Psychiatry and the Opioid Overdose Crisis

Magnitude of the Problem

For the third year in a row, the Centers for Disease Control and Prevention reported an unprecedented decline in life expectancy for the United States, a decline attributable mainly to drug overdose deaths and suicides (1, 2). Drug overdoses have continued to rise and are now estimated to account for 70,237 deaths in 2017 (3, 4). Adults 25–64 years old were the largest group affected, with the age 55–64 cohort manifesting a sixfold rise in death rate since 1999, yet individuals from all age ranges are contributing to the upward spiraling death rate. Death rates vary by states, with 20 states and the District of Columbia reporting drug overdose death rates that are higher than the national rate (21.7 per 100,000), eight states reporting rates comparable with the national rate, and 22 states exhibiting lower rates. Of the 70,237 deaths, approximately 49,000 were related to opioids, with methamphetamine and cocaine implicated in the majority of other deaths. Among opioid overdoses, fentanyl deaths rose precipitously since 2013, and fentanyl now accounts for more opioid deaths than prescription opioids, heroin, or methadone.

The first iatrogenic opioid crisis in the United States began in the mid-19th century and faded early in the 20th century. In the 19th century, persons with iatrogenic opioid and “street heroin” opioid use disorder were perceived by physicians as distinct populations, with different sources of opioids, with different reasons for use and for developing addiction. These boundaries have become unraveled in the current crisis, as persons increasingly transition from prescription opioids to heroin or fentanyl (5, 6); as treatment for opioid addiction becomes standardized; and as those affected increasingly are from economically advantaged or disadvantaged groups, in urban or rural settings, and from a broadening range of ethnic and racial groups.

Contributors to the Current Crisis

The root causes of the modern opioid crisis are complex and traceable to at least 30 factors (B.K. Madras, National Drug Early Warning System Webinar, Jan. 10, 2018; https://ndews.umd.edu/resources/opioid-commission-summary-and-lessons-learned). A prime driver has been the health care system. Pressure on medical practitioners to resort to opioids for managing chronic pain led to a nation awash with prescription opioids, from both legitimately prescribed and diverted prescription sources. An initial catalyst was a letter to the editor of the New England Journal of Medicine in 1980, with the title “Addiction Rare in Patients Treated with Narcotics” (7). The authors of this five-sentence letter scrutinized the records of hospitalized patients and concluded that opioid addiction was rare, even though they provided no information regarding doses, duration of opioid treatment, opioid consumption postdischarge, long-term follow-up, or criteria for addiction. The letter garnered an unusual 600, mostly affirmative, citations (8). Six years later, another and inadequately powered study concluded that “opioid maintenance therapy can be a safe, salutary and more humane alternative to the options of surgery or no treatment in those patients with intractable non-malignant pain and no history of drug abuse” (9, p. 1). These reports abetted aggressive advocacy for chronic pain management with opioids (9–11) by patients with chronic pain and by professional pain societies (12, 13). Critically, it empowered the opioid pharmaceutical industry to sponsor thousands of “educational” events for prescribers on the safety of opioids to treat chronic pain (14). In response to the pain movement, the Department of Veterans Affairs and then the Joint Commission designated pain as the “fifth vital sign” (15). Administrators and regulatory bodies pressured physicians to raise patient satisfaction scores primarily by addressing pain with opioids. In a recent survey of emergency department physicians, 71% reported a perceived pressure to prescribe opioid analgesics to avoid administrative and regulatory criticism, and 98% felt that patient satisfaction scores are excessively relied on by reimbursement providers to evaluate management of their patients. The physician requirement to address pain as the “fifth vital sign” (16)—reimbursement metrics based on patient satisfaction—may have inadvertently created a peculiar American environment conducive to opioid prescribing and exploitation by prescription opioid misusers (17). The erosion of opiophobia among health care providers, coupled with pressure from pain patients and the pharmaceutical industry, led to a >300% increase in opioid prescriptions. Conscientious physicians and detractors who issued cautionary statements and guidelines were essentially ignored, while advocates were given center stage (18). The vast excess of unused and unneeded opioids was heavily diverted for nonmedical use (as stated in the annual reports of the National Survey on Drug Use and Health [NSDUH; https://nsduhweb.rti.org/respweb/homepage.cfm] for 2006–2017).

