Fourteen things Trump needs to know about opioids

President Trump is promising to increase efforts to fight the growing opioid addiction crisis.

Trump met recently with victims of opioid addiction and members of his committee who will address the growing crisis. New Jersey Gov. Chris Christie is set to lead the commission.

“Opioid abuse has become a crippling problem throughout the United States,” Trump said. “This is a total epidemic. And I think it’s almost untalked about compared to the severity that we’re witnessing.”

With that, here are 14 things that healthcare execs want Trump to know about the opioid crisis.

1. This epidemic is costing the U.S. economy and loss of life is significant. According to HHS, it has been estimated to be costing the U.S. economy $55 billion in health and social costs and an additional $20 billion in emergency department and inpatient care for poisonings.

From 2000 to 2015 more than half-a-million people died from drug overdoses and 91 Americans die every day from an opioid overdose, according to the CDC.

Runyon

“This national problem is getting worse, not better,” says Kent Runyon, Novus Medical Detox Center’s compliance officer and vice president of community relations. “There needs to be a sense of urgency in our response to this. The use of the word ‘epidemic’ is appropriate given the extent of the problem however; our response to it and the coverage of it by the media does not match the degree of destruction it is causing.”

Investment into effective strategies on this issue will provide returns on many levels now and into the future, Runyon adds.

2.     The lack of non-addictive medications for long-term pain has left the 25 million chronic pain patients with no safe options to treat their pain, which means many who suffer from chronic pain are addicted to dangerous forms of opioids.

“The tolerance that develops from traditional opioids reduces the analgesic effects of the medication, causing the patient to require a higher dose to achieve the same level of pain relief,” said Greg Sullivan, MD, chief science officer and CEO of Bridge Therapeutics.

Sullivan

“Compared with traditional full agonist opioids, buprenorphine affects the receptors in the brain responsible for euphoria to a lesser degree, decreasing the potential for addiction," Sullivan says. "Of all the opioids that have been approved for chronic pain, only buprenorphine has been demonstrated to be safe for long-term use, while not causing tolerance. It’s important to note that buprenorphine is effective in treating certain types of pain, but not inflammatory pain-it must be used in conjunction with an NSAID to effectively treat chronic pain.”

Cathy Starner, PharmD, principal health outcomes researcher at Prime, believes that the Trump administration should look beyond opioid abuse since “Individuals who misuse/abuse opioids are often misusing other drugs such as benzodiazepines and stimulants,” she says. “The landscape of an individual’s drug use needs to be assessed, including doctor and pharmacy shopping, increasing use, use of several different controlled substances, and/or large volume of cash paid claims.” 

3.     Broader access to state prescription drug monitoring programs (PDMPs) will allow insurers to monitor for fraud, waste and abuse of controlled substances. 

Lenz

“This is also critical to allow clinically important coordination of care and discussions about potentially concerning combinations of controlled substances,” Kimberly Lenz, PharmD, clinical pharmacy manager in the UMass Medical School's Office of Clinical Affairs. “Very few states have granted insurers access to the PDMP. Washington State gave their Medicaid program access and noted several benefits, including, better treatment outcomes, better coordination of care, and reduction in costs by a reduction in medically unnecessary prescription drug use and diversion.” 

4.     There needs to be more, or an equal amount of attention on prevention rather than the already addicted. “Limit first-time prescriptions to short-acting and two- to three-day supply, require PDMP look ups, supply provider reporting and benchmarking,” Starner says. 

5.     Changes to the Affordable Care Act (ACA)- or repeal and replacement of ACA-should not impact Medicaid funding of treatment for substance use disorders (SUD).

“The Medicaid population contains a disproportionate share of individuals affected by SUD, and loss of coverage or funding for treatment of these individuals is likely to worsen the opioid abuse epidemic,” says Tyson Thompson, PharmD, a clinical consultant pharmacist in UMass Medical School’s Clinical Pharmacy Services.

“Treatment for SUD is costly; however, societal and healthcare costs that would result from individuals losing their access to treatment would likely be massive," Thompson says. "It is worth the cost to keep Medicaid patients in treatment for SUD from both a humanistic and pragmatic point of view.”

6.     Measures need to be in place to prevent opioid misuse, abuse and addiction, while not preventing access to those who have a legitimate need.

People with legitimate pain still need opioids but are they all same? Not according to Mark Sirgo, PharmD, president and CEO of BioDelivery Sciences.

Sirgo

“Opioids can be safe and effective in treating pain when used correctly,” says Sirgo. “It is important not to prevent access to those who have legitimate chronic pain and who require an effective analgesic. Severe pain can have negative effects on quality of life and prevent people from enjoying their daily activities, such as work, school, etc.”

Beth Darnall, PhD, clinical associate professor in the department of anesthesiology, perioperative and pain medicine, at Stanford University Pain Management Center, agrees. “Insurance coverage must be expanded to offer physicians and patients access to effective opioid alternatives for chronic pain,” she says.

Additionally, initiatives that aim to reduce opioid prescriptions must improve patient access to non-opioid treatment for chronic pain “such as evidence-based multidisciplinary pain care and behavioral pain treatment,” according to Darnall.

Also, not all opioids are the same. Buprenorphine, for example, is considered a Schedule 3 opioid, meaning it is classified by the Drug Enforcement Administration as having lower abuse potential than other opioids-including morphine, hydrocodone and oxycodone-which are Schedule 2 drugs, according to Sirgo. “And buprenorphine is the only opioid that can make this claim with the indication for chronic pain. There are new alternatives that effectively treat pain while minimizing some of the risks.”

