JANUARY 11–14, 2018

Costs of the Opioid Crisis

Brian Shiozawa, MD

Regional Director
Region 8
US Department of Health & Human Services

The Forum confronted the shocking statistics of the opioid crisis in the presentation by Brian Shiozawa, MD, whose role at HHS includes supporting the States in addressing this epidemic. About 90 people die from a drug overdose each day, and the rate of deaths associated with opioids has increased by 200% since 2000, with the highest number of deaths this year. More than 500,000 persons died from opioid overdoses between 2000 and 2014.

Overdose deaths involving opioids, by type of opioid, United States, 2000–2016

The Demographics of Death

The opioid epidemic cuts across every sector of society, raging across socioeconomic, gender, cultural, racial, and geographical lines, and endangering the nation’s entire social fabric. Among those who died from prescription opioid overdose between 1999 and 2014, rates were highest among people aged 25 to 54 years and among non-Hispanic whites and American Indian or Alaskan Natives, compared to non-Hispanic blacks and Hispanics.

Overdose is not the only risk related to prescription opioids. Misuse, abuse, and opioid use disorder (addiction) are also potential dangers and add significant costs to the problem. In 2014, almost 2 million Americans abused or were dependent on prescription opioids. Every day, over 1,000 people are treated in emergency departments for misusing prescription opioids.

Costs of the Opioid Crisis

In 2015, the White House put the cost of the opioid drug epidemic at $504 billion, or roughly half a trillion dollars. Most of that was attributed to health care costs. In published data, opioid abusers were found to be 4 times as likely to visit the Emergency Department (ED), 11 times as likely to have had a mental health outpatient visit, and 12 times as likely to have had an inpatient hospital stay, compared to non-abusers.

Because of this, additional excess costs were incurred in criminal justice expenditures, child and family assistance, and additional education expenditures necessitated by the opioid crisis. According to data from the Altarum Institute, a non-profit healthcare research organization, using measures such as productivity losses due to fatalities, incarceration and non-fatal productivity losses, direct and indirect health care and estimated criminal justice, child welfare, and education impacts, the potential societal benefit of eliminating the opioid crisis exceeds $95 billion per year.

Who Pays the Price of Opioid Abuse?

Data from 2016 indicate that the opioid crisis cost insurers $21.4 billion, with Medicaid paying for the largest share at $8.7 billion, a significant impact on States’ budgets. The epidemic cost Medicare an estimated $6.4 billion and private payers and the uninsured a combined $6.3 billion.

Dr. Shiozawa pointed out that Medicaid costs for treating HepC, a frequent comorbidity with opioid abuse, can range from $50,000 to $80,000 per year per patient, and only cures the acute infection, without conferring immunity. So abusers may experience repeated HepC infections. Clean-needle programs are important but, to be effective, must be coupled with education and support services that add to the costs, he reminded the Forum.

The remaining costs of the opioid epidemic were for criminal justice and education expenditures and child and family assistance spending. Many 2016 cases of child neglect were associated with parents with opioid addiction. Child and family assistance spending related to the epidemic was about $6.1 billion in 2016, again hitting the States’ budgets. “Who is raising the children when parents are addicted to opioids,” Dr. Shiozawa asked.

Distribution of spending (in billions) on SUD treatment by payment source (2014)

HHS Opioid Strategy

Dr. Shiozawa is one of 10 HHS Regional Directors, who are charged to ensure that the Department maintains close contact with State, local, and tribal partners and addresses the needs of communities and individuals served through HHS programs and policies. He urged the Senators to advise and partner with their Regional Directors and access resources through them.

He reported that addressing the opioid crisis is 1 of 4 major initiatives undertaken by HHS.  The HHS opioid strategy is comprehensive and evidence-based. It targets the drivers of the epidemic and remains flexible so that it is adaptable to changing realities, Dr. Shiozawa said. The strategy includes improving access to prevention, treatment, and recovery services, and broad distribution of overdose-reversing drugs, strengthening timely public health data and reporting, and supporting cutting-edge research on addiction treatment and on the practice of pain management.

The goals of the program are to empower the public, patients and providers through education and awareness, prevent opioid abuse and overdose and related health consequences, improve function and quality of life for individuals living with pain, ensure that patients who need opioid addiction treatment have access to it, and support people to achieve long-term recovery.

HHS opioid strategy

How is Opioid Addiction Treated?

Dr. Shiozawa pointed out that prescription opioid pain medications and heroin are all opioids and their treatments are the same, involving clinical care, medication, psychosocial interventions, and social supports. Comprehensive, multi-pronged treatment programs are critical to success, he said, noting that the burden falls on the States as Medicaid from the States’ coffers must cover many costs of people with opioid addiction, who may end up in jails or in residential treatment.

Clinical strategies to break opioid addiction involve a combination of FDA-approved medications (Medication Assisted Treatment (MAT)) for as long as the person benefits from the care. Such medications include naltrexone, which blocks effects of opioids and is a life-saving drug now in the hands of most emergency services and, in some states, available from a pharmacist. Medications that are alternatives to opioids include methadone, a long-acting, once-daily, opioid from specially licensed programs, and buprenorphine/naloxone: a long-acting, once-daily, opioid from doctor’s offices that is available by prescription.

Unfortunately, 80% of those who go through medical withdrawal or detoxification relapse in the year following treatment and are at high risk for overdose and death when relapse occurs. Opioid addiction treatment cannot be a stand-alone treatment but requires wrap-around services to be effective, such as psychosocial therapies/treatment, counseling for coping skills and relapse prevention, as well as education about issues related to substance use.

Where Can States Obtain Funding for Opioid Crisis Interventions?

Dr. Shiozawa presented a long list of government agencies that are funding efforts to address the opioid crisis, including SAMHSA, CDC, FDA, CMS, NIH, HRSA, and others.

Combating the opioid crisis: SAMHSA state targeted response to the opioid crisis grants (FY 17, $485M)

The Health Resources and Services Administration (HRSA), for example, awarded more than $200 million to 1,178 health centers and 13 rural health organizations in every US state to increase access to substance abuse and mental health services to fight the opioid crisis. Additionally, 496 of the health centers that receive Access Increases in Mental Health and Substance Abuse Services (AIMS) awards are located in rural communities, where the opioid epidemic is rampant. Nearly $3.3 million supports 13 rural health organizations to increase access to treatment and recovery services for opioid abuse under the Rural Health Opioid Program (RHOP) and the Substance Abuse Treatment Telehealth Network Grant Program (SAT -TNGP).

Signs of Progress

Dr. Shiozawa said there are signs of hope. Youth prescription opioid misuse has been declining over past decade, and heroin use is stable among youth. Awareness of the potential for abuse of these drugs among prescribers has reduced opioid prescribing. Prescription opioid misuse initiation and overall misuse has declined and overdose deaths involving commonly prescribed opioids are down. The number of people getting Medication-Assisted Treatment (MAT) is increasing, and there is an exponential increase in pharmacy dispensing of naloxone, Dr. Shiozawa concluded.

JANUARY 11–14, 2018

Costs of the Opioid Crisis

Christine Hahn, MD

Medical Director
Idaho Division of Public Health

Life expectancy in the US declined again this year, driven by opioid deaths, Dr. Christine Hahn told the Forum. The epidemic spurred President Trump to declare a national public health emergency, and federal, state, academic, and private organizations have developed crisis intervention resources. State Health Directors have come together to share access to information and resources, and to share evidence-based best practices that address the crisis, Dr. Hahn reported. Her presentation reviewed opportunities and finding from these resources.

