We are living through the deadliest drug crisis in American history. Opioid overdoses claimed more than 64,000 lives in 2017, more than guns or car accidents and faster than the HIV epidemic at its peak. Unless something is done to deflect this toxic trajectory, the death toll could exceed 500,000 over the next decade. The estimated economic burden of opioid abuse and overdose is staggering—nearly $500 billion annually.
How can we successfully confront this public health threat? Several approaches seem clear: ramp up efforts to prevent addiction and expand access to effective treatment. However, efforts to prevent opioid abuse or to increase access to treatment are not as straightforward to implement as it might seem, and implementation doesn’t necessarily translate into the desired outcomes. The research summarized here describes some facets of current prevention and treatment efforts and highlights how issues of equity and quality figure in efforts to expand treatment access.
Dynamics of the Opioid Crisis
The opioid crisis is an ever changing public health menace. Individuals who start using opioids for legitimate medical reasons are at risk for becoming dependent when they mix opioids with other drugs or use them recreationally. Treatment can help those who become dependent, but it is costly and access to treatment is not reliably available in all parts of the country. Opioid misuse can cause car accidents, health problems, and fatal or non-fatal overdose.
RAND work presents a comprehensive view of this dynamic crisis. We describe policies targeting different stages of the potential evolution from user to abuser, noting when policies focused on one stage may have unintended consequences elsewhere.
The opioid crisis is an ever changing public health menace.
- Patient with a current opioid prescription
- Recreational drug user
Reduce Initial Prescribing or Use
- Expand alternatives for managing pain
- Practice guidelines
- Physician education
"At Risk" Users
- Inappropriate or non-medical opioid user
- Heroin user
- Non-medical fentanyl user
Target Prescribing or Supply
- Prescription drug monitoring programs
- Prescribing restrictions: 7-day rules, clinical guidelines, etc.
- Drug formulations to deter abuse
- Seizure of illegal supply by law enforcement
- Dependent opioid user
- Dependent heroin user
- Dependent fentanyl user
- Expand access to treatment
- Waiver more physicians to provide treatment
- Monitor whether access to treatment is equitable
- Focus on treatment quality
- Fatal overdoses
- Nonfatal overdoses
- Crashes and accidents
- Opioid-addicted pregnant user and/or newborn
Harm Reduction Policies
- Overdose education and naloxone distribution programs
- Good Samaritan Laws
- Needle exchange programs
Expanding Alternatives for Managing Pain
Opioids are not the only option for managing pain. Non-pharmacologic approaches abound:
- high tech, such as electric nerve stimulation;
- more conventional, such as ultrasound or physical or occupational therapy;
- less conventional, such as acupuncture and mind-body techniques;
- over-the-counter medications, such as acetaminophen or nonsteroidal anti-inflammatory drugs;
- chiropractic care,
- psychotherapy; and
- corticosteroid injections, among others.
Evidence of the effectiveness of these approaches varies across studies and the type of pain. So does their use by clinicians, a target audience for increasing use of non-opioids for pain management. For example, about 60 primary care providers participating in focus groups as part of a larger study felt they did not have sufficient access to non-opioid alternatives. Perceived barriers included the distance that patients might have to travel for treatment and their out-of-pocket costs, and cultural issues such as providers’ belief that alternative approaches increased their workload and that patients would be resistant to alternative ways to manage pain. Providers also thought they lacked the training and leadership needed to make this shift in prescribing practice. When a healthcare system promotes non-medication approaches to managing pain and provides access to these approaches, use of non-opioid options rises.
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Practice guidelines could help providers make decisions about opioid prescribing, but to date, there is scant evidence that guidelines reduce opioid use. For example, a recent study used data from a large national workers’ compensation insurer to explore whether dosage guidelines affected prescribing patterns for patients after an injury. In the study, the insurer identified patients who use of opioids was out of compliance with dosage guidelines; then a physician working for the insurer called the prescribing physician to discuss the patient’s treatment plan. But even this physician-to-physician counseling had no effect on the treating physician’s prescribing behavior.
The evidence base for practice guidelines related to opioid prescribing is not strong. In a recent study for the Department of Defense, RAND conducted a systematic review of the guidelines and empirical literature for preventing, identifying, and treating prescription drug use in both military and civilian settings to identify best practices. Most of the guidelines they identified noted the lack of strong research evidence for many of the current recommendations for preventing misuse of prescription opioids—for example screening exams or written treatment plans. To date, there is little evidence that practice guidelines, by themselves, are effective.
"At Risk" Users
High doses or prolonged recreational use may put some opioid users at risk for addiction. Policies in this area focus on making it more difficult for users to abuse the drugs.
