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Advocacy Project: Literature Review

Prevention of Opioid Abuse

Rakhee R. Mathai and Kate Finn

School Of Counseling, Richmont Graduate University

CED 5122: Foundations in Counseling

Dr. Brian Mesimer

September 18th, 2023

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Abstract

The opioid crisis presents one of America's most significant public health challenges starting in

the late 1990s. Research, government policies, public awareness, regulations around opioid

prescription, and opioid drug reformulation have decreased mortality from prescription opioids.

However, illicit opioids such as heroin, fentanyl, and other synthetic opioids have entered the

market to cover the gap in the availability of prescription opioids. This Literature review paper

addresses the different kinds of opioids and their physiological effects, the history of the opioid

crisis, the rise of synthetic opioids, the various treatments and their effectiveness, future research

areas, prevention of opioid abuse, opioid abuse across cultures, and the role of faith agencies in

combatting the crisis.

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Advocacy Project: Literature Review

Prevention of Opioid Abuse

The opioid epidemic has affected every level of society, communities, and families in

America and shows no signs of slowing down. According to the Centers for Disease Control and

Prevention, 107,081 people died of drug overdose in 2022—out of this number, more than 68%

involved opioids (Kariisa, 2023). The impact of this crisis is beyond fatal overdoses. It has

contributed to the deterioration of the social fabric due to increased crime, distrust in

relationships resulting from the lying and coverups that an addict resorts to, and isolation caused

by rejection by friends and family. In addition, the sharing of injection equipment among addicts

is believed to have played a role in the tripling of hepatitis C virus infections (Compton et al.,

2019). According to the American Academy of Pediatrics (2018), one infant is born every

twenty-five minutes with neonatal abstinence syndrome due to maternal opioid use. The total

economic burden of the opioid epidemic in the United States, based on the incidence of overdose

deaths and the prevalence of prescription opioid abuse and dependence, was estimated to be

around 1.5 trillion in 2020 (Florence et al., 2020).

Prescription opioids and their physiological effects

In the early part of the 20th century, chemists began to make opium-like compounds that

were not produced from natural components of opium (Newton, 2018). The main compounds

were heroin, oxycodone, hydrocodone, hydromorphone, buprenorphine, and later, methadone

and fentanyl. These compounds were five to seven times more potent than codeine and

morphine, except for fentanyl, which was one hundred to two hundred times more potent than

morphine. Endogenous opioids belong to the class of neurotransmitters in the human body,
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which are produced to reduce the intensity of pain signal perception. Prescription opioids or

exogenous opioids are drugs that are chemically like endogenous opioids. Exogenous opioids,

like endogenous opioids, attach to receptor sites on the neurons in the same way as endogenous

opioids. Over prolonged use, the brain becomes accustomed to exogenous opioids and, in time,

requires higher and higher levels of the drug. This results in the patient who uses these opioids

for pain management needing one dose initially but three to four doses daily as they keep using

it. The brain becomes physically dependent on the exogenous opioid, effectively replacing

endogenous opioids. Finally, the patient goes from being physically dependent on the drug for

pain management to being addicted to it, as they cannot function normally without it.

History of the Prescription Opioid Epidemic

Opioids were often prescribed to treat cancer and post-surgery pain before the 1990’s. In

1996, Purdue Pharma unveiled their new drug called Oxycontin, made from oxycodone

(Compton et al., 2019). They started an aggressive marketing campaign to promote this drug.

Purdue Pharma convinced the American Pain Society, the American Academy of Pain Medicine,

and the Federation of State Medical Boards to publicly claim that prescription opioids could treat

chronic pain with a low risk for addiction. Purdue expanded its Physician Speaker Bureau,

conducted over 40 pain management conferences, and sponsored over 20,000 pain-related

educational programs. Soon, OxyContin was the number-one-selling pain drug in America.

(Newton, 2019). Other pharmaceutical companies like Cephalon produced fentanyl lollipops for

noncancer pain, and Jansen Pharmaceuticals developed tramadol combination pills. The medical

community was also complicit in the growing crisis. Without adequate pain management

training, primary care physicians prescribe almost half of all oxycontin in the United States.
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Doctors took vast amounts of money from pharmaceuticals to set up pain management clinics

instead of their regular practices.

