Opioid Use Disorder

Opioid Use Disorder

Within the United States, 4.1% to 4.7% of all adults over the age 18 have improperly used opioids. In 2016, 353 per 100,000 individuals were diagnosed with opioid dependence, globally (American Psychological Association, [APA], 2022). From June 2019 to June 2020, 48,006 individuals lost their lives to synthetic opioid overdose, excluding methadone (U.S Department of Health and Human Services, 2023). Substance use disorders have long term negative consequences for individuals, families, and communities (Jahan and Burgess, 2023).

The type of substance use disorder diagnosed is classified based upon the type of substance abused and the resulting physical and mental dependency. Individuals with Opioid Use Disorder have marked distress, dependency, impairment from opioid use. Opioids may include prescription and non-prescription drugs. Examples of opioids include oxycodone, hydrocodone, codeine, morphine, fentanyl, and heroin (Koehl et al., 2019). Unfortunately, individuals that abuse one substance have an increased likelihood of abusing multiple substances (Jahan and Burgess, 2023).This literature review will explore the etiology and symptomology of opioid use disorder, as well as treatment options, and rurality effects on treatment.

Etiology of Opioid Use Disorder

Many factors contribute to the abuse of any substance, including opioids. The factors may include social, biological, and physical reasons. Some theorize that peer pressure may be an initial contributing factor to substance abuse, starting addiction within adolescents that leads into adulthood. Environmental factors such as drug use by others in the home increases accessibility and probability of substance abuse. Women are more likely than men to abuse drugs for depression, pain, weight loss, and pressure from their sexual partner. Additionally, underlying mental illness is believed to increase the possibility of addiction (Volkow and Boyle, 2018).

Compared to the general population, individuals with substance use disorders are twice as likely to have comorbid mental health disorders. Likewise, individuals with underlying mental health issues are more likely to have substance use disorders (National Institute of Drug Abuse., 2018). Anxiety disorders are thought to increase the likelihood of substance use disorders by 2.9 times. ADHD is linked with an increased probability of substance use disorder (Iqbal et al., 2019). Substance use disorders and PTSD are commonly occurring and increase the risk of suicide and overall health risks (Forray and Yonkers, 2021).

Sociological theories, dating back to at least 1981, suggest that struggles with substance abuse are based upon an individual’s social interactions or social structures, rather than strictly physical traits (Wiatrowski et al., 1981). Social control theory attempts to explain aspects of substance use and addiction, asserting that an individual’s likelihood to abuse substances is related to control. This theory explains that an individual’s environment and social interactions may limit their individual control and condition them to behaviors, such as substance abuse (Groff, 2014).

Adverse childhood experiences (ACES) are believed to be linked to substance use disorders. Overall, ACES increase the risk of substance abuse and mental illness. Exposure to domestic violence, substance abuse, and mental illness within the childhood home negatively impact lifelong health outcomes. Neurological, psychological, and physiological systems of children are negatively impacted by trauma (Hughes et al., 2019). Substance abuse within the childhood social environment increases the odds of developing substance use disorders, depression, and anxiety (National Institute of Drug Abuse., 2018). ACES decreases the likelihood of developing adequate coping skills, increasing the likelihood of substance abuse later in life and in childhood (Hughes et al., 2019).

Biological theories focus on the notion that people have internal structures, such as the brain, which influence experimentation with drugs and resulting addiction (Prom-Wormley, 2017). Metabolic imbalances and genetic theories both contribute to the theoretical makeup of biological theories (Byanyima, et al., 2023). Genetic theories focus on the link between genetic makeup and increased risk of addiction. Genetic predisposition is strongly correlated with opioid dependence, with some citing as much as 50 percent of the liability linking back to genetics (Prom-Wormley, 2017). Metabolic imbalances are thought to be directly related to opioid use disorders. Metabolic disorders can cause decreased energy and depression. Opioids may counteract these feelings with increased sensations of happiness, thus reinforcing the urge to use them. Additionally, opioid use may contribute to the risk of developing metabolic disorders (Byanyima, et al., 2023).