Using and Improving Prescription Drug Monitoring Programs
A primary care physician may be the first but not the only provider to prescribe opioids for patients. For example, patients who are seeking opioids for non-medical reasons may “doctor shop” to obtain a supply larger than what any single physician might prescribe. Prescription drug monitoring programs are an important tool for preventing this kind of misuse. The programs are state-specific databases that track the prescribing and dispensing of controlled prescription medications. Physicians could use such information to inform their own prescription decisions, potentially preventing drug-related harms.
Although all 50 states now have prescription drug monitoring programs, they vary substantially in their components (e.g., the scope of the drugs monitored) and implementation (e.g., the degree to which providers have access to program data, or how often data are collected). Some studies have found that these monitoring programs reduce drug-related mortality and ED visits. Others have found no effect. But states with more complete and timely opioid monitoring have achieved greater reductions in overdoses compare with states that have less comprehensive programs. What’s needed are studies to better understand which features of prescription drug monitoring programs can drive policy impact.
Decreasing High Risk Prescribing
Overprescribing is widely viewed as a major reason for the continuous rise in opioid mortality through 2010. Eliminating “high risk” prescribing could preemptively thin the ranks of individuals who could become dependent on opioids for which they have legitimate prescriptions.
Researchers examined claims data for Medicaid enrollees in four states to understand the prevalence of high risk prescribing and to identify individual and county level factors associated with it. The team used three measures of high-risk prescribing-- high dose prescriptions (using a dose level defined as high in the literature), overlapping opioid prescriptions (where more than 25 percent of days in a treatment episode have overlapping opioid prescriptions), and overlapping opioid and benzodiazepine prescriptions for at least five days during an episode. These measures of high-risk prescribing are linked to overdose deaths.
The team found that about 40% of opioid treatment episodes involved at least one measure of high-risk prescribing—most commonly high dose opioid prescribing. Individuals most likely to be associated with high risk prescribing were white, older, and residents of non-metropolitan counties. Enrollees who had a recent prior diagnosis of major depression were most likely to have higher rates of all types of high-risk prescribing. Indicators of high-risk prescribing varied considerably across states, suggesting that efforts to reduce high-risk prescribing will need to be state-specific.
Drug Formulations to Deter Abuse
Many prevention efforts have sought to reduce the risk of abusing opioids by disrupting their supply. The largest such disruption to date is the reformulation of OxyContin in 2010. In its original formulation, OxyContin could be crushed to deliver highly concentrated amounts of oxycodone that could be ingested, inhaled, or injected. Reformulation eliminated the opioid “rush” by making it difficult to crush or dissolve the pill, and the original reformulation was removed from the market.
But disruptions can have unintended consequences. When OxyContin became harder to get, addicts switched to other drugs, including heroin and fentanyl. RAND researchers explored the relationship between reformulation and the dramatic increase in heroin overdoses, which more than tripled between 2010 and 2014. They found that states with the highest initial rates of OxyContin misuse had the largest increase in heroin deaths, and the increases began immediately after the reformulation.
Researchers concluded that as much as 80% of the increase in heroin mortality in the years after 2010 may be due to the reformation. Each percentage point reduction in the rate of OxyContin misuse led to three more heroin deaths per 100,000.
Better ways to monitor and track illegal drugs could help intervene in the black market. Budget cuts have eliminated agencies that monitor these markets (e.g., National Drug Intelligence Center) as well as systems that cover them—e.g., Drug Abuse Warning Network. Improvements in surveillance and data collection are urgently needed.
Disrupting the supply of opioids can have unintended consequences.
Many of the harms associated with opioid abuse can be mitigated by appropriate treatment. Medication assisted therapy, predominantly methadone and buprenorphine, is commonly accepted to be the most effective treatment for opioid use disorder. Buprenorphine has the additional advantage that it need not be administered in a methadone clinic. This flexibility is especially valuable in rural areas, where methadone clinics are scarce. But not every one who needs treatment can get it.
Expanding Access to Treatment
In 2002, policy makers sought to increase access to treatment by allowing physicians to get a waiver from the Drug Enforcement Administration to prescribe buprenorphine. Initially, waivered physicians were limited to treating only 30 patients simultaneously. In 2006, the limit was raised to 100 and subsequently to 250 patients.
Increasing the number of physicians who could prescribe buprenorphine substantially increased potential access to treatment, especially in rural areas. Physicians with 100-patient waivers are largely responsible for the increased access and utilization.
Patient Limits for Waivered Physicians Are Not Constraining Their Prescribing
Increasing patient limits for some waivered physicians was intended to provide more access to MAT by allowing them to see more patients than allowed by current limits. Researchers examined pharmacy records from January 2010 to December 2013 for 7 states with the most buprenorphine-waivered physicians (California, Florida, Massachusetts, Michigan, New York, Pennsylvania, and Texas) During that period, about 245,000 patients received a new prescription.
But during the period January 2010 to December 2013, most waivered physicians were not treating as many patients as their waiver permitted:
- Most treated 4 to 30 patients monthly
- Very few treated more than 75
- About 20% treated 3 or fewer.
