Opioid crisis update from the field

This week’s 2017 National Meeting of the American Public Health Association in Atlanta, Georgia, featured almost a dozen sessions on today’s opioid crisis in the United States. My commentary today seeks to provide an overview of where we currently stand in our national efforts to address this profound tragedy.

Status of the Crisis. Each day, 100 Americans die from an opioid overdose. Some are as young as 10 years old; some are senior citizens; almost every community has experienced this tragedy.  Looked at nationally, about 2.5 million persons misuse, are dependent upon, or are addicted to opioids. Some use opioids illicitly; others use prescription opioids for pain relief. About 1 in 4 persons who are on long-term opioid therapy for pain have problems with dependence or addiction.

Status of the Federal Response. This past week, the President declared an opioid public health emergency. This declaration provides some regulatory relief and expedites federal awards for treatment of opioids, but it does not provide the additional financial resources that currently are needed to address this crisis. Much more needs to be done.

The total current annual federal effort is estimated to be between $5.5 and $6.0 billion, with the bulk of these funds being made available through SAMHSA and CDC. At this level of effort, our care system is able to reach slightly less than 20% of those who have an opioid dependence or addiction. Clearly, this is unacceptable.

Very recently, the president’s commission on opioids issued its final report. This report calls for much better enforcement of parity for health insurance coverage through the state health insurance marketplaces, the state Medicaid expansions, and large private plans. It also calls for the Centers for Medicare and Medicaid Services to make Medicaid waivers for opioid care a high priority going forward.

Status of the Workforce. The current addiction treatment workforce does not have adequate capacity to deal with the magnitude of the opioid crisis we are facing and is confronting a crisis itself. This human resource crisis, which has been recognized by the president’s commission, is fueled by the large-scale retirement of baby boomers and the inability to recruit a sufficient number of physicians to offer medication assisted treatment. The consequence is that most persons who have an opioid dependence or addiction do not receive care. The U.S. Senate has recognized this dilemma. The Strengthening the Addiction Treatment Workforce Act (S-1453) currently is pending. This act would expand the number of addiction providers trained through the National Health Service Corps.

Status of Care. Medication assisted treatment, when combined with counseling, is quite effective in reducing the likelihood of relapse. Such treatments need to be much more broadly available.

Nalaxone, which can prevent an opioid overdose death, is becoming generally available. However, it is not yet universally available in police cars, EMS vehicles, emergency rooms, hospitals, schools, etc.

Alternatives to the use of opioids for pain management are known to be effective and are beginning to be used more broadly. These primarily include mindfulness interventions and acupuncture, among others.

Many rural communities have a severe opioid problem, but lack addiction care staff. Telemedicine now is being used to extend care to some of these high-need communities.

Status of Prevention.  The solution to the opioid crisis will require not only improved treatment but also the implementation of effective prevention strategies. New population health management approaches with early identification and intervention for those at risk or extreme risk could do much to reduce the incidence of new opioid use and abuse. Clearly, much more work is needed in this area.

I want to thank the American Public Health Association and its executive director, Georges Benjamin, MD, for elevating attention to the opioid crisis in this year’s national meeting. The opioid crisis truly is a public health emergency of tragic proportions.