Help from Federal Agencies

Center for Disease Control and Prevention

Dr. Hahn described the CDC’s Data-Driven Prevention Initiative (DDPI), which focuses on statewide planning with wide group of stakeholders, improving data collection and analysis through increased use of Prescription Drug Monitoring Program databases (PDMP), and prescriber and patient education and awareness.

Data-driven prevention initiative (DDPI): funded states

The Substance Abuse and Mental Health Services Administration

SAMHSA plays a critical role in fighting the opioid crisis, Dr. Hahn said, reporting on the agency’s grant-funding activities for state-targeted responses to the opioid epidemic. Grants have been allocated to help pay for medication-assisted treatment (methadone and buprenorphine); to fund data collection and send prescriber “report cards” on their opioid prescribing patterns; to forge links with agencies that see persons in crisis, such as jails and hospitals, in order to get them needed care and recovery support; and to increase access to naloxone (opioid overdose antidote) for first responders.

President’s Commission on Combatting Drug Addiction and the Opioid Crisis

A November, 2017 report from the President’s Commission made recommendations in 4 key areas: 1. Federal Funding and Programs, 2. Opioid Addiction Prevention, 3. Opioid Addiction Treatment, Overdose Reversal, and Recovery, 4. Research and Development. The programs would be funded by block grants to the States.

The US Congress

In November, 2017, the US Senate Health, Education, Labor, and Pensions Committee held a hearing focused on “The Front Lines of the Opioid Crisis: Perspectives from States, Communities, and Providers.” Dr. Omar Abubaker, Professor, Virginia Commonwealth School of Dentistry told the Congress: “We need federal reform of all of our educational systems to include scientific facts about addiction, drugs and all substances of abuse. We need to prevent the harmful effects of such exposure through education and by identifying those at risk and interrupting the disease at its earliest stages. We are also looking to you to allocate funds in the Comprehensive Addiction and Recovery Act and in the 21st Century Act coverage, not only for treatment of all forms of addiction and its underlying mental illness, but also to extend coverage for screening of those at risk for addiction, brief interventions and referral for treatment (SBIRT) of those affected.”

Following up in December, Senate Health Committee Chairman Lamar Alexander (R-TN) and Ranking Member Patty Murray (D-WA) sent letters to every Governor and State insurance commissioner in the nation. They asked for specific recommendations on how the federal government can be the most effective partner for states in the battle against the opioid crisis.

Help from the Private Sector

The information is categorized into 8 topics and includes a variety of resources, national and state guidelines, training, simulations, and case examples. The topics include:

1. Clinician education on prescribing practices

2. Non-opioid pain management

3. Addressing stigma

4. Treatment options for opioid use disorders

5. Patient, family and caregiver education

6. Transitions of care

7. Safeguarding against diversion

8. Collaborating with communities

Actions by the States

Dr. Hahn reported that 6 States (Massachusetts, Virginia, Alaska, Maryland, Florida, and Arizona) have issued Emergency Declarations to create Task Forces and Emergency Response Systems focused on opioid addiction.  Many States have tightened up prescribing laws and some, like Idaho, have allowed pharmacists to prescribe naloxone.

As reported in The New England Journal of Medicine, several States’ Attorneys General have filed high-profile lawsuits against companies that manufacture and/or market opioids, including West Virginia, Oregon, Kentucky, California, Illinois, and Massachusetts, alleging aggressive marketing and other violations. While companies did not admit any fault, settlements ranged up to $24 million.

The National Association of Attorneys General also issued a letter to America’s Health Insurance Plans, the insurance trade association, advocating: “Insurance companies can play an important role in reducing opioid prescriptions and making it easier for patients to access other forms of pain management treatment. Adopting an incentive structure that rewards the use of non-opioid pain management techniques for chronic, non-cancer pain will have many benefits.”

The View from Idaho

Idaho has taken an active role in combatting the opioid crisis, Dr. Hahn said, implementing programs focused on three goals.

Goal 1. Reduce exposure to opioids. Educate patients and prescribers to look for non-opioid alternatives for pain management, and encourage the CDC to issue new guidelines for treatment of chronic pain. Work with insurers and Medicaid to increase covered alternatives. Get better data to inform response by requiring participation in Prescription Drug Monitoring Programs (PDMP) and use the data to identify areas of state with large number of high-level prescribers and heavy opioid users. Increase drug take-back programs.

Goal 2: Decrease overdose deaths among patients using opioids. Educate patients and prescribers about safe opioid use, keep patients from overdosing, and wean them from opioids safely. Issue provider report cards to identify and track high-prescribers. Provide better referral resources and peer support for recovery. Encourage DEA waivers to prescribe MAT and provide Naloxone (antidote) distribution and training.

Goal 3: Increase treatment availability for those addicted. Enhance linkages to jails, hospitals, and others to get people in crisis access to support and treatment, improve support for those in treatment and recovery, train recovery coaches, define hand-off protocols as people move through the system, and increase access and provide financial support for Medical Assisted Treatment (MAT).

The Future

In closing, Dr. Hahn noted that each state is affected differently by the opioid crisis, but all are seeing a growing epidemic, and we are working together to find solutions. There are no long-term proven solutions yet, but States are in for the long haul! She reminded that Forum that in 1965, 40% of US adults smoked cigarettes. It took 20 years of education to reduce that number in half.

A variety of approaches will be needed to stem the tide of opioid abuse; however, some changes must happen universally, she said. The public perception of pain medication must be changed to one of greater caution and concern. Patients should reject opioids as a first line of pain treatment. Providers must also change prescribing patterns, choosing alternatives for pain management.  Insurance reimbursement for non-opioid pain management approaches and for addiction treatments must be increased. Finally, implementing these changes will require public investment in the problem, Dr. Hahn concluded.

Sen. Brent Hill (ID) and Ralph Fernandez (Recording Industry Association of America) share a lighter moment between sessions. Close friendships develop during the Forum, which creates an intimate and friendly setting.

Discussion

Sen. David Long (IN): There are 3 facts Senate Presidents should be aware of:  1. More people died from drug overdoses in 2016 than in the Vietnam war.  2. Fentanyl is a synthetic opioid that is similar to morphine but is 50-100 times more potent than morphine, and carfentanil is 10,000 times more potent than morphine, 4,000 times more potent than heroin, and 1,000 times more potent than Fentanyl. 3. Mexico and China are sources of carfentanil.

Sen. Ginny Burdick (OR): Medical marijuana seems like a good alternative that could keep people from using opioids. Marijuana has no known lethal dose. There are also non-psychoactive marijuana formulations that could be used for pain relief. Because marijuana is a scheduled drug equivalent to heroin, it is difficult to get research done by federally funded hospitals and academic medical centers.  Meanwhile, the Attorney General is trying to block access even to medical marijuana.

Dr. Shiozawa: Several years ago, Sen. Orrin Hatch (UT) questioned why marijuana was a Schedule 1 drug (those with high abuse potential and no medical uses) and introduced a bill to change its designation, which failed. It is difficult to get research on marijuana because it requires a Federal approval. It is reasonable to change this. The change could be made by administrative fiat, by the DEA itself, or by legislative action.

Dr. Hahn: Epidiolex is a new cannabinoid product candidate and is a proprietary oral solution of pure plant-derived cannabidiol, or CBD. It has been submitted for a Schedule 2 approval from the FDA for use in treatment-resistant epilepsy and a response is expected in June 2018. Once it receives FDA approval, providers can prescribe it off-label for other conditions.

