By DAVID HARLOW, MD

The opioid crisis has been upon us for years now, and we are now seeing the problem become more pervasive, with more than 90 deaths per day in the U.S. due to this scourge. The president recently said he would be declaring a public health emergency (which would free up some funds) but has not done so as of this writing. The public health threat is so persistent that it calls for responses on many levels, and those responses are coming. Some have been in place for a while, some are more recent. These responses may be broken down into a number of different categories:

• Broader availability of naloxone (antidote) and related training to first responders, health care providers and the general public (though of course in our litigious society, applicability of Good Samaritan laws to naloxone use by laypersons is a consideration)
• Medication-assisted treatment following acute episodes (emergency room visits)
• States imposing limits on prescribing and dispensing, mandating education and other innovations (for example, Massachusetts’ first-in-the nation opioids law (including the first state law limiting most opioid prescriptions to a seven-day supply), enacted in 2015, with a follow-up law enacted in 2016 that among other things offers a system for recording and communicating a voluntary opiate “opt-out” for individuals); and limiting pharma payments to physicians in order to discourage incentives for high-prescriber status (current proposal in New Jersey)
• Licensure and certification bodies imposing limits on prescribing and dispensing (state boards of registration in medicine, e.g., Ohio) and articulating management and operations frameworks for implementing those limits (Joint Commission)
• PBMs establishing limits for dispensing (Express Scripts, CVS Caremark)
• Payors imposing limits on payment (see, e.g., Cigna‘s opioid abuse detection and prevention program)
• The FDA mandating prescriber training (it is also being urged to ban high-dose formulations)
• Providers developing programs to limit the use of opioids in pain management along with specific targets on reduction in use (e.g., Intermountain)
• Professional and industry associations providing training of clinicians in pain management without opioids, or with limited opioid use (e.g., Massachusetts Medical Society, Colorado Hospital Association)

The overarching goal is to eliminate the use of opiates for all but the most critical short-term needs (limiting prescriptions to a seven-day supply) and medically-appropriate chronic and palliative pain management. There are alternative pain relief drugs — and a wide variety of other treatments for pain, ranging from TENS to meditation to VR.  Taken together, the initiatives highlighted and linked to above represent a good start. Of course, we need more than a good start, as the US consumes a wildly disproportionate share of opiates compared to other countries — follow link for some facts and figures — for predictable reasons of economics, politics and culture, and we are paying a staggering price in excess morbidity and mortality and in secondary effects (the effects on family and community).

We’ve gotten to this crisis point in part through the adoption of pain as a fifth vital sign (many have laid part of the blame at the feet of the Joint Commission, though the organization takes umbrage, pointing out that it described the practice rather than endorsing it, and also noting that the growth in opioid prescriptions predated its 2001 report on pain management). If pain is a vital sign, it must be addressed, and the healthcare-industrial complex has certainly addressed it. Oxycodone, hydrocodone, fentanyl and other opioid prescription volume went through the roof for acute pain and many, many people became addicted and have overdosed as a result. As noted in the articles linked to in the first line of this post, blame may be laid at the feet of medical journals, uncritical readers of those journals, the pharmaceutical firms that produced and marketed opioids in a manner that has led to over-prescribing and abuse, and societal and economic trends that have disenfranchised many Americans in many ways, making them more susceptible to opioid abuse.

The opportunities created by this crisis have not gone unnoticed by the capitalist class, as private equity investment in opioid addiction treatment demonstrates. (This causes me the same sort of distress as states relying on cigarette taxes for program funding; in neither case would the preferred public health outcome be seen as an unmitigated good by the green-eyeshade crowd.)

The problem is multi-dimensional, so the solution must be multi-dimensional. Initiatives by the FDA, the PBMs, by health care providers, by medical boards, by state governments, by third party payors will all have some effect, and together they have the potential to reverse the growth of opioid abuse and reduce, if not eliminate, the ongoing morbidity and mortality.

As one good example close to home for your HealthBlawger, check out the broad scope of the Massachusetts law, which has been promoted in a heartfelt way by Governor Charlie Baker. Massachusetts has a good website on the opioid crisis as well (see updates and reports here). Over two years later, it is clear that the Commonwealth is taking some positive steps forward (and follow-on legislation targeting inappropriate prescription of opioids has been enacted as well), though some parts of the law, such as the provision regarding offering counseling to patients in emergency rooms, watered down from “you will be counseled or we will hold you involuntarily for 72 hours” before it passed, have been criticized for not being particularly effective.

Some of the solutions offered around the country rely in part on technology. For example, drug-seeking patients may be prevented from obtaining medically unnecessary prescriptions thanks to sharing of data gleaned from electronic health records and made available as needed to other prescribing clinicians. (This highlights one reason that developing and maintaining interoperable electronic medical records with broad clinician access is so important; limiting access to clinicians approved by the patient would eviscerate this sort of approach to limiting opioid abuse. But the broad privacy question of who should have access to what data about a patient is one for another day.)

It is beyond the scope of this post to review each of the approaches to this crisis, but I expect that we will be hearing more about each health care system stakeholder’s experiences with these approaches in the coming months.

It will be interesting to see — and critical to track carefully so that we can know — whether the most recent round of interventions will have a real effect on the human cost of the epidemic.