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Introduction
Opioids are natural, synthetic, and semi-synthetic substances that interact with opioid receptors on nerve cells in the body and brain to diminish pain signals and sensations.
This category of narcotics includes heroin, synthetic opioids like fentanyl, and prescription pain relievers like oxycodone, hydrocodone, codeine, morphine, and a variety of others (CDC, 2018).
Prescription opioids, often known as opioid analgesics, are pain relievers used to treat patients with moderate to severe pain. It is only used for a limited period of time and only as advised by a doctor, but because it produces euphoria in addition to pain relief, it can be overused and lead to addiction. For mortality data, natural opioids, semi-synthetic opioid analgesics, methadone, and synthetic opioid analgesics are the different categories of opioids. Since 2007, fatal prescription (Rx) opioid overdoses have been the most significant cause of or contributor to death in the Commonwealth, with oxycodone being the most commonly prescribed substance (CDC, 2021).
The terms opiates and opioids are frequently interchanged; however, they are not synonymous. Natural opioids like heroin, morphine, and codeine are referred to as opiates. Natural, semisynthetic, and synthetic opioids all fall within the category of opioids. Between 2007 and 2015, opioids accounted for over 75% of all fatal drug overdoses in Virginia. However, due to a significant surge in fatal fentanyl and/or heroin overdoses in late 2013 and early 2014, this percentage is rising each year. One or more opioids were responsible for 83.0 percent of all fatal overdoses in 2020. All fatal opioid overdoses climbed by 47.5 percent in 2020 compared to the previous year (CDC, 2018).
According to the Centers for Disease Control and Prevention (CDC), from 1999 to 2014, the number of opioid painkiller prescriptions nearly quadrupled. Around the same time, from 1999 to 2015, the size of each patients prescription rose from 180 Morphine Milligram Equivalents (MME) to 640 MME, more than a three times increase. Patients who are given larger opioid dosages are more likely to die from an overdose. Higher opioid dosages are linked to an increased risk of overdose and mortality, but even low doses (20-50 MME per day) increase risk. Dosages at or above 50 MME/day increase risks for overdose by at least two times the risk at less than 20 MME/day. In the long run, higher dosages have not been proved to alleviate pain. There was no difference in pain or function between a more liberal opioid dose increase strategy (with an average ultimate dosage of 52 MME) versus maintaining the present dosage in one randomized experiment (average final dosage 40 MME). It should be noted that there is no safe dose of opioid. (CDC, 2018)
Some economists have referred to opioid overdoses as deaths of despair, citing the pandemic resulting from the fall in economic and social well-being. The death of despair theory matches well with the story of falling possibilities in Appalachia and portions of the Midwest, leading to people turning to drugs and alcohol. There could be a link between the rise in opioid overdoses and the loss in economic prosperity in some sections of the United States. On the other hand, other economists say that statistical examination of county-level overdose data reveals that the leading contributory causes are drug use in general. While the economic argument is compelling, they contend that it ignores aspects that contribute to increased drug use. This debate between academics is similar to the divide among policymakers regarding how to interpret the opioid epidemic (King, 2013). The opioid epidemic has been a problem in the United States for years, and the situation in some states is only getting worse. In particular, Virginia has seen a steady increase in the number of opioid overdose cases and deaths associated with it. The 2021 data also suggests that the situation is getting worse every quarter. 2021 is reported to have seen an increase in Emergency Department visits of Virginia residents with opioid overdoses. Moreover, in the second quarter of 2021, there is a significant increase in overdose cases compared to the first quarter. Every year, opioid overdose is the cause of the loss of not only people but also productivity. It is reported that economic costs of just the productivity losses in Virginia due to opioid overdose deaths, use disorders, and incarceration topped $1.5 billion in 20173(Fairfax county government, Opioid Use Disorder in Fairfax County).
Although many social scientists and economists have looked at multiple elements of the opioid epidemic, there has not been much research on all factors that contribute to the epidemic. At the same time, researchers and policymakers disagree about how the opioid overdose epidemic should be viewed. This study will look at a variety of variables. The emphasis of this study will be fatal opioid overdoses and their relationship with other independent variables.