Sen. Eli Bebout (WY): Opioid abuse starts with a doctor prescribing an opioid, and often prescriptions are then renewed automatically by a physicians’ assistant without any medical review. Now States are limited the prescribing of opioids to 3-5 days. What can the States do about doctors who are out of control in opioid prescribing? What can we do to make pain management and opioid addiction treatment more effective?

Dr. Hahn: Limiting opioid prescriptions to 3-5 days is good for acute pain, but is too short for a chronic pain course of treatment. Chronic pain sufferers will have a high rate of recidivism. SAMHSA is providing funding to increase support services for opioid addicted people with programs similar to Alcohol Anonymous.

Dr. Shiozawa: We should educate Emergency Department doctors NOT to prescribe opioids for adolescents, whose executive functions are not fully developed. We should screen people to identify those who are susceptible and are most likely to become addicted. A number of factors suggest greater susceptibility to addiction: age, family history, history of previous use of drugs. The key is to educate the public NOT to ask for or accept opioids.

Sen. Eduardo Bhatia (PR): Noted that former Secretary of State George Schultz states in his 2013 book, Issues on My Mind: Strategies for the Future, “Unfortunately, the war on drugs that the United States has waged for decades has proved to be a losing battle.” What is the solution? Should the States legalize the drugs and then regulate them? Or find other alternatives?

Dr. Hahn: Opioids are legal when prescribed, but they are dangerous and I would not want to see any lessening of restrictions on them.

Sen. Frank Lombardo (RI): We should start education earlier on the risks associated with opioids.

Dr. Hahn: Education is absolutely critical. We have to change the public perception and awareness of opioid risks with children and parents. Emergency Departments (ED) should simply NOT prescribe opioids. They are not going to be able to follow the patient effectively, once they leave the ED.

Dr. Shiozawa: All the HHS agencies are focused on education. I will explore to see what educational resources are available from HHS. I suggest that every prescriber be required to discuss the risks and benefits of opioids with patients before prescribing.

Tom Finneran (Moderator): There’s been a decline in lifespan 2 years in a row in the US. Is this a worldwide phenomenon or is it restricted to the US?

Dr. Hahn: It is definitely a US trend. In a study of 30 countries, the US had the highest rate of self-reported pain (34%) compared with South Africa (8%). This trend in pain is uniquely American.

Dr. Shiozawa: In other countries, such as Japan, there is zero tolerance for drugs. We have to educate people to get to that understanding, we have to make changes.

Speaker Biography

Brian Shiozawa, MD

Dr. Brian E. Shiozawa was appointed by the President as Regional Director in Region 8 on December 2017. As Regional Director, he leads the Denver based office as the personal representative of the Secretary. Dr. Shiozawa ensures the Department maintains close contact with state, local, and tribal partners and addresses the needs of communities and individuals in Colorado, Montana, North Dakota, Utah and Wyoming.

Dr. Shiozawa is an Emergency Physician from Utah and has served two terms as a Utah State Senator, representing District 8. He was elected to office in 2012 and 2016.  While serving as State Senator, Dr. Shiozawa sponsored and passed over 50 bills covering a range of health care related issues, opioid overdose, assault, and technology. He served on the Governor's Task Force on Health Care Reform, Chairman of the Business, Economic Development and Labor Appropriations Committee, Social Services Appropriations, and on Health and Human Services Committee. Dr. Shiozawa is a Past President of the Utah Medical Association. He also served on the Board of Trustees for St. Mark’s Hospital, was President of Emergency Physicians Group, and President of the Utah Chapter of the American College of Emergency Physicians.

More than 500,000 persons died from opioid overdoses between 2000 and 2014.

The opioid epidemic cuts across every sector of society, raging across socioeconomic, gender, cultural, racial, and geographical lines, and endangering the nation’s entire social fabric.

In 2015, the White House put the cost of the opioid drug epidemic at $504 billion, or roughly half a trillion dollars.

...the potential societal benefit of eliminating the opioid crisis exceeds $95 billion per year.

Data from 2016 indicate that the opioid crisis cost insurers $21.4 billion, with Medicaid paying for the largest share at $8.7 billion, a significant impact on States’ budgets.

Opioid addiction treatment cannot be a stand-alone treatment but requires wrap-around services to be effective.

Dr. Shiozawa encouraged the Senators to have staff track the Funding Opportunity Announcements (FOA) at https://www.samhsa.gov/sites/default/files/grants/grant_announcements/fy2018-samhsa-forecast-final.pdf.

We need federal reform of all of our educational systems to include scientific facts about addiction, drugs and all substances of abuse. We need to prevent the harmful effects of such exposure through education and by identifying those at risk and interrupting the disease at its earliest stages.

Insurance companies can play an important role in reducing opioid prescriptions and making it easier for patients to access other forms of pain management treatment…Adopting an incentive structure that rewards the use of non-opioid pain management techniques for chronic, non-cancer pain will have many benefits.

Fentanyl is a synthetic opioid that is similar to morphine but is 50-100 times more potent than morphine, and carfentanil is 10,000 times more potent than morphine, 4,000 times more potent than heroin, and 1,000 times more potent than Fentanyl.

Sen. David Long (IN)

Sen. Ginny Burdick (OR)

Sen. Eli Bebout (WY)

Sen. Eduardo Bhatia (PR)

Sen. Frank Lombardo (RI)

Tom Finneran (Moderator)

Brian Shiozawa, MD

CONTACT

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Tel: 914-693-1818

Copyright © 2018 Senate Presidents' Forum. All rights reserved.

JANUARY 11–14, 2018

Costs of the Opioid Crisis

Brian Shiozawa, MD

Regional Director
Region 8
US Department of Health & Human Services

The Forum confronted the shocking statistics of the opioid crisis in the presentation by Brian Shiozawa, MD, whose role at HHS includes supporting the States in addressing this epidemic. About 90 people die from a drug overdose each day, and the rate of deaths associated with opioids has increased by 200% since 2000, with the highest number of deaths this year. More than 500,000 persons died from opioid overdoses between 2000 and 2014.

More than 500,000 persons died from opioid overdoses between 2000 and 2014.

Overdose deaths involving opioids, by type of opioid, United States, 2000–2016

The Demographics of Death

The opioid epidemic cuts across every sector of society, raging across socioeconomic, gender, cultural, racial, and geographical lines, and endangering the nation’s entire social fabric. Among those who died from prescription opioid overdose between 1999 and 2014, rates were highest among people aged 25 to 54 years and among non-Hispanic whites and American Indian or Alaskan Natives, compared to non-Hispanic blacks and Hispanics.

Overdose is not the only risk related to prescription opioids. Misuse, abuse, and opioid use disorder (addiction) are also potential dangers and add significant costs to the problem. In 2014, almost 2 million Americans abused or were dependent on prescription opioids. Every day, over 1,000 people are treated in emergency departments for misusing prescription opioids.

Costs of the Opioid Crisis

In 2015, the White House put the cost of the opioid drug epidemic at $504 billion, or roughly half a trillion dollars. Most of that was attributed to health care costs. In published data, opioid abusers were found to be 4 times as likely to visit the Emergency Department (ED), 11 times as likely to have had a mental health outpatient visit, and 12 times as likely to have had an inpatient hospital stay, compared to non-abusers.

In 2015, the White House put the cost of the opioid drug epidemic at $504 billion, or roughly half a trillion dollars.

