Dr. Mark Gold’s Research You Can Use
The US Opioid Epidemic continues to grow. To counter the opioid use disorder, several policy responses have been initiated that focus on mitigation and prevention.
This article discusses an important study that assesses various policy responses to combat the opioid crisis and their short-term and long-term pros and cons. Findings suggest that no one policy can effectively reduce opioid addiction crisis but a portfolio of these interventions is needed.
Around 64,000 Americans have died due to a drug overdose in 2016. Most of these cases involved opioids. Over the years, skyrocketing rates of opioid prescriptions and consequent misuse have surfaced, raising serious questions about prescription policies. Today, the nation is in the midst of an opioid crisis and several public policy responses are in play to stem this epidemic.
More than 30 percent of people are struggling with some form of chronic pain in the United States. This prevalence of chronic pain is even higher (40 percent) among the older population. In the face of such wide prevalence of a debilitating ailment, opioid analgesics quickly rose to the most commonly prescribed medication in the country. In 2014 alone, U.S. retail pharmacies dispensed 245 million prescriptions for opioid pain relievers.
This recent and important Stanford University study aimed to estimate health outcomes and assess the impact of policies to mitigate the opioid epidemic through dynamic compartmental modeling of American adults in various states of pain, opioid use and addiction, project addiction-related fatalities, and quality-adjusted life years from 2016 to 2025 based upon 11 policy responses.
Methodology and model
The dynamic compartmental model categorized the population as per the parameters describing the dynamics of opioid prescription and addiction.
Such an approach is commonly used for the assessment of the spread of contagious diseases and suitable for modeling addiction incidence to mirror the fluctuating number of prescription holders.
The Researchers Considered 11 Interventions
Some of these policies were focused mostly at the prevention of new cases of severe opioid use disorders such as limited opioid prescription rates for acute and chronic pain, rescheduling opioids under the Controlled Substances Act which reduced prescription refills, widening excess opioid disposal programs to diminish drug diversion and abuse-deterrent opioid reformulation.
Other interventions targeted the treatment and mitigation of the impact of current cases of addiction including the expansion of MAT availability to encourage enrollment, increasing psychosocial treatment availability to curtail antisocial behavior, increasing naloxone availability to reduce overdose death rates and widening needle exchange programs to limit infection mortality among heroin users.
The final policy under consideration was the enhancement of prescription drug monitoring programs to establish appropriate prescribing for all patients and help identify any trends of misuse.
The 5-and-10-year impact of interventions in accordance with each outcome measure was evaluated for each base case.
A ‘status quo’ was established in the absence of interventions, 235,000 opioid-related deaths were expected from 2016 to 2020, and 510,000 opioid-related deaths were expected from 2016 to 2025. The model then depicted how these routes would be altered under the various interventions.
Five-year Analysis of the Opioid Epidemic
Probably, the most critical finding was that none of the 11 policies were noted to result in any substantial reductions alone, in opioid-related deaths. The increase in naloxone availability prevented the most significant number of addiction-related deaths among the others, representing a 4 percent reduction.
Naloxone availability, needle exchange programs, MATs, and psychosocial treatment policies generated more life years and quality-adjusted life years, without causing any harm to any other population groups.
Limiting prescription for transitioning pain also increased life years and quality-adjusted life years, while also decreasing opioid-related deaths. However, these policies did create an unintentional move of users from opioids toward heroin, resulting in greater heroin-related deaths. Tamper-resistant reformulation of opioid further worsened this problem as it subsequently increased heroin-related deaths to a greater extent.
Reducing the prescribing of pain medication created unintentional complications for pain patients who were not addicted and underwent significant losses in quality-affected life years due to undertreatment. Reduced chronic pain prescribing, drug rescheduling, and PMPs reduce deaths from prescription opioid use, but increase heroin deaths, yielding a net increase in addiction-related deaths.
Drug rescheduling and decreased prescribing for chronic pain limited the total amount of life years, but paradoxically, the net effect on quality-adjusted life years was rendered positive.
Ten-year analysis
The number of deaths averted under naloxone availability and needle-exchange policies grew almost proportionately to the timeline.
Certain policies such as reduced prescribing, excess opioid disposal, psychosocial treatment, and MATs prevent significantly more deaths over the course of 10 years than the proportional expectation over five years.
