Understanding the Opioid Epidemic

Understanding the Opioid Epidemic

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Public Health Threats and Pandemics

Speakers examine the growing opioid epidemic in the United States and compare global responses to opioid addiction, discuss the effects on the U.S. economy and labor force, and explore potential medical and policy solutions.

DENTZER: Good afternoon, everybody, and welcome to our conversation on understanding the opioid epidemic. I’m Susan Dentzer. I’m the president and CEO of the Network for Excellence in Health Innovation, and a Council member, and delighted to be moderating with such a terrific panel today.

Of course, as all of you know, in the U.S., the opioid epidemic really is the public health emergency of the 21st century. The latest available numbers on the greatest cost of the epidemic, of course, date from 2016, and that’s in the opioid overdose deaths, and those numbered just over 42,000. That was five times the rate of opioid use deaths in 1999 and more than any previous year, and although we don’t have the final data for 2017 even, we suspect the numbers went even higher. The drug overdoses now in the U.S. account for more deaths annually than those deaths due to falls, due to gun use, or even traffic accidents, so it truly is a public health emergency.

As has been very well documented, of course, the epidemic started with prescriptions of legal opioids—drugs like oxycodone, et cetera—for pain relief, but as we’ll hear from our speakers, it has since also morphed into a combined epidemic of both legal prescribed opioid use but also illegal drugs—heroin, synthetic opioids often used to—in counterfeit form—to mimic legal opioid drugs, and also mixed in oftentimes unknown to users. As we know, the rock star, Prince, died of having ingested a drug that was laced with fentanyl, probably unknowingly.

So a terrible—a terrible epidemic, and as we’ll hear from our speakers, not just due to the familiar drivers and causes. We know there has been a lot in the news of course about the role that some of the pharmaceutical companies played possibly in minimizing the addictive qualities of these drugs, but we also know that there are other reasons why people have become so addicted. We understand, of course, much more about brain science now and the factors that lead to addiction, and possibly that topic will come up today.

We also very much understand the social aspects of this epidemic throughout the country. And, as those of you who follow the research literature in life expectancy and mortality will know, in the U.S. we now have this stunning development of rising rates of mortality of people in mid-life, particularly in white, low-educated populations. And one of the primary drivers there has been addiction of various sorts, including in particular addiction to opioids, so just reversing every trend that we thought was normal in America. We tend to think of America as a country where these—life expectancy only gets better, and of course, we know that it has been thrown into reverse for so many populations. So we’ll be talking about that as well.

And then finally we hope we’ll have some conversation about the international dimensions of this. It’s hard to do that because the U.S. is such an outlier. Our legal opioid prescribing rate is—if you go to the next biggest prescribers, it is Canada, and they are already a third lower than we are, and the next one after that is Germany, and they are a third lower than that. So we are such an outlier in terms of our legal opioid use that we essentially have carved out a unique set of problems for ourselves as a country. That notwithstanding, there are some learnings from other countries that are also experiencing opioid—their opioid epidemics, particularly major cities, and we’ll be hearing some conversation about that, as well.

So with no further ado, let us go to our three marvelous speakers. You have your bios in front of them, so we won’t spend time on that, but we’re going to start with Vivek Murthy, who is going to speak from his unique perspective as the former surgeon general of the United States, and the surgeon general who presided over a landmark report that was issued on addiction, including in particular this aspect of the crisis, and has done so much, even since he has left that formal office, to continue to raise awareness around it.

So could you give us an overview of where we sit now—the 30,000-foot view of the epidemic and what you think are the most important things that we need to do as a country going forward to continue to address this?

MURTHY: Sure. Well, thank you, Susan, for that question and for hosting us on this topic which I believe is incredibly important. And I’m so glad that all of you are here. I know that many of you have probably been hearing about this topic, are probably deeply immersed in it in some cases, but this is a profound challenge that our country is facing that has—I believe has implications far beyond just the specific opioid epidemic. How we approach this, understand it, and address it, I think, has far wide-ranging implications for health more broadly.