7.     There will be no quick or easy fix.

“We have to approach this problem with the recognition that we have both a supply problem and a demand problem,” Runyon says. “We must address supply problems from both illicit drug suppliers and pharmaceuticals. We have prescription opioids getting into the wrong hands. We have to evaluate this at every level from production to prescribing and close the holes. Increasingly we need to address the problem of synthetic opioids that are being shipped to the doorsteps of addicts from overseas. Addiction always feeds upon opportunity. When prescription opioids became more difficult to get, addiction moved to illicit drugs such as heroin. There is now some movement to drugs available via the Internet. We cannot be myopic in our approach if we want to make a difference.”

8.     Investments should be made to empower patients to better control their own pain and symptoms.

Darnall

“Self-management courses, mindfulness-based stress reduction, physical therapy, and pain psychology are all science-backed, effective treatments for pain that help reduce reliance on opioids and other pain medication, according to Darnall.

“Yet often patients can more easily access opioids than these effective behavioral treatments; policy changes are needed to flip this and reduce patient risks,” Darnall says.

9.     Improved access to treatmentis needed.

“Substance use disorders are treatable and people do recover and go on to be productive citizens,” Runyon says. “Persons struggling with addiction need an array of treatment options because the underlying factors that contributed to the progression of the condition are varied. We have people who are using to cover the pain of past trauma, some covering very real physical pain, and others who were introduced to it by a physician but their bodies now crave it and they are powerless over the compulsion to feed the addiction.”

Recovery is challenging and there is no one solution, he says. “It includes detox, inpatient, outpatient, medication-assisted treatment [MAT], and more. People have to be able to get access to the treatment solutions that match their needs and what will work with their condition. Just because it is difficult does not mean it is impossible or that it is not worth the challenge. Life is always worth the effort.”

Ensuring access to MAT and other behavioral health interventions while closing the gaps in the care transitions for patients suffering from SUD need to remain a top priority for this administration, Lenz agrees. 

“Far too often, patients fail to transition from an acute care setting to a step-down program or outpatient program,” she says. “This failure to transition can put the patients at an increased risk of relapse.”

Thompson

In addition, expanding treatment of SUD, including MAT and behavioral health interventions for incarcerated individuals is essential, according to Thompson.

“In far too many correctional health facilities, patients who would want or benefit from MAT and behavioral health interventions are not treated while incarcerated,” he says. “This population is a captivated audience and could benefit significantly from interventions offered. Offering MAT to incarcerated individuals may also help to reduce recidivism rates and avoid that cost to the correctional system, as many are incarcerated due to drug-related crimes.”

10.  Not all opioids cause fatal respiratory depression during an overdose.

Regarding overdose, respiratory depression is what typically kills someone from an opioid overdose, according to Sirgo. “In other words, people stop breathing. Buprenorphine has been shown to have a ceiling effect on respiratory depression, which means at some point, the ability to lower the respiratory rate any further is saturated. This is another significant differentiating feature from Schedule 2 opioids.” 

11.  It’s important to consider lifting restrictions on MAT with buprenorphine for opioid addiction.

Until mid-2016, qualified U.S. doctors were only allowed to treat up to 100 opioid-use disorder patients at any one given time per year with buprenorphine, according to Sirgo. In August 2016, in an effort to expand treatment for opioid addiction, HHS lifted the limit to 275.

“In addition, separate legislation has allowed nurse practitioners and physician assistants to use buprenorphine for opioid use disorder,” Sirgo says. “However, while access to care has been expanded recently, it remains difficult to access for some. According to 2014 federal data, at least 89% of people who met the definition for having a drug use disorder didn’t get treatment.”

12.  Current strategy to limit prescription opiates to a five- to seven-day supply is a mistake and it will worsen the heroin epidemic.

Grover

According to Pawan Grover MD, interventional specialist, and medical correspondent, here's why: “We are reacting to facts on the ground from several years ago and not to the current reality. The opiate crisis might have started with the overprescribing of pain medications but now it is a growing heroin crisis, complicated by cutting of street drugs with illicit fentanyl.”

The CDC’s report that 91 Americans die every day from an opiate overdose can be misleading, according to Grover, because the term “opiate overdose” includes prescription opiates and illegal heroin and illegal street fentanyl. “These numbers are skewed because it is challenging to document the exact cause of an overdose death. To compound this, heroin is metabolized to morphine in the body, so even according to the CDC, heroin deaths are underreported,” he says.

“Analysis of the crazy number of prescription pills prescribed does not take into account that currently a disproportionate of those are originating from pill mills and unscrupulous providers. Most legitimate providers these days are afraid to write any opiate meds as a result of awareness of the opioid crisis and constant vilification of doctors in the media," Grover says. "Limiting all doctors from writing prescriptions and threatening their medical license will completely shut them down from writing any opiates and will drive the legitimate pain patients to seek the cheaper and more available street heroin.”

13.  There should be fast and effective implementation of Medicare pharmacy lock-in programs.

Starner

Health plans and pharmacy benefit managers (PBMs) should be allowed to develop and apply tools and processes that best identify Part D enrollees’ at-risk behaviors for abuse or overutilization of opioids and other controlled substances, according to Starner.

“Examples of types of behaviors considered to be the best criteria for such identification include the use of multiple pharmacies, the use of multiple drugs in the same therapeutic category, the filling of multiple prescriptions and the use of emergency rooms,” she says. “In addition, health plans and PBMs need the flexibility to lock the individual into a specific prescriber(s) or specific pharmacy or both based on the utilization behavior of the individual.”

14. Abuse-deterrent formulations (ADF) are not the only answer.

The approach should be multipronged and involve all stakeholders in the healthcare system, according to Starner. “If we start requiring coverage of ADF products with limited evidence of real-world overdose or death prevention, we will only add cost to the system. If 25% of short acting claims were filled with a new abuse-deterrent product at a cost of $250 per claim, potential increase trend in the category of over $5 billion for commercially insured Americans.”