The Opioid Enigma: How Can We Tackle This Public Health Crisis?

Written by: Tressel Holton

Edited by: Celine Cotran and Mark Nashi

Illustrated by: Rebecca Sidi

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Entangled in the roots of the poppy, opioids—and their predecessor, opium—have intertwined with human society since prehistory. The Unani branch of medicine sprouted around 2.6 million years ago during the Stone Age, promoting the herbalistic conversion of poppy juice into opium medicine [1]. By the sixth millennium BCE, Neolithic tribes in the Mediterranean region introduced poppy farming to their agricultural communities [2]. In the tenth century, opium joined the extensive medical catalog of India, where the subcontinent’s kaleidoscopic diversity enabled the drug to assume additional roles ranging from aphrodisiac to spiritual experience [3]. And in the past 300 years, opioids have evolved from nature’s narcotic into a global threat.

A proper understanding of opioids demands a corresponding understanding of pain. The multifaceted umbrella of pain includes physical sensations—such as burning or prickling— alongside complex emotional and cognitive experiences. The 19th-century cardiologist Sir Thomas Lewis summarized pain best by acknowledging its enigmatic qualities, pondering how he was “so far from being able to define pain…that the attempt could serve no useful purpose” [4].  From the physician’s perspective, pain acts as an early warning system, rapidly alerting individuals to looming internal or environmental dangers [5]. It serves as the nervous system’s emergency response mechanism [5]. This function is invaluable to a physician seeking a swift diagnosis, yet pain-related disorders can overwhelm patients, complicating efforts at effective treatment.

Before delving into the socio-cultural dynamics of the opioid crisis, a medical understanding of opioids and pain is imperative. Pain identifies and addresses imminent physical threats via biological signaling in the nociceptive, or pain, system. It is triggered when a sensory neuron transmits a pain signal from the damaged tissue to the spinal cord, prompting an immediate reaction [6]. In the instance of a nonvenomous snakebite, pain may be momentary, but serious causes, like venomous punctures, can lead to chronic pain that lasts for decades [7].

Pain, as a mere biological function, is not inherently devastating. Our skin is designed to process three main types of sensation: temperature, pressure, and pain [8]. Rather, our innate association of pain with aversive (unpleasant or painful) stimuli drives us away from sources of pain [6]. As such, pain biologists seek to understand the relationship between emotion and pain. Despite advances in treating physical pain through modern medicine, emotional pain can often feel more overwhelming. Understanding the full spectrum of physical and emotional pain is essential for improving patient well-being. Effective pain mitigation, therefore, requires addressing both dimensions of pain to enhance quality of life. This fulcrum between physical and emotional pain is where opioids tend to strike [9].

The medical field became reliant on opioid prescriptions to alleviate the physical and often emotional suffering that patients endure from pain. The term “opioid” refers to any medication designed specifically for binding to the opioid class of hormone receptors, many of which are intertwined with the nociceptive, or pain sensation, system [10]. Originally derived from poppy seeds, opium is a powerfully addictive narcotic drug. Several common opioids include hydrocodone, oxycodone, oxymorphone, methadone, and more widely known medications like fentanyl and morphine. There are over 100 variations of opioid medications currently available, and their common qualities of intense pain relief and high risk of addiction are intertwined with their interaction with opioid receptors [10].

Opioids share a common function by interfering with the body’s pain-signaling system. The human body contains numerous receptors for intercellular communication. When an opioid molecule binds to an opioid receptor, it inhibits pain signals, preventing them from reaching the brain and creating a sensation of relief [11]. However, opioids do more than inhibit pain—they also influence mood, often inducing intense euphoria. This pleasurable sensation, while useful in treating acute pain, also contributes to the drug's addictive nature [11].

