"One may ask, if opiates produce euphoria or pleasure...then why do addicts appear to be so unhappy?"
—Alfred Lindesmith1
KEY POINTS
■ Physician assistants need not specialize in addiction medicine to care for substantial numbers of patients who are opioid dependent.
■ The incidence of opiate addiction has been rising since the 1970s, for reasons that include the increased purity of heroin (from less than 10% in the 1970s to 50-80% in the 1990s); a decline in price; and a rise in prescription opiate abuse.
■ Despite the overall increase in all forms of opiate abuse, there has been no organized expansion of addiction services. Many barriers exist to the development of new treatment facilities.
■ The most successful detoxification process includes the support of a caregiver from early withdrawal, through maintenance and rehabilitation, and into the early months or even years of a drug-free existence.
■ The successes seen in addiction management during the past decade can be magnified in the coming years by expanding the number of treatment facilities and providers, including PAs, who are able to prescribe highly effective medications such as buprenorphine.
Physician assistants need not specialize in addiction medicine to care for substantial numbers of patients who are opioid dependent. Primary care PAs will often encounter these patients in the course of their practice and should understand the essentials of diagnosis and management of narcotic abuse and dependence. Armed with this knowledge, PAs can assume an expanded role in caring for the drug-dependent patient and become equipped to advocate for the reallocation of health care resources toward solving this burdensome public health problem.
BACKGROUND
Opiate addiction has plagued humanity since the discovery of the nectar of the opium poppy, Papaver somniferum (Figure 1). This annual herb is native to southeastern Europe and western Asia and is grown in Iran, Turkey, Holland, Poland, Romania, the former Czechoslovakia and Yugoslavia, India, Canada, and several Asian and Central and South American countries.2 The nectar, or latex, is harvested from immature seed capsules after the poppy has flowered and is collected by making incisions in the walls of the seed pods. The latex exudates are then collected and dried. Opium and the isoquinoline alkaloid morphine can be isolated from this material.2
Opiate derivatives, both synthetic and natural, affect the mu-opioid receptor (MOR) in the brain.3 This receptor site has high affinity for frequently abused opioid drugs such as morphine, codeine, and fentanyl. Diacetylmorphine hydrochloride, or heroin, is a derivative of morphine. Since heroin has increased hydrophobicity, it crosses the blood-brain barrier more readily than morphine and produces a more rapid and intense euphoria,3,4 which contributes to its addictiveness. Users most often inject, snort, or smoke heroin. An overdose can occur with any route of administration.
Epidemiology In 2006, the Substance Abuse and Mental Health Services Administration's National Survey on Drug Use and Health found that approximately 23.6 million persons aged 12 years or older needed treatment for an illicit drug or alcohol abuse problem. Fourteen percent of these patients abused heroin, but only about 11% of all patients with any addiction, or about 2.5 million, received specialized treatment.2 Forty percent of admissions to substance abuse treatment facilities were for alcoholism, while 18%, the highest percentage of drug-related admissions, were for users of heroin and other opiates. The majority of patients admitted to treatment facilities are white and 20 to 24 years old (14.4%), followed closely by 14% who are 25 to 29 years and 13.9% who are 40 to 44 years.2
Cost and public health issues Addiction to heroin and other opiates, as well as abuse of other illicit drugs, place a major burden on society. The total cost in the United States for illicit drug abuse is estimated to be more than $180 billion per year. This number includes health and crime-related costs and additional costs associated with lost productivity. Furthermore, the total sum for the untoward effects associated with all addiction, including tobacco use, exceeds half a trillion dollars annually.2 However, this figure does not represent the spectrum of toxic public health issues associated with illicit drug use, including family collapse, job loss, academic failure, domestic violence, child abuse, and other associated crimes.
OPIATE USE ON THE RISE
The incidence of opiate addiction has been rising since the 1970s,5 for reasons that include the increased purity of heroin (from less than 10% in the 1970s to 50-80% in the 1990s); a decline in price; and a rise in prescription opiate abuse.5 Emergency department admissions for heroin use more than doubled from 36,000 in 1991 to 85,000 in 1999. Moreover, there was a simultaneous rise in overdose deaths during this same time period.5 As heroin use increased, so did the move from noninjection use to IV use. Escalated IV use expands the incidence of HIV, hepatitis B and C, infectious endocarditis, and other infectious diseases.5
Another upsurge of opiate abuse has involved prescription narcotic analgesics. There are many legitimate uses for prescription narcotics, but as the use of these medications increases, the risk of misuse, such as diversion and overdose, grows as well. Since 1991, the number of opioid prescriptions quadrupled from 40 million to 180 million, and emergency department visits related to prescription opioid analgesic use more than doubled since 1994.5,6 Deaths from prescription opioids rose from about 2,500 in 1999 to nearly 6,000 in 2005.6
Despite the overall increase in all forms of opiate abuse, there has been no organized expansion of addiction services.2,4,5 Current estimates reveal that less than 25% of the 900,000 opiate-addicted patients in the United States participate in methadone treatment programs. Approximately 950 methadone maintenance programs are registered with the Drug Enforcement Administration (DEA).5 Considering the current rate of addiction, there appears to be a real need for additional treatment centers.