Literature Review
These articles explore three different areas of the opioid crisis. The first few articles focuses on the determinants, these articles describe the information necessary to establish the basis for this study. The second part of the review looks at the history of opioid in the United States. Finally, politics and laws are explored as they affect the way opioid is distributed, and limited.
Determinants
Singh et al. (2019) address the national healthcare crisis presented by an increase in the number of mortality outcomes connected to drug and opioid use in the United States that took place in the last twenty years. The article analyzes the cases of mortality from drug overdose to define empirical trends in the social determinants and features a review of literature that focused on the opioid crisis in the United States.
The article is based on the National Vital Statistics System data that provided informational context to drug overdose cases with terminal outcomes. The information and analyses by different categories that intersect with socioeconomic categories of population, such as age, gender, and racial component, were provided by the National Center for Health Statistics. The authors used a log-linear regression model to estimate the change in the number of mortality outcomes over seventeen years. The literature review covers 39 articles that focus on epidemiology, pain management, and treatment policy.
The authors determined that drug overdose mortality outcomes have substantial disparities by geographic, racial, gender, and socioeconomic factors in their research. The research defined a correlation between the number of opioid prescriptions and factors of population size, education level, poverty level, and insurance status. According to Singh et al. (2019), economic conditions such as the populations economic opportunities and working conditions contribute to mortality cases from a drug overdose. Moreover, unemployment and economic deprivation in rural areas influence the fast distribution of opioids (Singh et al., 2019). The authors emphasize that the economic situation is connected to the use of opioids, which could weaken the economy with legal aftermaths such as the mass incarceration rate.
After the FDA approved the use of opioid drugs in 1995, many companies have multiplied their revenues through sales. It led to citizens becoming more and more dependent on painkillers. The narcotic properties of opioid drugs have led to the onset of an opioid epidemic since 2000, including increased overdose deaths. The aim of the thesis reviewed was to analyze regulatory and socioeconomic factors of the Opioid Crisis.
King et al. (2014) narrates about the determinants of mortality resulting from the prescription of opioids and their overdoses. The main situation was prescriber behavior, which was linked to an overall increase in sales of these drugs in the United States and Canada over time. It explains why researchers are paying close attention to the topic, despite the fact that it is a profitable but dangerous activity. As a result, gender and age are highlighted as the primary factors influencing the outcome of the proposed treatment in this article. According to the researchers, men are more prone to the dangers of opiate overdoses, and middle age is another risk factor. Alongside the fact of belonging to specific population groups, such as non-Hispanic Whites and American Indian/Alaska Natives, under these circumstances, it is possible to draw conclusions about the key features of those who are at risk. These data show that, in terms of the following tendencies, the socioeconomic status of the affected individuals is generally worse than that of other citizens.
In addition, the authors examined the significance of geographic locations in the matter. As follows from their statements, any of the specified circumstances should be viewed as belonging solely to particular areas to avoid bias. In other words, it is impossible to consider mortality rates from overdoses universal since they differ depending on peoples places of residence. This determinant positively correlates with the need for ensuring clarity regarding the patterns of drug distribution across the countries.
Carroll et at., (2012) narrates how previous studies of postoperative opioid use have not declared how a history of substance abuse and psychological state, rather than injury and pain, can provide for a patients ongoing choice to stop rather than continue opioid therapy. The number of opioids being released for pain reduction or other needs is overgrowing. However, it remains unclear whether or not patients stop taking them immediately after their intensities are over.
In order to compare the duration of drug use with the persistence of pain, the Pearson correlation coefficient was determined. Carroll et at., (2012) used Kaplan-Meier analysis and potential hazard regression. The type of operation was a possible hazard variable in all studies. Lumpectomy, mastectomy, and arthroplasty were performed on 1109 patients. Before the operation, each of them had their psychological distress and psychotropic drug intake measured for the experiment. The exact dimensions were likewise taken till the patients claimed that the painkillers had worn off or that they were no longer in discomfort. The time it took each person to complete their intake was the key unit of analysis.
