An opioid emergency

{***Pause/Music***}
{***Noah***}

Coming up on Harvard Chan: This Week in Health…

President Trump declares America’s opioid crisis a public health emergency.

{***Michael Barnett Soundbite***}
(To really attack the opioid epidemic, you need to approach each part in the pipeline of how someone in the population progresses from first being exposed to opioids, to becoming dependent on them and being at risk of overdose.)

In this week’s episode we examine how we arrived at this point, and why President Trump’s actions likely won’t be enough to stem the tide of addiction and overdoses.

{***Pause/Music***}
{***Noah***}

Hello and welcome to Harvard Chan: This Week in Health. It’s Thursday, November 2, 2017. I’m Noah Leavitt.

{***Amie***}

And I’m Amie Montemurro.

Last week, President Trump declared America’s opioid epidemic a public health emergency.

That designation will allow the government to hire new personnel to address opioid addiction, expand access to telemedicine services—such as remote prescribing of drug treatment medications—and increased flexibility in the use of grant money to address the epidemic.

{***Noah***}

But that declaration fell short of a national emergency under the Stafford Act, which would have opened the door to even greater funding to address the opioid crisis.

We’ll talk more about the specifics of President Trump’s actions in a few minutes—and get some perspective from Howard Koh, who is Harvey V. Fineberg Professor of the Practice of Public Health Leadership here at the Harvard Chan School, and former Assistant Secretary for Health for the U.S. Department of Health and Human Services.

{***Amie***}

But first, we wanted to explore how we arrived at this point.

We spoke over the phone with Michael Barnett, who is an Assistant Professor of Health Policy and Management at the Harvard Chan School. He’s also a physician, and much of his research has focused on how variations in doctors’ prescribing habits can influence a person’s risk of long-term opioid use.

{***Noah***}

We started our conversation by asking Barnett to explain the scale of the opioid crisis in America.

And he says it’s enormous. According to preliminary figures from the CDC—an estimated 45,000 Americans died from opioid overdoses in 2016.

{***Michael Barnett Soundbite***}
(So just to give you a sense of perspective there, that has now definitely surpassed the number of individuals that typically die in car accidents or even from gun injuries, both of which are causes of death that I think most of us think are far more prevalent and a scourge just sort of in popular imagination. But opioids have really far overtaken that. Millions of Americans– in 2014, 2 million Americans– either abused or were dependent on prescription opioids. And 1,000 people a day are treated in emergency departments for opioid dependence-related problems. So this is really a major, major issue.)

{***Noah***}

The factors driving opioid addiction in the U.S. are complex, but Barnett says access and exposure to drugs is a serious issue and a main driver of the epidemic.

{***Amie***}

According to Barnett, state-level data shows that in some states 25-30% of people are exposed to opioids at least once a year.

And at the height of opioid prescribing in the U.S.—which was 2011—there were enough opioids prescribed for every American to receive a month’s worth of hydrocodone.

{***Noah***}

So what’s driving this access to opioids?

Barnett’s research has shown that doctors’ prescribing habits play a critical role in determining whether someone becomes a long-term user of opioids.

And Barnett says there are several factors driving these habits.

{***Michael Barnett Soundbite***}
(The volume of opioids prescribed in the US more than tripled from 1991 to its peak in about 2011. So that’s a 20-year period. And there’s been a lot written about exactly what was behind driving that increase. I think one thing is clear, that it’s not really related to a significant change in disease burden or the burden of pain in the US. But there are a lot of investigations and theories around exactly what drove this. A few of them are that in the 1990s and early 2000s, new formulations of opioids like OxyContin, which are long-acting and particularly addictive, were FDA approved and started to be marketed to physicians as treatments for pain. And kind of a combination of physicians, pharmaceuticals, and specialty societies started to promote the idea that actually pain is really under-treated, and that physicians were unnecessarily scared of opioids, and that patients who were really in pain really had a low risk of addiction from opioids, and it was the compassionate thing to do to treat them. This is actually something that I learned in medical school, which was really not all that long ago. But it was certainly well before I think the kind of current craze and epidemic awareness of the epidemic really started. And one of the more famous catchphrases that really personified this era of increasing opioid prescribing is the idea of pain as a vital sign, that we should really capture every patient’s pain, and that treating pain is one of the key parts of high quality medical care. I think no one would really disagree with that. But part of what came along with this is the idea that opioids were really the key ingredient to making sure that pain was adequately treated. And I think that’s something that’s becoming increasingly challenged as we realize that we’ve gotten into an enormous public health quagmire by having such free availability to these medications.)

