 1.6 Economic cost of opioid use disorder as a percent of state gross domestic product (GDP) in 2016.19

Social Costs Associated with Opioid Use Disorders

The social costs associated with opioid use disorders are high, with many of those costs realized through increased contact with the legal and criminal justice systems and family and community disruption. Greater than half (54.7%) of all 2015–2016 NSDUH participants with past-year opioid abuse or dependence had ever been arrested for breaking the law, a figure that was 77.6% among heroin users (Table 1.8).26 Furthermore, heroin users are more likely than pain reliever or all opioid users to report having been on probation in the previous year. Previous research has provided estimates that, among heroin users who sought treatment, 60% had recently been involved in criminal activity.34,35 Contact with the criminal justice system carries financial and economic penalties to the individual, but it also creates lifelong and significant barriers to employment and family disruption and trauma. In 2009 alone, the US Government Accountability Office estimated that 14,000 children entered foster care due to incarceration of a parent, a number that is likely conservative since it does not identify a common occurrence: namely parents who were incarcerated after a child entered foster care.36 Drug-related crimes have significantly increased over the past 40 years, with 41,000 US individuals incarcerated for drug offenses in 1980 to nearly half a million in 2014.37 Of those incarcerated, 68.5% of local jail inmates met the diagnostic criteria for past-year dependence on or abuse of drugs prior to incarceration.37,38 These trends illustrate the potential for significant and persistent family disruption due to SUDs and criminal activity.

Table 1.8 Criminal justice system contact among participants with past-year opioid abuse of dependence, 2015–2016

Ever arrested for breaking the law

Pain relievers

Heroin

All opioids

Yes

49.5%

77.6%

54.7%

No

48.8%

20.7%

43.9%

On probation at any time (past 12 months)

Yes

12.7%

25.7%

14.0%

No

86.9%

73.4%

85.7%

Source: US Department of Health and Human Services, 2017.

In addition to contact with the criminal justice system, the opioid epidemic has further costs to the individual and the family. The Substance Abuse and Mental Health Services Administration (SAMHSA) estimated in 2009 that 400,000 infants were exposed to alcohol or drugs in utero, and prescription opioid use has been rising in recent years among pregnant women.39 One study estimated a fivefold increase in infants born with neonatal abstinence syndrome over the past decade, which can result in symptoms of opioid withdrawal at birth15 (for more information on SUDs and pregnancy, see Chapter 11). In addition, SUDs among parents are a major risk factor for contact with child protective programs and services, further risking both trauma and disruption within a family unit.40 From 2013 to 2015, the number of children placed in foster care in the United States rose 7% to 429,000 children, and parental substance use accounted for more than 30% of those placements, an increase of 10% from 2005.41

Additional disruption to the family can be found in the costs associated with caring for a family member with opioid abuse or dependence, costs which are included in the economic cost of this epidemic but also deserve mention as a social cost in terms of the burden of caregiving on the families and children of those addicted. Among lost productivity costs mentioned earlier, some research estimates that as high as 35% of those lost wages are due to lost productivity of caregivers.42

The economic and social costs attributable to substance use, and particularly the opioid epidemic, are a significant and growing burden on individuals, families, and other institutions. These costs have required policymakers to implement significant changes to substance use monitoring efforts as well as the practice of care in order to effectively combat these adverse individual and societal outcomes.

Changes to Practice of Care to Address Substance Use Disorders

Policymakers at the federal, state, and local levels have implemented policy strategies to combat the opioid epidemic by changing practices of care, including increasing education for healthcare providers and the general public, monitoring the behavior of prescribers of prescription opioids, increasing the availability of opioid antagonists such as naloxone to combat opioid overdose deaths, and increasing the supply of providers and services used to treat SUDs. Each of these healthcare practice-level strategies is discussed next, beginning with PDMPs.

