Expert Insight: The 2020 opioids epidemic and the importance of drug screening

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Prof. Dr. Dr. (h.c.) Marilyn A. Huestis, Senior Fellow, Thomas Jefferson University, and President, Huestis & Smith Toxicology

The global opioid epidemic began with misuse of prescription opioids that were marketed aggressively by manufacturers bribing physicians to prescribe high oxycodone doses. This led the Drug Enforcement Agency to restrict opioid prescribing, resulting in addicted opioid users turning to heroin. The situation worsened with the release of numerous novel psychoactive opioids, including highly potent fentanyl analogs on the market that were initially "legal alternatives" but so potent that many overdoses and deaths resulted. Later, research suggests these potent designer opioids were laced in opioids, methamphetamine, cocaine and other drugs in an effort to create more opioid dependence.

In this on-demand SelectScience webinar, Prof. Dr. Dr. (h.c.) Marilyn A. Huestis, Senior Fellow, Thomas Jefferson University, and President, Huestis & Smith Toxicology, breaks down how this epidemic emerged, its continued prevalence in 2020, as well as detailing the current approaches for drug testing and the success of available treatment regimens for opioid dependence.
 

 Read on for the highlights of the live Q&A session or register to watch the webinar at a time that suits you.

Q: I would like to know how this pandemic could be managed in a low-resource setting, and if there are any strategies that can be used in a case where drug tests aren't available?

MH: Cost is a major issue - immunoassays are available that can be quite inexpensive for the screening portion. Chromatography and mass spectrometry are usually done for confirmation. Being able to determine if use of opioids (oxycodone or others) has occurred is a good way to use resources in lower-income countries. You may not be able to confirm it, but you can provide your physicians with an idea of whether opioids may or may not be present.

The National Institute on Drug Abuse and multiple pharmaceutical companies have developed a nasal spray for naloxone, the antidote to opioid overdose. In the United States, it is being distributed in parks, at public libraries, throughout the community, to family members, and friends of individuals who are opioid dependent. If a person accidentally overdoses, they have the antidote rapidly available.

One of the most critical factors, if the individual has been exposed to a very potent fentanyl analog, is that you use the naloxone and then get that individual to a hospital. Many times, the drug that they have been exposed to is so potent that you will need multiple doses of the naloxone to counteract the overdose and prevent death.

Many governments around the world are getting these less expensive and easy-to-administer naloxone preparations so that overdoses can be avoided. 

Q: Is it true that opioid addiction often stems from a real pain in the body? And if yes, are there other ways for an individual to get pain relief without opioids?

MH: Opioid dependence certainly can start with chronic pain. Many people have chronic pain and look for relief to improve their quality of life. Some percentage of dependence also comes from individuals who are abusing opioids for the euphoria that it produces, so it's a mixture. People can become dependent either way, from their chronic treatment of pain and also from their abuse of opioids. 

There are other medications, there's been a tremendous amount of work showing that non-steroidal anti-inflammatory, or NSAID drugs can treat much of the pain that people may be feeling. You would want to start first with over-the-counter medications, acetaminophen, Advil, and other over-the-counter NSAIDs and ibuprofen compounds. Those are of varying strengths, so you would work with your physician, or a pain-management specialist, and attempt the other levels before you needed to prescribe opioids. You could start with the less potent opioids.

Something like terminal cancer pain requires the strongest opioids. In those cases, individuals may be terminally ill, and the important part is to relieve that pain and to make them feel better in those last periods of time. It should always be decided with a physician and starting at the lowest levels, those that don't have abuse potential, and only when you may need opioids for a very short period of time. Initially, people were being given 90 days’ or 30 days’ worth of pain medication when they only needed it for two or three days. Prescribing practices have changed and those who need stronger opioids will only be taking them for the period of time when they have severe pain.

Q: What are the alternatives when opioid treatment is no longer functional?

MH: I wouldn't say that opioid treatment is non-functional. It's true that individuals develop tolerance to opioids and that that requires larger doses. That is part of the problem with the morbidity and the mortality that we see: individuals continue to increase their doses in order to obtain the effect that they need (or that they want, if they're abusing the substances). If there is any type of break in the amount of drug that they're taking, they can lose some of that tolerance.

One of the major problems that we have is, for example, someone who's been abusing opioids and is then incarcerated for a period of time. When they get out, they think they know the amount of drug that they need to take, but their tolerance has dissipated. They may overdose and die if they take the same amount of drugs that they were taking previously. So, it's not that the drug becomes non-functional.

People who develop a tolerance and are increasing the amount they need, for example, in terminally ill patients, will just continue to increase (under a doctor's care) the amount of drugs that’s necessary. If you can come up with a different drug that's not an opioid, that has less dependence potential, then you might be able to reduce the amount of opioids that are necessary, and some of that tolerance will decrease as well. The goal is to be able to produce the pain relief that the individual needs but to reduce the potential for drug overdose and death.

Q: Could you comment on the various methods used to screen the abused opiates? And do you see any of the methods becoming more popular than the others?

MH: I think you need multiple methods. If you use the basic opiate test, you're going to test for codeine, morphine, and heroin. But it's critical that you also screen for oxycodone if, in your particular area of the world, that oxycodone abuse is problematic. Hydrocodone is extremely important in the United States and less so in other areas.

Fentanyl testing is essential in most parts of the world because so much of the opioid overdoses are related to fentanyl itself and to its analogs. Another critical thing to mention is that we used to have so many different fentanyl analogs that were the main problem but, throughout the world now, fentanyl itself has become the major opioid of concern. However, the fentanyl immunoassays may or may not cross-react with all of the different analogs. It's extremely important for you to be aware, in your own area of the world, by being in contact with the crime labs and other Department of Justice laboratories to know what is commonly used in your area.

If the physician sees what appears to be an opioid overdose and the opioid assays are negative, it still could be one of these new designer opioids that do not cross-react with any opioid immunoassay. So, that is very important to keep in mind as well.

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