A Framework for Addressing the Opioid Crisis – The “State” of the Art – Harlow On Healthcare

Recently, I had the opportunity to speak with two state health policy leaders about the opioid crisis. Michael Fraser, Ph.D. (@mfraserdc1), is CEO of the Association of State and Territorial Health Officials (ASTHO) (@ASTHO) and Mark Levine, M.D. is the Commissioner of Vermont’s Department of Health (@healthvermont). Dr. Fraser has held senior leadership positions in other healthcare related organizations and has served with the US Department of Health and Human Services. Dr. Levine practiced as an internist and has had a career in academic medicine at UVM as well.

Across the United States there are approximately 130 opioid overdose deaths a day from both prescription and illicit opioids. There are a variety of responses to the opioid epidemic, and our fifty states are, in this field as in many others, “fifty laboratories,” experimenting with different ways to address the crisis. Mike and Mark coauthored a piece published in the Annals of Internal Medicine, laying out a framework for an outcomes-based public health approach to the opioid crisis, articulating a multi-faceted “silver buckshot” approach as opposed to looking for a “silver bullet.”

Substance use disorders and suicide are the two top contributors to the decrease in longevity in the U.S. over the past three years. The prevalence of these “diseases of despair” constitutes a public health crisis, a crisis that demands attention to strategies across the spectrum, from education to prevention to treatment to recovery to harm reduction. And the prevalence of opioid addiction and abuse let Mike and Mark to “put down on paper what we viewed as elements of a comprehensive public health approach to this crisis … spanning the continuum from education and prevention through treatment and recovery and harm reduction and the kinds of operational strategies one needs in terms of using data having great epidemiology and surveillance and leveraging that data to achieve the outcomes that are desired and using traditional public health strategies of engaging leadership and working in partnership and collaboration with a whole variety of sectors. It’s a very complex problem that requires a very complex and comprehensive set of solutions.”

Mike said that the inventory of approaches in the article had its genesis in Mark’s comprehensive program in Vermont, which he presented to an ASTHO meeting. At the federal level, Mike said, “there are some dominant strategies – specifically, prescription reduction and monitoring through PDMP, making medication-assisted treatment more available for folks, and also looking at overdose prevention through the distribution of naloxone. All three of those are pretty significant . . . [but] what’s really driving our opioid epidemic is an epidemic of addiction and we really need to have that conversation in the U.S. and think about what the public health approach [should be], versus the clinical approach, which is just a piece of the response.”

I noted that the federales recently awarded states $1B in grants addressing the opioid crisis, mostly through SAMHSA, and that there was a five-point strategy in issuing these grants which overlaps with the six-point approach described in the Annals piece. I asked my guests to discuss how all these different strategies may need to be prioritized and implemented. They noted initially that the SAMHSA priorities are mostly in the realms of secondary and tertiary prevention and that their piece focused more on primary prevention, on increasing the ability of people in communities around the country to build resilience, to avoid substance abuse in the first place, to seek other approaches to dealing with the stressors than can lead to substance abuse and addiction.

ASTHO has highlighted as a best practice the use of a statewide opioid dashboard to use in tracking key indicators. For example, highlighting the rate of death from unintentional opioid overdose drives certain strategies. Reducing the supply of prescription opioids drives other specific strategies. Tracking treatment program participation is important – how many people in a state are getting medication-assisted treatment in a timely fashion? Is such treatment available to all marginalized populations – including, for example, the incarcerated population? Are there prevention progams? Recovery programs? Prescription drug monitoring programs (PDMP)? Are there opportunities for people to have gainful employment as they proceed through recovery? Are we seeing a reduction in the numbers of children being taken from their homes due to the opioid crisis and put in state custody? “There are all kinds of outcomes [and if you think about them each one lends itself to a whole host of strategies and shows the need for such a comprehensive program in every state.”

Mark noted: “One of the things we wanted to make sure we highlighted in the article were those social determinants of health because as we look at recent history in America we’ve always had a problem with drugs and addiction [and we don’t want to deal with this] substance by substance or molecule by molecule. [We have] this real siloed approach. Part of what we wanted to do with the paper was talk about a comprehensive approach for substance misuse and addiction really focusing on opioids because that’s where there’s so much attention, but there’s plenty of [opportunity for] application of the elements to work to prevent alcohol addiction or meth use and some of the other substances that we see people using …. We see a cycle of these issues over the years as public health issues and as public safety issues as well …. Most of what we do in substance abuse prevention doesn’t have to single out one [substance] or another.”

We also spoke a bit about the contribution that health IT can make to addressing the opioid epidemic.

Communication between state PDMPs is starting to happen so that tracking across state lines is more readily accomplished (Vermont has systems in place now to communicate with PDMPs in the neighboring states of New Hampshire, New York and Massachusetts), though of course the truism is that “if you’ve seen one PDMP, you’ve seen … one PDMP.” There is a lack of standardization, and there are no standards coming from SAMHSA or the DEA on this front.

Mike said: “One of the things we’ve really been pushing nationally is a common definition of overdose and how that’s reported.” There are differences both within states and across states. There is also variation in timeliness of reporting, which can be delayed a year or more, and “a year ago the epidemic was different.” There is a need and an increasing ability to look at proxy markers that may be available closer to real time. There is also a need to link PDMPs to EHR systems, and a need to permit physician surveillance data inputs into the PDMP or into other systems.

We spoke about how the clinical and public health dimensions of the responses to the crisis intersect with law enforcement, and how law enforcement needs to tread with a light step in this realm, and to coordinate with the public health and clinical efforts, in order to be as effective as possible.

Many health care systems are exploring the idea of stepping away from the use of opioids entirely, though many chronic pain patient advocates have spoken out against this trend. Mark shared: “There’s more and more compelling data coming to light that indicates that perhaps opioids are not the solution to every pain problem.” For example, ibuprofen plus acetaminophen can be as effective as opioids for pain management in trauma in the emergency setting, and in the surgical setting, “even orthopedists who operate on joints are finding that when they offer their patients alternative pharmacologic medications that are not opioids they’re actually able to find that they can relieve their pain and are studying that now to try to create new protocols.” Mark also promoted the idea of looking to integrative medicine, to mind-body techniques, to address pain without drugs or with fewer drugs.

We then concluded our conversation with my “lightning round” final question: If you were to wake up five years in the future what is one thing in health care that you would hope or expect to be different?

Mark noted that “other developed nations that seem to have much better health outcomes than we do, no matter what metric you care to choose, whether it’s life expectancy, maternal death in pregnancy, infant mortality — you name it…. Perhaps if we could begin to spend a greater share of our healthcare dollars on public health, prevention and social services — much like these other developed nations do — rather than on health care itself we would have less of a problem…. With the opioid crisis we’ve emphasized … that so much of that emanates from the so-called social determinants of health and [it’s] remediable by addressing the circumstances that people live in.” Mike added: “I’d love to see a health system that pays for prevention rather than sick care … and certainly look at incentives [that need to change].… Social change is needed to move us there … the system we have isn’t sustainable now and we’re not getting the outcomes that we want.”

I spoke with Mike and Mark as part of my ongoing series of fireside chats with healthcare innovation leaders – Harlow on Healthcare, on HealthcareNOW Radio. Listen to our radio station online, or ask your smart speaker (Amazon Echo or Google Home): “Find Tune In station HealthcareNOW Radio.” You can catch me live weekdays at 8:30 am, 4:30 pm and 12:30 am ET. As each new show goes live, the last one joins the archive, available via SoundCloud or your favorite podcast app (iTunes, Stitcher, iHeartRadio). Your comments are welcome here. Join the conversation on Twitter at #HarlowOnHC.

David Harlow
The Harlow Group LLC
Health Care Law and Consulting