Even though reduced acute pain prescribing increased deaths over a 5-year period, the 10-year analysis showed decreases in deaths from heroin use and drug reformulation decreased total addiction deaths.
Reduced chronic pain prescribing and drug rescheduling still raised the total addiction deaths and the PMP policy lead to disproportionally more deaths over ten years. Total life years, however, increased under reduced chronic pain prescribing, despite decreasing relative to the status quo over a 5-year course.
Heroin use was observed to rise immediately as some “doctor shoppers” were no longer able to acquire a prescription and shot up a year after policy initiation when some addicted patients switched to heroin, who could no longer get diverted pills.
This trend, however, gradually declined as dependence on prescription opioids diminished. By 2023, the prevalence of severe heroin use disorder was projected to decline. By 2026, monthly opioid addiction-related deaths were less than that under the status quo.
Combining policies
The effects of combining policies were also assessed, and it was determined that pairing interventions had the potential to increase health benefits considerably. Pairing interventions that prevented further severe opioid use disorders with policies that focused upon the mitigation of effects was prioritized.
For instance, over five years, 13,800 addiction deaths were expected relative to the status quo if drug rescheduling and increased naloxone availability were to be implemented together, compared with 24,500 additional deaths and 10,200 fewer deaths if each intervention were implemented alone.
Despite considerable uncertainty regarding the probable magnitude of various policies, threshold analysis proposed that no single policy was able to have a large enough impact to significantly reduce addiction-related deaths over the 5-year or even the 10-year interval. Strategies focusing solely on the mitigation of immediate consequences of addiction failed to address the root problem.
Future Implications of the Opioid Epidemic for Public Health and Policies
Although certain policies proved to be more beneficial than others in the short-term, a longer-term perspective is crucial to understand the bigger picture.
Certain policy responses to combat the opioid crisis have immediate, favorable effects, whereas others lead to short-term adverse consequences that might be outweighed by long-term health benefits.
Policies directed toward currently addicted individuals yielded health benefits almost right away causing no harm. This is quite logical, and most tobacco experts remember nicotine.
Replacement therapies, involving patches and gums being handed out to tobacco addicts. MATs for tobacco was a new beginning. Clean air laws, prohibition and even stigmatization of cigarette smokers actually made the most significant difference in cutting smoking rates in half.
Ultimately, it is important to keep in mind that a crisis of such epidemic proportions can hardly be averted by addressing single affected cases only. More likely, a portfolio of interventions is needed that would target all areas of importance simultaneously: prevent addiction, treat addicts and mitigate the harmful consequences.
If anything, this timely Stanford analysis reminds us that more research and out of the box thinking is needed. It also supports both MATs and psychosocial treatment approaches while questioning some approaches to pain medications and pain medication prescribing.
References
https://www.nejm.org/doi/full/10.1056/NEJMra1507771
https://www.ncbi.nlm.nih.gov/pubmed/30138057
https://www.the-hospitalist.org/hospitalist/article/173990/addiction-medicine/policy-responses-opioid-epidemic-may-have-benefits
About the Author:
Mark S. Gold, M.D. served as Professor, the Donald Dizney Eminent Scholar, Distinguished Professor and Chair of Psychiatry from 1990-2014. Dr. Gold was the first Faculty from the College of Medicine to be selected as a University-wide Distinguished Alumni Professor and served as the 17th University of Florida’s Distinguished Alumni Professor.
Learn more about Mark S. Gold, MD
About the Transcript Editor:
A journalist and social media savvy content writer with extensive research, print and on-air interview skills, Sana Ahmed has previously worked as staff writer for a renowned rehabilitation institute, a content writer for a marketing agency, an editor for a business magazine and been an on-air news broadcaster.
Sana graduated with a Bachelors in Economics and Management from London School of Economics and began a career of research and writing right after. Her recent work has largely been focused upon mental health and addiction recovery.
The opinions and views of our guest contributors are shared to provide a broad perspective of addictions. These are not necessarily the views of Addiction Hope, but an effort to offer a discussion of various issues by different concerned individuals.
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Published on October 26, 2018
Reviewed by Jacquelyn Ekern, MS, LPC on October 26, 2018
Published on AddictionHope.com