Because of this, additional excess costs were incurred in criminal justice expenditures, child and family assistance, and additional education expenditures necessitated by the opioid crisis. According to data from the Altarum Institute, a non-profit healthcare research organization, using measures such as productivity losses due to fatalities, incarceration and non-fatal productivity losses, direct and indirect health care and estimated criminal justice, child welfare, and education impacts, the potential societal benefit of eliminating the opioid crisis exceeds $95 billion per year.

...the potential societal benefit of eliminating the opioid crisis exceeds $95 billion per year.

Who Pays the Price of Opioid Abuse?

Data from 2016 indicate that the opioid crisis cost insurers $21.4 billion, with Medicaid paying for the largest share at $8.7 billion, a significant impact on States’ budgets. The epidemic cost Medicare an estimated $6.4 billion and private payers and the uninsured a combined $6.3 billion.

Data from 2016 indicate that the opioid crisis cost insurers $21.4 billion, with Medicaid paying for the largest share at $8.7 billion, a significant impact on States’ budgets.

Dr. Shiozawa pointed out that Medicaid costs for treating HepC, a frequent comorbidity with opioid abuse, can range from $50,000 to $80,000 per year per patient, and only cures the acute infection, without conferring immunity. So abusers may experience repeated HepC infections. Clean-needle programs are important but, to be effective, must be coupled with education and support services that add to the costs, he reminded the Forum.

The remaining costs of the opioid epidemic were for criminal justice and education expenditures and child and family assistance spending. Many 2016 cases of child neglect were associated with parents with opioid addiction. Child and family assistance spending related to the epidemic was about $6.1 billion in 2016, again hitting the States’ budgets. “Who is raising the children when parents are addicted to opioids,” Dr. Shiozawa asked.

Distribution of spending (in billions) on SUD treatment by payment source (2014)

HHS Opioid Strategy

Dr. Shiozawa is one of 10 HHS Regional Directors, who are charged to ensure that the Department maintains close contact with State, local, and tribal partners and addresses the needs of communities and individuals served through HHS programs and policies. He urged the Senators to advise and partner with their Regional Directors and access resources through them.

He reported that addressing the opioid crisis is 1 of 4 major initiatives undertaken by HHS.  The HHS opioid strategy is comprehensive and evidence-based. It targets the drivers of the epidemic and remains flexible so that it is adaptable to changing realities, Dr. Shiozawa said. The strategy includes improving access to prevention, treatment, and recovery services, and broad distribution of overdose-reversing drugs, strengthening timely public health data and reporting, and supporting cutting-edge research on addiction treatment and on the practice of pain management.

The goals of the program are to empower the public, patients and providers through education and awareness, prevent opioid abuse and overdose and related health consequences, improve function and quality of life for individuals living with pain, ensure that patients who need opioid addiction treatment have access to it, and support people to achieve long-term recovery.

HHS opioid strategy

How is Opioid Addiction Treated?

Dr. Shiozawa pointed out that prescription opioid pain medications and heroin are all opioids and their treatments are the same, involving clinical care, medication, psychosocial interventions, and social supports. Comprehensive, multi-pronged treatment programs are critical to success, he said, noting that the burden falls on the States as Medicaid from the States’ coffers must cover many costs of people with opioid addiction, who may end up in jails or in residential treatment.

Clinical strategies to break opioid addiction involve a combination of FDA-approved medications (Medication Assisted Treatment (MAT)) for as long as the person benefits from the care. Such medications include naltrexone, which blocks effects of opioids and is a life-saving drug now in the hands of most emergency services and, in some states, available from a pharmacist. Medications that are alternatives to opioids include methadone, a long-acting, once-daily, opioid from specially licensed programs, and buprenorphine/naloxone: a long-acting, once-daily, opioid from doctor’s offices that is available by prescription.

Unfortunately, 80% of those who go through medical withdrawal or detoxification relapse in the year following treatment and are at high risk for overdose and death when relapse occurs. Opioid addiction treatment cannot be a stand-alone treatment but requires wrap-around services to be effective, such as psychosocial therapies/treatment, counseling for coping skills and relapse prevention, as well as education about issues related to substance use.

Opioid addiction treatment cannot be a stand-alone treatment but requires wrap-around services to be effective.

Where Can States Obtain Funding for Opioid Crisis Interventions?

Dr. Shiozawa presented a long list of government agencies that are funding efforts to address the opioid crisis, including SAMHSA, CDC, FDA, CMS, NIH, HRSA, and others.

Combating the opioid crisis: SAMHSA state targeted response to the opioid crisis grants (FY 17, $485M)

 

Dr. Shiozawa encouraged the Senators to have staff track the Funding Opportunity Announcements (FOA) at https://www.samhsa.gov/sites/default/files/grants/grant_announcements/fy2018-samhsa-forecast-final.pdf.

The Health Resources and Services Administration (HRSA), for example, awarded more than $200 million to 1,178 health centers and 13 rural health organizations in every US state to increase access to substance abuse and mental health services to fight the opioid crisis. Additionally, 496 of the health centers that receive Access Increases in Mental Health and Substance Abuse Services (AIMS) awards are located in rural communities, where the opioid epidemic is rampant. Nearly $3.3 million supports 13 rural health organizations to increase access to treatment and recovery services for opioid abuse under the Rural Health Opioid Program (RHOP) and the Substance Abuse Treatment Telehealth Network Grant Program (SAT -TNGP).

Signs of Progress

Dr. Shiozawa said there are signs of hope. Youth prescription opioid misuse has been declining over past decade, and heroin use is stable among youth. Awareness of the potential for abuse of these drugs among prescribers has reduced opioid prescribing. Prescription opioid misuse initiation and overall misuse has declined and overdose deaths involving commonly prescribed opioids are down. The number of people getting Medication-Assisted Treatment (MAT) is increasing, and there is an exponential increase in pharmacy dispensing of naloxone, Dr. Shiozawa concluded.

JANUARY 11–14, 2018

Costs of the Opioid Crisis

Christine Hahn, MD

Medical Director
Idaho Division of Public Health

Life expectancy in the US declined again this year, driven by opioid deaths, Dr. Christine Hahn told the Forum. The epidemic spurred President Trump to declare a national public health emergency, and federal, state, academic, and private organizations have developed crisis intervention resources. State Health Directors have come together to share access to information and resources, and to share evidence-based best practices that address the crisis, Dr. Hahn reported. Her presentation reviewed opportunities and finding from these resources.

Help from Federal Agencies

Center for Disease Control and Prevention

Dr. Hahn described the CDC’s Data-Driven Prevention Initiative (DDPI), which focuses on statewide planning with wide group of stakeholders, improving data collection and analysis through increased use of Prescription Drug Monitoring Program databases (PDMP), and prescriber and patient education and awareness.

Data-driven prevention initiative (DDPI): funded states

The Substance Abuse and Mental Health Services Administration

SAMHSA plays a critical role in fighting the opioid crisis, Dr. Hahn said, reporting on the agency’s grant-funding activities for state-targeted responses to the opioid epidemic. Grants have been allocated to help pay for medication-assisted treatment (methadone and buprenorphine); to fund data collection and send prescriber “report cards” on their opioid prescribing patterns; to forge links with agencies that see persons in crisis, such as jails and hospitals, in order to get them needed care and recovery support; and to increase access to naloxone (opioid overdose antidote) for first responders.

President’s Commission on Combatting Drug Addiction and the Opioid Crisis

A November, 2017 report from the President’s Commission made recommendations in 4 key areas: 1. Federal Funding and Programs, 2. Opioid Addiction Prevention, 3. Opioid Addiction Treatment, Overdose Reversal, and Recovery, 4. Research and Development. The programs would be funded by block grants to the States.

