Opioid Addiction

Nationally, opioid prescribing patterns and an increasing use of illicit heroin and fentanyl have contributed to what has been termed an “opioid crisis” or “opioid epidemic”. While opioid use has been around for decades, and has historically been viewed through the lens of the criminal justice system, the term “epidemic” signifies a shift in national thought. As opioid addiction has moved beyond low-income, minority and mostly urban neighborhoods and now cuts across all geographic, demographic and socio-economic boundaries, opioid use disorders are increasingly viewed as a public health concern, requiring a comprehensive, multi-pronged approach to address the underlying causes of addiction, as well as supply chain interdiction.

 

Prescription Opioid Epidemic

 

A combination of factors led to inappropriate opioid prescribing patterns and quadrupled sales of prescription opioids since 1999. In 1980, a one-paragraph letter from a doctor in a Boston hospital was published in the New England Journal of Medicine, asserting that addiction to opioids is exceedingly rare in hospitalized patients with no history of addiction. For years, pharmaceutical companies cited the letter in marketing the drugs directly to prescribers, asserting that prescription painkillers were a safe way to manage pain with minimal risk of addiction. In 1996, the American Pain Society introduced the concept of pain as a fifth vital sign, despite the fact that there is no objective way to measure pain. In 2001, the Joint Commission, a nonprofit that sets standards and accredits hospitals and medical centers, established assessing pain in all patients as a priority. The Centers for Medicare & Medicaid Services (CMS) administers several patient experience surveys, one of which, the Hospital Consumer Assessment of Healthcare Providers & Systems (HCAHPS) survey, affects Medicaid and Medicare payments. Under value-based purchasing initiatives, hospitals with higher scores receive higher reimbursement rates from CMS. With respect to a growing opioid crisis, three of the survey’s questions were of particular concern: if patients needed medication for pain during their stay, how often their pain was well controlled, and whether the hospital staff did everything they could to help with the pain.

 

Although these standards and surveys were designed to elevate the issue of pain management and did not explicitly tell doctors to prescribe opioids for pain, there is evidence that hospitals put additional pressure on doctors to aggressively treat pain. Independent studies have suggested that 28% of doctors are paid bonuses based on HCAHPS results, and one in five doctors reported that their jobs were placed in jeopardy as a result of low scores. The CDC has since released new guidelines for doctors prescribing opioids for pain, and CMS is eliminating pain-related questions from HCAHPS surveys as of October 2017. However, for many patients who have since developed opioid dependencies as a result of medical care, the damage has already been done.

 

Besides poorly-aligned incentives, physicians and other providers are often not well-equipped to present patients with a complete range of pain management options. There are no full residency training programs in pain medicine in the United States. Further, pre- and post-graduate training in pain management and opioid prescription is limited for general practitioners and specialists in family or internal medicine, and continuing medical education courses are often sponsored by pharmaceutical manufacturers who have promoted the use of opioids for pain management. Generally, there is a lack of research on how to treat pain effectively. Though some alternatives to opioids for chronic pain exist, like biofeedback, acupuncture, cognitive behavioral therapy, and alternative physical therapies, even if providers are aware of them, health insurers often exclude certain treatments from coverage. In response to the dramatic rise in prescription-related opioid addiction across the United States, HHS has released a National Pain Strategy, outlining the federal government’s plan for addressing the prevalence of chronic pain in more appropriate ways.

Illicit Opioids

 

Payment incentives and policies created a perfect storm that fueled a pattern of prescribing that resulted in opioid dependency in thousands of patients. As more research accumulates, it is increasingly evident that long-term use of opioids for chronic, non-cancer pain is associated with a high risk of adverse events and high death rates, with limited improvement in pain and function. Physicians and other health care providers across the country are slowly beginning to prescribe fewer opioids, although the amount of opioids prescribed today remains relatively high compared to 1999 levels. While prescribing fewer opioids is a move in the right direction, this inadvertently creates another problem. As the availability of prescription opioids decreases, and tolerance for the effects of the medications increases, many people turn to illicit opioid narcotics instead. According to the CDC, people who are addicted to prescription painkillers are 40 times more likely to become addicted to heroin compared to the general population, and according to SAMHSA, nearly 80% of recent heroin initiates began by misusing prescription opioids. According to another study published in JAMA, although the “high” produced by heroin was described as a significant factor in its selection, it was often used because it was more readily accessible and much less expensive than prescription opioids.

