Opioid Use in America: The “Pursuit of Oblivion”

Stories that caught our attention this week

yellow pills at a pharmaceutical production companyTo confront a public health issue of epidemic proportions, it takes a public policy effort of similar magnitude. At least that’s what we can infer from a bipartisan effort to address the nation’s opioid crisis. After weeks of negotiating to reconcile House and Senate bills, legislative leaders from both chambers released a 660-page bill containing public health and law enforcement measures aimed at decelerating the growth rate of opioid-related overdose deaths and at preventing addiction. This bill follows the Comprehensive Addiction and Recovery Act, which was signed into law by President Barack Obama in 2016.

In the New York Times, Abby Goodnough explains some of the measures tucked into the enormous opioids package. One of them increases access to inpatient treatment by partially lifting a longtime Medicaid rule, known as the Institutions for Mental Disease (IMD) exclusion (PDF). Essential CoverageThat rule prevented states from “spending federal Medicaid dollars on residential addiction treatment at centers with more than 16 beds.” California was the first state to lift the Medicaid IMD exclusion for the 40 counties participating in its Drug Medi-Cal Organized Delivery System pilot program.

In an effort to address the nation’s shortage of doctors who can prescribe buprenorphine (a Food and Drug Administration–approved medication that treats withdrawal and cravings), another provision permanently expands buprenorphine prescribing rights to nurse practitioners and physician assistants. The bill also expands telehealth services for addiction treatment in Medicaid and Medicare.

Some policymakers and addiction experts say the opioids package falls short. Sen. Elizabeth Warren (D-Massachusetts) and Rep. Elijah Cummings (D-Maryland) want more federal funding for addiction treatment and prevention services. Several measures, including a proposal that would allow doctors and other providers to easily share patients’ behavioral health information, were excluded from the conference bill. The House passed the bill 393 to 8 on Friday, September 28, and the Senate is expected to vote on it the week of October 1.

The Opioid Crisis Can’t Be Legislated Away

Though the opioids package is a start, it is no panacea for this complex public health crisis that kills an average of 115 Americans a day. However, addiction experts and seasoned reporters covering the issue agree on tangible solutions. In Vox, German Lopez outlines four strategies for fixing America’s painkiller problem. In a Longreads piece, freelance journalist Zachary Siegel weaves his personal narrative of opioid addiction into reviews of three books on the opioid crisis. Here’s a look at the solutions they recommend.

Lopez reports some encouraging news — researchers at the University of Southern California found that a simple intervention reduced doctors’ overprescribing. Some doctors were sent a letter from the county medical examiner informing them that a patient of theirs died of opioid overdose less than a year after the doctor prescribed them opioids. Those doctors went on to reduce opioid prescribing by nearly 10% compared to doctors who did not receive such a letter. (The California Health Care Foundation supported this study.)

Small nudges like this could be a critical step in the right direction, Lopez writes. Other cues to physicians include lowering the default number of opioid doses prescribed in an electronic medical record system or requiring a signed informed consent form for every first-time prescription that is written for more than a three-day supply. “The idea is not to constrain clinical decision making, but to make it a little harder for doctors to casually overprescribe,” Andrew Kolodny, MD, an opioid expert at Brandeis University, told Lopez.

Lopez also recommends carefully tapering patients off opioids. Experts warn that abruptly cutting pain patients off “could lead some to suffer unnecessary pain or withdrawal or, perhaps worse, push patients toward dangerous illicit drugs.” Siegel agrees, reminding us that “choking off the supply of prescription painkillers early on in the [opioid] crisis, without first installing a safety net to catch the fallout, was a major policy failure that worsened America’s opioid problem by orders of magnitude.”

Abstinence-based treatment facilities “prefer to give patients heart-shaped rocks instead of the two FDA-approved medications that reduce the risk of fatal overdose by 50% or more.” —Journalist Zachary Siegel

Lopez and Siegel agree that America’s broken health care system cannot be expected to solve the addiction emergency by itself. Lopez highlights the importance of considering a multitude of factors when treating pain — factors including “mental health issues and the potential causes of mental health problems, like a lack of purpose in life, poverty, joblessness, homelessness, and much more.”

Likewise, Siegel emphasizes the connection between mental health issues and substance use: “Opioids are merely the newest iteration in the pursuit of oblivion, a more effective reliever of emotional and physical pain.” He adds, “To be sure, growing up in a financially stable and supportive family didn’t immunize me from addiction. It’s not just poor people in despair who get addicted.”

Perhaps the most actionable strategy from either journalist stems from a heartbreaking memory. Siegel recalls his time in an abstinence-based addiction treatment facility where the “spiritual counselor” would give patients heart-shaped rocks that she collected. The tragedy of America’s opioid crisis, Siegel writes, is that when people struggling with substance use disorder are “drowning and begging for help, they’re callously thrown deflated life preservers” like abstinence-based facilities “that prefer to give patients heart-shaped rocks instead of the two FDA-approved medications that reduce the risk of fatal overdose by 50% or more.”

Medication-assisted treatment (MAT) is a solution that Lopez has advocated again and again. Previously, he wrote for Vox, “Studies show that the medications [buprenorphine, methadone, and naltrexone] reduce the all-cause mortality rate among opioid addiction patients by half or more and do a far better job of keeping people in treatment than non-medication approaches.” In fact, buprenorphine is “widely regarded as the gold standard for opioid addiction care,” Lopez wrote in another piece.

Despite evidence that MAT saves lives, there is high unmet need for it. AmfAR’s Opioid & Health Indicators database shows that nearly 90% of Americans who needed addiction treatment in 2014 did not receive it. To see how this treatment gap manifests in California, take a look at the Urban Institute’s county snapshots. The state is using federal grants to implement major expansions in MAT access  with a focus on rural areas and American Indian and Alaskan Native tribal communities. The federal opioids package would expand MAT through various measures.

Safe Injection Sites: Back in Favor?

We end with the news that a controversial major study on safe injection sites has been retracted. In August, University of South Wales researchers published in the International Journal of Drug Policy a meta-analysis questioning the efficacy of safe injection sites. The study concluded that safe injection sites did not have a significant impact on heroin use, overdose mortality, or syringe sharing. This result was disappointing to supporters of safe injection sites, including Vox’s Lopez and many addiction experts.

Now the International Journal of Drug Policy has retracted the study due to “methodological weaknesses.” Lopez reports that the researchers attributed the mistakes to an “honest human error in the use of methods.” Though the retraction bodes well for the movement favoring harm-reduction measures to combat the opioid crisis, the damage may already be done. Lopez writes: “The retraction probably won’t do much to quiet critics of supervised consumption sites, particularly their calls for more research into the sites before they’re adopted in the US.”

What have you read about the bipartisan opioids package? Tweet at me with #EssentialCoverage or email me.