Reducing Opioid Use Disorders: Prescription and Prescriber Behavior Monitoring

In 2011, the White House Office of National Drug Control Policy issued federal recommendations that included increasing drug tracking and monitoring to reduce prescription opioid misuse.43 State-based PDMPs are data repositories that can be accessed by qualified prescribers to review prescribing history for patients in order to reduce unsafe prescribing practices. Each of the 49 states that has implemented a PDMP funds its own program, though some have received additional funding from the federal Bureau of Justice to implement and expand capabilities of their systems.43,44 A PDMP’s capabilities include tracking prescriptions, creating reports that can flag “high-risk” patterns of prescription use (e.g., “doctor shopping,” where patients fill multiple prescriptions of the same drug from multiple providers),45 and making those reports available to providers who query the system. States have discretion to advise providers on expectations regarding use of the PDMP, ranging from a recommendation to use it during each encounter involving a prescription to mandates that all providers and prescribers register with and use the system.46 Available evidence suggests that states that have greater PDMP adoption rates have seen reductions in opioid prescribing as well as reduced opioid-related morbidity and mortality44,46 and that providers who use the system were more likely to implement a clinical response such as SUD screening and referral for treatment.45 However, evidence of PDMP effectiveness is not consistent, and much recent attention has focused on the association between provider training in use of PDMPs and improving opioid-related health outcomes.46 Preliminary evidence suggests that educational interventions that help providers register and retrieve patient information via their state’s PDMP and offer patient-centered training about opioid prescription guidelines and best practices increase the likelihood that providers use patient reports from the PDMP, a standardized scale to monitor pain, and urine toxicology screening to monitor patients with long-term opioid use.46 Currently, 13 states mandate some form of training for prescribers in the use of their state’s PDMP, and 40 programs provide education and outreach opportunities.47

Reducing Opioid Use and Mortality: Education for Providers, Emergency Responders, and the General Public

In 2018, US FDA Commissioner Scott Gottlieb released a statement suggesting that mandatory education on opioid prescribing risks might be a viable and necessary additional policy strategy to address the opioid crisis.48 Recent updates from clinical trials suggest that physicians educated about opioid overdose deaths among their patient populations reduced subsequent opioid prescribing behavior.49 Medical students who received opioid overdose prevention education rated their knowledge and confidence in intervening significantly higher after education.50,51 Taken together, these studies provide preliminary evidence that educating current and future prescribers about opioid misuse and abuse may be beneficial in preparing providers to intervene and change their practice to intervene on this epidemic.

In addition to educating prescribers about their role in reducing the burden of opioid addiction and mortality, emergency responders and members of the public have also been given critical information regarding their options to intervene in an opioid poisoning crisis. Chief among their options is the administration of a drug called naloxone, which can reverse the respiratory distress caused by opioid overdose. Many states have issued a “standing order” for naloxone, which means anyone can fill a prescription for this life-saving drug if needed, and emergency responders now have increased access to naloxone to administer when faced with opioid poisoning.9 National spending on naloxone has risen from $10.5 million in 2013 to $108 million in 2017; nonetheless, many states report difficulty funding sufficient access to and quantities of naloxone to meet the demands imposed by the opioid crisis.9

Finally, in 2016, the US Centers for Disease Control (CDC) issued guidelines for prescribing opioids for chronic noncancer pain in adults.52 The guidelines suggest considering non-opioid and nonpharmacologic pain management, setting treatment goals and opioid discontinuation plans, and openly communicating with patients about the benefits and risks of opioids. CDC guidelines also offer recommendations about the types, dosages, and durations of opioid therapy, including starting at the lowest effective dosage of immediate-release opioid formulations. These guidelines also recommend that clinicians should screen for factors that increase risk of harm and consider co-prescribing naloxone when indicated, use PMDPs, utilize urine drug screening when indicated, avoid co-prescribing opioids and benzodiazepines, and provide or refer patients to opioid use disorder treatment when necessary.

Epidemiology of Opioid Use Disorder Treatment

In 2016, 20 million Americans had an SUD, but only 3.8 million (<20%) received treatment. In addition, there are only approximately 3,600 physicians board-certified in addiction medicine.53 There are national guidelines available to providers from the American Society of Addictive Medicine (the ASAM criteria) to help them create a multidimensional assessment and results-oriented plan of care.54 Individuals who seek treatment face alternatives ranging from self-help to outpatient treatment to inpatient treatment and therapeutic assistance from medications for opioid use disorder (MOUD) (for more information on types of treatment see Chapters 8–10). Treating opioid use disorders typically requires use of MOUD long-term once treatment is initiated in order to reduce the likelihood of relapse and utilization of emergency services.55,56 Despite positive treatment outcomes, a low percentage of opioid-addicted individuals access any type of treatment.57 Evidence remains limited regarding variation in treatment utilization by different segments of the population, but that which is available suggests that adolescents are less likely than older adults to seek treatment, as are the uninsured and racial and ethnic minorities, and all three groups were less likely than non-Hispanic whites to seek inpatient treatment.55 Additional studies have found that individuals who are older, non-Hispanic white, male, and have high income were all more likely to access MOUD treatment,58 particularly buprenorphine,59 and that African American and Hispanic adults may be less likely than non-Hispanic white adults to be retained in treatment under certain circumstances.60 Further evidence is needed to better understand why certain demographic populations may be less likely to enter treatment, receive evidence-based MOUD, and complete treatment for their opioid use disorders.