The US Congress

In November, 2017, the US Senate Health, Education, Labor, and Pensions Committee held a hearing focused on “The Front Lines of the Opioid Crisis: Perspectives from States, Communities, and Providers.” Dr. Omar Abubaker, Professor, Virginia Commonwealth School of Dentistry told the Congress: “We need federal reform of all of our educational systems to include scientific facts about addiction, drugs and all substances of abuse. We need to prevent the harmful effects of such exposure through education and by identifying those at risk and interrupting the disease at its earliest stages. We are also looking to you to allocate funds in the Comprehensive Addiction and Recovery Act and in the 21st Century Act coverage, not only for treatment of all forms of addiction and its underlying mental illness, but also to extend coverage for screening of those at risk for addiction, brief interventions and referral for treatment (SBIRT) of those affected.”

We need federal reform of all of our educational systems to include scientific facts about addiction, drugs and all substances of abuse. We need to prevent the harmful effects of such exposure through education and by identifying those at risk and interrupting the disease at its earliest stages.

Following up in December, Senate Health Committee Chairman Lamar Alexander (R-TN) and Ranking Member Patty Murray (D-WA) sent letters to every Governor and State insurance commissioner in the nation. They asked for specific recommendations on how the federal government can be the most effective partner for states in the battle against the opioid crisis.

Help from the Private Sector

The information is categorized into 8 topics and includes a variety of resources, national and state guidelines, training, simulations, and case examples. The topics include:

1. Clinician education on prescribing practices

2. Non-opioid pain management

3. Addressing stigma

4. Treatment options for opioid use disorders

5. Patient, family and caregiver education

6. Transitions of care

7. Safeguarding against diversion

8. Collaborating with communities

Actions by the States

Dr. Hahn reported that 6 States (Massachusetts, Virginia, Alaska, Maryland, Florida, and Arizona) have issued Emergency Declarations to create Task Forces and Emergency Response Systems focused on opioid addiction.  Many States have tightened up prescribing laws and some, like Idaho, have allowed pharmacists to prescribe naloxone.

As reported in The New England Journal of Medicine, several States’ Attorneys General have filed high-profile lawsuits against companies that manufacture and/or market opioids, including West Virginia, Oregon, Kentucky, California, Illinois, and Massachusetts, alleging aggressive marketing and other violations. While companies did not admit any fault, settlements ranged up to $24 million.

The National Association of Attorneys General also issued a letter to America’s Health Insurance Plans, the insurance trade association, advocating: “Insurance companies can play an important role in reducing opioid prescriptions and making it easier for patients to access other forms of pain management treatment. Adopting an incentive structure that rewards the use of non-opioid pain management techniques for chronic, non-cancer pain will have many benefits.”

Insurance companies can play an important role in reducing opioid prescriptions and making it easier for patients to access other forms of pain management treatment…Adopting an incentive structure that rewards the use of non-opioid pain management techniques for chronic, non-cancer pain will have many benefits.

The View from Idaho

Idaho has taken an active role in combatting the opioid crisis, Dr. Hahn said, implementing programs focused on three goals.

Goal 1. Reduce exposure to opioids. Educate patients and prescribers to look for non-opioid alternatives for pain management, and encourage the CDC to issue new guidelines for treatment of chronic pain. Work with insurers and Medicaid to increase covered alternatives. Get better data to inform response by requiring participation in Prescription Drug Monitoring Programs (PDMP) and use the data to identify areas of state with large number of high-level prescribers and heavy opioid users. Increase drug take-back programs.

Goal 2: Decrease overdose deaths among patients using opioids. Educate patients and prescribers about safe opioid use, keep patients from overdosing, and wean them from opioids safely. Issue provider report cards to identify and track high-prescribers. Provide better referral resources and peer support for recovery. Encourage DEA waivers to prescribe MAT and provide Naloxone (antidote) distribution and training.

Goal 3: Increase treatment availability for those addicted. Enhance linkages to jails, hospitals, and others to get people in crisis access to support and treatment, improve support for those in treatment and recovery, train recovery coaches, define hand-off protocols as people move through the system, and increase access and provide financial support for Medical Assisted Treatment (MAT).

The Future

In closing, Dr. Hahn noted that each state is affected differently by the opioid crisis, but all are seeing a growing epidemic, and we are working together to find solutions. There are no long-term proven solutions yet, but States are in for the long haul! She reminded that Forum that in 1965, 40% of US adults smoked cigarettes. It took 20 years of education to reduce that number in half.

A variety of approaches will be needed to stem the tide of opioid abuse; however, some changes must happen universally, she said. The public perception of pain medication must be changed to one of greater caution and concern. Patients should reject opioids as a first line of pain treatment. Providers must also change prescribing patterns, choosing alternatives for pain management.  Insurance reimbursement for non-opioid pain management approaches and for addiction treatments must be increased. Finally, implementing these changes will require public investment in the problem, Dr. Hahn concluded.

Sen. Brent Hill (ID) and Ralph Fernandez (Recording Industry Association of America) share a lighter moment between sessions. Close friendships develop during the Forum, which creates an intimate and friendly setting.

Discussion

Sen. David Long (IN): There are 3 facts Senate Presidents should be aware of:  1. More people died from drug overdoses in 2016 than in the Vietnam war.  2. Fentanyl is a synthetic opioid that is similar to morphine but is 50-100 times more potent than morphine, and carfentanil is 10,000 times more potent than morphine, 4,000 times more potent than heroin, and 1,000 times more potent than Fentanyl. 3. Mexico and China are sources of carfentanil.

Fentanyl is a synthetic opioid that is similar to morphine but is 50-100 times more potent than morphine, and carfentanil is 10,000 times more potent than morphine, 4,000 times more potent than heroin, and 1,000 times more potent than Fentanyl.

Sen. Ginny Burdick (OR): Medical marijuana seems like a good alternative that could keep people from using opioids. Marijuana has no known lethal dose. There are also non-psychoactive marijuana formulations that could be used for pain relief. Because marijuana is a scheduled drug equivalent to heroin, it is difficult to get research done by federally funded hospitals and academic medical centers.  Meanwhile, the Attorney General is trying to block access even to medical marijuana.

Dr. Shiozawa: Several years ago, Sen. Orrin Hatch (UT) questioned why marijuana was a Schedule 1 drug (those with high abuse potential and no medical uses) and introduced a bill to change its designation, which failed. It is difficult to get research on marijuana because it requires a Federal approval. It is reasonable to change this. The change could be made by administrative fiat, by the DEA itself, or by legislative action.

Dr. Hahn: Epidiolex is a new cannabinoid product candidate and is a proprietary oral solution of pure plant-derived cannabidiol, or CBD. It has been submitted for a Schedule 2 approval from the FDA for use in treatment-resistant epilepsy and a response is expected in June 2018. Once it receives FDA approval, providers can prescribe it off-label for other conditions.

Sen. Eli Bebout (WY): Opioid abuse starts with a doctor prescribing an opioid, and often prescriptions are then renewed automatically by a physicians’ assistant without any medical review. Now States are limited the prescribing of opioids to 3-5 days. What can the States do about doctors who are out of control in opioid prescribing? What can we do to make pain management and opioid addiction treatment more effective?

Dr. Hahn: Limiting opioid prescriptions to 3-5 days is good for acute pain, but is too short for a chronic pain course of treatment. Chronic pain sufferers will have a high rate of recidivism. SAMHSA is providing funding to increase support services for opioid addicted people with programs similar to Alcohol Anonymous.