With the increase in the availability of prescription opioids, there was an increase in the

use of heroin. This increase was driven by a gateway effect, as demonstrated by the fact that four

out of five individuals who used heroin self-reported using prescription drugs first (Jones, 2013).

New restrictions in opioid prescribing practices could be one factor contributing to the increased

use of heroin. Fentanyl is 100-200 times more potent than morphine (Newton, 2018). Due to its

dosage difficulty, it could prove fatal with the slightest increase above safe levels. It is produced

mainly in China. Fentanyl is frequently made in pill form and is stamped with the Oxycontin or

Percocet logo, making it hard to differentiate from the original Oxycontin pills. The danger is

that the dosage of these pills varies greatly. One consignment of drugs might have ten times the

fentanyl as another consignment. Heroin can also be spiked with fentanyl (Compton et al., 2019).

Deaths because of cocaine overdose stayed steady at four thousand to seven thousand deaths in

the 2000s. But over the next decade, there was a significant spike in this number. The deaths

increased to fourteen thousand just in 2017. This increase is partly attributed to cocaine spiked

with fentanyl. (Radi et al., 2023).

Treatment Approaches, Effectiveness, and Future Research

Treatment for Opium Use Disorder (OUD) includes Medication, behavioral therapies,

and counseling used in residential and hospital outpatient treatments and clinics. (Geyer, 2023)

Medical management of opioid dependence

The medicines used to treat opioid use disorder are methadone, buprenorphine, and

Naltrexone (Leshner et al., 2019). Methadone is a synthetic opioid. A few of the properties that

make it an excellent substitute for other opioids include a long duration of action so it can be
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taken once daily and available in viscous liquid form, which prevents it from being injected.

Methadone can be used to reduce detoxification doses or non-reducing doses for maintenance. In

the United States, outpatient methadone treatment can only be administered to people enrolled in

state and federally certified opioid treatment programs. Because methadone sustains opioid

tolerance and physical dependence, if the patient misses multiple doses, this can lead to opioid

withdrawal. The other problem with methadone is the high risk of opioid overdose death, which

is at its highest in the first two weeks of the treatment. (Compton et al., 2019). No special

training is required for doctors working in an OPP to prescribe methadone.

Buprenorphine or suboxone is a high-affinity partial opioid agonist and an antagonist

(Compton et al., 2019). It has proven to be effective in the reduction of cravings and withdrawal

symptoms. Its chief advantage is its safety because it depresses respiration less than other opioids

and reduces overdose risk. It should typically be considered a treatment for those considering

detoxification, those with no history of injecting, and where methadone, a maintenance

treatment, has previously failed. In the United States, buprenorphine can be provided in the

opioid treatment program, but it is mostly prescribed in an office-based setting (Compton et al.,

2019). To treat OUD with buprenorphine, prescribers must undergo additional training and

obtain a waiver from the Drug Enforcement Administration.

Naltrexone is not an opioid but a complete antagonist of the mu-opioid receptor. It works

by completely blocking the euphoric effects of all opioids. Naltrexone treatment is complicated

because of its mechanism and long duration of action. Since it can lead to severe withdrawal

symptoms, this treatment typically requires medically supervised withdrawal followed by at least

seven days without any other opioids before it can be started. This is considered one of its main
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disadvantages. Naltrexone works best for patients who need to avoid any opioids and to prevent

the risk of relapse.

According to a review of medication to treat OUD, “the evidence for efficacy both in

reducing opioid use and retaining patients in care is strongest for agonist treatment” (Connery,

2015, p.2). People who abuse opioids are less likely to die while receiving treatment (Leshner et

al., 2019). It is estimated that medicinal treatment has led to a 50% reduction in mortality rate,

including overdose deaths (Sordo et al.,2017). Treatment with methadone or buprenorphine is

also responsible for improved social functioning, decreased injection drug use, and reduced HIV

and HCV infections compared to individuals not in treatment (Leshner et al., 2019).

