Personal Conclusions

G Cabrera: While doing this job, I found out a couple of things: the heroin epidemic never was overcome and society has a lot more power than what is granted for. The heroin epidemic was in the background after the 60’s decade, since it was per say controlled but was never eradicated fully. This is because similar medications to heroin where giving as a treatment for pain management. The upbringing of the opioid epidemic is an extreme case of an out of control epidemic, which is not seen in the US since the vaccines were implemented compulsory. Since most of the old epidemics consisted in killing viruses and bacteria, a new method to fight this type of epidemic has been issued since it is not cause by either of them (virus or bacteria). Even though at first it was battled with justice, it was noticed that this was a wrong way to face the illness. This is where society has to step up. The first mere advances to overcoming the epidemic are brought by people looking for a change in their communities. By doing this and showing results, their governments ensued policies that made somewhat easier their projects and made policies to make a constant progress of some kind. Even though, at some level, society is depreciate at some extent by some governments; it has the power  to overcome a lot of issues by itself, and this epidemic is an example of it. The only challenge that society has is to keep focus on the task at hand.

P Cruz: The growing opioid epidemic is concerning. What started off as a mild problem has turned into a socio-economic issue that impacts those closest to us silently. Looking for epidemiological statistics regarding opioid abuse and overdoses in Puerto Rico was very difficult and unfruitful. The government of Puerto Rico needs to take this problem seriously, taking legislative measures to ensure the safety of their citizens. Even though Narcotics Anonymous is a good and free option for opioid abusers and addicts, the accessibility to pharmacological treatments is very poor. Measures discussed in papers such as providing naloxone to relatives of known and previously treated opioid abusers seemed like a very effective option for preventing deaths due to overdoses. I’m aware that ASSMCA trained professionals such as paramedics and policemen recently to assess during opioid overdoses, but sometimes these people can’t arrive on time. Health insurance companies covering treatments would also be a good option to prevent drug abuse and overdoses, helping those that don’t have the income to cover such expensive options. Opioid abuse is a public health matter that needs to be taken more seriously.

A Colón: Through the process of the making of this blog, this author has managed to learn several important facts involved in our current opioid epidemic. I believe this epidemic is in great part caused by the health institutions themselves and their wanting to please the customer, being that this has caused many physicians and other health professionals to prescribe opioids unnecessarily. Many times drug screenings may be necessary and they’re not available at a moment’s notice due to lack of equipment or the physician’s own careless attitude. I’ve learned that wanting to please the patient has caused medical treatments to rely on opioids where they’re not necessary and may even be more hazardous to the patient’s health. In order to stop or lessen this opioid epidemic health institutions and their employees must begin to treat patients more responsibly and use medications backed up by science, not just rely on pain relievers that in the end might worsen the patient’s health and lifestyle.

D Guevara: Personally with this blog I learned many things. First off, Puerto Rico needs a more efficient way of complying all statistical information and a way to make this information public to all who need it. Whether for governmental reasons or for Public Health betterment, this type of study is key to understanding a worldwide epidemic. I think that the fact that the US has more resources leads to them being able to carry out more extensive research for a more significant study, that covers all the bases specifically. With the opioid epidemic, I would say that even though statistics show a reduction in usage from the beginning of the century, overdose statistics are still escalating quickly. More active action is needed to get to the true roots of the problem.

C Morfi: The opioid crisis has been progressing quickly yet it has been thoroughly documented to be studied from a statistical perspective. Being able to analyze the data and obtain trends and other useful data is what will aid in deciphering what our next steps will be to help those suffering due to it. And even though we have the data, we can’t forget that each new subject added to the data is an individual who is suffering and deserves a better standard in life. Also, it is highly worrisome how Puerto Rico lacks in statistics and data even though there’s clearly not a lack of people with opioid use dependence. Hopefully soon we will begin to document and analyze based on their experiences to get a better understanding as to what and how they should be treated.

Statistics of Medical Use of Opioids

Opiates are the most potent analgesic agents, therefore, they’re used commonly for the treatment of acute severe pain following trauma, extensive burns or surgery. They are often used for patients with painful terminal diseases like cancer in order to help alleviate the pain that comes with their disease and treatments. In the past years, their use has grown being that providing adequate pain relief is now considered an important standard of care and is even required by law in some states. Opiates are also known for being able to reduce anxiety and produce mild sedation. Their use is very controversial when chronic non-malignant pain is discussed. The most powerful opiate analgesics are also the most likely to cause abuse and addiction, and are therefore accountable for several deaths related to drug misuse. This has caused a reluctance among some physicians to prescribe them.