The result was that 6 percent of people continued to take the drugs after 150 days had passed since the surgical procedures ended. Depression and feelings of increased anxiety were directly related to the administered intake. Carroll et at., (2012) also found that the decrease in the frequency of postoperative consumption depended on the preoperative medication viscosity. The model was tested, and preoperative factors, including legitimate doctors appointments, anxiety, and depression, were found to be the main essences of continued use of drugs than the pain experienced by patients.
El-Bassel et at., (2021) focus on the awareness of opioids and their danger to society during the latest decades in the United States. As a large number of people die from drug overdoses, one of the reasons for this is the release of some over-the-counter drugs. However, the global coronavirus pandemic has exacerbated drug exposure and dependence. It is worth noting that medication overtreatments and suicides are named deaths of despair. This phenomenon is created by social and economic reasons such as high poverty, income inequality, and unemployment. Moreover, in specific regions, due to the reduction of the labor market and the inability to access social capital, high isolation has arisen, affecting peoples morale and emotional state. Moreover, it is statistically substantiated that black people from poor regions are more dependent on opioids.
Improving the social and economic situation to decrease poverty has been a means of opposing drug use. The article draws attention to racial and economic inequality, which leads to the limited access of indigenous peoples of the United States to treatment. Moreover, feelings of marginalization and reduced institutional support policies are reasons for decreased access to health care. At the same time, the cessation of funding for programs for drug addicts or the non-inclusion of poor people has a harmful effect on the situation. El-Bassel et at., (2021) highlights in the article the problem of narcotic use by pregnant women and argues that most of them can refuse the habit during pregnancy. However, their decisions are also influenced by many circumstances such as social status, level of financial support, and environment. In order to reduce the death rate from painkillers, the state and local governments need to increase funding for research into its causes. At the same time, there is value in investigating and developing cultural intervention strategies.
Desveaux et al., (2019) looks at family physicians and factors that cause their opioid prescribing habits. Opioids are required to effectively treat a large number of non-cancerous diseases. Therefore, doctors often prescribe high doses of painkillers to patients, which has caused concern due to the spread of drug abuse. Thus, experts have recently begun to prescribe narcotic pills in fewer doses. However, there is a tendency that not all physicians support this rule. In order to understand the need to prescribe such medications and decrease doses, people need to understand the basic principles of treatment. Additionally, the article notes that the current stage of prescribing such medications to those with mental illnesses is limited to a lower dose. Research shows that the state funds training and hiring specialists in neurotic issues in the primary care teams. This capital allocation makes a long-term contribution to the fact that patients will immediately receive treatment with accurate dosages of drugs. According to these physicians and specialists, sufferers will not become addicted to narcotics emotionally and mentally.
Desveaux et al., (2019) based the article on an analysis that claims that more experienced doctors use more potent painkillers in their practice. At the same time, young professionals, on the contrary, try to adhere to all the standards recommended by the government. However, specialists explained that attempts to decrease the dose of drugs were unsuccessful as such actions either did not help to mitigate pain in sufferers or disturbed their mental state. Accordingly, people who had financial means tried to find drugs outside hospitals. It is important to note that the difficulties of drug treatment are also related to a lack of research and availability of alternative treatments. Thus, today, there are significant gaps in medical practice that will lead to negative consequences.
Sugarman et al. (2020) based the article on previous studies that maintain that the mortality of former prisoners from painkillers is 13 times higher than in the rest of the population. In the United States, there is a problem of a drug overdose in the criminal justice system. However, statistics confirm that opioids cause one in eight deaths among convicts. Such indicators can be explained by many factors, such as distrust of the medical system. Additionally, such circumstances are a sudden return to drug usage after freedom or continued treatment with opioids on their own. Besides the treatment, economic and social factors are also significant. Thus, a possible negative effect is if former prisoners are released and returned to an unfavorable environment that encourages drug use. Moreover, ex-prisoners or defendants have certain limitations in the social conditions. For example, economic factors such as lack of access to high-paying jobs and resources have a detrimental effect on peoples morale, forcing them to use drugs.
