There were more than 63,000 drug overdose deaths in 2016, mostly related to opioids, according to the most recent national data from the U.S. Centers for Disease Control and Prevention (CDC). In Pennsylvania, the number of overdoses is increasing more rapidly than drug deaths in any other state — with 5,443 in the past year (1,200 in Philadelphia alone). And local lawmakers are taking notice: In an effort to reduce overdose deaths, Philadelphia may become one of the first cities in the country to open a safe injection site.
As the opioid epidemic continues to sustain the nation’s attention, six Drexel University experts answer what you want to know — but maybe didn’t want to ask — about opioids and addiction.
Why are opioids so addictive?
“Animals are wired for addiction,” said Rodrigo España, PhD, an assistant professor in the College of Medicine, who studies how drugs affect the brain’s reward systems. “Our brains and bodies produce endorphins, which are basically endogenous opiates, that help curb pain and increase pleasure.”
In the same way that eating a candy bar sets off a feeling of euphoria — and encourage us to keep repeating that behavior — opioids attach to receptors in the brain that set off a similar reward pathway and release a flood of dopamine. The release of that chemical then drives more pleasure-seeking cravings, and the cycle continues. Over time, the body’s receptors become highly tolerant to the opioids, España explains, and so it takes more and more for the body to feel “normal.”
What happens to the body during an overdose?
When your body overdoses you experience “excessive sedation accompanied by respiratory depression,” said David Vearrier, MD, an emergency medicine physician, toxicologist and associate professor in the College of Medicine. Your heart and your breathing starts to slow, and, eventually, “your brain stops telling your lungs to breathe.”
If your oxygen levels fall low enough, you may suffer from sudden cardiac arrest. You may also experience foaming at the mouth (due to fluids that have gathered in the lungs) choking or aspiration (from the body’s natural gag reflex).
What is fentanyl and why is it so particularly dangerous?
Heroin is derived from a poppy plant’s natural opiates (morphine), which are then synthesized into a drug, Vearrier explained.
Fentanyl, by contrast, is man-made in a lab (often in China and then shipped internationally), and can be 50-100 times more potent than morphine, according to The National Institute on Drug Abuse (NIDA). Because of its potency, it’s popular among dealers.
“We’re seeing increasingly that the local supply of heroin is being contaminated with fentanyl or fentanyl-derivatives that are particularly strong. Then we’ll see a spike in the number of overdoses that occur in the region,” Vearrier says.
What factors contributed to the current opioid crisis?
The causes are complicated and multifaceted. In the 1990s, pharmaceutical companies marketed prescription opioid painkillers as safe and non-addictive, which in turn led to significant overprescribing and patient misuse. When the prescriptions for opioids run out or become too expensive, patients then can turn from the painkillers to cheaper, stronger and more available street drugs, like heroin and fentanyl.
“The other part of the problem is a lack of education, health care providers’ lack of knowledge about how to manage chronic pain, and their inability to better evaluate and refer patients with substance use disorders,” said Barbara Schindler, MD, professor of psychiatry and pediatrics in the College of Medicine, and medical director of Drexel’s Caring Together Program, an outpatient treatment center for women with substance abuse disorders and their children. “Doctors did not want to be poorly evaluated or seen as unsympathetic to their patients’ pain.”
Having treated patients during the crack cocaine epidemic in the 1980s, Schindler draws parallels and distinctions between then and now.
“Politicians are paying attention now that white families are significantly affected by the opioid epidemic,” she says. “But addiction has no socio-economic, racial or ethnic boundaries.”
Why don’t we have better pain medications that are not so addictive?
Opioids work by acting on opiate receptors, which are built for regulating pain. The problem is, according to España, these receptors exist all over the body and brain, and so opioids can lead to addiction and overdose. Ideally, drugs would exist that could target only the correct set of opioids receptors involved in someone’s pain, or target a different system all together.