There have been many people who up to this moment have seen the problem first-hand and have asked others to help change it. One of them is Vivek H. Murthy, M.D., M.B.A., who on August 24, 2016, mailed a letter and pocket card to 2.3 million doctors, nurses, dentists, and other clinicians asking them to help address America’s escalating opioid epidemic.

Murphy states that the annual number of overdose deaths involving prescription and illicit opioids has nearly quadrupled since 2000. There’s a parallel between these deaths by overdose and the increasing growth in the amount of opioid pain relievers being prescribed, and there are more than 2 million people in the United States addicted to prescription opioids, with more than 12 million having misused these medications in 2015. Aside from this, there’s also an existing comeback in heroin use and the spread of HIV and hepatitis C that’s said to be one of the many by-products brought on by this opioid epidemic. With limited access to adequate treatment, many find themselves in a horrible situation. Murphy states that the police officers he met in Seattle, that began carrying naloxone in the spring of 2016, had saved 10 lives within a few months. Murphy presses that those in health professions need to use their position as leaders in society to help change how the country sees addiction He, along with the authors of this blog, want to change the ways people see addiction, from a personal failing to a chronic disease of the brain that needs help and understanding in order to get better.

In the US, the prevalence of opioid dependence in patients receiving prescription opioids is as high as 26%. In primary care, it’s seen that the estimated rate of opioid misuse is 21–29%.

The rate of addiction is 8–12%, while the estimated rates of substance use disorder in patients with chronic pain seen in pain clinics are as high as 45%. One current case in which opioids are continuing to be prescribed, where their use is more detrimental than beneficial to the patient's health, is in the management of abdominal pain and gastrointestinal diseases and conditions. It’s known that chronic opioid use can be detrimental to the gastrointestinal tract and central nervous system, and what’s worse the evidence for the efficacy of opioids for gastrointestinal pain is lacking. That being stated, there are still opioid prescriptions being made for people with these conditions. The truth is, there is evidence that supports opioid use for chronic noncancer pain; however, the evidence supporting the effectiveness of opioids is for short-term use (<3 months) and is largely focused on musculoskeletal pain.

Opioid-induced bowel dysfunction (OIBD) is a collection of gastrointestinal motility disorders induced by opioids. Some of the most common effects are constipation, nausea, abdominal pain or discomfort, gas, ileus, gall bladder contraction and gastro-oesophageal reflux. In a study, among 489 patients with chronic noncancer pain, opioid-induced constipation (OIC), one of the most common disorder in OIBD, had a negative effect on quality of life, particularly on work performance and productivity (38%), performing activities of daily living (49%), social interactions (45%), sex lives (45%) and the ability to leave the house (43%). If it’s still too hard to believe that opioid prescriptions are being given without good enough reasons, one study in 2016 revealed that emergency room physicians perceived pressure to prescribe opioids to avoid administrative criticism and poor patient satisfaction.

Medical use and nonmedical use of prescription opioids is often seen in studies about adults, but in the following graphs national trends in the medical and nonmedical use of prescription opioids among high school seniors between 1976 and 2015 were examined.

FIGURE 1

In Figure 1, we see the trends of medical and nonmedical use of prescription opioids among high school seniors from 1976 to 2015. (The dotted line reflects the update in the list of examples of prescription opioids in 2002). Here we see how lifetime medical use of prescription opioids among high school seniors was more likely and prevalent than nonmedical use of prescription opioids (NUPO) over this time period.

FIGURE 2

In Figure 2, the prevalence of NUPO differed less by sex even though the lifetime medical use of prescription opioids tended to be more prevalent among female adolescents relative to male adolescents.

FIGURE 3

In Figure 3, the trends are divided by race between the years 1983 and 2015. The timeline here changed mainly because there were changes in the response options to the race question, therefore, race trends were examined starting in 1983 to have consistent race categories over time. Here we see that the prevalence of medical use of prescription opioids and NUPO was higher among white adolescents relative to black adolescents. This could be because of the availability of these drugs to white adolescents, since in Figure 3 it’s shown how white adolescents already have a higher medical use for prescription opioids. This ready availability can lead to dependence in teens, and that dependence of opioid use could eventually lead to their nonmedical use.