{***Noah***}

So will President Trump’s declaration do enough to address the factors driving the opioid crisis?

{***Amie***}

Howard Koh says it is a positive step in some ways—but it doesn’t go far enough.

{***Howard Koh Soundbite***}
(On one hand this declaration brings heightened attention to a pressing national crisis. And I saw the president speak very passionately and personally about this. And he articulated some very important broad directions about the importance of prevention and education and treatment. But on the other hand, it does not provide any new additional funding to address the crisis. And that’s a major concern. Everybody agrees that more funding is needed. Thoughts are that tens of billions of dollars will be necessary to really move forward on prevention education and treatment. And no additional funds are made available by this declaration so far. So, the two options were to declare a public health emergency through the Public Health Services Act or a national emergency through the Stafford Act. If he had done the latter, that would have allowed funding from FEMA and other sources that could have amounted to substantial funds. By choosing the former route, the public health emergency, he can only announce at this point a redirection of current funds. So no additional funding has been freed up through this announcement. And so, the onus now falls back to Congress for the near future.)

{***Amie***}

Koh says it is urgent that Congress acts to provide the necessary funding because there is a growing awareness of just how severe the problem is.

{***Howard Koh Soundbite***}
(Well we are seeing commitment from both sides of the aisle. So that’s potentially promising. This is an issue that really is a bipartisan issue. And I think every policymaker across the country is seeing that this is a public health issue and not necessarily just a criminal justice issue, that it affects people of all walks of life. So, the fact that leaders have galvanized around this theme is very promising. But you know, we’re in a time with a lot of pressing demands. There are lots of issues that are being debated in DC right now. We really need to cut through all that and make this public health crisis our top priority if we’re going to save some lives.)

{***Noah***}

Koh say that when it comes to addressing the opioid crisis there are key areas that do need more attention.

He’d like to see more of a focus on primary prevention at a young age—taking steps to stop opioid mis-use before it begins.

Koh says it’s a strategy that has helped childhood and teen smoking rates in the U.S. drop to an all-time low.

{***Amie***}

And while prevention is important, access to treatment is also critical, says Koh, since it’s estimated that just 10% of Americans are receiving the addiction treatment they need.

And when it comes to treatment, that’s one area where President Trump’s emergency declaration can help, Michael Barnett told us.

{***Noah***}

The declaration gives the federal government more power to negotiate drug prices, which could help lower costs life naloxone—also known as narcan—which is a drug that can reverse opioid overdoses.

Lowering prices would increase availability around the country—especially among first responders.

{***Amie***}

Regulatory changes could also make it easier for doctors to treat addiction.

Barnett says the emergency declaration would also ease certain restrictions on doctors practicing telemedicine.

{***Barnett Soundbite***}
(There’s actually a regulation that blocks providers from prescribing medication-assisted therapies such as buprenorphine or methadone through telemedicine, in large part because the Drug Enforcement Agency, or DEA, is worried that providers would sort of unscrupulously distribute these medications to people who would use them for recreational purposes if they can just do it basically remotely with very little accountability. But I think there are increasing calls for the need for psychiatrists and other addiction providers to be able to use telemedicine to reach rural areas where there is really very few providers of any kind, much less addiction treatments, but where the burden of the opioid crisis is really quite severe.)

{***Noah***}

And while these are all positive steps, Barnett agrees with Koh, that the declaration doesn’t go far enough because it doesn’t open up. the funding needed to address the complex causes of the opioid epidemic.

{***Michael Barnett***}
(The way I think about it is that to really attack the opioid epidemic, you really need to approach each part in the pipeline of how someone in the population progresses from first being exposed to opioids to becoming dependent on them and being at risk for overdose. And there isn’t a single solution that will deal with all of those. My own research really focuses on understanding physicians prescribing and how can we make that happen in a more responsible way, so fewer people who don’t necessarily need them are initially exposed to that opioid. This public health emergency really does very little to actually address that. And many states are really taking it into their own hands as to addressing that with policies such as prescription monitoring programs and other prescription policies.)