Opioid use alters the functioning and structure of the brain. The use of opioids imitates chemical messengers and results in overstimulation of the reward circuit in the brain. Opiates decrease main and increase pleasure. The brain attributes this to an overproduction of dopamine, resulting in the decrease of natural dopamine production. Subsequently, individuals increase opiate use to increase the pleasure sensation, and eventually just to feel normal (Gold et al., 2020). Studies of the brain have shown a link between opioid use disorder and the brain “opioid receptor mu 1 (OPRM1) and dopamine receptor d2 (DRD2) genes.” These receptors and opioid use change the structure of the anterior cingulate, nucleus accumbens, and putamen areas (Picci et al (2021). Other brain changes linked to opioid use include changes to the OPRM1, CNIH3, KCNC1, APBB2, RGMA, KCNG2, and changes to Copy Number Variations (CMV), including deletion of CMV 18q12.3, deletion of CMV Xq28, and duplication of CMV 1q21.3 (Prom-Wormley, 2017).

Overall, substance abuse, including opioid use, is believed to negatively impair the brain’s gray matter; however, this is not true for all individuals, specifically those with schizophrenia. Individuals with schizophrenia have been shown to already have a decrease in the gray matter volume throughout the brain, including “bilateral precentral gyrus, right medial frontal cortex, right visual cortex, right occipital pole, right thalamus, bilateral amygdala, and bilateral cerebellum regardless of substance use history.” Individuals with schizophrenia do not appear to have any further impairment in these brain areas with substance abuse addiction (Turner et al., 2018).

Symptoms and Manifestation of Opioid Use Disorder

Opioid use disorder may be diagnosed at any age; however, issues related to opioid use usually begin in the early 20s or before. The American Psychological Association (APA, 2022) provides that an individual must have significant distress or impairment, within the prior 12 months, caused by opioid use, to be diagnosed with Opioid Use Disorder. The significant stress or impairment must be marked by two of eleven criteria set forth in the DSM5-TR. If two out of these eleven criteria are met, the provider should specify if the client is in early remission, sustained remission, on maintenance therapy, in a controlled environment and, also, specify whether the disorder is mild, moderate, or severe. The eleven criterions include:

• The opioids are used for longer periods or in larger quantities than intended.

• The client has the desire or effort to reduce use but is unsuccessful.

• The client spends considerable time trying to obtain opioids, using opioids, or recovering from the effects of opioids.

• The client has strong urges or cravings to use opioids.

• The client fails to fulfill work, home, or school obligations due to opioid use.

• The clint continues to use opioids despite persistent and ongoing social and interpersonal problems related to the opioid use.

• The client gives up or reduces social, recreational, and/or occupational activities because of opioid use.

• The client recurrently partakes in opioid use in physically hazardous situations.

• The client’s opioid use has caused physical and/or psychological problems that are persistent and/or recurrent; despite knowing this, the client continues the opioid use.

• The client has built a tolerance to opioid use. The tolerance is marked by needing more opioids to achieve the desired effect or level of intoxication or a decrease in effect when using the same amount opioids. This criterion is not applicable when only receiving opioids under medical supervision.

• The client is experiencing withdrawal symptoms and/or taking opioids to reduce or relieve these symptoms. This criterion is not applicable when only receiving opioids under medical supervision.

Withdrawal may be marked a reduction in opioid use that is significant and prolonged, or use of an opioid antagonist. After receiving an opioid antagonist or reduction of the use, the client experiences nausea, vomiting, yawning, muscle aches, tearing of the eyes, sweating, dilated pupils, diarrhea, fever, insomnia, and/or dysphoric mood. These symptoms must cause distress or impairment and not be caused by another condition to classify as opioid withdrawal (APA, 2022).