But how do we get here, and why is this important? Let me mention a bit about that. You know, you’ve heard from Susan that the statistics are not getting better when it comes to opioid overdose deaths, and opioid use is—to start with—are medications—prescription opioids are medications that we typically give in the hospital to treat pain. They are remarkably effective for treating pain. They can reduce your symptoms of pain like that, especially when given in intravenous formulation, and therein lies both the blessing and the curse of opioid medications because some years ago, in the 1990s, when the medical profession was being urged to be more aggressive about treating pain, when there was a recognition that we in fact had been undertreating pain and allowing people to suffer unnecessarily, the first question was, well, what can we reach for that will treat pain and do so quickly, and opioids seemed like the magic answer.

I was training in medicine, you know, around this time, and working in public health, as well. I remember that there was very little education that we were given as to how to really approach pain in a really thoughtful, and comprehensive, and safe way.

Opioids appeared on the scene almost as a panacea, and so what you saw was a combination of that lack of training and education to clinicians combined with this increased emphasis on treating pain aggressively, and there were different ways that emphasis was provided in the form of, like, pain scales and also in the form of sometimes often reimbursement strategies that were tied to the elimination of pain. So there was a whole incentive structure built around that.

But those combined with several other factors which were unfortunate: one, there was in fact an aggressive marketing of these medications to doctors and to patients by certain pharmaceutical companies, and in some cases, that marketing was done in a way that underemphasized the actual addictive potential of these medicines. And so you combine all of that with the lack of treatment that we had in our country, a lack of training to get physicians to understand how to diagnose opioid use disorder, and all set against a background of cultural stigma around addiction, which prevented many people from coming forward if they had trouble with addiction and that often led communities to be uncomfortable with treatment centers in their neighborhood. And all of that came together to create the epidemic that we have today.

So we saw a near-quadrupling of opioid prescriptions between 1999 and just a few years ago. We also saw a near-quadrupling in the number of opioid overdose deaths that tracked that change in prescribing patterns.

And even today we see that the latest numbers from 2016 show that we have over 42,000 people who have died from opioid-related overdose deaths. That’s a double-digit increase from the prior year. But then if you delve more deeply into this number, you know, as Susan will talk about as well, you will see that it is not all actually from prescription opioids. Prescription opioids have in fact also increased in terms of overdose deaths. We’ve seen a dramatic increase in the number of deaths related to fentanyl, which is a synthetic opioid, one that people are in fact consuming, if you will, often unknown to themselves. It’s often being introduced into their supply without their knowledge. But fentanyl is much, much more powerful than the traditional prescription opioids. Morphine, which you have heard of, which is one type of prescription opioid—if you compare that to fentanyl, fentanyl is 50 to 100 times more potent than morphine, and carfentanil, which you may have heard about as well, is dramatically more potent than fentanyl. And so these are really powerful synthetic substances that are out there that are being introduced into the supply, often without people’s knowledge.

So this is all contributing to the epidemic that we have today, and while we have been making progress on some fronts, which we will talk about today—for example, we’ve seen a nearly 25 percent decrease from the peak in terms of prescribing—the quantity of opiates prescribed, and that’s good. We’ve also seen more treatment options that are available to people today than was true ten years ago, and that’s also good. We’ve seen more availability of naloxone in communities, which is fantastic. We’ve seen states like Rhode Island implement medication-assisted treatment throughout the prison system, which is fantastic, and that’s actually demonstrating reductions in overdose deaths in the state. There are many bright spots, but ultimately we have not yet been able to curb overdose deaths, and that’s deeply concerning.

The last piece I’ll just say about this is on the international front and what this sort of means more broadly beyond just opioids. The international stage, as Susan alluded to, the rest of the world looks very different from the United States. We consume somewhere in the neighborhood of 75 to 80 percent of all the opioids in the world, despite the fact—despite the fact that we have a much smaller percent of the poor population. And what has been really striking is that the increase in opioids that we have seen used in the United States has occurred at a time when the amount of pain that Americans are reporting has not actually significantly changed. And so I think we—that, to me, begs a deeper question: what is driving the pain that we are experiencing? Is it purely physical injury, for example, or the consequences of being in a post-operative state where you’ve had an incision that’s painful? Or is there something deeper that’s happening within the minds and social milieu in America that is leading to, and accentuating, and exacerbating this pain?

But the rest of the country actually is—in some places—the rest of the world rather, pockets are actually experiencing the opposite problem of what we have where they cannot in fact get as the result of chronic illnesses like cancer or heart disease, who need relief from pain but can’t get access to opioid medications.