Part of what makes the crisis so deadly and so difficult to address is how quickly the illicit supply is evolving. Increasing numbers of synthetic opioids, like carfentanil and other fentanyl analogs, are orders of magnitude more potent than heroin. Drug dealers and drug users are often unaware when their supply has been cut with these additives, greatly increasing the risk of a fatal overdose. Manufacturers can manipulate the chemical structure of these drugs faster than law enforcement can test for and track them, making local interdiction efforts difficult and dangerous. Exposure to fentanyl analogs can be deadly, and often requires multiple doses of naloxone to reverse the effects of an overdose. Thus, they also pose a threat to first responders, law enforcement, and other public health workers, as these drugs can be absorbed through inhalation or the skin.

(VCU CNS, Flickr)

Treatment and Policy Considerations

 

Policies are in place to interrupt opioid use disorders at various points in their progression, using a combination of prevention, harm reduction, and treatment. Various screening tools exist to help medical professionals and others identify individuals at risk for developing an opioid use disorder. Furthermore, all states have adopted their own prescription drug monitoring programs (PDMPs), which provide prescribers with information pertaining to their patients’ controlled substances prescriptions, making it more difficult for patients to “doctor shop” and/or divert drugs from their intended use. Despite the useful information they offer, PDMPs are often underutilized by providers. PDMPs are administered and operated differently in each state, but promising features of effective monitoring programs include integration with already-established electronic health records systems, real-time data collection and updates, inter-state data-sharing capabilities, and mandated prescriber enrollment and utilization.

 

The best practice for treatment of opioid use disorders is medically-assisted treatment (MAT), which combines medication with behavioral therapy to manage withdrawal symptoms and address the underlying psychosocial factors contributing to problematic drug use. Methadone, buprenorphine, and naltrexone are all approved for the treatment of opioid use disorders, and have different mechanisms of action. Therefore, they each have different effects—methadone and buprenorphine reduce withdrawal symptoms and cravings, while naltrexone blocks the “high” associated with opioid use—and vary in terms of how early into the withdrawal process they can be used. Opioid Treatment Programs offering MAT have been shown to reduce opioid use, mortality, and crime associated with opioid use disorders, as well infectious disease transmission.

The Substance Abuse and Mental Health Services Administration (SAMHSA) has released medication-assisted treatment (MAT) facility maps to identify areas on a state-by-state basis that may be potentially underserved by existing treatment facilities. The maps are meant to be used as a tool for policy makers to determine potentially underserved areas—not as a definitive representation of these areas. Click on each map for a better view.

Despite efficacy, medically-assisted treatment is under-used, due to a number of factors, including cost, a shortage of physicians who are certified to prescribe medications, and a shortage of beds in treatment programs. While patients in stable recovery may be prescribed medication to take at home, outpatient treatment programs commonly require patients to go to a treatment center each time they need to take their medication, which may be prohibitive for patients who do not live or work near a treatment center. Further, while the ACA requires that insurance plans provide coverage for MAT, the specific medications and length of time treatment is covered varies widely. This is especially problematic as short-term use of medications for detoxification has been linked to relapse and increased overdose risk. It is not yet clear when or for whom short-term medication therapy can be used effectively. Long-term MAT maintenance therapy is supported by a strong evidence base and has proven successful for many patients. However, there are still a significant number of people with opioid use disorders for whom MAT is not successful. Research into new treatment modalities, improved treatment delivery and better access is necessary to effectively treat people with opioid disorders.

Besides prevention and treatment, a number of harm reduction strategies are being employed across the nation to reduce morbidity and mortality related to opioid addition. States are expanding access to naloxone, a life-saving drug that can reverse the effects of opioid overdose, and providing overdose prevention education to patients and their family members. Needle exchange is an evidence-based harm-reduction strategy for reducing the risk of HIV, Hepatitis B and C, and other blood-borne diseases, as well as overdose, and can serve as a first point of contact for entry to treatment. Needle exchange programs provide access to sterile needles and syringes and facilitate safe disposal to reduce the risk of transmitting blood-borne diseases.