Family and friends may recognize signs of opioid abuse. An individual abusing opioid may begin to isolate or have secretive behaviors, loss of interest in activities, changes in eating patterns, erratic emotional changes, changes in speech patterns, changes in friend groups, decreased performance in school or work, small pupils, slowed respiration rate, and flu-like symptoms. Family members or friends may notice a change in the individuals’ dressing patters, such as suddenly always wearing long sleeved shirts, even in warm weather. Other worrisome signs might include missing medication, legal issues, unknown powder residue on surfaces, syringes, burnt spoons or caps, and missing items like shoelaces (Fairfax County Community Service Board, 2024).

Treatment Options for Opioid Use Disorder

Dating back to the 90’s, it has been acknowledged that treatment needs to focus on disease management and relapse prevention (McCartney, 1999). Treatment of Opioid Use Disorder should utilize a holistic approach, including social support. Social support needs that may be identified may include housing, nutrition, legal, and family support. The treatment plan may include supervised detoxification, inpatient treatment, outpatient services, residential treatment, community engagement, psychotherapy, and medication management. Providers will need to be mindful of any cooccurring illnesses, both mental and physical. Any comorbidities should be addressed within the treatment plan (Chavez and Riggs, 2020). Historically, traditional treatment options for opioid use disorder have focused on harm reduction and abstinence. However, given the probability of comorbidities, social problems, and polysubstance abuse, treatment should be multifaceted and target psychological, economic, social, and physical impairments (Körkel, 2021).

Cognitive Behavioral Therapy (CBT) is a common therapeutic technique for opioid use disorder. This technique involves using cognitive and behavioral concepts to help the client learn new skills and reframe their thinking. CBT is a structure, time limited, direct approach, which focuses on working on the present with the client. This technique requires the client to contribute significantly to their own therapy. Client participation requires homework tasks outside of the therapy session. CBT begins with the precontemplation phase where the individual is unaware of the problem. Once the client has become aware of the problem and knows that change is needed, they have moved to the contemplation phase. The next phase of CBT is preparation: when the client intends to act towards change. The action phase is where the client will practice the desired behavior. Then, the final stage is maintenance, where the client will sustain the change (Chand et al., 2023). While CBT has been shown to be moderately effective with substance use disorders, some researchers argue that mindfulness-oriented recovery enhancement is more effective than CBT when treated for co-occurring mental illness and polysubstance abuse (Garland et al., 2015).

Dialectical behavior therapy (DBT) is another therapeutic technique that shows promise in the treatment of opioid use disorder. This technique incorporates mindfulness and acceptance of change. The therapeutic process involves skills training, individual therapy, consolation as needed, and scheduled therapy sessions (Rizvi, et al., 2014). In studies, DBT has shown increased success when used in combination with methadone maintenance treatment (Rezaie et al., 2021) and buprenorphine-naloxone maintenance treatment (Durpoix et al., 2023). While Durpoix et al., (2023) supports the use of DBT, the study proposes a five-step treatment process requiring counseling, motivational interviewing, contingency management, CBT, and DBT. Counseling or step one requires the patient to meet with the physician one time per month and a nurse one time per week. Step two or motivational interviewing is for those that lack intrinsic motivation. Step three involved three-to-five-minute interviews twice per week, plus a urine test, for those patients that lack extrinsic motivation. Step four or CBT requires CBT therapy one time per week for the first four months. This step focuses on change and is particularly useful for dual diagnosis. Step five or DBT is used for acceptance and change. The researchers propose DBT for the first year of treatment. DBT may be two hours per week with a group setting, one hour per week with individual setting, two-hour team consultation, and/or phone coaching. The researchers assert that step five is particularly useful for clients that exhibit suicidal behaviors (Durpoix et al., 2023).

Methadone maintenance treatment (Rezaie et al., 2021) and buprenorphine-naloxone maintenance treatment (Durpoix et al., 2023) are the two standard pharmacological methods to assist in the treatment of opioid use disorder. Pharmacological treatment options generally fall into three categories, partial agonists, full agonists, or antagonists. Methadone is a full agonist medication that binds to the opiate receptors in the brain. Buprenorphine is a partial agonist, which aids in detoxing opioids and the maintenance of opioid use disorder. Partial agonists do not stimulate to the same extent as a full agonist (Douaihy et al., 2013). Naltrexone, an antagonist medication, binds to brain receptors without stimulating them. This medication block agonists from binding with these brain receptors, thus preventing opioid intoxication and physical dependence. (Singh and Saadabadi, 2023).