The lack of access may be comprised of several interrelated issues. First, stigma against opioid use disorder and MOUD acts a barrier to effective treatment, reducing both treatment-seeking and treatment availability.61 Greater stigma toward people with prescription opioid use disorders is associated with lower public support for expanding Medicaid SUD treatment availability and increasing government funding for SUD treatment.62 Reducing negative attitudes toward SUDs may be an important first step toward enhancing access to treatment.63,64 Additional barriers to accessing treatment include coverage gaps and a limited supply of treatment providers, both issues particularly acute for those at lower levels of income and for those in rural areas. The 2010 Patient Protection and Affordable Care Act (ACA) included mental health and substance abuse benefits in the list of essential benefits plans offered that state exchanges must include.65 Initial evidence suggests that expansion of Medicaid benefits has been associated with an increase in admissions to specialty facilities for treatment, many of which use MOUD.66 To address a shortage of qualified providers, high costs associated with treatment for low-income adults and limited access to treatment centers, state policymakers are experimenting with strategies such as incorporating addiction education into physician education, incorporating MOUD into primary care settings, and expanding Medicaid insurance benefits for inpatient and outpatient treatment among low-income residents.53 These efforts are currently being evaluated for effectiveness in increasing access to SUD treatment, and results will be of great interest to federal, state, and local policymakers struggling to allocate funding to alleviate the significant and growing burden of SUD in the United States.

Conclusion

The United States is facing a serious and costly opioid epidemic, with nearly 3 million individuals suffering from opioid abuse or dependence,5 totaling nearly $80 billion in annual costs.16 In addition to measurable, growing costs such as healthcare and treatment for these individuals, lost wages due to work absence and early mortality, and costs to law enforcement and other public agencies, there are also significant and important social costs as families and communities bear the burden of caregiving, family disruption, and contact with the criminal justice system that is associated with opioid use and abuse. Policymakers at the national, state, and local levels are using many different strategies at their disposal to try to combat opioid abuse, including monitoring prescribing practices and prescribers to control access to highly addictive prescription opioids; educating providers, patients, and the public about the dangers associated with opioid use; and expanding access to treatment alternatives. While early indicators suggest that some of these efforts may aid in slowing the growth of this epidemic, the magnitude of the issue may require a more comprehensive look at how the structure of the US healthcare system aids or impedes efforts to address this issue and prevent future epidemics.

In the United States, opioid overdose mortality has been rising continuously since 1999, constituting a major public health crisis. Recent decreases in overall life expectancy at birth, already lower in the United States than in many other higher income countries,67 are attributable to increases in the number of “unintentional injuries,” a category which includes fatal drug overdoses.6,7,8 The same pattern has not, however, been seen in other high-income nations. This difference may be attributable to structural challenges unique to the US healthcare system, which is characterized by fragmented care delivery, high cost, and inequities in access. Fragmented care and a lack of health information technology infrastructure allowed for individuals to receive opioid prescriptions from multiple providers prior to the implementation of PDMPs, while poor integration of primary, emergency, and mental healthcare systems has impeded successful referrals to opioid use disorder treatment services. Treatment and recovery services are often out of reach for the patients who need them, with waiting lists for treatment and high costs, especially for those without health insurance. Moreover, widening social and economic disparities likely contributed to the US opioid epidemic. Income inequality and poverty are on the rise despite the fact that US GDP has outranked other nations for decades. Opioid overdose deaths appear to be one part of the larger trend of rising mortality rates attributable to multiple diseases and across multiple racial and ethnic groups,22 requiring solutions that tackle systemic socioeconomic causes of poor health.68

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