HSS Policies Addressing Opioid Epidemic
Posted: October 27th, 2022
A description of the current federal policy approach for addressing opioid use disorder (OUD).
The Department of Health and Human Services policies in addressing the opioid epidemic are as follows: More addiction prevention treatment and recovery services, addiction prevention education in public schools, more advanced systems in place to receive real-time data in the different regions of the country, better pain management options (MAT – medically assisted treatment) by the medical community, and an overall increase of overdose-reversing drugs such as naloxone (AMA, 2019). However, these policy updates addressing OUD were discussed in a pre-COVID world. Therefore, although the policies regarding OUD have remained in place, new revisions have come into play in leu of the COVID pandemic.
According to the American Medical Association (AMA), over 40 states have reported increases in OUD deaths as of December of 2020. In combatting this ever-increasing number of lives lost (roughly 800,000 since the year 2000 with a 4% annual average), new policies involving access to care, increased use of medically assisted treatment (MAT), as well as psychosocial therapies and recovery services, and increased accessibility to naloxone is all the more crucial according to the National Center for Drug Abuse Statistics (NCDAS, 2020).
In August 2019, for example, the CDC examined approximately 12,000 opioid deaths from a recently implemented database. The data showed that in those 12,000 deaths, roughly 41-45% were witnessed by a bystander during the overdose, yet naloxone, which reverses the effect of the opioid on the body and saves the person's life, was only administered 0.8 - 4.4 of the time (NCDAS, 2020). According to the same CDC report, tens of thousands of lives could have been saved every year if naloxone had been used.
Finally, referencing the federal policies both in place and being revised (primarily due to COVID) is the CDC guideline/policy of co-prescribing. Co-prescribing is based on morphine milligram equivalents (MME) when prescribing opioids. Simply put, naloxone is now added to the prescription if the opiate being prescribed meets CDC protocols. The problem, however, is that people who have this naloxone option as a precautionary measure, utilize it less than 3% of the time, leaving them all the more vulnerable to overdose and death (AMA, 2019).
A description of the current policy goals for addressing OUD.
In 2018 the White House released a detailed report titled "Health Research and Development to Help Stem the Opioid Crisis: A National Roadmap" by the National Science and Technology Council. The information was broken down into eight main sections, defining what they hoped to achieve in stemming the epidemic. Section one addressed the biology and chemistry of pain and opioid addiction in getting a better understanding of "the mechanisms and pathways that underlie both opioid addiction and pain" (NSTC, 2018). This section speaks explicitly to the current policy approach of pain management options, understanding the complexities/correlations of opioid addiction and pain, and the need for new models/methods in the basic biology of opioid addiction and pain (NSTC), 2018).
Section two addresses goals that are non-biological contributors to OUD. This section includes addressing the "stigma" of addiction, socioeconomic and sociocultural factors, geographic disparities that have an impact on treatment approaches, better information on the "gaps" in public and professional knowledge of OUD, clinical coverage policies efficacy, and the study of the overall effectiveness of the policies that were designed around OUD treatment and prevention (NSTC, 2018).
Section three's goals were on pain management itself. They included the development of non-addictive alternatives in treating pain, the transition from chronic to acute pain, test models, and clinical practice guidelines in pain management.
Sections four through six focused on prevention, treatment of addiction and withdrawal, and overdose prevention and recovery. The goals in these three sections were all "built" around policies that focused on addiction prevention treatment and recovery services. Key "takeaways" included prescription practices, population-based interventions such as national media awareness campaigns, interconnected databases, new medications (MAT), education on overdose reversal medications (naloxone), and identifying successful and unsuccessful long-term treatment plans for those who have overdosed. Essentially, this section "moves" from proactive goals to reactive goals in the fight to stem the tide of the increasing number of OUD and OUD-related deaths (NSTC, 2018).
The goals for sections seven and eight focus on community consequences (reactive) and, finally, the opportunities to better coordinate the community's resources in working together. For example, public health services, law enforcement, crisis centers, and mental health professionals have access to interrelated databases in coordinating efforts and prioritizing which areas within the community are in greatest need of attention (NSTC, 2018).
A description of the population the current policy approach covers.
A 2019 journal article by the International Journal of Drug Policy did an extensive study on the population(s) the current policy approach covers. Their research concluded that there was no specific population the current policy covers, essentially because the opioid epidemic, in many regards, can also be seen as a pandemic (Bowen, Irish, 2019). Socioeconomic factors, race, ethnicity, age, and geography were all considered with the conclusion that OUD and the current opioid epidemic has, in reality, has negatively impacted all populations within the United States.