It is essential to emphasize that the article considered studies that reported the impact of treatment on the subsequent lives of prisoners. After analyzing the statistics, it can be concluded that the medical interventions that began at the start of the imprisonment period had a significant positive effect on the results of opioid usage. Thus, there is evidence that medical treatment while serving a sentence is an effective method of preventing the use of narcotics after freedom. At the same time, support for former convicts also included social adaptation and financial assistance. It was confirmed that such actions helped the program participants feel comfortable in the social environment.
Wall et al. (2000) aimed to assess opiate users who are not in treatment for addiction and calculate social expenditures based on the results. To estimate data, a typical human capital approach was used, and an anonymous survey was undertaken to gather the required socioeconomic information. The annual expenses paid by this sample were estimated to be around $5 million dollars. Its a big number, and it means that the social costs per person are around 40-60 dollars. It has a significant negative impact on the economy as well as the overall level of illness and death.
An analysis of this data was done to estimate the total economic burden from the study sample of dependent people. For this purpose, the sum of the economic activities reported by respondents was used. The cost, in turn, was calculated as the product of the reported activities over 12 months multiplied by the corresponding unit cost and adjusted for the fate associated with opioid addiction. All results are divided into appropriate sectors that reflect the level of economic loss. For example, health care costs were $311,000 and related primarily to high loads and drug expenses.
Furthermore, untreated opioid addiction results in weighty law enforcement costs. The research also discovered that the level of expenditures in the health care sector for drug addicts is about 42 percent, which is a significant blow to the economy. Programs to control opioid use behavior are ineffective and will incur many economic costs. Therefore, new plans need to be introduced with radically different approaches to reduce social expenses.
Rudd et al. (2016) provides statistical information on drug overdose during 2010-2015. In connection with the problem of opioid use and mortality due to overdose, the question arose about the study of the root causes and drugs that impose it. However, certain types of pills have been selected that contain high levels of drugs and relatively impact human health. The study compares the rates of mortality from drug overdoses provided by 28 states. Thus, it was found that 61 percent of all deaths caused by overdoses were related to opioids. Accordingly, government agencies responded to the statistics by introducing guidelines on the application of opioids. However, it was difficult to determine which drugs produced the death. It was found that several cases of opioids caused some losses, or the registers did not indicate which type of medication led to the overdose.
The research presented in the article allows people to conclude, such as the recent increase in the number of deaths produced by heroin and synthetic opioids (except methadone). It is essential to note that an analysis of trends in methadone-induced death was performed. It has been established that since 2008 the authorities action against high doses of opioids and new clinical guidelines have had the effect of reducing mortality. Thus, such an example shows the influence of compliance by physicians and patients with legislative changes. In addition, the article argues that heroin and fentanyl pose the greatest threat to public health. Hence, in order to decrease opioid usage, interactions between health and public safety need to be coordinated.
Alexander et al. (2018) explores how ethnicity can be crucial for understanding long-term biases in opioid use. For this purpose, a statistical analysis was conducted, and a table that accounted for mortality rates according to race and type of painkiller was created. Technical programs and delta approximation were taken into account for the morbidity valuation. There were three major waves of opioid-related deaths between 1975 and 2015. The first affected all populations equally and was caused primarily by heroin. Although mortality rates were higher among the black population, the increase was the same. The second was caused by prescription or semi-synthetic substances; during this period, the rates among the white community began to prevail.
The third wave is sprung by heroin and synthetic opioids and concerns both groups. The epidemic of abuse is rapidly unfolding, but clinical behavior differs significantly by ethnicity. Through analysis of the data, it was found that mortality rates also rose unevenly. Heroin use increased proportionately for both populations, while the data for other opioids were different. While it grew steadily for whites, rates among blacks remained stable between 1994 and 2011. It is related to a large number of prescription drugs and the use of opioid painkillers. It led to several initiatives to curtail the number of such medications, and therefore the death rates began to stabilize. However, widespread heroin use is still a problem, and consumption speeds are skyrocketing in both populations.