FIGURE 4

In Figure 4, the trends in patterns of lifetime use history for prescription opioids among US high school seniors show that the most prevalent pattern of exposure to prescription opioids was medical use only (without a history of NUPO) over the course of the study period. These patterns ranged from a low of 8.5% (SE = 0.9) in 2000 to a high of 14.4% (SE = 0.8) in 1989.

It’s shown in Figure 4 how there is a prevalent pattern that those who misuse prescription opioids for nonmedical purposes had initiated medical use previously and then began NUPO.

This pattern ranges from a low of 2.6% (SE = 0.2) in 1979 to a high of 5.4% (SE = 0.6) in 1990. Among all these patterns the least prevalent one tended to be NUPO before initiating medical use of prescription opioids. This data helps put into perspective the important role that those in medical professions play in a person’s NUPO, since it’s their part in over prescribing powerful opioids that has helped lead the opioid epidemic.

Usage Statistics within the United States in 2017

Introduction

For the misuse statistics associated with opioids in the United States, the main source utilized was the Substance Abuse and Mental Health Services Administration's 2017 report titled "Key substance use and mental health indicators in the United States: Results from the 2017 National Survey on Drug Use and Health". This report, published in November 2018, includes statistics from this drug group's misuse in the past year, the misuse of the subtypes of pain relievers and the reason why they misused as well as where they sourced their drugs. It also talks about the statistics of those using opioids for the first time in 2017, always diving the numbers for pain relievers and heroin. Finally we'll explain Substance Use Disorders (SUDs) in the past year within the United States.

Past Year Opioid Misuse

Opioid misuse includes the misuse of prescription pain relievers or the use of heroin. It puts heroin into a separate category as it's not usually known as an opioid. In 2017, there were 11.4 million past year opioid misusers aged 12 or older, the vast majority of whom misused prescription pain relievers (Figure 20). Specifically, 11.1 million people aged 12 or older in 2017 misused prescription pain relievers in the past year compared with 886,000 people who used heroin. The majority of prescription pain reliever misusers had misused only prescription pain relievers in the past year and not used heroin (10.5 million). Approximately 562,000 people had misused prescription pain relievers and used heroin in the past year. About 324,000 people used heroin in the past year but had not misused prescription pain relievers. Although 5.1% of prescription pain reliever misusers also used heroin in the past year, 63.5% of heroin users also misused pain relievers in the past year.

In this figure opioid misuse is defined as heroin or prescription drug misuse. It is also worth to note that the percentages do not add up to 100% due to rounding of these.

As discussed beforehand, approximately 11.4 million people aged 12 or older in 2017 misused opioids in the past year (Figures 20 and 21). This number represents 4.2% of the population aged 12 or older. About 769,000 adolescents aged 12 to 17 misused opioids in the past year, which rounds to the estimate of 0.8 million people shown in Figure 21. This number corresponds to 3.1% of adolescents who misused opioids in the past year. About 2.5 million young adults aged 18 to 25 misused opioids in the past year, which corresponds to about 7.3% of young adults. An estimated 8.1 million adults aged 26 or older misused opioids in the past year, which represents 3.8% of adults in this age group.

In this figure, the numbers are correlated to the percentages seen in Figure 20. With this you can relate the numbers given by age groups to the whole group interviewed.

Past Year Heroin Use

An estimated 886,000 people aged 12 or older in 2017 used heroin in the past year (Figure 20). The estimate of past year heroin use in 2017 (0.3%) was higher than the estimates for most years between 2002 and 2011, but it was similar to the estimates in 2012 to 2015 (Figure 22).

In this figure what is being demonstrated is the past year heroin use among people aged 12 or older,
dividing the age groups with the different colors. Due to overlapping they add a table (Figure 22 Table)
that illustrates the data clearly. Difference between this estimate and 2017 estimate is significant at the 0.05 level.

With this figure you can see the date neatly distributed that is illustrated in Figure 22.
It shows the heroin use by age groups and from 2002-2017.

