Leah Steckler, MD
December 6, 2017
As we approach the end of the calendar year, lawmakers have been pushing to keep their promises and pass important legislation. This year, opioids have been a topic with less controversy than others in terms of bipartisan agreement that something must be done. To emphasize this need, the president even donated his third-quarter salary to the cause (1). However, how to accomplish this bicameral, bipartisan goal has been more of a challenge. The true question is, how federal funding be spent in order to have the greatest effect on this crisis? This is where the true innovation and thinking must happen.
Many strategies (summarized in Figure 1) have been suggested and implemented to combat the opioid crisis, however their success is limited. Everything from developing abuse deterrent drug formulations (2) to incinerating leftover medications has been attempted (3). Recently the focus seems to be on using alternative medications (4), treating opioid withdrawal symptoms (5), changing prescribing practices (6) and prevention of opioid use (7).
- Regional pain blocking
- Topical medications
- Alternative medications
- Alternative medicine (e.g. acupuncture)
- Opioid-free practices
- Pharmacy factors
- E-prescribing
- Medical school curriculum
- Required physician education
- Buprenorphine
- Methadone
- Clonidine
- Addiction treatment programs
- Adjunct medications
- Novel drug development
- Prescription drug monitoring
- Policies to promote innovation
- Research funding
- Disposal of extra drugs
- Prevention programs
- Drug testing
- Manage patient expectations
- Medical devices
- Patient education
- Identify risk factors for opioid abuse
Figure 1. Summary of suggested strategies to solve the opioid crisis
Despite each of these attempts to help ameliorate this crisis, we have a long way to go. Even with decreasing the number of prescriptions (8), learning about these medications in medical school, promoting patient awareness, and coming up with several alternatives, many states have experienced increases in opioid deaths (Figure 2). None of these strategies are “new” however they are being applied in a novel way to this particular crisis. A recent New York Times article suggests that the answer is in education for school-age children (7) with the caveat that this may help us in the future, but currently, overdose rates are highest among individuals aged 25-54 years old (9).
Figure 2. Statistically significant drug overdose death rate increase from 2014 to 2015, US States (CDC) (9)
This crisis is pervasive and has proven to be a difficult problem for lawmakers and practitioners alike. Perhaps the best approach to this problem is to start from the beginning by thinking carefully about who it affects, understanding the risk factors for opioid abuse, providing safe alternatives, educating patients and practitioners, in evaluating data to guide policy. Perhaps if we identify where in this approach we are having trouble in the fight against opioids we can find a more comprehensive solution. Undoubtedly, what we learn from solving this problem will help solve the next health care crisis.
Resources
1. Trump Donates Third Quarter-Salary to Health Department. New York Times. 2017. https://www.nytimes.com/aponline/2017/11/30/us/politics/ap-us-trump-salary-donation.html
2. Changing course: A new approach to opioid pain medication at FDA. FDA Voice. 2016 https://blogs.fda.gov/fdavoice/index.php/2016/02/changing-course-a-new-approach-to-opioid-pain-medication-at-fda/
3. Four police departments across state receiving drug incinerator. MetroNews. 2016. http://wvmetronews.com/2016/10/25/four-police-departments-across-state-receiving-drug-incinerator/
4. Introducing the ALTO Alternatives to Opioids Program. EMResident. 2016. http://www.emresident.org/introducing-alto-alternatives-opioids-program/
5. Gowing L, Ali R, White JM, et al. Buprenorphine for managing opioid withdrawal. Cochrane Database Syst Rev. 2017;2:CD002025.
6. Barnett, ML, Olrnski, AR, and Jena AB. Opioid-Prescribing Patterns of Emergency Physicians and Risk of Long-Term Use. N Engl J Med 2017; 376:663-673.
7. Where is the Prevention in the President’s Opioid Report? New York Times. 2017. https://www.nytimes.com/2017/11/27/upshot/where-is-the-prevention-in-the-presidents-opioid-report.html
8. Annual Surveillance Report of Drug-Related Risks and Outcomes. CDC. 2017. https://www.cdc.gov/drugoverdose/pdf/pubs/2017-cdc-drug-surveillance-report.pdf
9. Drug Overdose Death Data. 2014-2015 Death Increases. CDC. Available from: https://www.cdc.gov/drugoverdose/data/statedeaths.html