Opioids are also capable of influencing the entire nervous system beyond the pain receptors. A 1784 study published in the London Medical journal details opium’s early usage in the treatment of “mortification,” an outdated term for dead tissue that we would consider gangrenous—rotted due to bacterial infection [12]. The patient in question was suffering from excruciating pain due to necrotic tissue in his leg, which contributed to his difficulty in sleeping. His surgeon provided him with a prescription of opium, which not only alleviated the pain but also enabled easier sleep and stimulated intense euphoria [13]. By itself, euphoric pleasure presents no significant problem, as it is a natural response to pain relief. However, the intensity of opiate euphoria would later prove to be a major driving force behind opium’s addictive properties.

We have discussed a few of the medical consequences of opioids, but the opioid crisis is ultimately a tragic societal disorder. Prescription opioid misuse tends to affect low-income communities the most, but members of any socio-economic demographic can become vulnerable to opioid misuse [14]. As individuals grapple with opioid use disorder (OUD) and the result of overdose, the consequences bleed into the lives of their loved ones, often inciting stress-based disorders like depression and anxiety [15]. Due to opioid addiction’s persistent nature, individuals living with OUD typically experience its chronic repercussions throughout their lifetimes. However, the high risk of overdose simultaneously threatens to cut many lives short [16]. As such, addressing and analyzing the opioid crisis demands methodical, comprehensive research.

According to a briefing by the National Center for Health Statistics, the rate of deaths by drug overdose nearly quadrupled over the last twenty-two years [17]. Currently, opioid medications are responsible for approximately 22% of drug-related deaths each year in the United States—a testament to the sinister threat they pose [17]. The use of synthetic opioids like fentanyl is also on the rise due to the highly addictive nature and relative ease of production these synthetic drugs possess [18]. Pharmaceutical researchers typically engineer synthetic narcotics to be more intense than their natural counterparts by disrupting a wider breadth of opioid receptors; this often produces a greater risk of addiction and, subsequently, a greater risk of overdose [19]. Ultimately, both natural and synthetic opioid medications endanger individuals in the US and abroad. 

Experts at Stanford University and Harvard Medical School confirmed these numbers, noting that almost 450,000 Americans passed due to opioid-linked misconduct between 1999 and 2018 at an increasing rate [20]. The ambiguity of dynamically threatening opioids makes crisis response challenging. Authorities are currently collecting data for a subsequent national report in 2025, but until then, the opioid epidemic is considered a profound public health concern.

What can we do to combat an enemy as complex as widespread opioid addiction and misuse? One solution lies in precision medicine, which tailors treatment to each patient’s unique physiology [21]. Some physicians currently employ a diagnostic scale that assesses how vulnerable a patient may be to opioid addiction and misuse, contemplating variables like family medical history, substance use and abuse, and biological predispositions to certain medications. Individualized treatment plans minimize the risk of abusing or misusing prescription opioids [21]. Alternatively, an immediate overdose response typically includes the use of naloxone, a fast-acting counter to opioids. Naloxone echoes the biochemical mechanisms of common opioids by binding to opioid receptors, reversing narcotic effects, and eliminating the present danger [22]. While safe and effective, naloxone is only an individual solution to a wider problem.

History indicates that the most effective counter to the opioid epidemic is reciprocal to its greatest proponent: societal norms. American and international legislation criminalizes opioid misuse with minimal social impact beyond targeting criminal empires [23]. By redirecting cultural focus against opioid misuse, public health groups like the World Health Organization aim to stigmatize drug abuse and normalize safety around prescription drugs. Just as perceptions of peer pressure abet the creation of OUDs, a culture of drug safety should alleviate societal danger and limit the detrimental impact of the opioid crisis [24].

Ultimately, individuals living with OUDs are rarely content with their quality of life [25]. A mindset of empathy is critical when approaching emotionally charged conditions like drug abuse, and the patient’s well-being should always be prioritized. The Hippocratic Oath emphasizes the twin principles of beneficence—the exemplification of patient well-being—and non-maleficence—the avoidance of harmful actions [26]. These principles, embedded in the ever-evolving Hippocratic Oath, are linked to past medical atrocities, including—but not limited to—intentional opioid misuse [27]. By reframing the global approach to the opioid crisis around these pillars of beneficence and non-maleficence, the healthcare community can endeavor to swiftly and effectively address the consequences of opioid abuse.

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