Aged 12 to 17

In 2017, 0.1% of adolescents aged 12 to 17 were past year heroin users (Figure 22). This percentage represents 14,000 adolescents who used heroin in the past year. The percentage of adolescents in 2017 who were past year heroin users was similar to or slightly lower than those in 2002 through 2016.

Aged 18 to 25

Among young adults aged 18 to 25 in 2017, 0.6% were past year heroin users (Figure 22). This percentage represents 214,000 young adults who used heroin in the past year. The percentage of young adults in 2017 who were past year heroin users was similar to those between 2005 and 2016 (ranging from 0.4 to 0.8%), but it was slightly higher than those in 2002 through 2004 (ranging from 0.3 to 0.4%).

Aged 26 or Older

In 2017, 0.3% of adults aged 26 or older were past year heroin users (Figure 22). This percentage represents 658,000 adults aged 26 or older who used heroin in the past year. The percentage of adults aged 26 or older in 2017 who were past year heroin users was similar from 2014 to 2016, but it was slightly higher than those in all years from 2002 to 2013.

Past Year Pain Reliever Misuse

Approximately 11.1 million people in 2017 misused prescription pain relievers in the past year (Figure 20), representing 4.1% of the population aged 12 or older (Figure 23). Among youths aged 12 to 17, 3.1%  misused prescription pain relievers, corresponding to 767,000 youths, which rounds to the estimate of 0.8 million shown in Figure 23. There were about 2.5 million young adults aged 18 to 25 who misused pain relievers in the past year, which corresponds to about 7.2% of young adults. An estimated 7.8 million adults aged 26 or older misused pain relievers in the past year, which represents 3.7% of adults in this age group.

In this figure, past year pain reliever misuse is seen both in numbers and percentages.
Within the numbers, the most observed are 26 or older but in percentages, 18-25 is the group with the highest impact.

Misuse of Subtypes of Pain Relievers

Respondents were asked in 2017 to identify the specific prescription pain relievers that they used in the past year. For each specific pain reliever that people reported using in the past 12 months, they were asked if they misused it. The specific pain relievers that individuals misused in the past year were categorized into subtypes. For example, respondents who reported the misuse of the pain relievers Vicodin® or hydrocodone were classified as misusers of hydrocodone products. This section presents estimates of the subtypes of pain relievers that were misused by individuals aged 12 or older.

In 2017, hydrocodone products were the most commonly misused subtype of prescription pain relievers, including: Vicodin®, Lortab®, Norco®, Zohydro® ER, and generic hydrocodone (Figure 24). An estimated 6.3 million people aged 12 or older misused these products in the past year, representing 2.3% of the population. An estimated 3.7 million people misused oxycodone products in the past year; this number represents 1.4% of people aged 12 or older. Oxycodone products include: OxyContin®, Percocet®, Percodan®, Roxicodone®, and generic oxycodone. An estimated 0.3% of people aged 12 or older misused buprenorphine products in the past year, which represents 766,000 people. About 261,000 people aged 12 or older (0.1%) misused methadone.

With prescription fentanyl products, 245,000 people reported misusing it in 2017, representing 0.1% of the population (Figure 24). Because NSDUH respondents were asked about the misuse of only prescription forms of fentanyl, this estimate for its misuse may under represent people who misused fentanyl that was illicitly manufactured in clandestine laboratories. This would be as opposed to the misuse of diverted fentanyl that was produced by the pharmaceutical industry. This estimate of fentanyl misuse also may not include people who misused illicitly manufactured fentanyl that was mixed with heroin or sold as heroin.

 This figure illustrates the type of opioids misused in 2017, excluding statistics for heroin.
It does not illustrate all the opioids described in the questionnaire. It shows the most relevant answers given.

Main Reasons for the Last Misuse of Pain Relievers

People who reported prescription pain reliever misuse in the past year were asked to recall the last prescription pain reliever that they misused. They were then asked to report the reason for misusing this prescription pain reliever that last time. Those who reported more than one reason for misusing the last prescription pain reliever were asked to report only the main reason. If they reported only one reason for misusing their last prescription pain reliever, then that reason was classified as the main reason for misuse.