India—since I used that example—is in the process of rolling out a national health insurance system that will cover in the neighborhood of 500 million lives. It’s an extraordinary program. But once that program comes on board, how are the people who need opioids actually going to—going to get it. These are unanswered questions.

So—but we also have to be concerned about the fact that the international situation could change very quickly. One of my great concerns has been, in the same way that the tobacco industry went to other countries, you know, throughout the world after the U.S. started to get stricter about regulation around tobacco, and in the same way that they went—not only went to those countries but also were able to dramatically increase the rates of smoking in those nations, especially those that had poor public health infrastructure, we actually have the potential for something similar to happen. As drug makers look at the evolving, you know, environment in the United States, they are—some of them are also starting to look abroad and say, well, are there other markets where we can bring our medications which will have less regulation, less red tape. And some of that might be OK if there was a strong public health infrastructure and a careful, thoughtful way to bring these medications to people who need them. And clearly there are populations that need them abroad, but my worry is that if that’s not done in a careful way, if that’s not—if this aggressive push for opioid happens in countries that don’t have a robust infrastructure for data collection and public health, we risk seeing a calamity that is far greater in proportion than what we’ve experienced here in the United States.

So I think there’s a lot to discuss here. I’ll leave you with this final thought, which is that, to me, what is disturbing and fascinating—pardon me—about the opioid epidemic is what it ways in a broader sense about what our country is going through right now. We have evolved in our understanding of addiction more broadly. We thought years ago that this was a disease of character, that it was bad people who made bad choices that developed substance use disorders. We evolved later into understanding that this is perhaps a disease of biology, that there is something that happens actually in our brain, a lot of which we detailed in our surgeon general’s report in 2016 on addiction.

But there are actual changes in happen in three key parts of our brain that lead us to develop these cravings and the sort of behavior patterns that you see with addiction. But what we also are now starting to understand is it’s not just a disease of the brain, but this is also a social disease, if you will. But it’s the—it’s a symptom of a larger set of challenges we are facing in a society that is more disconnected than ever before, where rates of loneliness are growing; a society where people feel disconnected from opportunity and meaning often in their life, whether that’s from economic hardship or from bullying, as many children are facing in school. And it’s generally the product of a society that is experiencing an extraordinarily high level of chronic stress. And if chronic stress seems like something that we should be able to kind of blow off, and suck it up, and deal with on our own, we are in fact living out the consequences of that understanding of chronic stress because the truth is that there are—we don’t equip our young people, in particular, to deal with stress in healthy, meaningful ways. We certainly have many colleagues—and some of us may fall into this box, as well—who never learned those tools, as well, and what we realize, that being adaptive organisms, as human beings, when we are under stress, we are experiencing pain. When we are experiencing pain, we will seek to relieve that pain. And if that happens with drugs, with alcohol, with food, with other—with violence, with other unhealthy behaviors, then the consequences will be paid not just by us, but by the people around us.

So this is why I think opioids is a fascinating but also urgent issue to address, because it’s not just about changing how we prescribe. It’s about rethinking the fundamental factors that drive this disease in our society.

DENTZER: Great. Well—and thank you, Vivek, for that sobering and compelling overview.

So Susan Sherman, you are from the Bloomberg School of Public Health, just up the road at Johns Hopkins, and your work has focused, as said, a lot on this question of fentanyl, and you had a major study published recently on rapid testing of fentanyl to determine where it can be found, and these drugs—often unknowingly for most people.

And you also do a lot of active work with users on harm reduction. So pull all of that together for us and give us your perspective on the epidemic from those unique vantage points.

SHERMAN: So thank you for being here, and I appreciate being invited to sit on this esteemed panel.

I want to take a little bit—go back a little bit with framing before I talk about fentanyl because there were so many storms—it’s not a perfect storm that happened to create where we are today; it has been many perfect storms. And I’ll start by saying I’ve been working in the area of substance use and addiction for 20 years in India and Thailand, in Baltimore City, so I just—we need to state that many of the social diseases and the notion of despair has been in our inner cities for a long time, where jobs have left, where people are isolated, where whole parts of the society are locked up in jails, and drugs have really filled a void.