Buprenorphine treatment has been linked to better fetal outcomes. Infants tend to have less

severe symptoms of neonatal abstinence syndrome when their mothers have been treated with

buprenorphine (Thomas et al., 2014). Many comparative studies suggest higher retention in

treatment and patient satisfaction with methadone (Ali. et al.,2017). While buprenorphine

maintenance treatment is as effective as methadone, it is less effective than methadone at

keeping people in treatment. In contrast to methadone and buprenorphine, randomized controlled

trials have been much less in the case of Naltrexone. Clinical studies demonstrate that oral

naltrexone does not seem to lead to long-term treatment adherence and has a higher mortality

rate after the patient is discontinued (Degenhardt et al.,2015).

Despite solid evidence for the effectiveness of medications for opioid use disorder, there

are barriers to using this treatment. These medications carry a certain level of stigma. Healthcare

professionals see these treatment medications as very similar to illicit opioids. Treatment

professionals also suspect profit motives of facilities offering these medications (Madden et al.,

2022). They also view people with OUD as lacking self-discipline. The fear of misuse and
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diversion of drugs prevents health professionals from prescribing them. Only a limited number of

providers pursued the waivers required to issue buprenorphine. Until recently, only two to three

percent of physicians were waivered, and most of them were based in urban areas, limiting

people's access to this medication in rural areas (Leshner et al., 2019). This limits access to

buprenorphine. Cost is also a barrier because it is an expensive medication, and low-income or

uninsured people cannot afford it (Compton et al., 2019). There is a lack of professional training

for healthcare professionals and personnel in law enforcement and the judicial system. A lack of

integration exists between the delivery and care of OUD treatments within the more extensive

medical system (Leshner et al., 2019).

There are significant gaps in understanding which medication works best and for whom

and the long-term efficacy of these medications (Leshner et al., 2019). Another limiting factor is

that the medical treatment for OUD has only three main drugs. Future research must include

other treatment options to increase treatment rates and provide individualized care for people. It

would be beneficial to do further exploration of opioid signaling. Most current treatment options

are based on the opioid reward pathway, but advanced studies need to be done on other neural

systems like craving and cognitive control. There is also the need for research on the

medication's relative effects on brain functions and social outcomes. Although there is evidence

that individuals may respond adequately to medication management alone and medicines prevent

OUD death and stabilize patients, it does not deal with the many other complex psychiatric,

medical, and social problems individuals with OUD have. There are very few studies that have

been done on the effectiveness of different types of behavioral interventions along with

medication. Future research will also examine how variation in intervention stigma towards

different types of mood is seen and experienced by patients and how provider-based stigma
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towards Medication based opioid use disorder (MOUD) influences treatments (Leshner et al.,

2019).

Psychosocial Interventions

In a recent study, people who received treatment for addiction reported that

psychotherapeutic and spiritual interventions, not medications, contributed to their long-term

sobriety success. (Geyer, 2023). Since MOUD is considered the first line of treatment and helps

stabilize cravings and manage withdrawals, various psychosocial interventions can address the

patient's long-term social, mental, and emotional health. There are different psychosocial

approaches to the treatment of OUD. They include cognitive behavioral therapy, motivational

interviewing, contingency management, and relapse prevention.

Cognitive behavioral therapy is done in an individual or group counseling setting

(Compton et al., 2019). It focuses on the relationship between thoughts, feelings, and behaviors

and how that affects and perpetuates OUD. CBT helps patients recognize negative thought

patterns, belief systems, and perceptions and how to replace them with more rational ones,

leading to changing problematic behavior.

Contingency management involves offering rewards and other incentives for good

behavior (Compton et al., 2019). It is goal-based and could include attending therapy sessions,

not using drugs, or using medications as prescribed. Voucher-based reinforcement is also used to

exchange outers for food and services. Conversely, the voucher is withheld if the individual does

not perform or fulfill the goal. The incentives offered range from financial rewards to

opportunities to participate in events. The limitation of contingency management, however, is the

availability of funds for providing the reinforcers in clinical settings. Some clinics are trying to

counter this by offering job-based reinforcements instead of cash reinforcements.