The United States became awash with prescription opioids, a crisis unique to the country, as it ranks well above other “high-prescribing” nations on opioid-prescribing practices and prescription opioid deaths (19). A significant excess entered the system, as unused and unneeded opioids were diverted for nonmedical use. Excessive prescribing of opioids continues to this day, even though new opioid prescriptions are declining (20). Prescribing levels in 2015 were three times those of 1999, but trends are encouraging. Analysis of the NSDUH data indicate that nonmedical use of opioid analgesics declined from 48.4 per 1,000 persons between 2003 and 2005 to 43.3 per 1,000 persons between 2012 and 2014. In contrast, increases in abuse or dependence were observed during the same time interval (6.0 to 7.5 per 1,000 persons) (21). The prevalence of prescription opioid use disorder among users of nonmedical prescription opioids during this time period significantly increased among 18- to 34-year-olds but stayed relatively stable for 12- to 17-year-olds (22). Counterbalancing this movement is déjà vu, with the current evidence once again questioning the safety and efficacy of prescription opioids for chronic pain: (1) Treatment with opioids was shown to be not superior to treatment with nonopioid medications for improving moderate to severe chronic back pain or hip or knee osteoarthritis pain and pain-related function over 12 months, with findings not supportive of opioid therapy initiation (23); and (2) a meta-analysis of 96 randomized clinical trials and 26,169 patients with chronic noncancer pain showed that the use of opioids (compared with placebo but not with other analgesics) was associated with small reductions in pain (−0.69 cm on a 10-cm scale) and small improvements in physical functioning (2.04 of 100 points) (24). Accordingly, opioids may provide benefit for chronic noncancer pain, but the magnitude is likely to be small and the potential for adverse events high.

The current crisis is more lethal than it was at the onset of the problem, because fentanyl and its analogs have replaced prescription opioids as a primary cause of opioid overdose deaths (25). Fentanyl is lethal at vanishingly low doses (26); its high potency makes even distribution of fentanyl powder/crystals within “fillers” difficult. Fentanyl can catalyze respiratory depression rapidly, often long before first responders become aware, are alerted or can react. Counterfeit pill presses disguise fentanyl in pills marketed on the street as prescription opioids, or sedatives, and counterfeit powders sold as cocaine can be lethal to users who have not developed tolerance to opioids (26). Strategies to end the opioid crisis are grounded in these realities but are bolstered by the advent of large-scale data analytics, evidence-based pharmaceutical treatments, early detection, and lessons learned from the previous crisis (27).

The President’s Commission on Combating Drug Addiction and the Opioid Crisis

In 2017, an unprecedented action was taken by President Donald J. Trump. He signed an executive order on March 29, 2017, establishing the President’s Commission on Combating Drug Addiction and the Opioid Crisis, tasked with providing guidance on reversing the crisis. Chaired by Governor Chris Christie (New Jersey), the six-member Commission included Governor Charlie Baker (Massachusetts), Governor Roy Cooper (North Carolina), former Congressman Patrick Kennedy (Rhode Island), Attorney General Pam Bondi (Florida), and the first author of this article (Massachusetts). An interim report requested that the president declare the opioid crisis a public health emergency under federal law, which he did. Charged with coordinating and developing the final report, the first author of the present article developed a perspective that informs the focus of this article. We explored the root causes of the current crisis both to devise strategies to reverse-engineer reversible factors and to provide a blueprint to prevent the same errors from recurring. Strategies include, for example, improving the following: scrutiny from the Food and Drug Administration of opioid abuse liability and mandatory reporting of addiction as an adverse event; medical education in opioid prescribing, pain management, and the diagnosis and treatment of substance use disorders; guidelines for opioid prescribing that are informed by pharmacoepidemiological analyses; information flow of patients’ opioid prescriptions, substance use disorder, and overdose chronicles among physicians, treatment centers, emergency departments, first responders, medical examiners, and pharmacies; removal of unwarranted institutional, professional, legal, patient, insurance, and financial pressure on physicians to address pain aggressively with opioids; removal of barriers such as health care insurers’ prior authorization approval for pain management alternatives, pharmacotherapeutics, and addiction treatment; enforcement of compliance with mental health and addiction treatment parity laws; quality of addiction treatment services, with provisions of pharmacotherapies and mental health care; and responsiveness to overdoses. The 56 recommendations of the President’s Commission report were grounded in the reality of past errors and current weaknesses in management of pain, in addiction treatment, and in reimbursement systems and represent advanced strategies for prevention, treatment, rescue, recovery support, research, improved data analytics, and accountability (28). With a focus on the quality of treatment services and recovery homes, the report calls for implementing high standards of care for treatment. Specialists in addiction medicine and addiction psychiatry are best positioned to develop and implement high-quality care. Advanced data analytics to strengthen data collection, integration, and real-time surveillance of the opioid crisis at the national, state, local, and tribal levels are embedded throughout the report. The report also calls for scientific research as a key component in mitigating the opioid crisis. The development of analgesics with limited or no abuse liability, antagonists to reverse newly emerging high-potency opioid agonists while mitigating withdrawal symptoms, and new pharmacotherapies to treat opioid addiction are listed as attainable goals. New technologies are mentioned, including wearable devices that sense respiratory depression to alert the user, devices that automatically inject naloxone when blood oxygenation levels are dangerously low, and devices that wirelessly report a looming crisis to a first responder. Also included are apps for wireless electronic devices (e.g., phones, watches, and virtual reality devices) to function as behavioral coaches, to reduce pain, or to increase compliance, among others. On October 24, 2018, President Trump signed sweeping legislation to address the nation’s opioid crisis, the SUPPORT for Patients and Communities Act, which was shaped to an extent by the President’s Commission report.