Among people aged 12 or older in 2017 who misused prescription pain relievers in the past year, the most common main reason for their last misuse of a pain reliever was to relieve physical pain (62.6%) (Figure 25). According to the NSDUH definition, use without a prescription of one’s own or use at a higher dosage or more often than prescribed are both classified as misuse even if it was for the purpose of pain relief. Other common reasons were to feel good or get high (13.2%) and to relax or relieve tension (8.4%). Less common reasons among past year misusers of pain relievers included to help with sleep (5.4%), to help with feelings or emotions (3.6%), to experiment or see what the drug was like (2.8%), because they were “hooked” or needed to have the drug (2.2%), and to increase or decrease the effects of other drugs (0.7%). Some other reason was the main reason for misuse among 1.0% of past year misusers of pain relievers.

This figure illustrates the main reason people misused pain reliever in 2017,
excluding statistics for heroin. The percentages do not add to 100% due to rounding.

Source of the Last Pain Reliever That Was Misused

Among people aged 12 or older in 2017 who misused prescription pain relievers in the past year, the most common source for the last pain reliever they misused was from a friend or relative (Figure 26). More than half (53.1%) of people who misused pain relievers in the past year obtained the pain relievers the last time from a friend or relative. Specifically, 38.5% of people who misused pain relievers in the past year obtained pain relievers the last time by getting them from a friend or relative for free, 10.6% bought their last pain reliever from a friend or relative, and 4.0% took their last pain reliever from a friend or relative without asking.

About one third of people who misused pain relievers in the past year (36.6%) obtained pain relievers the last time through prescription(s) or stole pain relievers from a health care provider, typically getting the pain relievers through a prescription from one doctor (34.6%). About 1 in 18 people who misused pain relievers in the past year (5.7%) bought the last pain reliever they misused from a drug dealer or other stranger.

This figure illustrates the main source of the pain relievers taken people misused,
excluding statistics for heroin. People with unknown data for the source were excluded.

In this table, you can observe with more detail where the people surveyed
answered the source of the pain relievers they had used.

Substance Use Disorders in the Past Year

Substance use disorders (SUDs) represent clinically significant impairment caused by the recurrent use of alcohol or other drugs (or both), including health problems, disability, and failure to meet major responsibilities at work, school, or home. Respondents were asked SUD-related questions if they previously reported use in the past 12 months of any drugs described in the NSDUH questionnaire. These questions classify people as having an SUD in the past 12 months and are based on criteria specified in the Diagnostic and Statistical Manual of Mental Disorders, 4th edition (DSM-IV).

This figure illustrates an estimated number of people reporting SUD's as well as the number of
people misusing certain subtypes in 2017.The number reported are not mutually exclusive
as the people questioned could have misused more than one type of drug.

Pain Reliever Use Disorder

Pain reliever use disorder occurs when someone experiences clinically significant impairment caused by the recurrent use of pain relievers, including health problems, physical withdrawal, persistent or increasing use, and failure to meet major responsibilities at work, school, or home. NSDUH respondents who misused pain relievers in the past 12 months were categorized as having a pain reliever use disorder if they met the DSM-IV criteria for either dependence or abuse for pain relievers. Dependence and abuse criteria for illicit drugs (including misused pain relievers) were described previously.

In 2017, an estimated 1.7 million people aged 12 or older had a pain reliever use disorder, which corresponds to 0.6% of people aged 12 or older (Figure 35). An estimated 0.4% of adolescents aged 12 to 17 had a pain reliever use disorder in the past year, which represents about 99,000 adolescents. Approximately 339,000 young adults aged 18 to 25 and 1.2 million adults aged 26 or older had a pain reliever use disorder in the past year. These numbers of adults with a pain reliever use disorder correspond to 1.0 percent of young adults and 0.6 percent of adults aged 26 or older.

This figure illustrates SUD's related to misuse of  pain reliever in 2017 by age group.
It compares the numbers in thousands and the percentages within the 1,678 that reported this.

Heroin Use Disorder

Heroin use disorder occurs when someone experiences clinically significant impairment caused by the recurrent use of heroin, including health problems, physical withdrawal, persistent or increasing use, and failure to meet major responsibilities at work, school, or home. NSDUH respondents who used heroin in the past 12 months were categorized as having a heroin use disorder if they met the DSM-IV criteria for either dependence or abuse for heroin. Dependence and abuse criteria for illicit drugs (including heroin) were described previously. Approximately 652,000 people aged 12 or older in 2017 had a heroin use disorder. This number of people with a heroin use disorder represents 0.2% of people aged 12 or older (Figure 37). The percentage of people aged 12 or older in 2017 with a heroin use disorder was higher than the ones in 2002 to 2011, but it was similar to those from 2012 to 2016. Although there are significant differences, all percentages from 2002 to 2017 were 0.2 or less.

