Currently Viewing:
Supplements Deaths, Dollars, and Diverted Resources: Examining the Heavy Price of the Opioid Epidemic
The Economic Burden of the Opioid Epidemic on States: The Case of Medicaid
Douglas L. Leslie, PhD; Djibril M. Ba, MPH; Edeanya Agbese, MPH; Xueyi Xing, PhD; and Guodong Liu, PhD
Estimated Costs to the Pennsylvania Criminal Justice System Resulting From the Opioid Crisis
Gary Zajac, PhD; Samaan Aveh Nur, BA; Derek A. Kreager, PhD; and Glenn Sterner, PhD
Considering the Child Welfare System Burden From Opioid Misuse: Research Priorities for Estimating Public Costs
Daniel Max Crowley, PhD; Christian M. Connell, PhD; Damon Jones, PhD; and Michael W. Donovan, MA
The Opioid Epidemic, Neonatal Abstinence Syndrome, and Estimated Costs for Special Education Services
Paul L. Morgan, PhD; and Yangyang Wang, MA
Opioid Misuse, Labor Market Outcomes, and Means-Tested Public Expenditures: A Conceptual Framework
Joel E. Segel, PhD; Yunfeng Shi, PhD; John R. Moran, PhD; and Dennis P. Scanlon, PhD
Participating Faculty
Currently Reading
Preventing the Next Crisis: Six Critical Questions About the Opioid Epidemic That Need Answers
Dennis P. Scanlon, PhD; and Christopher S. Hollenbeak, PhD
The Cost of the Opioid Epidemic, In Context
Sarah Kawasaki, MD; and Joshua M. Sharfstein, MD
The Opioid Epidemic: The Cost of Services Versus the Cost of Despair
Alonzo L. Plough, PhD, MPH

Preventing the Next Crisis: Six Critical Questions About the Opioid Epidemic That Need Answers

Dennis P. Scanlon, PhD; and Christopher S. Hollenbeak, PhD
Because all prescription opioid pain medications are subject to Automation of Reports and Consolidated Orders System reporting by distributors, the Drug Enforcement Administration (DEA) has rich data on the flow of opioids to pharmacies across the country. As reports have shown, these medications were flowing to pharmacies that were facilitating their illegal use or flooding certain communities with significantly higher volumes of pain medications than could be justified based on the health needs of the patient populations in these communities.45 Former senior administrators within the DEA argue that the agency had gathered thorough evidence documenting that certain opioid distributors were not in compliance with the Federal Controlled Substances Act,46 allegedly turning a blind eye to knowledge that the drugs they were distributing were being used for illegal purposes, thus catalyzing opioid addiction across the United States.47-49

Can Professionals Be Trusted to Do the Right Thing?

Much of the criticism and blame for the opioid epidemic have been aimed at individuals and organizations that society generally holds in high regard as trusted professionals, tasked with protecting the health and welfare of patients and populations. For example, a New York State survey conducted by Siena College Research Institute in February 2018 demonstrated that most New Yorkers blame physicians for exacerbating the opioid epidemic by overprescribing opioid medications.50 News stories and reports from ongoing legal disputes report that some high-profile physicians took money from the pharmaceutical industry in exchange for promoting the long-term safety of opioids; that safety claim has subsequently been proved false.51

Many physicians face a difficult decision when weighing the necessity of treating a patient’s pain symptoms with the possibility of addiction if the patient is prescribed an opioid. Many still believe, however, that physician organizations at both the community and the national levels have not done enough to slow down or stop the epidemic.49,52,53 Some argue that these organizations had the expertise to recognize the addiction, mortality, and morbidity that were occurring in their communities, yet they failed to recognize the issue and act in an organized, timely fashion.54 This raises the important question of whether we can trust professionals to identify and detect problems of this magnitude early on and act in the best interests of the health of the patients and the population at large.

Other trusted professional organizations that are afforded autonomy by the government and the healthcare industry have been denounced. Most notable is the Joint Commission on Accreditation of Healthcare Organizations (JCAHO). JCAHO accredits hospitals to ensure that they practice safe and high-quality medicine. JCAHO accreditation is required for hospitals and other healthcare facilities to receive reimbursement through the federal government’s Medicare and Medicaid health insurance programs. Thus, hospitals tend to respond quickly and completely when JCAHO implements standards or requirements. With respect to the opioid epidemic, JCAHO has been criticized for pushing pain as a “fifth vital sign,” allegedly based on research and reports about pain that were funded by the manufacturers of opioids.55 Many, including state attorneys general, have argued that it was JCAHO’s focus on the need to measure, treat, and monitor pain, similar to measuring, treating, and monitoring hypertension, that created an excess demand for opioid medications that otherwise would not have been prescribed.56,57

Why Haven’t States Invested in Better Data and Surveillance to Facilitate a More Rapid Response to Emerging Epidemics?

