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26 SPOTLIGHT ON THE OPIOID EPIDEMIC Opioids in America: 6 Things to Know About the Evolution of an Epidemic By Alyssa Rege T he misuse of opiates — heroin, oxycodone, hydrocodone, codeine, morphine and fentanyl, among others — represents one of the leading causes of accidental death in the U.S. Addiction rates have increased among most demographics during the past decade. Nearly 13,000 people in the U.S. died from heroin overdoses in 2015, a roughly 2,000-case increase from the previous year, according to the CDC. CDC officials said the number of opioid-related deaths in 2015 averaged more than 30,000 people, narrowly surpassing the total number of gun-related homicides that occurred during the same year. Here are six things to know about the opioid epidemic. 1. Many Americans first encounter opioids as a treatment for severe pain. In 2000, e Joint Commission introduced pain management standards to help medical professionals effectively treat patients' pain. According to the 2000 report, pain was to be regarded as the "fih vital sign" — a symptom clinicians should be aware of and aim to mitigate as much as possible. While the standards didn't explicitly advocate for opioid use, they acknowledged that opioids proved to be an effective treat- ment for chronic pain. Over time, clinicians began to raise con- cern over medical professionals' increasing reliance on opioids for pain management. In 2004, e Joint Commission stripped the designation of pain as the fih vital sign from its accreditation standards manual and issued new pain management standards in January that included the monitoring of opioid prescriptions and the promotion of nonpharmacologic pain treatment options. In May 2016, the CDC released guide- lines aimed to assist medical officials in prescribing opioids to treat chronic pain. e recommendations were based off of an updated 2014 systemic review of scientific evidence discussing the effectiveness and risk of opioid prescriptions, and a supplemental review of the benefits and harms, values and preferences and cost of such drugs. e agency also consulted with experts within the medical community and the public. However, the proposed suggestions were met with criticism from a number of prominent national medical organizations. e Ameri- can Medical Association said in a statement that though the organization was "largely supportive of the guidelines," the suggestions may have unintended consequences, such as encouraging "access and insurance coverage limitation for nonpharmacologic treatments" and expressed concern about "the potential side effects … strict dosage and duration limits [may have] on patients." e American Cancer Society Cancer Action Network took issue with the fact the guidelines failed to ad- dress opioid prescribing as it relates to cancer care, arguing cancer patients also "experience severe pain that limits their quality of life." 2. OxyContin. A recent working paper au- thored by researchers at the RAND Corp., and the Philadelphia-based University of Pennsyl- vania Wharton School of Business suggests the release of OxyContin directly coincided with, and potentially spurred, the increase in fatal heroin overdoses between 1999 and 2010. e drug, released by Purdue Pharma during the mid-1990s, was designed to provide extended pain relief over the course of 12 hours. However, drug users discovered that crushing the pill before injecting or snorting it could allow them to bypass the time release mechanism. Following the drug's release, Pur- due Pharma was met with a slew of criticism for failing to warn users of the drug's potential addictive qualities. In 2007, the drug manu- facturer pled guilty to misleading consumers about OxyContin's addictive nature and was ordered to pay $600 million in fines. In 2010, Purdue Pharma released a second version of the pill that was allegedly "harder to crush," according to e Washington Post. e reformulation became the first drug to receive the "abuse-deterrent" designation from the Food and Drug Administration because of its ability to "deter" abuse, even if it cannot fully prevent it. e researchers posit the spike in heroin deaths began "precisely the year fol- lowing [the] reformulation [of OxyContin]." States with the highest initial rates of OxyCon- tin abuse experienced the largest increases in heroin deaths, researchers said. 3. Fentanyl. In recent years, fentanyl — a synthetic opioid 50 times more powerful than morphine — has quickly become a leading contributor to the opioid epidemic. ough introduced to the medical industry in the 1960s, officials did not name the drug as a significant driver of the epidemic until 2013, a report from e New York Times suggests. Health experts believe the drug's increasing prominence in the market stems from the ease with which fentanyl can be mixed with other opioids, such as heroin, to increase its potency. Lewis Nelson, MD, a medical toxicologist and emergency physician at NYU School of Medicine in New York City, told Forbes mere micrograms of fentanyl can mimic the effect that milligrams of other opioids induce. "is difference in fentanyl's potency is critical — it takes very little to have the same effect as other opioids. e reason so many are dying is be- cause the dose is relatively uncontrolled with street fentanyl, and small excesses can lead to overdose," Dr. Nelson said. According to a 2016 report released by the U.S. Drug Enforcement Agency, law enforce- ment agencies recovered 167 kilograms of illicit fentanyl across the nation in 2015. e report claimed illicit fentanyl is oen manu- factured in foreign countries and smuggled into the U.S. Fentanyl can appear in several forms, including pressed into pills and sold as counterfeit oxyco- done prescriptions. "You can't move. When you inject [fentanyl], it hits before you're even done giving the shot," a fentanyl user who chose to remain anonymous told e New York Times. "at's why so many people get caught with the needle still hanging out of their arm. It's bam! To your brain." 4. Medical industry's perspective. To curb the effects of the epidemic, some phy- sicians argue prescriptions should be scaled back; others suggest the cost of untreated chronic pain is too high for patients to bear, necessitating the use of opioids. e discrep- ancy has created a "civil war" within the medi- cal community as to how to address the issue. A highly publicized example of the ongoing debate came in December 2015 aer the New England Journal of Medicine published an article by Jane Ballantyne, MD, and Mark Sullivan, MD. e article proposed that phy- sicians should aim to provide patients with strategies to cope with the pain rather than provide medication to decrease pain intensi- ty. Some readers claimed the authors lacked compassion for patients and their needs, while others lauded their approach to reduce patients' dependency on medication.