To: New York State Senators Kristen Gillibrand and Charles Schumer

From: Mariyanthie Linaris

Date: January 20, 2019

Re: Nation-Wide Policy for Opioid Abuse Epidemic

 

Statement of Issue: Every day in the United States, it is estimated that upwards of 130 people die from an opioid overdose. The United States Department of Health and Human Services (HHS) estimates that 11.4 million people misused opioid prescriptions between 2016 and 2017. This public health emergency, as it has so been described by the HHS since 2017, stems from the introduction of opioid painkillers in the earlier 20th century and their more widespread use in the 1990s. Use of these medications, including hydrocodone, oxycodone, oxymorphone, morphine, codeine, and fentanyl, has skyrocketed in three main waves since 1999, with the most recent wave that had been ongoing since 2010 displaying a hand-in-hand increase with heroin use, a more cost effective alternative to prescription opioids. Government agencies have not swept this issue under the rug, however, as several attempts at reversing these statistics have been made. For example, individual state governments have implemented prescription drug monitoring programs (PDMPs) to allow providers to track controlled substance prescriptions for patients prior to prescribing dangerous medications, like opioids. Additionally, methadone clinics and promotion of opioid overdose reversing medications have been implemented. Prescription opioid abuse is an issue that affects not only the people abusing the medications, but also friends, families, and entire communities.

• Opioid abuse is extremely costly for the United States. The opioid crisis has reportedly cost the United States $1 trillion between 2001 and 2017 and is projected to cost upwards of an additional $500 billion by 2020.
• Adverse effects of opioid abuse cause overcrowding in hospital emergency departments. The combination of opioid abuse and limited resources and staffing in hospital emergency departments results in adverse outcomes for all patients seeking care.
• Opioid abuse is linked with increased heroin use. Since prescription opioids are more expensive and harder to acquire, patients who misuse prescription opioids are likely to transition to heroin, which is cheaper, but carries with it the additional dangers of injectable illicit drugs.
• The rate of opioid abuse among pregnant women has quadrupled in the last 15 years, which has resulted in increased risk of miscarriage, stillbirth, developmental problems, and neonatal abstinence syndrome
• Current policies and programs have been marginally effective, but often focus more on harm reduction with opioid abuse rather than getting to the root of the problem. Despite these efforts, opioid abuse rates seem to be steadily climbing.

 

Policy Options:

 

• Two possible causes leading to such widespread abuse of opioids in the United States might be lack of patient education and premature prescribing by providers. To combat this, the federal government can mandate a more detailed pre-prescribing process consisting of a detailed review of alternate pain management treatments, a patient education course, urine drug testing, and a provider-patient treatment contract. By conducting a detailed review of alternate pain management treatments, the provider assures that all possible treatments have been explored and opioid use is treated as a last resort. The patient education course would be a short training to be completed by the patient prior to receiving an opioid prescription to confirm that they are aware of the possible risks taking opioids hold. The course would culminate in a short quiz where a minimum passing score must be achieved, the results of which must be included in the patient’s chart from the visit where the prescription is given. The urine drug testing would be an extra precaution to avoid giving controlled substances to patients who are likely to abuse them. Finally, the provider-patient treatment contract serves to agree on the treatment specifications and assures that the patient has been properly counseled on opioid treatment. All of these items should be included in the patient’s chart. Failure to adhere to these guidelines should result in a monetary fine.
  • Advantages: Patients and providers both become more involved in the care. Additionally, insuring that the patient is properly educated on the risks of opioid use as a pain management treatment allows the patient to decide whether they are willing to take those risks. This process would also make it easier for providers to determine who truly needs the opioids.
  • Disadvantages: This process would be more time consuming than the current prescribing process and might foster an environment of distrust between the patient and provider.
• A restriction on the number of pills and frequency of prescription without a follow-up visit can be implemented. For example, if the provider prescribes 10 pills per month, the patient should come in for a follow up visit for re-assessment of treatment before being able to prescribe another set of pills. Failure to adhere to these guidelines should result in a monetary fine and potential loss of opioid prescriptive authority.
  • Advantages: The follow-up visits allow for screening for opioid abuse and adjustments to the treatment, with the potential of detecting instances of opioid abuse early on and allowing the provider to refer the patient to substance abuse specialists.
  • Disadvantages: It can be inconvenient for patients to go to an appointment every month, and it can leave patients who require opioid pain management treatment to go without this treatment if they cannot make it to the appointment.
• As of today, opioids are the most effective pain management medications, but their addictive qualities have caused this epidemic. The government should put money into developing safer, non-addictive pain medication with effectiveness on par with opioids. Exploring other neurobiological systems like the endocannabinoid system can be extremely effective as a target.
  • Advantages: This offers a new area of research for medicine. Additionally, developing a new, effective medication could replace current opioid pain management treatments and end the opioid crisis.
  • Disadvantages: There is no guarantee that this research will result in an effective drug. Additionally, getting funding for this kind of research may be difficult. Finally, it may take time for providers to get accustomed to using a new drug.

 

Policy Recommendation: Rates of prescription opioid abuse are steadily rising in the United States, with more than 130 people dying as a result of overdoses every day. Reserving this public health emergency requires a coordinated effort by the federal government, medical providers, pharmaceutical companies, and patients. Despite some efforts on behalf of the government, including PDMPs, access to overdose-reversing medications, and increased awareness of the opioid problem in the country, we are not getting to the heart of the problem. A solution in the form of a federal mandate that combines patient and provider education and risk assessment before prescribing opioids for pain management may be more successful in eradicating opioid abuse in the country. This process might be time consuming and can shake up the patient-provider relationship at first, but it involves the patient in their care and can allow the patient and provider to work together to find the best possible care option on a case-by-case basis.