The Role of Psychiatry in Alleviating the Opioid Crisis

Multiple weaknesses exist in our current system of care that can be addressed by the practice of psychiatry. The following recommendations were partly inspired by two recently published articles (27, 29).

Recommendation 1: improve psychiatric training in substance use disorders, screening, diagnosis, and treatment (30).

Addiction is associated with or can lead to multiple health consequences, including death as well as acute poisoning and overdose crises. In examining a large sample of patients, Young et al. (31) reported that the prevalence of any medical comorbidity and chronic diseases was significantly higher in patients with substance use disorders (74.0% versus 59.9% for those without substance use disorders) and who had a higher prevalence of chronic diseases, leading to elevated symptom burden, functional impairment, and increased health care costs. Current needs for treating substance use disorders far exceed specialized addiction therapeutic resources (32). Fewer than 30% of individuals with a substance use disorder—currently estimated at 20 million people—receive treatment, and treatment is substandard in many treatment centers. The shortage of trained addiction psychiatry staff to meet residents’ educational needs to be addressed as the United States, with a population of 320 million people, is served by a meager 2,000 board-certified addiction psychiatrists and 2,500 physicians certified in addiction medicine (33). To add to the list of needs, the Accreditation Council for Graduate Medical Education requires a mere month of addiction treatment experience during 4 years of training (34). Approximately 8.9 million adults have co-occurring disorders (both a mental health and substance use disorder). Training in the treatment of opioid use disorder with medications such as buprenorphine or naltrexone should be mandatory in psychiatry residency programs (and in all residency programs and medical school curricula) but are increasingly encouraged in psychiatry residency programs (35). The curriculum outlined by Iannucci et al. (30) is an excellent model for integrating substance use disorder treatment training into a standard psychiatry residency (29).

Recommendation 2: improve psychiatric training in pain management (36).

Addiction psychiatrists are increasingly being recruited to assess or treat chronic pain, as chronic pain can be comorbid with psychiatric illness (37) or psychogenic. Chronic pain increases the risk for suicide and depression, and it can compromise sleep, which affects mental health. Opioid analgesics are a legitimate medical therapy for certain patients with severe chronic pain. The risks of opioids support the need for appropriate assessment and selection of patients and monitoring for the duration of the painful state. Risk assessment includes knowledge of factors that may contribute to misuse or suicide, the latter likely to be misclassified in opioid-related deaths (38). Greater understanding and better assessment are needed of the risk associated with suicide in patients with pain. Clinical tools and an evolving evidence base are available to assist clinicians with identifying patients whose risk factors put them at risk for adverse outcomes with opioids (39). Psychiatric conditions such as depression can also reduce the motivation to engage in alternatives (e.g., exercise and physical therapy) to opioids for pain management. Ballantyne (37) provided an excellent overview of the studies showing higher prevalence of problematic opioid use among persons with psychiatric comorbidities (i.e., loss of control over use, opioid or other substance use disorder, accidental overdose, suicide, analgesic failure, and escalation of dose) (40–44). She concluded that patients who have difficulty controlling opioid use and who eventually progress to risky, high opioid doses are a self-selected group of patients with preexisting risk, including stress, which can escalate vulnerability to chronic pain. Alternatives to opioids exist, and a number of these reside within the domain of psychiatry and behavioral health. Guidance and curricula for psychiatrists are limited in this area, and training in management of chronic pain should be another priority area.