There is an interesting caveat to OUD in this country, however, that remains left relatively ignored. Data pulled from this study showed that OUD (primarily heroin) was having devastating effects on minorities in inner-city communities throughout the 1960s and 70s (Bowen, et al., 2019). It was not until big pharma (Purdue led the onslaught) introduced opioids that they deemed as safe, only having a 1% addictive risk (oxycontin) in the mid-1980s that "White America" began to see the impact of OUD. Big pharma purposefully targeted working-class, industrial, undereducated white populations where there were high rates of injuries due to the nature of the work (coal miners, steel mills, commercial fishing, and timber states) (Bowen et al., 2019). In the early to mid-1990s, when the "red flags" began to emerge and prescription opioids were overprescribed regularly, did the opioid epidemic have its actual launching point in evolving into the epidemic we are in today (Bowen et al., 2019). Ironically, however, the opioid epidemic for underserved minorities in impoverished sections of major inner cities had been in full swing 30 years prior. The racism/classism inherent in the system, especially during the 1960s and 70s, enacted no policies of any substance to address the scourge/death of tens of thousands of poor, minority, and marginalized populations. (Bowen, et al., 2019) There was already an opioid epidemic in this country, but, in my opinion, these populations were pushed to the side.
An explanation of the funding levels for the current policy approach and whether they are sufficient to address the issue.
According to a 2019 Network of Quality Improvement and Innovation Contractors (NQIIC), a division of the Centers for Medicare and Medicaid Services, overdose deaths increased from 4% to 4.9% in 2019 (roughly 71,000 deaths), which "erased" a slight decrease seen in 2018. The total federal opioid funding for fiscal year (FY) 2019 was 7.6 billion dollars, an increase from FY2018 of $7.4 billion (NQIIC, 2019). The Department of Health and Human Services (HHA) has received $5.3 billion in disbursements thus far, while the Substance Abuse and Mental Health Services (SAMSHA) has received $3.7 billion (NQIIC, 2019). The funds are distributed according to need, geographically, with the counties having the highest overdose deaths receiving the most. In addition, all states have been allocated funds for naloxone training and distribution, however, there is a significant flaw in the system with no funding going toward any "standards for care" regarding incarcerated individuals who suffer from OUD. This is quite troubling in that the number one cause of death for these individuals, once released, is overdose (NQIIC, 2019).
Is the funding sufficient to address the issue, in my opinion, is far too simplistic and not quickly answered, nor can it be. OUD federal policies show an inverse relationship from 2018 to 2019 in terms of spending and overdose deaths. $300 million more federal dollars were spent on these policies/programs in 2019 than in 2018, yet there was almost a 1% increase in overdose deaths in 2019. I agree with the statement, "failure to plan how to sustain effective programs for persons with OUD will cost lives" (Caton, et al., 2020).
This policy may affect at-risk, marginalized, underrepresented, overlooked, or oppressed populations.
The stigma associated with SUD/OUD is a well-documented historical reality in the United
States.
Stigma toward people with OUD and people with substance use disorders (SUDs) more broadly is intertwined with persistent stigma (including labeling, stereotyping, status loss, and discrimination) based on race and social class in the United States. Historically, U.S. drug policies have disproportionately targeted marginalized groups. For instance, early restrictions on opium were implemented during a period of heightened xenophobia toward Chinese immigrants. Studies have also focused attention on race-based stigma and discrimination directed toward African Americans as a profound legacy of the war on drugs. An analysis of a small sample of news media published between 2001 and 2015 found that white non-urban people with OUDs were represented more sympathetically than non-white urban people with heroin use disorder. Substance use is often featured in media representations of economically disadvantaged populations. By typing populations that are already disenfranchised to substance use, these media representations may contribute to reinforcing negative attitudes among the public toward people with SUD/OUDs.
In short, the above citation, and referring back to the inner-city heroin epidemic that received little media attention in the 1960s and 70s (and still very much alive today), is objective proof that current policies regarding many disenfranchised populations are inadequate.
An analysis of whether or not the policy meets the needs of the population groups most affected by the policy.
Opioid overdoses are highest among people between the age of 25-34. (NIH, 2020) Almost 80% of overdose and overdose-related deaths are noon-Hispanic White, 10% are Black and non-Hispanic, and 8% are Hispanic. This data, however, is far too general/simplistic, in my opinion. The opioid epidemic has ever-changing data on what populations are currently being most affected, making it necessary for the federal policies to be aware of unintentional barriers that may exclude its citizens. For example, a 2019 study in Orthopedic Nursing showed that overdose deaths are higher among males than females, however, women aged 40-64 represented the fastest growing population (2019) of emergency room visits and death by overdose (Salmond & Allread, 2019). The same study showed high-risk populations veterans, adolescents, and people with mental health issues. Federal policies to combat the opioid epidemic must remain "open" and "fluid," especially in terms of funding, as to where resources are most needed.
Recommendations for alternative policies that would address gaps identified in the policy.