Dr. Shiozawa: We should educate Emergency Department doctors NOT to prescribe opioids for adolescents, whose executive functions are not fully developed. We should screen people to identify those who are susceptible and are most likely to become addicted. A number of factors suggest greater susceptibility to addiction: age, family history, history of previous use of drugs. The key is to educate the public NOT to ask for or accept opioids.

Sen. Eduardo Bhatia (PR): Noted that former Secretary of State George Schultz states in his 2013 book, Issues on My Mind: Strategies for the Future, “Unfortunately, the war on drugs that the United States has waged for decades has proved to be a losing battle.” What is the solution? Should the States legalize the drugs and then regulate them? Or find other alternatives?

Dr. Hahn: Opioids are legal when prescribed, but they are dangerous and I would not want to see any lessening of restrictions on them.

Sen. Frank Lombardo (RI): We should start education earlier on the risks associated with opioids.

Dr. Hahn: Education is absolutely critical. We have to change the public perception and awareness of opioid risks with children and parents. Emergency Departments (ED) should simply NOT prescribe opioids. They are not going to be able to follow the patient effectively, once they leave the ED.

Dr. Shiozawa: All the HHS agencies are focused on education. I will explore to see what educational resources are available from HHS. I suggest that every prescriber be required to discuss the risks and benefits of opioids with patients before prescribing.

Tom Finneran (Moderator): There’s been a decline in lifespan 2 years in a row in the US. Is this a worldwide phenomenon or is it restricted to the US?

Dr. Hahn: It is definitely a US trend. In a study of 30 countries, the US had the highest rate of self-reported pain (34%) compared with South Africa (8%). This trend in pain is uniquely American.

Dr. Shiozawa: In other countries, such as Japan, there is zero tolerance for drugs. We have to educate people to get to that understanding, we have to make changes.

Speaker Biography

Brian Shiozawa, MD

Dr. Brian E. Shiozawa was appointed by the President as Regional Director in Region 8 on December 2017. As Regional Director, he leads the Denver based office as the personal representative of the Secretary. Dr. Shiozawa ensures the Department maintains close contact with state, local, and tribal partners and addresses the needs of communities and individuals in Colorado, Montana, North Dakota, Utah and Wyoming.

Dr. Shiozawa is an Emergency Physician from Utah and has served two terms as a Utah State Senator, representing District 8. He was elected to office in 2012 and 2016.  While serving as State Senator, Dr. Shiozawa sponsored and passed over 50 bills covering a range of health care related issues, opioid overdose, assault, and technology. He served on the Governor's Task Force on Health Care Reform, Chairman of the Business, Economic Development and Labor Appropriations Committee, Social Services Appropriations, and on Health and Human Services Committee. Dr. Shiozawa is a Past President of the Utah Medical Association. He also served on the Board of Trustees for St. Mark’s Hospital, was President of Emergency Physicians Group, and President of the Utah Chapter of the American College of Emergency Physicians.

JANUARY 11–14, 2018

Costs of the Opioid Crisis

Brian Shiozawa, MD

Regional Director
Region 8
US Department of Health & Human Services

The Forum confronted the shocking statistics of the opioid crisis in the presentation by Brian Shiozawa, MD, whose role at HHS includes supporting the States in addressing this epidemic. About 90 people die from a drug overdose each day, and the rate of deaths associated with opioids has increased by 200% since 2000, with the highest number of deaths this year. More than 500,000 persons died from opioid overdoses between 2000 and 2014.

More than 500,000 persons died from opioid overdoses between 2000 and 2014.

Overdose deaths involving opioids, by type of opioid, United States, 2000–2016

The Demographics of Death

The opioid epidemic cuts across every sector of society, raging across socioeconomic, gender, cultural, racial, and geographical lines, and endangering the nation’s entire social fabric. Among those who died from prescription opioid overdose between 1999 and 2014, rates were highest among people aged 25 to 54 years and among non-Hispanic whites and American Indian or Alaskan Natives, compared to non-Hispanic blacks and Hispanics.

Overdose is not the only risk related to prescription opioids. Misuse, abuse, and opioid use disorder (addiction) are also potential dangers and add significant costs to the problem. In 2014, almost 2 million Americans abused or were dependent on prescription opioids. Every day, over 1,000 people are treated in emergency departments for misusing prescription opioids.

Costs of the Opioid Crisis

In 2015, the White House put the cost of the opioid drug epidemic at $504 billion, or roughly half a trillion dollars. Most of that was attributed to health care costs. In published data, opioid abusers were found to be 4 times as likely to visit the Emergency Department (ED), 11 times as likely to have had a mental health outpatient visit, and 12 times as likely to have had an inpatient hospital stay, compared to non-abusers.

In 2015, the White House put the cost of the opioid drug epidemic at $504 billion, or roughly half a trillion dollars.

Because of this, additional excess costs were incurred in criminal justice expenditures, child and family assistance, and additional education expenditures necessitated by the opioid crisis. According to data from the Altarum Institute, a non-profit healthcare research organization, using measures such as productivity losses due to fatalities, incarceration and non-fatal productivity losses, direct and indirect health care and estimated criminal justice, child welfare, and education impacts, the potential societal benefit of eliminating the opioid crisis exceeds $95 billion per year.

...the potential societal benefit of eliminating the opioid crisis exceeds $95 billion per year.

Who Pays the Price of Opioid Abuse?

Data from 2016 indicate that the opioid crisis cost insurers $21.4 billion, with Medicaid paying for the largest share at $8.7 billion, a significant impact on States’ budgets. The epidemic cost Medicare an estimated $6.4 billion and private payers and the uninsured a combined $6.3 billion.

Data from 2016 indicate that the opioid crisis cost insurers $21.4 billion, with Medicaid paying for the largest share at $8.7 billion, a significant impact on States’ budgets.

Dr. Shiozawa pointed out that Medicaid costs for treating HepC, a frequent comorbidity with opioid abuse, can range from $50,000 to $80,000 per year per patient, and only cures the acute infection, without conferring immunity. So abusers may experience repeated HepC infections. Clean-needle programs are important but, to be effective, must be coupled with education and support services that add to the costs, he reminded the Forum.

The remaining costs of the opioid epidemic were for criminal justice and education expenditures and child and family assistance spending. Many 2016 cases of child neglect were associated with parents with opioid addiction. Child and family assistance spending related to the epidemic was about $6.1 billion in 2016, again hitting the States’ budgets. “Who is raising the children when parents are addicted to opioids,” Dr. Shiozawa asked.

Distribution of spending (in billions) on SUD treatment by payment source (2014)

HHS Opioid Strategy

Dr. Shiozawa is one of 10 HHS Regional Directors, who are charged to ensure that the Department maintains close contact with State, local, and tribal partners and addresses the needs of communities and individuals served through HHS programs and policies. He urged the Senators to advise and partner with their Regional Directors and access resources through them.

He reported that addressing the opioid crisis is 1 of 4 major initiatives undertaken by HHS.  The HHS opioid strategy is comprehensive and evidence-based. It targets the drivers of the epidemic and remains flexible so that it is adaptable to changing realities, Dr. Shiozawa said. The strategy includes improving access to prevention, treatment, and recovery services, and broad distribution of overdose-reversing drugs, strengthening timely public health data and reporting, and supporting cutting-edge research on addiction treatment and on the practice of pain management.

The goals of the program are to empower the public, patients and providers through education and awareness, prevent opioid abuse and overdose and related health consequences, improve function and quality of life for individuals living with pain, ensure that patients who need opioid addiction treatment have access to it, and support people to achieve long-term recovery.

