Opioid use disorder (OUD) is defined by the Diagnostic and Statistical Manual of Mental Disorders (fifth edition) as the maladaptive use of opioids, prescribed or illicit, resulting in two or more criteria that reflect impaired health or function over a 12-month period. OUD is scaled according to severity (mild/moderate/severe) and does not require physiological tolerance or dependence in order to be considered a substance use disorder. Text Box 1 summarizes core criteria and provides a mnemonic to assist clinical diagnosis and teaching.
The rate of death from over-doses of prescription opioids in the United States more than quadrupled between 1999 and 2010 (see graph), far exceeding the combined death toll from cocaine and heroin overdoses. In 2010 alone, prescription opioids were involved in 16,651 overdose deaths, whereas heroin was implicated in 3036. Some 82% of the deaths due to prescription opioids and 92% of those due to heroin were classified as unintentional, with the remainder being attributed predominantly to suicide or “undetermined intent.”
For every fatal opioid overdose, there are approximately 30 nonfatal overdoses. Nonfatal overdoses that receive
medical attention represent intervention opportunities for clinicians to mitigate risk by reducing opioid prescribing or ad-
vocating addiction treatment. Studies evaluating commercially insured patients suggest these potential interventions
are underutilized. For example, a 2000-2012 study reported high rates of opioid prescribing for patients even after they had sustained a nonfatal opioid overdose. Another study of patients with opioid use disorder (OUD) showed low rates of buprenorphine treatment after hospitalization for overdose. However, little is known about how opioid prescribing and medication-assisted treatment (MAT) changes from before to after overdose among Medicaid enrollees, who have a 3-times higher risk of opioid overdose. We used data from a large Medicaid program to compare (1) prescription opioid use, (2) duration of opioid use, and (3) rates of MAT (buprenorphine, methadone, or naltrexone) among enrollees before and after an overdose event.
Background: Only 1 in 5 of the nearly 2.4 million Americans with an opioid use disorder received treatment in 2015. Fewer than half of Californians who received treatment in 2014 received opioid agonist treatment (OAT), and regulations for admission to OAT in California are more stringent than federal regulations.
Changes in Substance Abuse Treatment Use Among Individuals With Opioid Use Disorders in the United States, 2004-2013
During the last decade, nonmedical use of opioid analgesics and heroin increased substantially in the United States, contributing to an increased rate of overdose deaths. Expanding access to substance use treatment among individuals with opioid use disorders (OUDs) may be an important strategy for reducing harmful use. In the early 2000s, less than one-sixth of individuals with OUDs received any treatment, and use of office-based treatment was rare. It is unknown whether treatment patterns have changed in recent years.
Mortality risk during and after opioid substitution treatment: systematic review and meta-analysis of cohort studies
Objective: To compare the risk for all cause and overdose mortality in people with opioid dependence during and after substitution treatment with methadone or buprenorphine and to characterise trends in risk of mortality after initiation and cessation of treatment.
In many countries opiate overdose remains the main source of the 10-fold excess mortality among opiate addicts, notwithstanding the effects of HIV/AIDS. Treatment reduces mortality but can sometimes increase mortality transiently for example, during the first few weeks of methadone maintenance treatment and among former opiate addicts after their release from prison. The increase in mortality among released prisoners who were formerly opiate addicts has been attributed to loss of tolerance and erroneous judgment of dose when they returned to opiate use. We wished to investigate whether opiate addicts who have undergone inpatient detoxification might have a similarly increased mortality after treatment. We followed up patients who received inpatient opiate detoxification, looked for evidence of increased mortality, and investigated the distinctive characteristics of patients who died.
The United States is facing a vast epidemic of opioid-related deaths. More than 2.4 million Americans have a severe opioiduse disorder (OUD) involving dependence on pain medications, heroin, or both, and rates of drug-overdose deaths in this country have outpaced mortality from motor vehicle accidents since 2013. The rising death toll has been rivaled in modern history only by that at the peak of the AIDS epidemic in the early 1990s. Although these epidemics differ in nature, the large-scale, highly coordinated response to AIDS that was eventually mounted may be instructive for combating the opioid epidemic.