I live in Baltimore City, I work in Baltimore City, and that has been the case. So it’s unique that my home state of Kentucky is experiencing this now, but I think it’s really important to remember we have had an opioid epidemic that has been symptomatic of very similar problems, but now it’s much broader and it’s much wider, so—in many ways, so I think it’s important to say that.

So in terms of thinking about kind of the chapters of this—you know, I think of things in terms of, like, the chapters of this story, which hopefully will have a good ending at some point, but I don’t—as Vivek said, we’re not near the peak, I think, of this, and it’s really hard—just like pain, once pain breaks through, it’s hard to take medication to stop the pain. I think we’re at such incredibly extraordinary rates of death, which is an indicator of so many other things, it’s going to take some real innovation and really changing our thinking about how we intervene with this problem.

 

So we kind of heard Chapter 1 with prescribing, with marketing to people. You know, I think for some reason—and even, you know, up to the administration, there is still safety in talking about it’s the doctors and it’s the pharmaceutical company as opposed to we live in a system where people might be isolated, or why are people in so much pain, or what does it mean to people when their jobs—there are no jobs, and, you know, what fills the void. I mean, opiate of the masses—we know that it makes people feel better. So I think Chapter 1 was that piece.

Then, you know, internationally—and this is something that is unknown to most of us, and I’m learning about this—you know, Mexico and Colombia, drug wars, who has what turf, what heroin is getting to what places. It was unheard of that you would find heroin in West Virginia, Kentucky, Ohio, Vermont, to the degree that it is there now, and that is what is adulterated in part because distributed patterns changed. And I’m not an expert on the illicit drug distribution market—I work with the people that are impacted by that—but, you know, things are distributed not just coming in large shipments, but deliveries being made in the middle of West Virginia via cell phones, place where you never could have gotten heroin before. So you—

DENTZER: And much more cheaply.

SHERMAN: And much more cheaply because it’s a market. The market was flooded. In the last few years street heroin is half—you can buy a pill in Baltimore City for $5. When I started doing this work 20 years ago it was $10, and that—you know, with inflation, that’s less than half, so—and you also create a whole lot of people who now are susceptible to—you know, they are addicted to opioids, the pills are no longer available. Street value of OxyContin is incredibly expensive or Buprenorphine, which is a very effective treatment when it gets diverted to the street. Heroin is much cheaper. Why would you not use heroin?

And so we’ve created—that’s kind of—the next chapter is, you know, drug market shifts, and then we have—we have these worlds that hadn’t really met before of the illicit supply and consumers to the illicit supply and consumers. And then you have interdiction rising, so bulky packages of heroin are much easier to detect, even if they come in tires, and milk cartons, and however they come in shipment or on planes. And you have fentanyl, which—a much smaller amount is so potent, and all of its analogs, one of which is carfentanil, an elephant tranquilizer. You can imagine what it takes to tranquilize an elephant, and you can imagine what that does to anyone that’s around it.

So it creates this market where people are unknowingly—or in some markets, as we know from HIDTA and from the DEA, from drug confiscations, and work that I’ve done with the Baltimore City police—some markets are mostly fentanyl, so then you actually have young people who use drugs, like in the state of Rhode Island, who—that’s all they know, so they are seeking fentanyl because that is the high that they know. It’s a qualitatively different high, it’s a short—than heroin, it’s a shorter—which people have written about; I don’t know that personally—but you can tell a difference. It looks different, it smells different, it’s different in your body, it’s shorter lasting. So not at this point, but hopefully we’re going to get to—I’m going to talk about some interventions that I’ve worked on that allow people to know a bit about what is in the drug that they consume, but I hope, from what I’ve said, you really get—it such a confluence of intractable issues that we, as a society, have to grapple with. It’s beyond just this epidemic.

DENTZER: Thank you, Susan.

And Alan, among the many, many costs—and Vivek and Susan have both laid out the enormous social pressures that created the epidemic and the social costs that ensued from it—but among the many costs is the economic cost, which is your area of expertise. You and some colleagues published a study in Pain Medicine, I think it was—

WHITE: That’s right.

