Alex, a 47-year-old man, became addicted to prescription opioids after he injured his back at his construction job. Alex is a typical victim of the prescription opioid crisis — he was not drug-seeking, he was taking pain medication in quantities prescribed by his physician, and yet he ended up with a substance use disorder that will be a lifelong struggle to manage.
Unfortunately, there are thousands like Alex. The grim statistics are well known by now: opioids were involved in 33,091 deaths in the United States in 2015, and opioid overdoses have quadrupled since 1999. Deaths from opioid overdoses have nearly surpassed deaths from car crashes, and deaths from heroin have exceeded those from gun violence. Year over year, states are seeing significant increases in opioid-related morbidity and mortality, with seemingly no end in sight.
The exponential growth of opioid-related morbidity and mortality has raised national attention, and along with it a proliferation of funding and local, state, and federal initiatives — most prominently, $1 billion to expand access to treatment through the 21st Century Cures Act. With good reason, much of this funding targets health care providers and organizations. Prominent among multiple causes of the current opioid epidemic is health care providers’ inadvertent contribution to creating it.
Providers’ Roles and Responsibility in the Opioid Crisis
Physicians, nurses, and other practitioners have important roles to play combatting opioid abuse — which may be a new and uncomfortable role for some, but essential to turning the tide. Changing prescribing practices is an urgent need, but not the only thing providers and their organizations can and should do. Health care has multiple roles to play in changing the trajectory of the opioid crisis in the communities they serve, including limiting the supply of prescription opioids in circulation, raising awareness of the risk of opioid addiction, identifying and treating opioid-dependent individuals, and collaborating closely with community efforts. (See “Four Tasks for Providers.”)
The complexity and severity of this crisis requires coordinated approaches at the local, regional, and state levels, because the solutions involve diverse sectors within communities such as public health, government regulators, law enforcement, and social services, in addition to health care. Communities need to take a systems approach that simultaneously addresses multiple parts of the complex pathway of opioid misuse, dependence, addiction, and recovery.
If Alex were a patient at a health system participating in a coordinated systems approach across his local community, things may have looked different. An integrated delivery system in California and a coordinated care organization in Oregon demonstrate what this approach can look like:
Prevention through changing prescribing practices: Alex may not have developed Opioid Use Disorder had he been prescribed opioids appropriately after his back pain became chronic. If Alex lived in Southern California and were a member of Kaiser Permanente (KP), his physician, after determining that opioids were indicated over other non-opioid treatment options, would have encountered a series of decision support prompts in the electronic health record to guide the selection of an appropriate opioid at reasonable dose and duration, along with reminders about the high risk of addiction, abuse, and diversion. Alex’s provider and his service chief would also receive feedback reports about his prescribing rate and, if he showed a high-risk prescribing pattern, would receive additional attention and education. According to federal evidence-based prescribing guidelines, after his initial injury, Alex should have had a conversation with his physician about the risks and known benefits of treating chronic pain with opioids, and been initially prescribed the lowest effective dose of immediate-release opioids, for 3 or fewer days and not exceeding 7 days, followed by a reassessment of benefits and harms of continued opioid therapy.
If Alex lived in Northwest Oregon and received care through the Columbia Pacific Coordinated Care Organization (CPCCO), his primary care provider could refer him to one of CPCCO’s behavior-based pain clinics, a 10-week group program that uses non-prescription methods of reducing pain including yoga, Acceptance and Commitment Therapy, and education on the biopsychosocial aspects of pain. CPCCO’s data shows that, over the past year, the average morphine-equivalent dose amount taken by pain clinic graduates has decreased, indicating that the pain clinic is associated with a reduced desire of patients to take opioids as their pain is better managed in other ways.
Raising Awareness: Kaiser Permanente’s health education about chronic pain and pain management may have increased Alex and his family’s knowledge about the potential for opioid abuse; at CPCCO, he likely would have been exposed to efforts to raise public awareness about the risks of opioids in the community. KP Southern California physicians are required to take SCOPE of Pain, a free online training for physicians on safe and responsible opioid prescribing within their first year of practice. Providers report improved knowledge, attitudes, confidence, and changes in clinical practice after receiving training in safe opioid prescribing for chronic pain. For example, Kaiser Permanente shows a 91% reduction in the number of high-volume opioid prescriptions for non-cancer, non-palliative pain and a 95% reduction in the net number of brand name opioids dispensed when there is a generic alternative over 3 years (brand names have higher street value and thus are at greater risk for diversion).
Identification: Health systems like CPCCO and Kaiser are identifying patients with opioid use disorder like Alex earlier by educating primary care providers in recognizing substance use disorder.
Treatment: If Alex were a patient at a CPCCO clinic when diagnosed with Opioid Use Disorder, he would remain in the CPCCO system to receive treatment. This is not always the case; patients across the country often need to find private treatment, for which there are often long waitlists and high fees, or they must cobble together treatment themselves in disconnected systems. At CPCCO, Alex would receive comprehensive, evidence-based treatment while continuing to live at home and look for a job that does not require heavy lifting. His treatment plan would include a Medication-Assisted Treatment option (such as buprenorphine or naltrexone) that works for him, along with behavioral health services.
It is time for health care providers to prevent more people like Alex from becoming a statistic and expand their view of how they can help stem the opioid crisis that is devastating communities around the country. They should act now.
Four tasks for health care providers to address the opioid crisis in their communities
1. Limit supply of prescription opioids in circulation.
- Decrease supply by changing prescribing practices, reducing both dose and quantity.
- Provide non-opioid alternatives for effective chronic pain management, and work with payers to adequately reimburse for effective pain management modalities.
- Be diligent in follow-up on diversion/prevention opportunities.
- Partner with pharmacists and check their state’s Prescription Drug Monitoring Program before prescribing opioids.
2. Raise awareness of the risk of opioid addiction among providers, patients, and families.
- Identify and educate those patients at greatest risk for addiction.
- Educate all patients and their families about the risks of prescription opioids, elevating the danger of prescription opioids equivalent to that of non-prescription opioids, such as heroin.
3. Identify and treat opioid-dependent individuals.
- Learn to recognize the signs of Opioid Use Disorder.
- Provide compassionate and consistent care.
- Actively manage and taper opioid use among individuals who are not benefiting from continued opioid therapy and who may be exhibiting concerning behaviors.
- Educate patients about treatments that help address chronic pain management.
- Provide ongoing, comprehensive addiction treatment, including Medication-Assisted Treatment and behavioral health support. (With regulatory changes and increased funding options, more providers can be trained to treat this chronic condition just as they have been trained to treat other chronic conditions.)
4. Collaborate closely with community organizations also working on the opioid crisis.
- Prevent overdose by supplying naloxone to hospital emergency departments, first responders, and those in their community who have the ability to react to an individual in crisis.
- Provide health care expertise as needed within communities, e.g., providing counselors to drug courts and to law enforcement.
- Be open to new approaches, such as forming partnerships with law enforcement to, for example, be informed if prescription opioids are found at the scene of an overdose.
- Identify areas of mutual work and opportunity to enhance and avoid duplication of efforts.