There are many ways to tackle America’s growing opioid addiction crisis. In articles in USA Today, a behavioural economist and a chief medical examiner propose letting doctors know when patients overdose and die, in order to reduce opioid prescription; an addiction expert accuses US senators of dragging their heels on legislation; and Republican Bill First – heart surgeon and former Senate majority leader – outlines five actions that need to be taken.
To reduce opioid prescriptions, tell doctors when their patients overdose and die
A year-long study found that doctors prescribed fewer opioids after receiving letters telling them their patient had died from an opioid overdose, write Jason Doctor and Jonathan Lucas for USA Today.
Doctor, a behavioral economist at the Leonard D Schaeffer Center for Health Policy & Economics at the University of Southern California, and Lucas, Chief Medical Examiner-Coroner for Los Angeles County, write:
By now it is well known that the US is in the grips of its worst drug crisis in history. Illicit and prescription opioid overdoses killed 351,630 individuals between 1999 and 2016. Over two million Americans today are addicted to these powerful painkillers. Unlike most other epidemics, human behavior, not a virus or bacteria, is responsible for it.
Although prescribing peaked in 2011, it has declined only moderately and is still much higher than it was prior to the epidemic. As a behavioral scientist and a county medical examiner who has to deal with more and more bodies arriving at the morgue, we wondered why physicians continued to overprescribe despite the obvious harms.
A few things became clear to us. First, opioid deaths can easily go unnoticed by clinicians. Clinic visits involve patients who are alive and who are either treated with a new opioid prescription or who are returning, often uneventfully, for a refill. This “survivorship bias” can lead doctors to believe that the opioid crisis is not impacting their own practice, because they deal day-to-day with living patients.
Second, the real damage being done by opioids can seem remote to doctors who are not given the personal experience of knowing a patient has died. If they perceive that the crisis is happening elsewhere, doctors may underestimate risk.
Third, aside from the so-called “pill mill” clinics, nobody has been paying close attention to the behavior of individual prescribers. We know that behavior changes when people know they are being observed. Medical examiners and coroners handle deaths that involve unusual circumstance and sometimes these come under intense public scrutiny.
We wondered if more careful prescribing would result if doctors were told by the county medical examiner that an opioid patient in their practice had fatally overdosed.
Doctors heed information on opioid deaths
To find the answer, we set up a trial in San Diego County covering 861 doctors who prescribed to 170 persons who subsequently overdosed and died. We observed over 1.2 million prescriptions during the study period of July 2015 to June 2016.
Prescribers to half of the decedents were randomly selected to receive a personal letter from the county’s chief deputy medical examiner notifying them when one of their patients died from an overdose. The letter was carefully worded to not seem accusatory and was supportive in tone.
It encouraged the physicians to check CURES – the California prescription drug monitoring program – before prescribing to a patient to ensure the patient was not already receiving other pain medications from another source. The letter also reiterated guidelines from the Centers for Disease Control and Prevention for safe prescribing. The other half became a control group and did not receive letters.
In the three months following the receipt of a letter, doctors decreased their opioid prescribing (as measured by milligram morphine equivalents) by 9.7 percent as compared to those in the control group. The doctors contacted by the medical examiner also started fewer patients on opioids and wrote fewer high dose prescriptions.
While the letter plainly contained powerful information, it was not threatening and gave the clinician a path toward safer prescribing. The intent was to encourage caution without restricting physician freedom to prescribe appropriately. Indeed, the results of the study suggest that clinicians who received the letter exercised greater vigilance with opioids without abandoning use.
Some worry that reduced prescribing causes a rise in people switching to illicit opioids, but evidence of that is inconclusive. Historically, price – not restrictions –has driven the increased demand for illicit opioids. In fact, prescription opioids can be a risk factor for transition.
Heroin admissions to hospitals among young white adults rose every year from 2004 to 2010 even as opioid prescriptions were still increasing. Fewer initial exposures to prescription opioids is one way to help reduce the risk of switching.
Reducing opioid prescriptions saves lives
It is impossible to say how many deaths were avoided by the cutbacks in San Diego. Reduced prescribing is only one of many components needed to fight the crisis, including access to counseling, medication-assisted therapy and efforts to address the social and economic causes for increased addiction.
But the intervention we initiated is scalable nationwide. The approach we used was simple, understanding and inexpensive to send. Each medical examiner and coroner in the US catalogs and reports opioid deaths to the National Center for Health Statistics. Medical examiners and coroners have access to prescription drug monitoring databases that can help identify who needs to know about a death in their practice.