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Motivational enhancement therapy guides people through thought processes that cause

them to want to change or improve their behavior to achieve specific life goals and desires

(Compton et al., 2019). Open-ended questions, affirmations, reflections, and summaries are all

part of the skills used in this therapy. The focus is to guide the patient towards the positive

impact of changing harmful behavior while helping them to identify how current actions prevent

them from achieving their life goals.

According to an article in the American Psychological Association (2019), standard

behavioral therapies have minimal efficiency in addressing the complex symptoms and physical

aspects of opioid use disorder. Psychosocial intervention is typically done in combination with

the use of medication. It has been observed that when patients were provided CBT in

conjunction with medication, the CBT participants displayed significant improvements in their

positive appraisal and lower emotional discharge (Dugosh et al., 2016). When behavioral

interventions are used with medications to treat OUD, they target many problems and issues that

cannot be dealt with alone, like comorbid psychiatric symptoms, lack of social support, etc. It

also helps address limitations associated with each medication, like high attrition rates.

Contingency management interventions that reward positive behavior have been proven effective

in conjunction with methadone treatments. Treatment retention has also been seen to improve

when one of the incentive vouchers is take-home medication.

Other incentive programs, such as vouchers for goods and services for reward time

without drug use, also seem to reduce illicit drug use (Leshner et al., 2019). A study with eight

randomized controlled trials and a systemic review found mixed results concerning behavioral

therapy when administered with buprenorphine. Four of the trials found no additional benefit of

behavioral therapy interventions. However, the other four randomized controlled trials
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demonstrated a further use of behavioral interventions (Carroll & Weiss,2017). However, apart

from contingency management, there is no clarity on which behavioral intervention works with

which medication. One determining factor as to whether to start with psychosocial interventions

is the level of severity and addiction. A person who has just started experimenting with opioids

but has not yet developed physical dependence may benefit from psychosocial intervention to

address the drug use and prevent it from escalating. An individual diagnosed with high levels of

addiction to opioids may benefit best from being referred to an inpatient service that provides

detoxification followed by amity and, eventually, outpatient treatment (Compton et al., 2019).

Future research needs to be done on the relationship between behavioral intervention and

medication adherence (Leshner, 2019). It also needs to be stated that investigating behavioral

techniques to facilitate improvements in psychiatric, legal, interpersonal, and occupational

functioning may support sustained remission. Future research must also focus on providing peer

support to enhance treatment. Peer support groups like the 12 Steps have been very effective in

alcohol addiction scenarios. Although there are similar programs for drug addiction, further

research needs to be done about whether peer support groups will increase treatment engagement

and reduce substance use and risk behaviors. Very few studies have investigated the

effectiveness of different behavioral interventions in treating OUD at different phases of care

(Leshner, 2019).

Prevention of Opioid Abuse

Recommendations for the prevention of opioid abuse come from governmental agencies,

professional organizations, academic organizations, institutions, etc. (Compton et al., 2019). A

report issued by the Substance Abuse and Medical Health Services Administration Center for the

application of prevention technologies in 2016 listed four areas in which prevention programs
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can be developed: education tracking and monitoring, proper medication disposal, and

enforcement of laws. Healthcare workers like physicians, dentists, pharmacists’ nurses, and

physician assistants who write to fill prescriptions for opioids and deal with patients at risk or

already in addiction should be updated. It has been identified that opioid abuse is rarely

discussed adequately in professionals' training experiences. Many healthcare workers have

reported that they have had only a few hours or no instruction at all on the topic of drug abuse in

their training programs. One example is the risk evaluation and mitigation strategy program

administered by the FDA. This law requires the FDA to require drug manufacturers to have

programs to explain a drug's relative risks and benefits to healthcare workers. Another place

where education is necessary is in the schools and colleges. Plenty of programs from commercial

publishers and professional organizations can be used at individual schools and college districts.

Opioid and heroin addiction and other awareness training courses should be implemented as part

of the curriculum for all incoming students in a university. The most common approach to

training at the college level is the use of free online courses on different opioid abuse topics. For

example, the Harvard University online learning website offers a course called “The opioid crisis

in America” as part of its global health and medicine series.