HHS opioid strategy

How is Opioid Addiction Treated?

Dr. Shiozawa pointed out that prescription opioid pain medications and heroin are all opioids and their treatments are the same, involving clinical care, medication, psychosocial interventions, and social supports. Comprehensive, multi-pronged treatment programs are critical to success, he said, noting that the burden falls on the States as Medicaid from the States’ coffers must cover many costs of people with opioid addiction, who may end up in jails or in residential treatment.

Clinical strategies to break opioid addiction involve a combination of FDA-approved medications (Medication Assisted Treatment (MAT)) for as long as the person benefits from the care. Such medications include naltrexone, which blocks effects of opioids and is a life-saving drug now in the hands of most emergency services and, in some states, available from a pharmacist. Medications that are alternatives to opioids include methadone, a long-acting, once-daily, opioid from specially licensed programs, and buprenorphine/naloxone: a long-acting, once-daily, opioid from doctor’s offices that is available by prescription.

Unfortunately, 80% of those who go through medical withdrawal or detoxification relapse in the year following treatment and are at high risk for overdose and death when relapse occurs. Opioid addiction treatment cannot be a stand-alone treatment but requires wrap-around services to be effective, such as psychosocial therapies/treatment, counseling for coping skills and relapse prevention, as well as education about issues related to substance use.

Opioid addiction treatment cannot be a stand-alone treatment but requires wrap-around services to be effective.

Where Can States Obtain Funding for Opioid Crisis Interventions?

Dr. Shiozawa presented a long list of government agencies that are funding efforts to address the opioid crisis, including SAMHSA, CDC, FDA, CMS, NIH, HRSA, and others.

Combating the opioid crisis: SAMHSA state targeted response to the opioid crisis grants (FY 17, $485M)

 

The Health Resources and Services Administration (HRSA), for example, awarded more than $200 million to 1,178 health centers and 13 rural health organizations in every US state to increase access to substance abuse and mental health services to fight the opioid crisis. Additionally, 496 of the health centers that receive Access Increases in Mental Health and Substance Abuse Services (AIMS) awards are located in rural communities, where the opioid epidemic is rampant. Nearly $3.3 million supports 13 rural health organizations to increase access to treatment and recovery services for opioid abuse under the Rural Health Opioid Program (RHOP) and the Substance Abuse Treatment Telehealth Network Grant Program (SAT -TNGP).

Signs of Progress

Dr. Shiozawa said there are signs of hope. Youth prescription opioid misuse has been declining over past decade, and heroin use is stable among youth. Awareness of the potential for abuse of these drugs among prescribers has reduced opioid prescribing. Prescription opioid misuse initiation and overall misuse has declined and overdose deaths involving commonly prescribed opioids are down. The number of people getting Medication-Assisted Treatment (MAT) is increasing, and there is an exponential increase in pharmacy dispensing of naloxone, Dr. Shiozawa concluded.

JANUARY 11–14, 2018

Costs of the Opioid Crisis

Christine Hahn, MD

Medical Director
Idaho Division of Public Health

Life expectancy in the US declined again this year, driven by opioid deaths, Dr. Christine Hahn told the Forum. The epidemic spurred President Trump to declare a national public health emergency, and federal, state, academic, and private organizations have developed crisis intervention resources. State Health Directors have come together to share access to information and resources, and to share evidence-based best practices that address the crisis, Dr. Hahn reported. Her presentation reviewed opportunities and finding from these resources.

Help from Federal Agencies

Center for Disease Control and Prevention

Dr. Hahn described the CDC’s Data-Driven Prevention Initiative (DDPI), which focuses on statewide planning with wide group of stakeholders, improving data collection and analysis through increased use of Prescription Drug Monitoring Program databases (PDMP), and prescriber and patient education and awareness.

Data-driven prevention initiative (DDPI): funded states

The Substance Abuse and Mental Health Services Administration

SAMHSA plays a critical role in fighting the opioid crisis, Dr. Hahn said, reporting on the agency’s grant-funding activities for state-targeted responses to the opioid epidemic. Grants have been allocated to help pay for medication-assisted treatment (methadone and buprenorphine); to fund data collection and send prescriber “report cards” on their opioid prescribing patterns; to forge links with agencies that see persons in crisis, such as jails and hospitals, in order to get them needed care and recovery support; and to increase access to naloxone (opioid overdose antidote) for first responders.

President’s Commission on Combatting Drug Addiction and the Opioid Crisis

A November, 2017 report from the President’s Commission made recommendations in 4 key areas: 1. Federal Funding and Programs, 2. Opioid Addiction Prevention, 3. Opioid Addiction Treatment, Overdose Reversal, and Recovery, 4. Research and Development. The programs would be funded by block grants to the States.

The US Congress

In November, 2017, the US Senate Health, Education, Labor, and Pensions Committee held a hearing focused on “The Front Lines of the Opioid Crisis: Perspectives from States, Communities, and Providers.” Dr. Omar Abubaker, Professor, Virginia Commonwealth School of Dentistry told the Congress: “We need federal reform of all of our educational systems to include scientific facts about addiction, drugs and all substances of abuse. We need to prevent the harmful effects of such exposure through education and by identifying those at risk and interrupting the disease at its earliest stages. We are also looking to you to allocate funds in the Comprehensive Addiction and Recovery Act and in the 21st Century Act coverage, not only for treatment of all forms of addiction and its underlying mental illness, but also to extend coverage for screening of those at risk for addiction, brief interventions and referral for treatment (SBIRT) of those affected.”

We need federal reform of all of our educational systems to include scientific facts about addiction, drugs and all substances of abuse. We need to prevent the harmful effects of such exposure through education and by identifying those at risk and interrupting the disease at its earliest stages.

Following up in December, Senate Health Committee Chairman Lamar Alexander (R-TN) and Ranking Member Patty Murray (D-WA) sent letters to every Governor and State insurance commissioner in the nation. They asked for specific recommendations on how the federal government can be the most effective partner for states in the battle against the opioid crisis.

Help from the Private Sector

The information is categorized into 8 topics and includes a variety of resources, national and state guidelines, training, simulations, and case examples. The topics include:

1. Clinician education on prescribing practices

2. Non-opioid pain management

3. Addressing stigma

4. Treatment options for opioid use disorders

5. Patient, family and caregiver education

6. Transitions of care

7. Safeguarding against diversion

8. Collaborating with communities

Actions by the States

Dr. Hahn reported that 6 States (Massachusetts, Virginia, Alaska, Maryland, Florida, and Arizona) have issued Emergency Declarations to create Task Forces and Emergency Response Systems focused on opioid addiction.  Many States have tightened up prescribing laws and some, like Idaho, have allowed pharmacists to prescribe naloxone.

As reported in The New England Journal of Medicine, several States’ Attorneys General have filed high-profile lawsuits against companies that manufacture and/or market opioids, including West Virginia, Oregon, Kentucky, California, Illinois, and Massachusetts, alleging aggressive marketing and other violations. While companies did not admit any fault, settlements ranged up to $24 million.

The National Association of Attorneys General also issued a letter to America’s Health Insurance Plans, the insurance trade association, advocating: “Insurance companies can play an important role in reducing opioid prescriptions and making it easier for patients to access other forms of pain management treatment. Adopting an incentive structure that rewards the use of non-opioid pain management techniques for chronic, non-cancer pain will have many benefits.”

Insurance companies can play an important role in reducing opioid prescriptions and making it easier for patients to access other forms of pain management treatment…Adopting an incentive structure that rewards the use of non-opioid pain management techniques for chronic, non-cancer pain will have many benefits.