Politics
Since opioids have always represented a polarizing issue with only two approaches, namely, that one of a ban and that one of allowing opioids as medications in their entirety has developed. The current stance on the subject at hand is complex primarily due to the socioeconomic and sociopolitical contexts related to the issue at hand. By considering opioids outside of the political and economic settings, one will recognize the necessity to use the specified medication to manage constant pain and the method of addressing the related concerns.
Moffitt (2020) analyze the abuse of painkiller drugs and its effect on the credibility of the health care system and diminished economic progress. The economic and social situation in the United States of America was negatively affected by the overuse of opioids. Medical structures and programs in the criminal justice system were brought in to deal with the obstacle. At the same time, government policies and the steps taken by regional agencies also had a significant influence on preventing the spread of the opioid epidemic. It should be regarded that the high mortality from overdose was among black people, and racial theories were strong. Additionally, there are statistics from which it can be argued that legislators were more reasonable to support bills during the opioid epidemic. At the same time, many ordinances were passed during this period that was focused on providing treatment for addicts.
Furthermore essential is how the media covered the trends that dominated Congress on the opioid crisis. The study noted that journalists often used medical terminology and pharmaceutical issues when discussing opioids. Instead, during the cocaine crisis, more attention was paid to criminal justice. The article provides an example of state Medicaid and opioid assistance plans. That is, it can be observed that conservatives rely on the fragmentation of the program. The opioid crisis only reflects the domestic situation in the United States. That is, the problem of racial policy, health care delivery, and institutions of incarceration are rooted in structural challenges that have always existed in the public system.
Another source that addresses the issue of the opioid epidemic in the U.S., the article by Green et al. (2015), discusses specifically the case of Naloxone in five American states, applying a legal perspective. Namely, the study emphasizes the evident presence of an overdose risk in a patient to whom opioid treatment has been prescribed. The study shows that, when left to develop uncontrollably, the issue of opioid dependency becomes a tremendous health issue that affects patients quality of life.
The studys findings show that a better approach to treating pain in patients with severe diseases is required to avoid such negative consequences for them and their health. As a result, the article emphasizes the critical importance of reshaping current rules to make opioid treatment more accessible to patients while also reducing negative effects by integrating more modern approaches to the therapy. Third-generation opioids, in particular, must be incorporated into the current healthcare environment, particularly in pain management.
The study inspires further considerations of the opportunity to focus on the needs of patients requiring pain management, highlighting flaws in current legal standards and a lack of unity in approaching the issue of the opioid epidemic in the United States from a legal and political perspective. Third-generation opioids, in particular, which have a low risk of addiction, must be included in the framework and funded appropriately.
The threat of overdose, which is the logical progression of opioid dependency in patients and leads to unavoidable death, has also been thoroughly examined, with the implications of political and economic changes serving as critical precursors to incorporating the practical steps into the current framework for caring for patients in need of pain management. The existing variations in delivering opioids as part of preventative care for patients in need of pain treatment, according to Campbell (2020), mirror inconsistencies observed in certain areas.
The lack of access to crucial healthcare resources for vulnerable people, notable representatives of ethnic and racial minorities, has been identified as a significant issue in the current opioid crisis scenario. Indeed, in the absence of better pain treatment options, therapists turn to prescribing first-generation opioids to patients in need of pain relief, increasing the problem of opioid addiction in the United States.
Finally, Shepherd (2021) sheds light on the current opioid crisis, highlighting the tendency for federalization to influence the current political stance on healthcare development significantly. According to Shepherd (2021), the lack of consistency in addressing the opioid epidemic and prescribing opioids has defined the rise in patient levels of opioid dependency. Therefore, this research encourages social and political change by recognizing the current presence of economic differences in the United States, the lack of resources and access to healthcare in the target population, and the flaws in current legal standards for administering opioid treatments to patients in excruciating pain.