{***Noah***}
We asked Barnett to expand on what’s happening at the state-level.

{***Amie***}

He said it’s still too early and difficult to tell which measures are most effective, but he did outline some promising strategies to address opioid addiction.

{***Michael Barnett Soundbite***}
(We know that medication-assisted therapy works. For people who are addicted to opioids, if they can get a long-acting opioid therapy like methadone or buprenorphine, they relapse less often. They stay sober for longer. And they can go back to leading normal lives. In terms of other state-level policies, we have encouraging evidence that prescription monitoring programs, which are basically databases that physicians can look into to check a patient’s prescription history and look for patterns of potential opioid abuse or risky behavior, those seem to reduce prescribing to patients who might be at the highest risk for overdose. And there’s some preliminary data that it may be associated with a decrease in overdose rates. But it’s still pretty early. I think one thing that we do know is that states really need to actually mandate that physicians use these programs and make them as accessible as possible for them to have any impact. Because if you create them and doctors don’t use them, there’s really no point. Other policies that have been out there– there are a lot of different policies states are trying to enact to, say, for instance, limit the number of pills that patients can get with any single prescription or make doctor shopping illegal or mandate, for instance, that patients who are taking above a daily dose of opioid above a certain amount have to have a consultation by a pain management physician. None of these policies have really, really been shown to be effective. Either they’re not evaluated or actually there’s data showing that they’re in fact not effective. But I think at this point, it’s too scattered to really make a clear conclusion about what does and doesn’t work at the moment. And that’s part of why I think in this public health emergency, really, in addition to all the funds necessary to try to actually expand access to addiction treatments and enable states to enact broader policies, we also need money to implement evaluations of all these policies. Because we don’t have time to waste while thousands of thousands of people are dying every month to basically just work on policies that maybe feel like they’re a good idea, but actually haven’t been evaluated, and then we find out years after the fact they don’t work. And so that’s part of what I want to see in some kind of emergency declaration or some federal appropriation of funds, that we don’t just have the policy itself, but also make funds available for evaluators to really give as rapid feedback as possible to policymakers, so that we can abandon ideas that don’t work. That’s the key thing.)

{***Amie***}

When it comes to President Trump’s emergency declaration, Koh and Barnett say the biggest positive is that it helps cement just how widespread this problem is—that it is affecting people across the country from every socioeconomic level.

{***Noah***}

Both Koh and Barnett say this move may also be helpful in reducing the stigma surrounding addiction—by helping people understand that it’s a disease and not a moral failing.

{***Howard Koh and Michael Barnett Soundbite***}
(If you heard the president’s remarks, he spoke quite personally about his brother and his brother’s issues with alcohol use disorders. And so, he connected on a very personal level. And that’s, if there’s a silver lining here, people are seeing this as a family issue and a personal issue, and also, as a health issue and not necessarily just a criminal justice issue. So that’s progress. We’ve discussed before that to continue to humanize this epidemic is hugely important, and using the appropriate language to talk about substance use disorders and not substance abuse, for example, to talk about people being in recovery and not being clean versus dirty. We need to modernize and humanize these terms. And I think the more we do that, the more people we can engage. And then we can also encourage people who are wrestling with addiction to step forward because the stigma is holding many people back from even searching for treatment in the first place.

This isn’t something that is going to be solved by basically shaking our finger at people who are using opioids and kind of are caught in the throes of addiction, and just kind of equating it to a moral failure that can just be solved with stronger law enforcement and tougher moral fiber.

I think that’s an approach which has not been successful for other substance abuse epidemics in the past. And I think it’s not going to be successful for this one. And I think there needs to be awareness that we need to attack both the root causes of the problem itself and reduce the availability of supply, but also enable communities to recognize that people who are dependent on opioids deserve treatment and sympathy and a community that’s there to actually try to help them as opposed to shun and stigmatize them.)

{***Noah***}

That was Michael Barnett and Howard Koh on President Trump’s emergency declaration on the opioid epidemic.

{***Amie***}
If you’re interested in learning about Barnett’s research on opioids, we’ll have a link on our website, hsph.me/thisweekinhealth.

We’ll also have a link to a past interview we did with Howard Koh focusing on efforts to change the language surrounding addiction.

{***Noah***}

That’s all for this week’s episode.

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