 

The Affordable Care Act (ACA) expanded access to behavioral health care services including addiction prevention and treatment in several ways. By classifying mental health and substance use disorder services as “essential health benefits,” the law requires that all health insurance plans offered on and off insurance exchanges in the individual and small group markets cover these services. Further, it reinforced the Mental Health Parity and Addiction Equity Act of 2008, requiring that plans offer coverage for mental health and substance use disorders that is on par with their medical and surgical benefits. Perhaps most significantly, the ACA allowed states to expand Medicaid, greatly increasing the number of people with access to health care coverage. Individuals with substance use disorders were disproportionately uninsured prior to the ACA. The most affected population trends toward lower-income adults without dependent children, and represent a significant portion of the newly-insured population under the Medicaid expansion. In fact, in 2014, Medicaid paid for one-quarter of public and private spending for drug treatment. According to one study, an estimated 14-15% of adults living in non-expansion states who would otherwise be eligible for Medicaid have a substance use disorder. Despite increased health coverage, only one in five people who currently need treatment for opioid use disorders are receiving it, according to the Surgeon General’s 2016 report. A number of barriers still remain, including an undertrained health and behavioral health workforce, insufficient capacity to meet current demands and lack of funding for substance abuse treatment and aftercare programs.

 

Health care is not the only sector that frequently comes into contact with individuals suffering from opioid use disorders; rather than being strictly punitive, rehabilitation-focused policies within criminal justice and law enforcement systems can serve to link people to treatment. “Good Samaritan” laws provide immunity for minor drug violations when a person calls 911 for assistance if experiencing or witnessing an opiate-related overdose. Pre-booking diversion programs divert low-level drug offenders to community-based services, rather than processing them through the traditional court system, and show promise in reducing recidivism. After an arrest, some states are employing drug courts and other diversion methods to place nonviolent drug offenders into treatment programs, overseen by the courts, rather than jail. Drug courts have high rates of treatment completion, and reduced rates of recidivism, incarceration, and subsequent drug use; however, treatment capacity limits the number of people that can be diverted from the traditional criminal justice system. Additionally, as these courts traditionally enforce complete abstinence with the threat of incarceration, they do not always offer MAT as a treatment option, and individuals who relapse are quickly sanctioned. Although many states are seeing positive outcomes with diversion programs, recent reinstitution of mandatory minimum sentences for low-level nonviolent drug offenders may put these programs at risk.

Regional Look

 

In 2015 alone, over 400 residents of the National Capital Area lost their lives to fentanyl and/or heroin, while another 137 lost their lives to prescription opioids. In 2014, Maryland had the highest rate of opioid inpatient stays out of 44 states and the District of Columbia, at 403.8 per 100,000 population. D.C. was not far behind, with a rate of 389. Maryland also had the second highest rate of opioid-related emergency department visits out of 30 states and the District of Columbia, at 301. In Virginia in 2014, drug overdoses became the most common cause of accidental death, with 56% of drug/poison deaths attributed to opioids, and a 12% rise in heroin deaths from 2013. These trends have led to the governors of both Virginia and Maryland declaring opioid emergencies in their states. In October 2016, DC Mayor, Muriel Bowser, Maryland Governor Larry Hogan and Virginia Governor Terry McAuliffe signed the National Capital Region Compact to Combat Opioid Addiction to promote regional collaboration around public awareness, prevention and intervention.

Opioid-Related Drug Overdose Death Rates

per 100,000 people

The opioid epidemic and its underlying causes are complex and require a multi-pronged, cross-sector approach. Law enforcement, social services, and public health providers are coming together at local, state, and federal levels to combat the ongoing crisis. In July of 2016, Congress passed the Comprehensive Addiction and Recovery Act (CARA) with wide bipartisan support, increasing the availability of naloxone to law enforcement and first responders, and improving prescription drug monitoring programs. Maryland and Virginia have gone beyond this, expanding access to naloxone without a prescription to anyone trained and certified to use it.

 

Virginia has recently enacted legislation requiring all opioid prescriptions to be transmitted to pharmacies electronically by 2020 to enhance prescription monitoring capabilities. It has expanded the role of local health departments to implement harm reduction programs, including needle exchange, hepatitis C and HIV testing, and connecting people to addiction treatment. In Fairfax County, police are implementing a “Recovery Call List”, sending volunteers currently in recovery to meet with people admitted to the hospital for overdoses to encourage them to seek treatment.