Aged 12 to 17

Less than 0.1% of adolescents aged 12 to 17 in 2017 had a heroin use disorder in the past year (Figure 37), which corresponds to about 4,000 adolescents. The percentage of adolescents in 2017 with a heroin use disorder was similar to the estimates in most years from 2002 to 2016.

Aged 18 to 25

Approximately 165,000 young adults aged 18 to 25 in 2017 had a heroin use disorder in the past year, which represents 0.5% of young adults (Figure 37). The percentage of young adults in 2017 with a heroin use disorder was greater than those seen in 2002 to 2008, but it was similar to the ones from 2009 to 2016.

Aged 26 or Older

In 2017, approximately 483,000 adults aged 26 or older had a heroin use disorder in the past year, which represents 0.2% of adults in this age group (Figure 37). Between 2002 and 2017, 0.1 to 0.2% of adults aged 26 or older had a heroin use disorder in the past year. The 2017 estimate was higher than the estimates in 2002 to 2012, but it remained steady when compared with the percentages between 2013 and 2016.

This figure illustrates an estimated number of people reporting heroin use disorders in percentages
 from 2002-2017. Differences between the estimates are statistically significant at the 0.05 level.

Opioid Use Disorder

Misuse of opioids include two categories of drugs: the use of heroin and the misuse of prescription pain relievers. NSDUH collects dependence and abuse information for these two categories of drugs. A respondent was classified as having an opioid use disorder if he or she met DSM-IV criteria for heroin use disorder or pain reliever use disorder, as described previously. In 2017, an estimated 2.1 million people aged 12 or older had an opioid use disorder, or 0.8 percent of people aged 12 or older (Figure 38). An estimated 0.4 percent of adolescents aged 12 to 17 had an opioid use disorder in the past year, which represents about 103,000 adolescents. About 445,000 young adults aged 18 to 25 had an opioid use disorder in the past year. This number corresponds to 1.3 percent of young adults. An estimated 1.6 million adults aged 26 or older had an opioid use disorder, which corresponds to 0.7 percent of adults in this age group.

This figure illustrates an estimated number of people reporting opioid use disorders in thousand vs. percentages in 2017. Opioid use disorder is defined as meeting DSM-IV criteria for both heroin or pain reliever disorder in the past year.

Usage Statistics within Puerto Rico in 2017

Introduction

With statistics in Puerto Rico, information is scarce. Only one paper was found, which is the one referenced here. It was published in March 2018 and it utilizes data from a survey done in 2013-14. This survey was designed to study social and familial factor associated with drinking. The analysis done provides 12-month rates of any drug use, use of various illegal drugs, and use of legal drugs used in a non-prescribed manner. Two previous papers analyzed drug use in household samples of Puerto Rican adults. One analyzed 1987 data and reported that the proportion of ever-users was 8.2% (men: 12.1%; women: 4.8%), and lifetime DSM-III drug abuse and/or dependence was 1.2% (men: 2.2%; women: 0.37%). Another reported information taken from a 1998 survey which showed a past year rate of illegal drug use of 2.6% with DSM-IV abuse and dependence present in 1.3% of the sample. Apart from those done, there wasn't much more found on opioid use and abuse statistics for Puerto Rico. The investigation referenced is titled "Illegal drug use and its correlates in San Juan, Puerto Rico".

Results

Overall, a little less than 1 in 6 adults in San Juan, Puerto Rico used an illegal drug or a licit drug in a non-prescribed way in the previous 12 months (Table 1). The prevalence of this use was 20.6% among men and 12.9% among women. The most prevalent drug was marijuana, which was used by just over 10% of the adult population. This was followed by opiates, speed/amphetamines, tranquilizers, and cocaine/ crack, which all had prevalence rates between 2% and 3%. Heroin/ opium, hallucinogens, and methadone were all used by less than 1% of the adult population. If all the opium derivatives (Opiates, Heroin, opium & methadone) are added up, the total usage of this drug group would be 3.99% of the prevalence use in Puerto Rico. This would still put opioids as the second most utilized drug group in 2013-14.