Let’s close the loop in opioid prescribing. Doctors need to know what’s happened to their patients, and that someone is paying attention, so they can help avoid deaths while they seek to alleviate pain.
Opioid addiction is a full-on public health crisis – But Senate isn’t acting that way
The scale of America’s opioid crisis is described in an opinion article in USA Today by Michael King, director of outreach and engagement for Facing Addiction and The National Council on Alcoholism and Drug Dependence. He writes:
This is about the life and death of neighbors and loved ones. The Senate must put politics aside and treat opioid addiction as the health crisis it is, King contends.
If this were any other public health crisis, decisive action would have been taken long ago.
Three hundred and fifty of our sons, daughters, brothers, daughters, husbands and wives are lost every day to alcohol and other drugs, including opioids.
The House passed the SUPPORT for Patients and Communities Act on 22 June – a package of more than 50 individual opioid bills designed to help communities in dire need. They cover everything from stronger guidance for sober living facilities to ensuring treatment for those who overdose to studying new pain management protocols and treatments.
And, yet despite the overwhelming 396-14 vote in the House 10 weeks ago and the death toll rising in our communities, the Senate is still mulling details and trying to reach an agreement.
Senate must get past politics and delays
Why would our elected policymakers ignore and delay on a public health crisis this pressing? Because it impacts people like me. People they think do not vote, people they perceive to have brought this issue on themselves, people we have always let them get away with ignoring.
I am a person in long-term recovery. For me, that means I haven’t had a drink or a drug, and haven’t place a bet, since 16 February 2013. Recovery has given me a new way of life. I’m a taxpayer, a loving, responsible and attentive father, a conscientious friend and partner, and a voter.
Addiction had taken everything from me – a political career I valued, a home and all my finances. But most importantly, addiction stole my dignity. It snatched my sense of self and held it in its grips. It took a lot of pain and heartache, for myself and for those around me, to break the grip this devastating illness had on me and find recovery.
Over 20 million Americans are currently suffering from a substance use disorder — but there are 23 million more in recovery from alcohol and other drug problems. These numbers are daunting. This is not an obscure illness. To put it in perspective, this adds up to one in three households on your block who directly impacted by addiction.
Untreated addiction costs our economy $442 billion and nine out of 10 individuals in need of treatment don’t receive it. And yet despite the colossal failure of the war on drugs, too many in our communities continue to believe that addiction is solely a law enforcement problem that requires solutions within the criminal justice system instead of health care.
As the death toll rises, we can’t continue down this road. In order to change course and take the addiction response closer to health-care driven solutions, Senate leaders must stop playing politics. This is about life and death for our loved ones and our neighbors.
Addiction is not a partisan issue
Addiction is non-partisan. This isn’t an issue that is going to fire up either political base, turn them against the other side and then turn them out to the polls. I spent a decade in politics —I know how election-year dynamics work. Stick to the issues that drive a wedge between us all, don’t get anything done, then run home to your districts and blame the other side. I’ve seen it before and even played a part in it. But this one is too serious.
And politicians better take note: Out of the ashes of the worst drug epidemic in American history by order of magnitude, a constituency of consequence is emerging. Over 2,300 individuals and 70 organizations have added their names to a letter, sent by Facing Addiction with NCADD, demanding action from Senate leaders. All who signed our letter know they and their loved ones aren’t immune. Many have already been affected — and they are not going to sit quietly by and let elected officials play politics with the wellbeing of their communities.
Whether we are Democrats, Republicans, independents or apolitical, we are just as susceptible as anyone else to be affected by addiction. That’s why Senate leaders must act, and act soon. Your life and the lives of your loved ones may depend on it.Opioid addiction is a full-on public health crisis but the Senate isn’t acting that way
The five things we must to do together to end the opioids epidemic: Bill Frist
Republican Bill Frist of Tennessee – a heart transplant surgeon, former Senate majority leader and co-chair of the Bipartisan Policy Center’s Future of Health Care Initiative – wrote an earlier article in USA Today, in May. He reminded Americans that they had came together in 2003 to turn the tide on the HIV-AIDS epidemic – they must unite again to overcome the opioids crisis.
For the first time in history, drug overdoses are now the leading cause of death for Americans under age 50. For the first time in nearly a quarter century, US life expectancy has declined, driven by diseases of despair like alcoholism and drug addiction.