 

Maryland has expanded provider education programs, and has acquired a Medicaid waiver that prioritizes the role of medication-assisted treatment and allows reimbursement for residential substance use treatment services delivered in large facilities. To curb opioid prescriptions, Maryland’s Medicaid program is encouraging providers to consider non-opioids as a first-line treatment for chronic pain and screen patients thoroughly before prescribing opioids. Montgomery and Prince George’s Counties have expanded access to Screening, Brief Intervention and Referral to Treatment (SBIRT), an evidence-based practice designed to identify individuals at risk of a substance use disorder and link them to treatment. In FY2018, these two counties will receive funding for local Opioid Intervention Teams, led by each jurisdiction’s emergency manager and health officer, to coordinate with the community and determine how to best address the heroin and opioid epidemic.

 

Similarly, in 2016 the District of Columbia received a 3-year, $900,000 grant from the CDC to prevent prescription opioid-related deaths by developing a comprehensive strategy, improving data collection and analysis, and working with communities to develop overdose prevention programs.

 

For more information on opioid addiction in our region, check out the resources below.

Facing Addiction in America

The Surgeon General’s Report on Alcohol, Drugs, and Health compiles the latest research to paint a comprehensive picture of substance use in America. View the report for:

  • evidenced-based prevention, treatment, and recovery policies and programs
  • opportunities to integrate substance use disorder treatment and mainstream health care
  • information on the neurobiology of addiction

State Data

Jurisdictions across the region are experiencing a significant increase in opioid-related death rates. View state-level trends in opioid-related deaths for Maryland with breakdowns by county, age, race/ethnicity, and gender, from 2007 through 2016. View opioid addiction indicators for Virginia including trends in fentanyl and/or heroin and prescription opioid-related deaths, heroin and opioid overdose ED visits, Narcan administrations by emergency medical services, and rates of Hepatitis C and HIV at both state and county-level from 2011 through 2016. Breakdowns of mortality rates by age, race/ethnicity, and gender can be found in the Office of the Medical Examiner’s annual reports. View incidence of opioids and trends in deaths breakdowns by race/ethnicity, gender, age, and Ward for the District of Columbia from 2014 through 2017.

Regional Opioid and Substance Abuse Summit

In October 2016, D.C. Mayor Muriel Bowser, Maryland Governor Larry Hogan, and Virginia Governor Terry McAuliffe signed the National Capital Region Compact to Combat Opioid Addiction, increasing inter-jurisdictional collaboration to combat the opioid crisis. As part of this initiative, in May of 2017, the Regional Primary Care Coalition joined the Metropolitan Washington Council of Governments, CareFirst, and Kaiser Permanente to sponsor a Regional Opioid and Substance Abuse Summit. The summit brought together state and local leaders, healthcare providers, and researchers to discuss clinical, communication, harm reduction, policy, prevention, and public safety strategies to combat opioid addiction in the National Capital Area. View the summit program and presentations here.

WTOP Series: Hooked on Heroin

In this 5-part WTOP series, reporter Jamie Forzato examines opioids’ effect on the National Capital Area and measures underway to combat the crisis. Read the series for profiles on the following issues in affecting the region:

  • synthetic opioids changing the game for law enforcement and spiking death rates
  • over-prescription of painkillers leading to heroin addiction and what DC, Maryland and Virginia are doing to combat over-prescribing
  • what schools and hospitals in the area are doing to prevent and treat opioid dependency in children and infants
  • access to naloxone in the region
  • proposed legislation to fight the region’s opioid crisis

(Dimitris Kalogeropoylos, Flickr)

Before It's Too Late

Before It’s Too Late is a statewide effort to bring awareness to the opioid crisis and its effect on Marylanders. Their website provides information about:

  • where to find treatment for opioid use disorders in Maryland
  • what the Maryland government is doing to alleviate the crisis
  • where to properly dispose of prescription medications
  • the Overdose Survivors Outreach Program, a Department of Health and Mental Hygiene-funded effort to link recent overdose survivors to treatment services and naloxone training

VaAware

In Virginia, VaAware is a collaboration between the Departments of Health, Behavioral Health and Developmental Services, Criminal Justice Services, and Health Professions. Their website provides:

  • information on where to find treatment and access resources for opioid use disorders in Virginia
  • information for practitioners on prescribing, pain management, addiction, and continuing education opportunities
  • information for law enforcement, including training resources and tools
  • research and data on the opioid crisis

Header photo credits: Sacred Heart/Flickr