More Waivered Physicians Isn't Necessarily the Answer
Having more waivered physicians with 100 patient limits doesn’t necessarily translate into a lot more prescribing and many more patients for each new physician. Other research examined data from prescription monitoring programs in California, Maine, and Ohio between January 2010 and April 2015. Researchers analyzed the prescribing patterns of physicians, looking at the number of patients they treated monthly, how long a treatment episode lasted, and how close prescribers were to practicing near their patient limits.
Waivered physicians with 100-patient limits accounted for more than half of all treatment episodes. But nearly half of 30-patient waivered physicians did not prescribe any buprenorphine at all during the study period; 100-patient prescribers also had some months in which they did not prescribe any buprenorphine. It’s not clear why. Reasons might include lack of physician confidence in treating a complicated patient population, insufficient availability of counselors for patients receiving buprenorphine, low reimbursement rates, inadequate coordination and payment systems, and the potential stigma associated with treating these patients.
Overall, few physicians were practicing near their patient limits, so just increasing the number of waivered physicians and raising patient limits may not increase access to buprenorphine in any meaningful way.
Integrating Treatment into Primary Care
Treatment for individuals with opioid use disorders could be effectively delivered within community health clinics by primary care physicians. This approach increased the proportion of primary care patients with OAUD receiving evidence-based treatment.
Many of the harms associated with opioid abuse can be mitigated by appropriate treatment.
Is Expanded Access to Treatment Equitable?
Medicaid pays for more than one-third of treatments for opioid use disorder, so understanding how expansion efforts affect Medicaid enrollees is essential for assessing this approach. Researchers analyzed Medicaid claims data from 2002 to 2009 from 14 states representing about half of the U.S. population and about half of all 2009 Medicaid enrollees. They found that increased access to buprenorphine was indeed benefiting Medicaid enrollees, substantially increasing the number who were receiving medication assisted treatment.
But the benefits were not the same everywhere. Enrollees living in urban counties with a low poverty rate and a low percentage of Hispanics or blacks were significantly more likely to receive buprenorphine than enrollees living in other counties. Unfortunately, this finding is consistent with many other studies highlighting an historical pattern of disparities in health care services for these vulnerable populations.
How Good Is Current Treatment for Opioid Use Disorders?
In other clinical areas, quality of care can be measured by examining how well the care delivered meets recommended standards, as determined by clinical experts. Unfortunately, we do not currently have validated quality indicators for treating opioid use disorders.
To assess the quality of care for opiod abuse, a RAND team used quality indicators developed by clinical experts, found in the scientific literature, or define by clearinghouses such as the National Quality Forum. Measures included treatment retention, treatment engagement, and psychosocial therapy and psychotherapy associated with substance abuse disorders. The team examined administrative records for nearly 340,000 veterans who were treated by the Veterans Health Administration for an opioid abuse disorder between October 2006 and September 2007. Their goal was to determine if the quality of care for opioid abuse these veterans received affected their mortality 12 and 14 months after treatment.
Results show unequivocally that quality of treatment for an opioid abuse disorder does matter. Overall, veterans whose care met the quality requirements had up to 25 percent lower mortality rates 12 and 14 months after treatment. These findings suggest that validated quality of care measures for substance abuse treatment, and applying those measures to ensure that quality care is being delivered, are essential in the war on opioid abuse. Developing measures of quality for treatment should be a national priority. Access to treatment is a necessary but not sufficient strategy for improving patient outcomes. This study is one of the first to assess how quality of care affects patient outcomes.
Adopting this kind of comprehensive perspective can be challenging. Different actors often focus primarily on one population (e.g., providers focused on patients, criminal justice agencies on illicit and illegal opioids, substance abuse specialty providers on treatment population).
Policies and initiatives can:
- Target different dimensions of the system, including efforts to minimize harm (e.g., distribution of naloxone, needle exchange programs);
- Expand treatment (insurance coverage, buprenorphine access);
- Reduce the risk of escalating to dependence (prescription drug monitoring program pain clinic regulations, abuse deterrent formulations, and law enforcement); and
- Decrease the number of individuals with unnecessary exposure (prescribing guidelines, promotion of non-opioid analgesic strategies for managing chronic pain).
The opioid crisis may have been driven initially by widespread access to opioid analgesics such as OxyContin, but based on overdose data, the crisis now appears to be fueled by heroin and fentanyl, purchased on the black market. If policies do not consider access to other illicit opioids – or at a minimum access to treatment to reduce the demand for opioids more generally – users may not reduce their use of opioids, but instead shift to illegal heroin and fentanyl markets, especially when these illegal markets already exist in their area.
Because of these kinds of interactions, decisionmakers need tools to help them pay attention to multiple parts of the ecosystem, at the same time. They also need reliable information to understand how policies interact and what effects of the interaction are likely to be.