Recommendation 3: engage psychiatrists as motivators for the untreated.

Expansion of treatment slots alone will be insufficient to address treatment needs in the United States. It is estimated that 70% of the population with opioid use disorder do not receive treatment. The reasons are varied and complex, but included among them is a denial of needing treatment or a lack of motivation to seek treatment. Included in this population is the large number of people dying of an overdose alone, without anyone present to raise an alarm or administer naloxone. Psychiatric expertise in detecting opioid use disorder, in motivational interviewing, and in determining root cause stressors (e.g., depression/anxiety, trauma disorders) for continued use could be instrumental in recruiting persons into an appropriate level of care. Psychiatrists are uniquely qualified in motivating patients in denial to engage in treatment, to educate other physicians, law enforcement, and the public on treatment effectiveness, on hope for improvement and reducing rampant stigma associated with this, and other brain diseases.

Recommendation 4: psychiatrists serve as essential providers of treatment for comorbid mental illness and substance use disorders.

Many individuals with substance use disorder also have other psychiatric disorders, which may confound treatment, thwart compliance with medications, or lead to misuse of prescription medications. Psychiatrists are trained specifically to address co-occurring psychiatric disorders and suicidal ideation. As described in the Commission report, screening and addiction treatment should address all mental health needs, and psychiatrists are best positioned to provide this “holistic” care. An earlier report (45) commissioned by the National Institute on Drug Abuse discovered that 43% of persons in treatment had diagnosed co-occurring substance use and mental health disorders; in Federal government-operated facilities, comorbidity was 62%. As outlined in Appendix E of the report, in a table prepared by the author (BKMadras), of the 14,000 treatment facilities in the nation, 63% offer screening for mental health disorders, 43% offer comprehensive mental health assessment, and 57% offer mental health services, but only 35% offer medications for psychiatric disorders. Inclusion of practicing psychiatrists in the care and treatment of substance use disorders is an imperative.

Recommendation 5: engage psychiatrists as prescribers of medications for opioid use disorder.

Of the evidence-based practices to treat opioid use disorder, none is more compellingly effective than the use of three medications: the full agonist methadone, the antagonist naltrexone, and the partial agonist buprenorphine. Each has surmountable regulatory or pharmacological limitations. Methadone must be dispensed in a federally licensed facility, creating unnecessary restrictions for its use. Buprenorphine can be prescribed in an office-based setting, but an eight-hour training session is necessary to obtain a waiver to prescribe. The effective antagonist naltrexone requires detoxification before use. These medications are effective in reducing opioid use and overdose deaths and in improving social functioning. If more psychiatrists engaged in treating substance use disorders, these medications would have a much broader reach, especially considering the large proportion of persons with comorbid psychiatric disorders requiring mental health care.

Recommendation 6: engage psychiatrists as providers for the chronicity of addiction and relapse.

Many major psychiatric illnesses are chronic relapsing diseases that require an ongoing relationship with a patient, a continuum of care, and maintenance evaluation and management. Treatment of a substance use disorder has similar requirements for continuum of care, but treatment in conventional facilities has rarely considered assessment of meaningful life changes during long-term recovery, focusing instead on short-term retention and abstinence. Results from a review of 28 cohort studies—including data from 1952 to 2013 evaluating opioid use, with a follow-up period of at least 3 years—show that, whereas mortality, morbidity, and other negative consequences increased in people who used opioids, recovery was facilitated in people who engaged in rewarding non-drug-related activities, such as employment and relationships (46). Psychiatrists are highly suited to tracking clinical, environmental, health-related quality of life, and socio-economic changes (e.g., patient characteristics, employment, and criminal history). A patient-centered development of opioid use disorder treatment that incorporates recovery-related, life-activity outcomes resides in the domain of addiction psychiatry (47).

Recommendation 7: engage psychiatrists as providers of help for children at risk.

The current opioid epidemic has many unrecognized victims. Among the most vulnerable in this social crisis are children neglected, endangered, or orphaned by parents with an opioid use disorder or who are deceased because of an overdose. Psychiatrists can assist in recognizing children at risk and facilitating the provision of safe environments and mental health support for this vulnerable cohort.