One federal entity that has been commended for its work on the opioid epidemic is the CDC. The CDC is credited with tracking and monitoring data regarding mortality due to opioid overdose, thus allowing the magnitude of the problem to be acknowledged and reported. The CDC also issued its first guidelines on prescribing opioids in 2016, making it clear that opioids are not typically indicated for long-term use associated with chronic pain that is not related to cancer or palliative, end-of-life care. The guidelines also stated that there were alternatives, such as non-narcotic pain medications or other non–drug-based therapies, that have been shown to be effective and associated with less risk.58

The CDC monitors infectious disease outbreaks, working with state and local public health departments to monitor the same issues regionally. In this capacity, the CDC reports on and cautions about problems as they arise in communities, which could spread across the country. For example, the CDC’s Wide-ranging Online Data for Epidemiologic Research (WONDER) database has been used to track cause of death in communities and associate it with drug overdose and opioid overdose.59 This data set is not perfect, as there are many challenges associated with obtaining accurate and comparable cause of death information from coroners’ offices across the United States. Nonetheless, the CDC’s efforts have shed light on the impact of the opioid epidemic.

Unfortunately, state-level data and surveillance systems vary significantly and are often not as accurate or useful for recognizing the magnitude of a brewing epidemic or producing reliable, real-time estimates of the impact of an ongoing epidemic. As the articles in this supplemental issue illustrate, there are many reasons state data systems often do not connect the dots and provide actionable intelligence by linking, for example, data from a variety of sources, such as coroners’ reports; criminal justice records; children, youth, and family services records; and health insurance claims data. Improved systems are possible by incorporating the concept of Integrated Data Systems, as described by the group Actionable Intelligence for Social Policy at the University of Pennsylvania.60 As this group and others have documented, many important data points are often stored in silos, thus preventing linkage across different sectors of state and local governments and precluding a more holistic picture of the relationship between one social issue (eg, illegal drug prescription and use) and another (eg, an increased demand for foster care due to a higher prevalence of children with drug-addicted parents). Although the need for the privacy of confidential data and personal records is paramount, the societal benefits of states investing in integrated data systems are likely to be huge, and, in the case of the opioid epidemic, it may have resulted in an earlier, more effective response to the epidemic.

Is It Possible to Effectively Regulate the Conflicts of Interest in American Healthcare, Including the Drug Industry?

Relevant to the discussion of many of the issues above is the fact that healthcare in the United States is “big business,” with many professionals, organizations, health systems, insurers, and product and service suppliers making significant profits. This includes the often-criticized pharmaceutical industry, including specific manufacturers and distributors directly involved in the opioid prescription business. Because in the United States we have accepted a multiparty health system with a significant profit motive, and the associated responsibility of regulating appropriate business and ethical behavior to ensure that patients and society are not exploited, it is important to determine whether the multilayered system we have created is meeting the needs of society in this regard. Given the ongoing legal cases alleging that the owners of privately held and publicly traded companies have made billions of dollars by peddling addictive prescription pain medications, the question is now more important to answer than ever before. Specifically, society should examine whether appropriate regulatory mechanisms are in place and whether the model of federalism in the United States is working to protect the health, safety, and well-being of its citizens.

Why Is Substance Misuse So Common? What Are the Underlying Factors?

Finally, the question that must be addressed is: What drives substance misuse and addiction? Although using government or regulatory mechanisms to prevent or significantly curb the supply of addictive narcotics is certainly valuable, there is also value in preventing or reducing addiction at its core. This is a complex topic that involves expertise across many disciplines, including neurology, substance misuse and addiction, and social distress and economic inequalities. As highlighted in the recent work by Case and Deaton,61 which discusses the rise in the rate of “deaths of despair” in the United States, particularly among middle-aged white men—a group previously thought to be relatively privileged—the explanations are likely multifaceted, including social justice concerns, economic equality, and the current social stigmas associated with mental illness. Substance misuse and addiction existed long before the current opioid epidemic, but the destruction they wreak has never been as damaging and as costly as now. This, in turn, spurs the need to further commit to research to better understand the key drivers of addiction and what can be done to prevent future epidemics.

Conclusions

Much of the discussion about opioids has focused on very specific topics, including industry liability in a number of high-profile lawsuits. It is important to take a step back and think about this epidemic more broadly. At the forefront, we should not lose sight of the damage the epidemic has wrought on entire communities and on families who have lost loved ones or have struggled to help those addicted to prescription opioids.

Admittedly, although our commentary is heavy on questions and light on answers, we believe that the citizens of the United States deserve to have these questions asked. They are critical to learning from the existing epidemic and helping prevent the next one. We offer the questions in this commentary as a starting point, and we encourage Congress, the National Governors Association, and the National Academy of Medicine to prioritize and provide leadership and resources to appoint a qualified, unbiased panel of experts and citizens to pursue the answers. 

Dennis P. Scanlon, PhD, is a distinguished professor in the Department of Health Policy and Administration at the Pennsylvania State University.
Christopher S. Hollenbeak, PhD, is a professor and department head of the Department of Health Policy and Administration at the Pennsylvania State University.
 
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