And for the first time in a long time, policymakers and providers are serious about trying new approaches and making a real investment in turning the tide on addiction.
The US had more than 64,000 drug overdose deaths in 2016 – more people died from overdoses than those who died in motor vehicle accidents; more died than those who were killed in the 20-year Vietnam War.
It is a staggering loss of life caused by a complex epidemic. All segments of society bear responsibility: from aggressive pharmaceutical advertising with misleading information on addictive potential; to the push in the medical field, furthered by government regulation and reimbursement, to make pain a fifth vital sign; to the rise of the Mexican heroin trade that has infiltrated sleepy American towns and cities.
Solutions must be as varied as the drivers of the epidemic. Criminal justice system reform, for instance, must play a role, and our first responders – police, firefighters, EMS – need access to naloxone to prevent overdose deaths.
But as a physician and a former senator, here are the health care system changes I recommend.
First, physicians must be educated on providing patients with adequate non-addictive alternatives to manage pain. Even when Ibuprofen would be sufficient, doctors may write opioid prescriptions because that’s the approach they learned in medical school or residency.
Changing these habits is not as simple as changing prescribing guidelines. It will require comprehensive reeducation and engagement of our providers at multiple touchpoints, including continuing medical education, health care organization efforts and peer mentorships.
Second, private sector health insurers also have a role to play. As an example Cigna, a company that is demonstrating real leadership in the fight against the opioid epidemic, recently announced that it achieved a 25% reduction in opioid use among its customers.
The gains were achieved through collaboration with 1.1 million prescribing clinicians using an integrated analysis of pharmacy, medical, and mental health benefits to personalize the level of customer care.
“One patient at a time, we were able to create a feedback loop that educated physicians on their own prescribing patterns,” David Cordani, Cigna’s CEO, told me. “Our analysis flagged where patients may have been more likely to overuse opioids.
It takes visibility on all touchpoints of care – hospitals, doctors, dentists, pharmacists, and mental health professionals – to rush interventions to those at risk, and to help prevent people from becoming at risk at all. That complete picture is key.”
Third, lawmakers must work to change federal reimbursement rates that incentivize opioid prescribing over non-addictive alternatives. As the House Ways and Means Committee explained in a bipartisan report on the opioid epidemic, “Studies have demonstrated that a number of non-opioid treatment options (eg non-opioid analgesics, acupuncture, physical therapy, etc.) can be just as effective as opioids in treating chronic pain – if not more so. But Medicare and other payers often do not cover these alternatives to the same degree as opioid treatments or may not cover them at all.”
Fourth, we must make mental health treatment and addiction rehabilitation more accessible and affordable. Our nation’s inadequate treatment of mental health has also contributed to this epidemic, as those who struggle with such challenges are more likely to self-medicate with drugs and alcohol.
Nearly eight million Americans have both a mental health disorder and a substance use disorder. And despite the passage of the Mental Health Parity and Addiction Equity Act in 2008, mental health treatment is still out of reach for many due to high out-of-pocket costs and a shortage of mental health providers, among other reasons.
Finally, we must make it easier for those with active addictions to get the care and support they need. One quirk in our privacy laws makes it difficult for doctors to access patients’ previous treatment for drug abuse and addiction; that makes it harder to coordinate care and understand a patient’s health history.
Another challenge is that Medication Assisted Treatment may not be covered by insurers. In the case of Medicare, it can generally only be given in an in-patient setting, putting it out of reach for many.
There is also the perception that a 30-day stay in rehab should be a cure, when in fact the disease of addiction changes brain chemistry for years following cessation. You wouldn’t expect a patient to beat cancer with only half a dose of chemo, and we can’t expect those struggling with substance use disorder to overcome the disease with only a partial course of treatment.
Thankfully, both the House and Senate have taken bipartisan action to advance legislation that will tackle some of the challenges listed. But successful, lasting change will require a cultural convergence.
We need think of opioid misuse as a chronic illness that often have behavioral and medical components to their disease just like other chronic illnesses.
In 2003 when I was Senate majority leader, we were able to come together to turn the tide on the global HIV-AIDS epidemic, and I’m convinced that today we can again unite to overcome this crisis. Leadership in Washington must be matched by commitment and action on the ground.
It will require everyone – payers, providers, physicians, legislators, regulators, law enforcement and patient-consumers – to collaborate and coordinate. As a society, we are all affected by the opioid crisis. Together we can and must do better.The five things we must to do together to end the opioids epidemic: Bill Frist