What the Opioid Epidemic has to Do with Algae Blooms in the Gulf of Mexico

Every year, a “dead zone” appears in the Gulf of Mexico due to a gigantically large algae bloom. This summer, the National Oceanic and Atmospheric Administration predicted the dead zone to be the size of both Delaware and Connecticut combined.

The origins of the dead zone are traceable to over a thousand miles away from the farms of the upper Midwest, and all points further south. The origin, in other words, is farm run-off of nutrients from manure and chemical fertilizers. 

Farmers in these states have animals that produce manure. They also use fertilizers on their fields. With time and rainfall, nutrients from these sources seep into the Mississippi and any of its countless tributaries. Making their way eventually to the Gulf of Mexico, these nutrients in the manure and fertilizers combine with the heat of the Gulf to spawn catastrophically large algal blooms that kill everything in its wake.

Well-meaning farmers of the Dakotas, say, or Minnesota, or Wisconsin, may never know of the distant consequences of their actions. As such, it’s nearly impossible, and perhaps even unfair, to hold any one person responsible. How would you ever know, for instance, that this farmer’s fertilizer applications, as opposed to that farmer’s application, led in part to the dead zone that occurs so far downstream in space and time? In general, we can rightly say that farm manure and the application of chemical fertilizer and its subsequent nutrient-rich run-off cause of the dead zone in the Gulf, but for any one particular farmer it is much harder to make a causal attribution. 

The Gulf of Mexico dead zone, along with its distant causes, is a perfect analogy to the use of prescription opioids and the resultant opioid epidemic of addiction and overdose. 

Prescription Opioid Use & Addiction

The corresponding rise of both opioid prescriptions and subsequent opioid addiction and overdose is well-documented. Life-time prevalence rates of opioid addiction among patients engaged in long-term opioid management for persistent pain are as high as 40% (Boscarino, Hoffman & Han, 2015). Use of prescription opioids is a common vehicle to subsequent use of illicit opioids (Cicero, et al., 2014; Lankenau, et al., 2015; Monico & Mitchell, 2018). Since 1999, over 800,000 people have died of a drug overdose, with the majority of these involving opioids (CDC, 2021).

It would be fair to say that no one intentionally sets out to become addicted to opioids when using prescription opioids for the management of pain. It would also be fair to say that no prescribing provider intends for their patients to become addicted or die when prescribing opioids. Nevertheless, it does happen.

Much attention in recent years has been on the long-term use of opioids for persistent pain, but new long-term use of opioids also occurs following surgery as well (Hah, et al., 2017). Whatever the clinical indication for the use of opioids, the trajectory of prescription opioid use leading to addiction and/or overdose follows a common pathway involving multiple prescribing providers over time.

Typically, these days, it is uncommon for patients to be intentionally started on long-term use of opioids. Rather, patients tend to drift into it. A provider prescribes opioids to a patient to manage, say, acute or post-surgical pain and everyone expects it to be a brief duration. The pain, they assume, will subside on its own and the use of opioids will come to an end. When the pain, however, fails to subside, a second, third, fourth and fifth prescriptions come to occur. After awhile, the initial prescribing provider comes to refer the patient out to a different prvider after becoming concerned about the length of time the patient has been taking opioids. Or, perhaps, the initial prescribing provider becomes concerned with behaviors on the part of the patient, such as using more pills than were prescribed and subsequent early refill requests. In either scenario, patients commonly protest against the provider's concerns with denials that they are addicted and that they need the medication to manage their pain. In turn, the initial prescribing provider refers the patient to another provider, such as at a pain clinic, where the process over time repeats. Indeed, this process of concern about the patient’s use and subsequent referral to another provider can occur a number of times before any real sense of acceptance that opioid addiction has become an issue.

Opioid addiction thus only becomes apparent downstream in time and space. The initial prescribing provider may never know the eventual outcome of the patients that they start on opioids. The same may be true of the second and third provider in the process. They too may never know of the overdose death that occurs far from the time that they had delivered their care. 

Like the algae bloom in the Gulf of Mexico that is caused by unintentional behavior of farmers in the Midwest, the contributors to the opioid epidemic are both unwitting and separated in time and space from the consequences of their actions.

So, who takes responsibility for the opioid epidemic? It is easy to blame the addicted and the dead, for each of them are the one constant in their individual and often long, complicated trajectory of opioid addiction and overdose. They are, however, not the only responsible party. It’s easy to fail to fully appreciate this fact. 

To resolve the opioid epidemic, everyone in the healthcare system needs to take responsibility. Changes in prescribing practices are necessary, particularly in the difficult-to-predict-for transition period from early use to chronic use. Providers, patients and insurers continue to require education on alternatives to opioids for pain. We also need to de-stigmatize opioid dependency and addiction: while some of us are more prone than others, all of us will become dependent given sufficient exposure to opioids. We also need to educate providers, patients and insurers on pain — how to best treat it when able, and how and when to accept it, and acquire the abilities to self-manage it when necessary.

The Institute for Chronic Pain aims to do its part in achieving all these goals. We provide academic information on pain related topics that is approachable to all. 

References

Bloch, S. (2021). Gulf fishers brace for a “dead zone” the size of Connecticut and Delaware. Retrieved from: https://thecounter.org/gulf-of-mexico-fishers-dead-zone-climate-change-algal-blooms/

Boscarino, J. A., Hoffman, S. N., & Han, J. J. (2015). Opioid use disorder among patients on long-term opioid therapy: Impact on final DSM-5 diagnostic criteria on prevalence and correlates. Substance Abuse and Rehabilitation, 6, 83-91. doi: 10.2147/SAR.S85667

Center for Disease Control (CDC). (March 25, 2021). The drug overdose epidemic: Behind the numbers. Retrieved from: https://www.cdc.gov/opioids/data/index.html

Cicero, T. J., Ellis, M. S., Surratt, H. L., & Kurtz, S. P. (2014). The changing face of heroin use in the United States: A retrospective analysis of the last 50 years. JAMA Psychiatry, 71(7), 821-826. doi: 10.1001/jamapsychiatry.2014

Hah, J. M., Bateman, B. T., Ratliff, J., Curtain, C., & Sun, E. (2017). Chronic opioid use after surgery: Implications for preoperative management in the face of the opioid epidemic. Anethesia and Analgesia, 125(5), 1733-1740. doi: 10.1213/ANE.0000000000002458

Lankenau, S. E., Teti, M., Silva, K., Jackson, J. Haracopos, A., & Treese, M. (2012). Initiation into prescription opioid misuse among young injection drug users. International Journal of Drug Policy, 23(1), 37-44. doi: 10.1016/j.drugpo.2011.05.014

Monico, L. B & Mitchell, S. G. (2018). Patient perspectives of transitioning from prescription opioids to heroin and the role of route administration. Substance Abuse Treatment, Prevention, and Policy, 13(4). doi.org/10.1186/s13011-017-0137-y

Date of publication: September 20, 2021

Date of last modification: September 20, 2021

About the author: Murray J. McAllister, PsyD, is a pain psychologist and consults to clinics and health systems on improving pain care. He is the founder and editor of the Institute for Chronic Pain.