Regardless of treatment techniques utilized, it is imperative for providers to practice with a strength focused, resiliency focused, and culturally appropriate approach. Strength based and culturally responsive treatment modalities reduce negative outcomes for minorities groups. However, these approaches are underutilized and under studied in the treatment of substance abuse addiction treatment (Banks et al., 2023). Ezell et al., (2023) recommends that treatment should be focused on harm reduction, strength based, trauma informed, and culturally focused for the best outcomes. However, the study further asserts that strengths-based approaches are under investigated in drug treatment. Focusing on a client’s individual, familial, and community strengths will improve success in treatment and development of positive coping skills. Failure to consider the patient’s culture in treatment can result in negative outcomes for the client, including relapse of opioid use. Certain cultural factors may impact treatment seeking, as well as impact techniques used. For example, individuals in rural areas may be less likely to seek mental health or opioid use treatment, due to the stigma surrounding these in rural areas (Lister et al., 2020).

Controversy and the rural impact on the treatment of Opioid Use Disorder

Despite a rise in opioid related deaths in rural communities, pharmacological treatment of opioid use disorder remains low (Lister et al., 2019). Since 2004, the opioid death rate has been trending higher in rural communities than urban communities (Rubin, 2019). Some reasons that pharmacological approaches are underutilized in rural communities include lack of providers, lack of community clinics, lack of resources, lack of adequate training for providers, stigma, and accessibility. Patients have reported negative provider perceptions and attitudes as barriers to treatment (Lister et al., 2019). Physical barriers and driving times are increased in rural areas (Kiang et al., 2021).

Stigma and negative perceptions of opioid use disorder are not isolated to providers. Overall, people in rural areas have a negative outlook on mental health and opioid use disorder. The stigma and negative perception lead to other controversial concerns such as the failure to even recognize opioid use disorder as a real illness. Rural community members may view individuals with opioid use disorder as dangerous, undeserving of employment, and fail to recognize the importance of medication assisted treatment. This stigma, also, applies to the use of naloxone in overdose situations, as some individuals in rural communities do not believe naloxone should be used in every overdose (Beachler et al., 2020).

Unfortunately, the stigma and barriers surrounding opioid use disorder and treatment results in increased risks for rural populations. Rural communities in the United States continue to be the hardest hit areas and most vulnerable to the opioid epidemic. Rural individuals with opioid dependency are less likely to receive a diagnosis of opioid use disorder and less likely to receive adequate treatment. Failure to implement policies and harm reduction programs in the areas increases health risks such as endocarditis and increases the spread of infectious diseases such as hepatitis B, hepatitis C, and HIV. Furthermore, opioid related deaths continue to rise in rural communities (Akhtar and Feinberg, 2021).

Conclusion

Overall, opioid use and substance abuse has had a detrimental impact on the United States and increasingly in rural areas (Akhtar and Feinberg, 2021). Opioid Use Disorder may be linked to biological, psychological, and environmental factors (Volkow and Boyle, 2018). Adverse childhood experiences may substantially increase the risk of substance abuse and opioid use. Underlying mental health disease processes may increase the risk of substance abuse and opioid use disorder (Jahan & Burgess, 2023) and opioid abuse may contribute to other psychiatric disorders (APA, 2022). Given the factors surrounding opioid use and other related disorders, social workers are one of the primary providers to the individuals and families impacted (Wells et al., 2013). There is a growing for providers and social workers specializing in substance abuse treatment (Lapari et al., 2017). Additionally, there is a need for increased investigation of outcomes of strength based and culturally based approaches and an increased need for these approaches in treatment of Opioid Use Disorder (Banks et al., 2023; Ezell et al., 2023).

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