This table illustrates usage statistics for all drug groups studied, the totals for opioids being 3.99%,
divided here in: Opiates, Methadone and Heroin/Opium.

Results correlating sociodemographic with of drug use were not surprising. Men were more than 1.5x more likely than women to report past year drug use. Those who were 18–29 and 30–39 years of age were approximately 2x more likely to use drugs compared to those 50 years of age and older. Those with low to medium family cohesion and/or pride were 2x and 1.5x more likely, respectively, to use drugs than those with high family cohesion and/or pride. Respondents with “no religious preference” were 2x more likely than those identified as Catholics to report drug use. Finally, those with an annual family income above $40,000 were protected against drug use in comparison to those with an annual income equal to or less than $10,000. This reflects previous findings for Puerto Rico and for the U.S. mainland. Low and medium family cohesion and/or pride are also positively associated with drug use. Family cohesion has been identified as protective against a series of problem behaviors among Hispanics. Similarly, “no religion” is positively associated with drug use. Results in the literature consistently indicate that religion is negatively correlated with alcohol and drug use. Finally, an annual income above $40,000 is associated with decreased odds of drug use. Findings on this topic are fragmented, with papers focusing on different population subgroups (e.g., adolescents, low income populations) and different measures of income (e.g., personal, familial, neighborhood level). This could be the reason why the results are not as cohesive as those observed with the US statistics.

This table breaks down all the statistics analyzed and compiled for this study.

In conclusion, with this paper was tried to achieve, was done but not to its full potencial. More surveys could've been administered to a bigger population size, thus making the results more palpable and believable. Also, these types of studies should be done annually as they can be compared and demographics of a posible epidemic can be determined by their own statistics. This would be as opposed to basing the courses of action off the statistics seen in the US, which are not comparable because of the different socioeconomic situations of their people and the obvious physical differences in country sizes.

"Pressured": Statistics Regarding the Physician's Look on Prescribing Opioids

Prescription of opioids can sometimes be seen as a requirement in order to guarantee patient satisfaction. Emergency Department (ED) physicians face a difficult challenge when it comes to assessing appropriate management of patients exhibiting “drug seeking” behavior, mainly due to lacking development of continuing medical education and standardized regulatory and legislative protocols. ED physicians were surveyed (n = 141) and 71% reported a perceived pressure to prescribe opioid analgesics to avoid administrative and regulatory criticism. Meanwhile, 98% related patient satisfaction scores as being too highly emphasized by reimbursement entities.

Figure 1: Utilization of opioid abuse identification methods

In Figure 1, the physicians were asked asked about the five methods of opioid abuse identification: physical examination, history, use of the (electronic medical records) EMR, query of the states’ prescription drug monitoring program (PDMP) database, and drug screening. It’s shown that a physical exam, history checks, and use of the EMR are almost always a preferred method amongst physicians in order to identify opioid abuse, however, drug screens seem to be the least utilized method.

Figure 2: Drug screen availablilty for opioids

Drug screen availability is important when trying to assess a patient who is suspected of opioid abuse, misuse or even of “doctor shopping” for different prescriptions. In Figure 2, only 25% of the respondents had the ability to screen for synthetic opioids in their respective ED's. This limitation could severely impact the ED’s ability to determine a patient’s health status. Testing for synthetic opioids required submission to the hospital laboratory according to 29% of the respondents and 33% had to send samples to an outside laboratory. As mentioned before, this severely limits a physician’s ability to diagnose a patient correctly in order to bring them the best care without accidentally contributing to it in a negative way.

As seen in Figure 1, the use of drug screens for proper diagnostics is rarely employed. Meanwhile, in Figure 2, the drug screening availability seems to be limited in many ED’s. In Figure 3, the participants were asked how regulatory and administrative factors affected their opioid prescribing practices. A majority (72%) felt pressured to prescribe in order to avoid administrative complaints from the patient that pain was inadequately treated.