Another means of prevention is properly disposing of prescription painkillers (Newton,

2018). In a 2017 study, researchers reported that 65.2% of individuals over the age of 12 who

abused opioids obtained them for free by paying for them or by stealing from a friend or relative

(Lipari & Hughes,2017). Many individuals who get prescription drugs legitimately do not store

them properly in the medicine cabinet at home. Neither do they dispose of unwanted or unneeded

medications properly. Most times before 2014, the only legal method of disposing of unused or

unwanted prescription drugs was to flush them down the toilet, throw them in the trash, or send
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them to law enforcement agencies. Then, the DEA established various disposal techniques, such

as mail-back programs and community take-back events.

Enforcement of existing laws regarding the crisis should be part of the prevention

program (Newton, 2018). There is a range of rules that can be used for the investigation of illegal

manufacturing and distribution of opioids. There are pill mill laws aimed at pill mills, which are

doctors' offices that dispense controlled substances out of the scope of the law and doctor

shopping practices. These laws included increased criminal penalties to address doctors and

clinics convicted of prescription drug trafficking. It is recommended that stricter regulations

surround the increased monitoring of pharmacies and companies that dispense prescription

drugs. However, one of the unintended consequences of these laws has been the rise in overdoses

from using illicit drugs like fentanyl when patients lose access to prescription opioids. Syringe

exchange and syringe needle access programs, developed in the context of HIV prevention and

treatment, currently provide services specific to opioid use, including primary prevention of

overdoses, provision of naloxone for overdose reversals, and connection to substitute substance

abuse treatments. Unfortunately, currently, these programs are not accessible in the United

States. As of 2017, only 196 cities on the East and West Coasts offered such programs (Newton,

2018).

Opioid Abuse across Culture and Race

The OUD epidemic initially in the 2000s was most prevalent among the white population

in suburban and rural areas (Compton et al., 2019). There has been an increase in opioid

prescriptions among the white population because of factors like the high prevalence of chronic

conditions and pain and higher enrolment in Medicaid (Guy et al., 2017). Research has also

shown that doctors are more likely to prescribe opioid painkillers to whites than any other
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population due to racial bias and stereotypes, thereby increasing the use of prescription opioids

and the risk of addiction. Blacks and Latinos are less likely to be insured and have less access to

medical care, which for the longest time served as protection against medical opioid addiction.

Opioid overdose deaths remained relatively stable between 1999 and 2010 among blacks and

Hispanics. However, since 2010, there has been an increase in the death rates due to fentanyl.

This is partly because morbidity and mortality from conditions related to intravenous opioid use,

such as HIV and HCV infections, are high among black people (CDC, 2018). American Indians

have the highest rate of opioid overdose death of any racial group, although the medical

community and the public have overlooked it (Compton et al., 2019). This rate is due to the

inequities in rates of depression, post-traumatic stress, violence, and suicide, along with limited

treatment resources in tribal and Indian health services facilities (Gone and Trimble, 2012).

There has been a shift in the afflicted demographic from rural white to urban black Americans

between 2017 and 2019 (Gondré-Lewis et al., 2022). This finding should contribute to a national

recognition of the shift in the profile of the opioid epidemic and serve as justification for

resource allocation to address opioid addiction in black and American Indian communities.

Role of Faith-Based Agencies in the Opioid Crisis

Faith-based communities respond to the opioid crisis largely reactively rather than

working toward prevention; at least research appears to indicate such. Studies point to the

efficacy of faith-based treatment programs such as the 12-step or Celebrate Recovery (Brown et

Al., 2011). Addiction recovery paradigms show the importance of self-efficacy, meaning an

individual’s faith and confidence to remain sober in recovery. Research indicates that an

individual’s spirituality, at least within a faith-based recovery program, might contribute to their

rescue by increasing this self-efficacy (Brown et Al. 2011). Qualitative studies also indicate the
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need to respect and accept different recovery pathways (Von Greiff & Skogens, 2021).

Furthermore, many voices in the medical community argue that programs offered by faith-based

communities to address opioid addiction fail to provide other types of treatment programs that

might be more beneficial to an individual’s recovery, such as medication-assisted therapy

(Woody, 2015). So, while faith-based communities offer programs that work for some

individuals’ recovery from opioid addiction, there is room for growth in prevention and

advocating for an individual’s best treatment plan.

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