“I think the reason we don’t have good, useful medicines that aren’t opiates is precisely because there aren’t that many systems in the body that we can target without having tons of other side effects,” he said.
How can doctors and hospitals respond to the opioid epidemic?
“I think there is a lot that individual providers can do, and there is a lot that physician leaders and health care systems can do to address the opioid epidemic,” said Jason Fodeman, MD, associate medical director and assistant professor at the College of Medicine.
After the CDC released a set of guidelines for prescribing opioids in 2016, Fodeman spearheaded efforts at his Drexel Medicine clinic to implement several new policies for treating patients with chronic pain. The new policies included requiring patients on chronic, controlled substances to have more frequent physician visits to discuss their pain and opioid usage, as well as systematic implementation of risk mitigation strategies, like urine drug screens. Most importantly, prescribers were advised to have a high threshold to start new patients on opioids.
“I think providers must try to emphasize and prioritize alternative therapies with their individual patients and use opioids as a last resort,” Fodeman said.
What is the best way to treat opioid addiction?
There are three types of medications that are used in the treatment of opioid addiction: methadone, buprenorphine and Vivitrol (naltrexone).
Methadone treatment must be performed in a highly structured and regulated clinic, while buprenorphine and Vivitrol can be prescribed in physician offices. While these medications have been shown to be highly effective in treating opioid use disorders, their uses are also misunderstood and underutilized, said Angela Colistra, PhD, an assistant clinical professor in the College of Nursing and Health Professions, who has specialized in treating opioid use disorders.
“We hear all sorts of negative language about how people want to talk about this method of care: ‘Oh, you’re just replacing one drug with another,’ or ‘The only path to recovery is abstinence.’ But what we know about opioid use disorder is that the symptoms of this disease carry a lot more risk within periods of trying to move on to recovery,” Colistra said.
She explains that suddenly cutting off patients who are addicted to opioids can lead to intense, physical symptoms and actually makes them more susceptible to relapsing and overdosing. “The safest path to recovery is to move patients along a continuum,” she said.
Schindler said effective treatment requires developing a specific plan tailored to a patient’s specific goals and lifestyle, as well as treating any underlying emotional or mental health problems.
“Eighty percent of women who self-medicate do so because of an underlying psychiatric disorder,” Schindler said. “And chronic pain in itself can lead to depression. We need addiction treatment paired with mental health treatment.”
Philadelphia could become one of the first cities in the United States to house a supervised site for safe drug injection. What exactly is a “safe injection site?” Supervised injection sites (also known as supervised injection facilities or SIFs) are regulated, supervised spaces where people can more safely use drugs. By providing access to sterile injection equipment and Naloxone (Narcan), the sites are a type of harm reduction model able to mitigate the risk of overdose and spread of infections, said Laura Vearrier, MD, a clinical assistant professor in the College of Medicine who has studied the intersection of bioethics and emergency medicine.
“What the models in Canada and Europe have shown is that these sites dramatically decrease overdose mortality and the number of new HIV and hepatitis C infections, and they increase public order. For instance, decreasing the persons who are injecting in public and numbers of needles found on the sidewalk,” she said.
Most importantly, these sites are staffed by trained medical professionals, who can provide health information and referrals to other resources, Vearrier emphasized.
“We’ve seen that people who use those facilities end up being hooked into further social and health care resources and detox services,” she said. “It serves as kind of a bridge to the medical community.”
Data shows that these sites have been overwhelmingly successful in preventing overdoses and hepatitis C and HIV infections. Also, there is no evidence to suggest that they draw first-time drug users or increase drug use. The costs of running such facilities can be high, but are often far less than the economic toll of treating newly infected patients, Vearrier adds.
However, in addition to swaying public opinion about the benefits of safe injection sites, other questions will need to be answered before they would be successful in Philadelphia, Colistra cautioned.
But any solution that can decrease overdoses and link people to care is a step in the right direction, she feels.
“When people are alive, we have the opportunity to intervene and help them to change,” she said.
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