Figure 3: Perceived pressures to prescribe opioids

Another phenomenon observed in opioid addicts is the so-called “doctor shopping”. What this means is that a person will go to several doctors in order to receive different medications, or to get the response they most want (in this case the prescriptions). Most of the participants stated a lack of clarity on the issue or course of action (Figure 4). An alarming response would be that many (52%) disagree that a failure to report this type of behavior would result in civil liability. Another worrying fact, is that 86% of the participants agreed that hospitals don’t provide protocols for this type of behavior, meaning that there is no established method for dealing with this behavior and there may not be an overall surveillance to make sure that physicians don’t help worsen the condition these patients might be in.

Figure 4: Physician course of action when “doctor shopping” indicated

As seen by Figure 5, most of the participants (98%) believed that patient satisfaction scores should not be used as a metric to assess quality patient care. The heavy weight given to satisfaction scores is a main problem in the opioid epidemic because many patients with opioid addiction, or those who misuse opioids, will give a bad score to any physician who doesn’t meet their demands. In turn, this will make physicians care more about their satisfactory rates and lean more towards overprescribing in order to not get in trouble with their administration.

Figure 5: Emphasis on patient satisfaction scores

Overall, the results of this study have identified gaps in training, regulation, and administrative healthcare practices regarding management of patients with a drug-seeking behavior. They’ve also helped to point out many of the attitudes and positions the physicians have themselves regarding the safety and opinion of their patients.

Medically Assisted Treatments and their Effectiveness

The war on opioids has been an uphill battle since they were marked as a Type 2 Schedule on the Schedule of Controlled Substances according to the Controlled Substances Act of 1970. According to the U.S. Government, drugs in this category have a high abuse potential with severe psychic or physical dependence liability. This is now more clear than ever due to the rampant opioid epidemic that has been going on worldwide. As a means to treat those who have become victims, synthetic opioids have been created which can substitute stronger drugs and eventually be completely eliminated. This allows a person suffering from opioid use disorder to limit or eliminate the drug’s consumption.

Currently, there are three primary drugs in the medication-assisted treatment such as: methadone, Buprenorphine and Naltrexone. Methadone is an opioid agonist so it is capable of providing the same effects as regular opioids. Yet this drug lasts in the human body for far longer periods of time while providing a weaker analgesic effect than common narcotics which makes it a great option to treat opioid dependence. Buprenorphine is an opioid agonist as well yet it is mainly used when withdrawal symptoms have recently appeared. It can remain in the body even longer than methadone. And lastly, naltrexone is an opioid antagonist which isn't as long lasting as the other treatments but an extended-release version has been created since it has proved to be quite effective.

There are countless studies to address this issue. To better understand the increase in opioid consumption, data has been recollected by different means of people who were suffering from opioid use disorder, people who were under treatment or those whose death was related to opioids.

One study consisted on using carefully selected data from PubMed and Embase databases using keywords related to analyzing them in order to study the effectiveness of the aforementioned opioids as a method of treatment. The methodology to obtain data that could be used to scrutinize the data is presented as Figure 1. The analysis focused on studying the mortality rate of people not receiving any treatment and those who were under treatment yet with different drugs. There were 21 studies focusing on the effects of drug consumption, there was a 0.92 per 100 person-years of crude mortality rate while receiving medicated-assistance, a 1.69 after cessation and a 4.89 for those untreated. There was another analysis done with 16 studies to obtain a clearer conclusion. Based on the crude mortality rate per 100 person-years of the 16 studies, the following conclusions were drawn: there was a 0.24 while receiving medically-assisted treatment, 0.68 after treatment cessation, and 2.43 for those who were untreated. On the 21 studies which focused on all-cause deaths, those who were on MAT with methadone or buprenorphine were 0.93 and 1.79, meanwhile naltrexone were 0.26.

Another statistical analysis provided even more information about the effectiveness of the opioid agonists, buprenorphine and methadone. The databases used were: Cochrane Drugs and Alcohol Review Group, Cochrane Register of Controlled trials, MEDLINE, EMBASE, Current Contents, PsycLIT, CORK, Alcohol and Drug Council of Australia, Australian Drug Foundation, Centre for Education and Information on Drugs and Alcohol and Library of Congress. Through them, it was possible to obtain 31 trials of 5430 participants. The risk ratio was calculated for each treatment at different concentrations (low, medium and high) to see if there was a correlation between the consumption. It was concluded that buprenorphine at any dosage was more effective than the placebo. It was also stated that methadone was more effective in retaining people in treatment than buprenorphine.