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OPIOID CRISIS
The Reversal of the Pendulum
By Brian Boies, MD
Opioid Addiction: in developing addiction to opioids; other contributory factors in-
Opioids are mu receptor agonists, meaning that they offer pain clude, but are not limited to, age and social situations.
relief by primarily binding to those receptors in the brain and spinal Addiction, tolerance, and dependence together can lead to patients
cord. These same receptors, however, also exists in parts of the taking increasingly higher dosages of opioids in a quickly escalating
brain that are not directly related to pain perception, namely the re- pattern. The eventual result is commonly overdose. Opioid over-
ward centers that, when activated, are responsible for the euphoria doses were the direct cause of death in over 28,000 people in 2014,
of the opioid class of medications (1). This euphoric effect drives with over half of those deaths being from prescription opioids (6,7).
human behavior with continued use of the drug though classic con- Furthermore, in 2015, the number rose to over 33,000 people in just
ditioning mechanisms (2). Tolerance of the analgesic and euphoric that year alone (8). Statistically, that correlates to 91 people a day
effects develops relatively quickly, requiring more frequent dosing that die from opioid overdose, and many of those are from physician
intervals and increased doses than previously needed, but other as- written prescriptions. Physicians have played a substantial role in
pects of tolerance develop more slowly, such as respiratory depres- this epidemic; how did we get here?
sion, making a rapid dose escalation a dangerous proposition (3,4).
In time, patients develop physical dependence with opioids, experi- Back to the Beginning:
encing withdrawal symptoms such as nausea, vomiting, chills, and Alleviating pain is a common goal amongst the majority of physi-
agitation if abruptly decreased or stopped, or if a mu receptor an-
tagonist such as naloxone is administered. cians. Considering that pain complaints are one of the top reasons
for primary care physician visits across the country, and with more
Contrast this to addiction. Addiction is more of a disease process, than 30 percent of Americans having some form of chronic or acute
with compulsive, continued use despite harm, cravings, and reduc- pain (9), it’s understandable how the opioid epidemic started. The
tion of social, occupational, or recreational activities (5). This occurs acute pain relieving properties of opium and its derivatives have been
in a smaller percentage of people who are exposed to opioids, but well known for millennia, just as the addictive potential of these
can last much longer than tolerance or physical dependence — on drugs has been well documented throughout history and extending
the order of months to years. Genetics may play an important role
14 San Antonio Medicine • October 2017
