The United States is in the midst of a serious opioid epidemic. Driven largely by an explosion of prescribed pain medications, opioid misuse has significantly increased in recent years. In fact, overdose-related deaths have quadrupled since 1999, according to the CDC.1 As a result, the opioid epidemic now has the attention of nearly every sector of society that can play a role in addressing the problem, including law enforcement; local, state, and federal health departments; drug treatment programs; community groups; and healthcare delivery. Although healthcare providers are under particular pressure to improve assessment of the need for pain medication and the risk of addiction, it is clear that no single or simple solution to the current crisis exists.
Federal and State Measures to Combat Opioid Misuse
Congress has authorized appropriations totaling an estimated $7.9 billion for programs to address the opioid epidemic in the United States, distributed among the CDC, Substance Abuse and Mental Health Services Administration, Office of the Secretary of HHS, Administration for Children and Families, and other agencies within HHS.2
Many states are now working intensively to limit supplies of prescription painkillers and illicit drugs, such as heroin and fentanyl. This encompasses enhanced law enforcement efforts to track drug trafficking and use shared data systems to identify where illicit opioids are being sold; this is often done in partnership with public health officials and local healthcare providers, who are frequently the first to see overdose spikes. States are also increasingly focused on tracking opioid prescriptions, educating prescribers about the risks of opioid-based medications, and identifying medical providers who overprescribe and patients who seek prescriptions from multiple sources. These efforts have involved the development of prescription drug monitoring programs (PDMPs), which feed prescriptions into state-maintained databases to identify overprescribers. In 2017 alone, states enacted 42 laws to strengthen PDMPs, according to a tally by the National Conference of State Legislatures.
At the same time, states are setting standards for how opioids are used to treat pain, in many cases building from the 2016 CDC guidelines for safe opioid prescribing.3 Twenty-three states now have laws that set guidelines or limits on how long opioid-based painkillers should be prescribed to patients, often with exceptions for certain medical care, such as cancer treatment or palliative care. Some states, including Oregon and Ohio, have also begun implementing policies to encourage the use of nonopioid treatments for pain, often through their Medicaid programs. In addition to controlling the supply of opioids, most states are actively bolstering their emergency response capacity to reduce the death toll from drug overdose. Much of this work has focused on increasing access to naloxone kits to revive overdose victims; kits are becoming available not only to emergency response personnel but also directly to members of the public in some cases. Several states are experimenting with over-the-counter distribution of naloxone or, as in Massachusetts, coprescribing naloxone kits to the family members of individuals who use opioid-based medication for chronic pain. Health officials in many states are also working to develop better opioid surveillance systems that will allow emergency responders to see where drug overdoses are happening in real time and deploy resources accordingly.
Finally, states are increasingly looking to expand access to medical treatment for those with substance use disorders, while working to overcome the stigma associated with addiction. This reflects, in part, a realization that addiction is a chronic disease, like diabetes, that requires ongoing medical attention. The interest in treatment also comes out of an emerging body of evidence that medication-assisted therapies, including methadone and buprenorphine, can be very effective in controlling opioid addiction and helping people return to normal lives.
RWJF’s Approach to the Opioid Epidemic
It is critical for states and communities to engage and align all actors to create systems that prevent new individuals from becoming dependent on opioids, while supporting the recovery of those who are already dependent. The structural and social determinants of health framework is widely understood to be critical in responding to public health challenges. Therefore, to help turn the tide of the opioid crisis, the Robert Wood Johnson Foundation (RWJF) is taking initial steps and encouraging others to adopt this framework. Some examples of a systems approach include RWJF’s work with complex-care patients (including opioid-dependent patients), trauma-informed care, and healthcare access (Medicaid expansion).
RWJF is supporting activities that can enhance opioid-surveillance systems, and policy analyses to improve treatment through health insurance coverage. The foundation is also coordinating efforts with a number of private funders and federal agencies to ensure that we maximize resources to be most impactful. Most recently, we supported the Mayors Institute on Opioids developed by the National League of Cities, which included 6 mayors and their teams to discuss challenges and opportunities that have arisen along with the opioid epidemic in their communities. A report from Manatt Health (“Communities in Crisis: Local Responses to Behavioral Health Challenges”) explores how cities and counties have launched local initiatives to address the human and economic impact of untreated serious mental illness and substance use disorder (SUD).4 The report provides detailed profiles of 13 local programs and a comprehensive taxonomy that categorizes program elements and features.
Finally, RWJF is supporting peer-to-peer learning among researchers who are studying the impact of Medicaid SUD 1115 waivers. As of March 2018, 19 states are using Section 1115 waivers to provide enhanced behavioral health services (mental health and/or SUD services) to targeted populations, expand Medicaid eligibility to additional populations with behavioral health needs, and/or fund delivery system reforms, such as the integration of physical and behavioral health services. RWJF is also a sponsor of and an active participant in the National Academy of Medicine’s Action Collaborative on Countering the U.S. Opioid Epidemic.
Putting a Price on Cost
The articles in this special issue delve deeply into the question of the costs of the opioid epidemic to the nation, particularly at the state level.5-9 Each presents a methodologically solid analysis of estimated financial costs, while clearly recognizing that the challenges of cost analysis of a problem like opioids, which reverberates through a state and each of its localities in complex ways, is not fully captured by existing state-level data sets. For instance, state-level criminal justice cost data, in most cases, do not include city- and county-level criminal justice costs. Further, county jail costs, local-level costs for diversion programs, and locally funded treatment costs are not captured in state-level data. The costs of a parent incarcerated for opioid use to their children, who might be placed in foster care, are not included, and these costs include the emotional stress of the child (with life-course implications, economic and otherwise) and the direct cost of the foster care system. If we, as a nation, are to better understand the systemic nature of the opioid crisis, it is imperative that we study the place-based and other contextual factors that can improve prevention, treatment, and recovery, potentially reducing criminal justice and other downstream costs.
This special volume makes an important contribution, as the papers represent solid research using available data and studies. However, each paper points to the need for a deeper level of analysis that goes beyond documenting the financial impact of opioids and provides enhanced understanding for prevention and recovery.Alonzo L. Plough, PhD, MPH, is vice president of Research-Evaluation-Learning and chief science officer at the Robert Wood Johnson Foundation, Princeton, NJ.