Applying the political and economic lens to the issue at hand, one will realize that although the general discussion associated with opioids typically leads to the assumption that the use of opioids as the healthcare tool for ameliorating pain, the introduction of a pain management strategy that will allow avoiding the use of opioids is virtually impossible. Therefore, to minimize the number of cases of patients developing a dependency, healthcare professionals must consider the issue of opioid usage as a part of the treatment with due care and consideration.
History
Over the past decade, opioids have warranted a significant amount of suspicion from patients and healthcare providers alike. Due to the high rates of dependency development and the difficulty of overcoming the addiction, opioids have become notorious for their massive side effects and their threat to patients. Thus, the core factors in the emergence of the present-day opioid epidemic become apparent since opioids have been prescribed for patients suffering from immense pain, thus, causing them to develop an addiction. However, the specified stance has not always been the prevalent opinion regarding opioids. Delving into the history of U.S. medicine and the process of building healthcare in any other country, one will recognize similar patterns.
Shulte (2018) provides an in-depth analysis of Purdue and its marketing strategy, which has led to numerous civil lawsuits and the beginning of an epidemic of addiction. A review of their marketing position shows that about 75 percent of all investment in advertising was spent after the number of deaths and abuses began to rise. The drug makers funded virtually all areas of health care to control standards of opioids and to encourage pharmacists to profit from prescribing their medicines. The company had a perfect cost-effective strategy to expand the market and increase sales. Their main goal was to retain the leadership position and become the highest sales volumethe figures provided for more than 75 million dollars in profits for a year. The company also conducted mass mailings and sent their sales agents to hospitals and companies to achieve the desired. At the same time, the major risk for the corporation were leaks and the spreading of information about the adverse effects of the prescriptions.
The drugs became increasingly addictive, and as a result, the company was hit with many lawsuits. They had to pay criminal indemnity however this compensation is disproportionate to the economic damage from the abuse, which exceeds $500 million. The aggressive advertising of opioids has brought considerable profits to the producers and, at the same time, led to an addiction. Claims against the company continue to this day. Still, they have not been successful, and the opioid crisis has already led to a decrease in the average life expectancy of Americans.
Ryan et al. (2016) writes about Purdue Pharma, which promoted and produced a drug that was supposed to relieve pain twice as effective as other medications. Due to their unique properties, these drugs became the top-selling painkillers in America. However, there was a bitter truth behind such high numbers because OxyContin is similar in properties to heroin, and those who used it felt a regular craving. Without OxyContin, people felt pain, nausea, and trivia, while each subsequent dose produced euphoria. This particular drug is considered the beginning of the national epidemic of prescription opioids, which has caused several hundred thousand deaths.
While its manufacturers point solely to its 12-hour effects, analysis of the information gathered suggests the exact opposite. There were numerous cases when a perfectly healthy person became psychologically and physically ill due to taking this medicine. The manufacturing companies for a long time did not recognize the harmful effect of the drug and claimed that it is effective, safe, and lasts longer than other painkillers. At the same time, their studies showed that patients switched to 8-hour dosing over time, which the producers did not admit.
Moreover, before this pill, narcotic painkillers were considered very dangerous and were used exclusively for cancer patients, while Purdue has dramatically expanded the market. Addiction and overdose rates skyrocketed along with the rise in prescriptions. The criminal prosecution was launched and found the company guilty of significantly changing the addictive effects of the drug, and they paid a fine of $635,000,000. Over the years, the number of court cases has only increased, but the drug remains prevalent.
In order to understand the problem of the opioid epidemic in the U.S., one will need to consider the very beginning of the problem development. Specifically, tracing the origin of the issue to the beginning of the 20th century, one will realize that the issue has been addressed. Namely, the study by Shepherd (2021) indicates that the specified approach to managing the problem of opioid addiction is rooted in the history of the specified medicine development. Thus, to counteract opioids in the current healthcare setting, one will be able to make a difference in the rapidly changing world.
Despite the fact that there have been several initiatives to address the opioid epidemic, the outcomes have not been outstanding. Guy et al. (2017) detail the history of the opioid epidemic in the United States, arguing that the widesprea
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