The View from Idaho

Idaho has taken an active role in combatting the opioid crisis, Dr. Hahn said, implementing programs focused on three goals.

Goal 1. Reduce exposure to opioids. Educate patients and prescribers to look for non-opioid alternatives for pain management, and encourage the CDC to issue new guidelines for treatment of chronic pain. Work with insurers and Medicaid to increase covered alternatives. Get better data to inform response by requiring participation in Prescription Drug Monitoring Programs (PDMP) and use the data to identify areas of state with large number of high-level prescribers and heavy opioid users. Increase drug take-back programs.

Goal 2: Decrease overdose deaths among patients using opioids. Educate patients and prescribers about safe opioid use, keep patients from overdosing, and wean them from opioids safely. Issue provider report cards to identify and track high-prescribers. Provide better referral resources and peer support for recovery. Encourage DEA waivers to prescribe MAT and provide Naloxone (antidote) distribution and training.

Goal 3: Increase treatment availability for those addicted. Enhance linkages to jails, hospitals, and others to get people in crisis access to support and treatment, improve support for those in treatment and recovery, train recovery coaches, define hand-off protocols as people move through the system, and increase access and provide financial support for Medical Assisted Treatment (MAT).

The Future

In closing, Dr. Hahn noted that each state is affected differently by the opioid crisis, but all are seeing a growing epidemic, and we are working together to find solutions. There are no long-term proven solutions yet, but States are in for the long haul! She reminded that Forum that in 1965, 40% of US adults smoked cigarettes. It took 20 years of education to reduce that number in half.

A variety of approaches will be needed to stem the tide of opioid abuse; however, some changes must happen universally, she said. The public perception of pain medication must be changed to one of greater caution and concern. Patients should reject opioids as a first line of pain treatment. Providers must also change prescribing patterns, choosing alternatives for pain management.  Insurance reimbursement for non-opioid pain management approaches and for addiction treatments must be increased. Finally, implementing these changes will require public investment in the problem, Dr. Hahn concluded.

Sen. Brent Hill (ID) and Ralph Fernandez (Recording Industry Association of America) share a lighter moment between sessions. Close friendships develop during the Forum, which creates an intimate and friendly setting.

Discussion

Sen. David Long (IN): There are 3 facts Senate Presidents should be aware of:  1. More people died from drug overdoses in 2016 than in the Vietnam war.  2. Fentanyl is a synthetic opioid that is similar to morphine but is 50-100 times more potent than morphine, and carfentanil is 10,000 times more potent than morphine, 4,000 times more potent than heroin, and 1,000 times more potent than Fentanyl. 3. Mexico and China are sources of carfentanil.

Fentanyl is a synthetic opioid that is similar to morphine but is 50-100 times more potent than morphine, and carfentanil is 10,000 times more potent than morphine, 4,000 times more potent than heroin, and 1,000 times more potent than Fentanyl.

Sen. Ginny Burdick (OR): Medical marijuana seems like a good alternative that could keep people from using opioids. Marijuana has no known lethal dose. There are also non-psychoactive marijuana formulations that could be used for pain relief. Because marijuana is a scheduled drug equivalent to heroin, it is difficult to get research done by federally funded hospitals and academic medical centers.  Meanwhile, the Attorney General is trying to block access even to medical marijuana.

Dr. Shiozawa: Several years ago, Sen. Orrin Hatch (UT) questioned why marijuana was a Schedule 1 drug (those with high abuse potential and no medical uses) and introduced a bill to change its designation, which failed. It is difficult to get research on marijuana because it requires a Federal approval. It is reasonable to change this. The change could be made by administrative fiat, by the DEA itself, or by legislative action.

Dr. Hahn: Epidiolex is a new cannabinoid product candidate and is a proprietary oral solution of pure plant-derived cannabidiol, or CBD. It has been submitted for a Schedule 2 approval from the FDA for use in treatment-resistant epilepsy and a response is expected in June 2018. Once it receives FDA approval, providers can prescribe it off-label for other conditions.

Sen. Eli Bebout (WY): Opioid abuse starts with a doctor prescribing an opioid, and often prescriptions are then renewed automatically by a physicians’ assistant without any medical review. Now States are limited the prescribing of opioids to 3-5 days. What can the States do about doctors who are out of control in opioid prescribing? What can we do to make pain management and opioid addiction treatment more effective?

Dr. Hahn: Limiting opioid prescriptions to 3-5 days is good for acute pain, but is too short for a chronic pain course of treatment. Chronic pain sufferers will have a high rate of recidivism. SAMHSA is providing funding to increase support services for opioid addicted people with programs similar to Alcohol Anonymous.

Dr. Shiozawa: We should educate Emergency Department doctors NOT to prescribe opioids for adolescents, whose executive functions are not fully developed. We should screen people to identify those who are susceptible and are most likely to become addicted. A number of factors suggest greater susceptibility to addiction: age, family history, history of previous use of drugs. The key is to educate the public NOT to ask for or accept opioids.

Sen. Eduardo Bhatia (PR): Noted that former Secretary of State George Schultz states in his 2013 book, Issues on My Mind: Strategies for the Future, “Unfortunately, the war on drugs that the United States has waged for decades has proved to be a losing battle.” What is the solution? Should the States legalize the drugs and then regulate them? Or find other alternatives?

Dr. Hahn: Opioids are legal when prescribed, but they are dangerous and I would not want to see any lessening of restrictions on them.

Sen. Frank Lombardo (RI): We should start education earlier on the risks associated with opioids.

Dr. Hahn: Education is absolutely critical. We have to change the public perception and awareness of opioid risks with children and parents. Emergency Departments (ED) should simply NOT prescribe opioids. They are not going to be able to follow the patient effectively, once they leave the ED.

Dr. Shiozawa: All the HHS agencies are focused on education. I will explore to see what educational resources are available from HHS. I suggest that every prescriber be required to discuss the risks and benefits of opioids with patients before prescribing.

Tom Finneran (Moderator): There’s been a decline in lifespan 2 years in a row in the US. Is this a worldwide phenomenon or is it restricted to the US?

Dr. Hahn: It is definitely a US trend. In a study of 30 countries, the US had the highest rate of self-reported pain (34%) compared with South Africa (8%). This trend in pain is uniquely American.

Dr. Shiozawa: In other countries, such as Japan, there is zero tolerance for drugs. We have to educate people to get to that understanding, we have to make changes.

Speaker Biography

Brian Shiozawa, MD

Dr. Brian E. Shiozawa was appointed by the President as Regional Director in Region 8 on December 2017. As Regional Director, he leads the Denver based office as the personal representative of the Secretary. Dr. Shiozawa ensures the Department maintains close contact with state, local, and tribal partners and addresses the needs of communities and individuals in Colorado, Montana, North Dakota, Utah and Wyoming.

Dr. Shiozawa is an Emergency Physician from Utah and has served two terms as a Utah State Senator, representing District 8. He was elected to office in 2012 and 2016.  While serving as State Senator, Dr. Shiozawa sponsored and passed over 50 bills covering a range of health care related issues, opioid overdose, assault, and technology. He served on the Governor's Task Force on Health Care Reform, Chairman of the Business, Economic Development and Labor Appropriations Committee, Social Services Appropriations, and on Health and Human Services Committee. Dr. Shiozawa is a Past President of the Utah Medical Association. He also served on the Board of Trustees for St. Mark’s Hospital, was President of Emergency Physicians Group, and President of the Utah Chapter of the American College of Emergency Physicians.