DENTZER: —back in 2007 pegging the total cost of the epidemic at that point at just under $56 billion annually. Last year, the White House Council of Economic Advisers estimated the cost at more than $500 billion annually—or 2.8 percent of gross domestic product. That’s obviously a huge increase. Those numbers aren’t necessarily comparable, but it gives one a sense of the magnitude of the cost just from an economic standpoint.

So let’s unpack those numbers a bit. What is behind the economic cost, and how do we see that increasing, at it clearly has over time?

WHITE: OK. Well, good afternoon, everybody, and thank you to the Council for inviting me here. It’s great to be here in spite of the rain.

So my involvement in opioid—the opioid crisis, as Susan pointed out, was sort of my involvement as an economist. I worked on a study over 10 years ago for Johnson, and they had a drug, Duragesic, on the market which is a fentanyl product. And they were interested in getting a handle on what is the cost of opioid abuse, what sort of a burden—financial burden is it imposing on society. So as Susan mentioned, published a paper—I think it was 2011—but we found—myself and some colleagues found that the annual societal burden of prescription opioid abuse was over $50 billion per year, and I’ve seen estimates where it’s higher than that. My sense is it is much higher than that, but notwithstanding what the precise dollar amount is, it is a huge number. It is staggering.

And let’s just take sort of the $50 billion number. The way it sort of breaks down is as follows. About 40 percent of it is medical and drug costs, so the costs associated with prescription opiate abusers who are in substance abuse treatment programs. They are attending, say, a methadone clinic on an outpatient basis. So a large component of the cost is accounted for by medical costs.

But the other piece, which is quite staggering, is the work loss cost associated with the epidemic. And by work loss I mean costs associated with disability and medically related absenteeism. So persons with abuse disorders tend to go out on disability, have lots of doctor visits, and this imposes a pretty significant employer cost.

And the other piece—or at least one of the other pieces is a criminal justice component, so many abusers end up in prison. Obviously, it imposes costs at both the federal level, the state level, the local level, and so in thinking about the epidemic in a very broad, societal sense, it is imposing significant costs on insurance companies, the prison system, employers, and so it’s an epidemic which touches all of us.

DENTZER: And there’s the dead weight loss to the economy of productivity—

WHITE: Correct.

DENTZER: —that ensues from that which is—was not what you estimated—

WHITE: Right.

DENTZER: —but that is what pumps these numbers up in the larger—

WHITE: That’s actually—right—actually a very good point, Susan. You know, the $56 billion doesn’t account for everything, so for example, an abuser who is at work sort of staring out the window being unproductive, that is not accounted for in our numbers so, you know, there is a significant productivity loss associated with abuse.

And maybe just, you know, at an individual patient level—just to give you some ballpark numbers—you know, using medical claims data, the per-patient cost of opiate abuse is somewhere in the order of 20(,000) to 25,000 (dollars) per year per patient. So these are huge, huge numbers.

And maybe I’ll just mention one other piece which is important. Understanding the magnitude of the problem, the cost of it, is an initial step to saying, OK, what can we do to bring these numbers down. What initiatives might one think about? And one of the things that has happened in the past few years, the FDA has approved a number of opioids which have abuse-deterrent properties; that is, they are less—at least as approved, they are less prone to being tampered with and potentially being abused.

I think—there are not enough data yet to sort of understand what the implications of these new drugs are, but early signs suggest that they may be more effective at potentially reducing abuse, but I think the verdict is still out on them. And it’s something that, you know, we’ll sort of monitor over the next few years. But I think the key thing is—at least from my perspective in the work I’ve done—the societal impact, the burden—the economic burden is really substantial and touches many, many, many aspects of society. And I think any initiatives to help curb the epidemic will involve kind of a multifaceted approach.

I think abuse-deterrent opiates are a piece of the potential solution, but it will involve many others as well.

DENTZER: Well, thank you, Alan, and as you can see, we could have a five-day-long session on this crisis and just really begin to almost scrape the surface of it. But we can’t do that.

We do want to move now to questions from all of you members, so if you would just introduce yourself by name and affiliation, that would be great, and we have a microphone that we will get over to you as well, so—

Q: Thank you for your fascinating discussion. I’m Louise Shelley. I’m a professor at the Schar School of Policy and Government at George Mason University, and I direct the Terrorism, Transnational Crime and Corruption Center.