In my opinion/experience in addiction prevention education in Washington, D.C., my company concluded that it is often a case of "throwing good money after bad". This is a "broken system" by design, in my opinion, peppered with failed/misinformed policies. Federal legislation, special interest groups, high-powered big pharma lobbyists, massive corruption in the unregulated world of rehabilitation centers and halfway houses, and our trillions in debt to China, the largest importer of fentanyl in the world, are some of the major "players" who make trillions of dollars keeping the "SUD/OUD pipeline" full. Working alongside dozens of others, our company agreed that there would never be an answer to ending OUD or any other SUD as long as the demand remains high. This begs the question of why? Why are millions wanting/needing to cope with life synthetically? Why is our mental health system growing more and more overburdened with SUD, depression, suicidal ideation, etc.? If there is no willingness to change/alleviate the demand for legal/illegal substances, there is a 100% chance that nothing will change. People can recover, die, or live decades in active addiction, but billions of dollars and multiple policies/resources will positively impact only 10%-12% of the OUD population. (SAMSHA, 2021) The fact of the matter is most, close to 90%, will die from the disease of SUD. The questions that need to be answered are not the "what, when, or how, but the WHY"?
In conclusion, the most significant gap in coming up with more effective, actionable, and prosperous policies is to give voice to the populations and their families who have lived through it. Nothing about us, without us, is the demand for justice from the very source itself, those in long-term recovery. How can policymakers develop an effective policy if they are not bringing the recovery community leaders to the table? How could any policy be written without the people who have the disease of OUD/SUD? It is impossible!!! It would be analogous to Congressional leaders sitting down with Luciano Pavarotti and saying, "teach us to sing like you." Social justice demands that the leaders in the recovery community (Ryan Hampton) keep a "seat at the table," and are taken seriously! Otherwise, in my opinion, we will continue to "fly blind." SUD is a symptom of deeper issues in a person (trauma history being the most common denominator) (SAMSHA, 2020). That, in my opinion, is the "tip of the iceberg" of coming to understand the WHY.
References:
Adams, Z. W., Taylor, B. G., Flanagan, E., Kwon, E., Johnson-Kwochka, A. V., Elkington, K. S., Becan, J. E. Aalsma, M. C., (2020). Opioid use disorder stigma, discrimination, and policy attitudes in a national sample of young adults. Journal of adolescent health 69, 321-328.
https://doi.org/10.1016/j.jadohealth.2020.12.142
American Medical Association, (2019). The opioid epidemic and emerging public health policy priorities. Retrieved from: https://www.amam-asn.org/delivering-care/opioids/opioids-epidemic-and-emerging-public-health-policiy-priorities
Andraka-Christou, B., & Atkins, D., (2020). Beliefs about medications for opioid use disorder among Florida criminal problem-solving court & dependency court staff. The American journal of drug and alcohol abuse, Vol. 46, NO. 6, 749-760. Retrieved from:
https://www.doi.org/10.1080/00952990.2020.1807559
Bowen, E. A., & Irish, A. (2019). A policy mapping analysis of goals, target populations, and punitive notions in the U.S. congressional response to the opioid epidemic. International journal of drug policy 74, 90-97. Retrieved from:
https://doi.org/10.1016/j.drugpo.2019.09.014
Caton, L., Yuan, M., Louie, D., Gallo, C. Abram, K., Palinkas, L., Brown, C. H., & McGovern, M. (2020). The prospects for sustaining evidence-based responses to the US opioid epidemic: state leadership perspectives. Substance abuse treatment, prevention, and policy 15:84. Retrieved from: https://doi.org/10,1186/s13011-020-00326-x
Department of Health and Human Services (2018). Health research and development to stem the opioid crisis: A federal roadmap. Retrieved from:
https://www.hhs.gov/sites/default/files/Health-RD-to-Stem-Opioid-Crisis-2018-Roadmap-for-Public-Comment.pdf
Hendricks, A, Barry, C. L. Stone, E., Bachhuber, M., McGinty, E. E., (2020). Comparing perspectives on medication treatment for opioid use disorder between national samples of primary care trainee physicians and attending physicians. Science Direct 216 (2020) 108217 Retrieved from: https://doi.org/10.1016/j.drugalcdep.2020.108217
Mancher, M. (2019). Barriers to broader use of medications to treat opioid use disorder. National academies of sciences, engineering, and medicine. Washington, D.C. Retrieved from: https://www.ncbi.nlm.nih.gov/books/NBK541389/.
Report: (2020). Tracking FY2019 federal funding to combat the opioid crisis. Network of quality improvement and innovation contractors, Retrieved from:
https://qi.ipro.org/2020/11/02/tracking-fy2019-federal-funding-to-combat-the -opioid-crisis/
Salmond, S. & Allread, V., (2019). A population health approach to America’s opioid epidemic. Orthopedic Nursing March/April 2019 – Vol. 38 Issue 2 – p 95-108. Retrieved from: