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Dr Marcelina Jasmine Silva: Applying Lessons From COVID-19 to the Opioid Epidemic

Even before the coronavirus disease 2019 (COVID-19) pandemic, the struggle to curb the opioid epidemic in the United States has produced disappointing outcomes. Now that COVID-19 and the resulting social distancing requirements have allowed the opioid epidemic to flourish, authors in the July issue of The American Journal of Managed Care® suggest an alternative approach that emphasizes building resiliency and investing in social support. Marcelina Jasmine Silva, DO, joined us to discuss the current approaches to opioid use and potential lessons to be learned from COVID-19.


Even before the coronavirus disease 2019 (COVID-19) pandemic, the struggle to curb the opioid epidemic in the United States has produced disappointing outcomes. Now that COVID-19 and the resulting social distancing requirements have allowed the opioid epidemic to flourish, authors in the July issue of The American Journal of Managed Care® suggest an alternative approach that emphasizes building resiliency and investing in social support. Marcelina Jasmine Silva, DO, joined us to discuss the current approaches to opioid use and potential lessons to be learned from COVID-19.

Transcript

AJMC®: Welcome to MJH Life Sciences News Network. Can you introduce yourself and tell us a bit about your work?

Marcelina Jasmine Silva: Yeah, thanks for having me. My name is Dr Marcelina Jasmine Silva, and I’m the creator and medical director of the FOOT Steps Program, and FOOT Steps stands for focus on opiate transitions. And it’s a program that helps patients with chronic pain transition away from classic opiate use. We’ve had great success, we’ve had a 90% success rate of helping patients transition away from classic opiates, and a 97% success rate at maintaining those results for up to 24 months of follow-up. So I feel pretty well qualified to talk about opiates and speak to the factors that aid in opiate cessation.

My program, FOOT Steps, was initially rooted in a workers compensation reimbursement model. And it was when I started looking at our outcomes and wanting to provide it for a broader range of patients that I started to investigate other types of managed care resources and fiscal models, and that’s when I came across the AJMC® supplement “Deaths, Dollars, and Diverted Resources.” And that’s when it became apparent that the current way that the medical community has been treating the opioid epidemic is not only insufficient clinically, but also fiscally, it’s having some pretty poor outcomes. And I thought there’s a very strong case to be made, that on all accounts, we really need to change our tactics. And that’s when I became inspired to write this current article with my coauthor, Zak Kelly, and we wanted to overlay in some of the information that was presented in “Deaths, Dollars, and Diverted Resources” and also some of our own collected readings on industrial outcomes, public health outcomes, and the overall intersection of some really poor health results, to write this article entitled “The Escalation of the Opioid Epidemic Due to COVID-19 and Resulting Lessons About Treatment Alternatives.” I did most of this work before COVID came to the United States, but watching COVID act as an accelerant, kind of, on this flame of the opiate epidemic, I feel really illuminates a lot of issues and a lot of ways in which we can use this catalyst for bad change in order to make a better change in the future and treatment options.

AJMC®: Going back to before COVID-19, what were some ongoing strategies to curb the opioid epidemic and what were the results?

Silva: The largest push towards a strategy came from the 2016 CDC guidelines for opiate prescribing. These were very thoughtful guidelines, and they were based on abundant published evidence. The main focus was on decreasing opiate exposure, and then also some suggestions for risk mitigation for patients who were already exposed chronically to opiate use. And a number of new practices came from those guidelines, which involved concerted efforts from the entire medical community. And again, the premise was to decrease or eliminate opiate exposure, and one of the ways we do that is by calculating opiates into what we call morphine equivalent doses, or MEDs. And there became a focus throughout physicians with patient care and prescribing practices to either decrease MEDs or eliminate opiates altogether. We saw pharmacists starting to question opiate prescribing, holding prescriptions even; managed care institutions denying coverage or modifying prescription coverage. And ERs and urgent cares revamping their protocols to deal with acute pain in ways that didn’t involve opiates at all. And so overall, we had this large-scale, coordinated effort to change opiate prescribing. Additionally, a lot of really thoughtful risk mitigation strategies were suggested, like frequent urine drug sampling, recommendations for naloxone prescribing. Simultaneously the DOJ bolstered their access to the prescription monitoring drug program, which is where clinicians can go and monitor controlled substance use and access for their patients to make sure that there’s not duplications happening.

It was impressive, and it was well organized, and it was a large-scale effort. But overall, despite all of that heroic work, really, the outcomes have been less impressive. So you know, those guidelines came out in 2016. Behavior change has been implemented since that time. But since that time, opioid-related deaths have continued to increase, and they’ve taken a real toll on US life expectancy. And in fact, the US life expectancy has been going down since 2014, and this is mainly attributed to unintentional injuries, which includes fatalities related to drug overdoses. And now there was a large headline that came out recently that said that in 2018, there was a plateau, finally, in life expectancy, actually a slight increase compared to 2017. But that reduction ended up being measurable in about a tenth of a year, which is around a month, and so it was sort of a small improvement and likely it was due to these really large-scale efforts that were implemented. But still, it’s a small improvement, and we’re still not back to the peak of American life expectancy, like we were back in 2014. And so we are still one of the lowest ranked countries in life expectancy and a large part of it is due to the opioid epidemic. So, on a public health front, we’re still not making the progress that we’d like to see; simultaneously, fiscal cost overall have continued to skyrocket despite all of these collective efforts. And so clearly, this approach of restricting opiate access is not the entire answer.

AJMC®: Why do you think it’s insufficient to simply restrict access to opioid prescriptions?

Silva: Well, you know, the outcomes are just disappointing, frankly. We talked about the fact that restricting access hasn’t done much to move the needle in terms of poor US life expectancy. And in terms of financial and societal outcomes, we have evidence of decreasing opiate insurance coverage and decreasing prescribing practices occurring simultaneously with still increasing managed care costs for patients who use opiates. So for example, commercial insurance medical charges for patients with opiate dependency or abuse are 550% higher than patients who aren’t using opiates on an an annual per-patient charge. And that data encompasses things like comorbid conditions, other substance use, psychiatric/physical disorders, pain-related disorders, emergency room, and hospitalization visits to. And you know, most clinicians who are well acquainted with patients who are using opiates chronically, as soon as they’re cut off from their medication, the most common coping mechanism is to appear to the emergency room, which is inefficient, expensive, and it doesn’t really get anybody where they want to be. And so you can start to see that simply removing the cost of a prescription medication doesn’t remove all the costs that are associated with managed care around opiate use. And the reason that this happens overall is complex.

It’s, I believe, based on a theory of trauma and resulting lack of resiliency and lack of ability to heal. I didn’t discuss this theory explicitly in my article, but it’s implied. And this is a theory that I base my own clinical program and practice upon. And I think the dynamics of this theory has been illustrated by the negative effects of COVID-19. Basically, social distancing, while it’s been epidemiologically necessary, it’s cutting people off from any of the resources that enable them to be resilient. There’s an open discussion occurring currently, both in popular and clinical addiction literature, about the hazards that this current epidemiological climate is presenting for substance abuse triggering and relapse. I think overall, this dynamic is really best explained by a robust body of research that’s rooted in the effects of trauma, the foundation of which is the original, what we call the ACE studies or Adverse Childhood Experiences studies, which were studies that were founded by Dr Vincent Felitti and then were enlarged by a partnership with the CDC and Dr Robert Anda there, which basically has shown that there is a very strong association between trauma and health throughout life and chronic disease, and even things like chronic heart disease, cancer. Turns out that the more traumatic experiences you experienced, especially earlier in life, the more likely you are to have cancer. And so especially if you start to think about chronic conditions that have a behavioral health component, like chronic opiate use, or opiate misuse, or alcoholism or tobacco use, there’s a very strong association with a background in trauma.

And I’m not saying that everybody who uses opiates for chronic pain or everyone who has an opiate addiction—and those two things are not the same thing, but they’re both encompassed in the opiate epidemic—not all those people have had an abusive or traumatic childhood or traumatic past, but data shows that if you have a background of physical or emotional trauma, which is actually very common, then you’re much more likely to rely on opiates for chronic physical and/or emotional pain and simultaneously experience other health conditions that make a person feel nonresilient or otherwise physically or emotionally compromised and unable to heal. And as you start to think about the opiate epidemic in those terms, it obviously becomes much more complicated than simply refusing access or coverage for a prescription. That’s not going to solve the problem, and we need to start looking at our focus on identifying and treating the factors that make a person susceptible to chronic opiate use in the first place.

AJMC®How does the opioid epidemic inflict costs on both individuals and society?

 
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