One of the things I didn’t hear you mention, which I think is a unique problem in the U.S., is the extent to which we have dark web marketplaces on which you can order this, and you can order the materials also sometimes through the web. And there are no comparable dark web sites that have been detected in any other part of the world, so we’re sort of the Amazons of the illicit drug market. And we need to think about that, and I wondered if you had some ideas on this issue.

DENTZER: Vivek, do you want to speak to that? I think it’s probably fair to say that that is obviously the case. You can get these drugs without going to the dark web pretty readily, and so it just—it will be another issue, I think, going forward as we try to clamp down on the availability of supply. But go ahead. Please address it.

MURTHY: Well, you raise a really good point, and this is part of what makes—the supply side is what makes this a really challenging epidemic, too, because in addition to the dark web, like Susan mentioned, there are—when I was Ohio, I remember—a year and a half ago, visiting with the law enforcement and public health community there around this, they were finding that people in their community were literally just going online and ordering from China, and getting sources of opioids, including fentanyl. And they were worried because they didn’t know how to stop it. I mean, boxes look the same when they come to the post office often, and unless there is—and you have to figure out the right kind of screening and figure out what kind of workforce that’s going to take or technology to do it well.

So there is a major role that—both from a cyber security perspective and, more broadly, from a law enforcement perspective, that we need to bring when it comes to the strategy to address opioids. That’s also why I think what is important and, I think, potentially instructive for other public health crises here is that there is a true collaboration here that’s required between the traditional public health folks, between the medical establishment, between law enforcement, and between employers if we really—and, of course, government not to—not to be forgotten. It has to be an essential piece of that.

But this is not an issue that we can solve—that people are just walking—working on their own in silos. The bright side, to me, is that we have seen this kind of collaboration really developing in many parts of the country. Ohio, I mentioned—it was Cleveland, specifically, where I was—but they have really pulled together all of these, the different sectors that I mentioned, to be very thoughtful about a coordinating strategy and targeting the key elements in this epidemic. But we have to have that happen on every element.

I will say one last thing, which is a caveat I think we have to be cautious about, which is that as much as there is a role for law enforcement here when it comes to addressing supply, I mean, the place where we cannot afford to backslide is in assuming that the solution to addressing the opioid crisis among people who are addicted is a law enforcement approach of putting them in jail and assuming that that’s—that punishing them is how we’re going to get rid of their substance use disorder.

We have tried that playbook with disastrous results over the last several decades. I do worry that we are potentially sliding a bit back into that mindset, that stronger prison sentences and, you know, and the death penalty, et cetera, are how we’re going to essentially address the opioid epidemic.

That does not work, and that only works if you assume that addiction is a purely rational illness. But as I often used to share when I was in office, like, if you remember that the parts of your brain that are impacted including the prefrontal cortex by addiction are the ones that help govern judgment and decision making, and if you also try to think about your own life, about any time that you’ve tried to, for example, go on a new exercise plan or a diet plan, you know how hard it is to stick to that plan.

And I’ll be the first to raise my hand to say I’ve fallen off the wagon on plenty of diet and exercise plans over the years. But imagine if the very part of your brain that was responsible for helping you make decisions and stick to them was in fact compromised at a structural level. How much harder would it—would it be to stick to that? And that’s what you're seeing. That’s what people with addiction are experiencing each and every day.

And so I think that without that understanding of the illness then, you know, we think of this as purely a rational weighing of pros and cons that people are doing and that is, I think, where we go down the wrong path when it comes to the law enforcement approach, you know, being applied to folks struggling with addiction.

DENTZER: Great. Let’s go to the rear and take a couple of questions back at that table. Then we’ll move forward.

Q: I’m Glen Fukushima at the Center for American Progress.

I’d like to ask Dr. Murthy if the president were to call you up today and say, I’m giving you limited resources to put together a strategy to address this problem to solve it, what would be the outline of the strategy that you would put together and are there examples in the past of similar problems—epidemics or other problems that you can use as a model to try to put together such a strategy or is this something so unique and different that there really is no model to use?

MURTHY: That’s a great question. I’m not anticipating that phone call is coming anytime soon—(laughter)—but if it does, there’s certainly some thoughts that I have. I mean, one of the first things I’d say—I’d say, Mr. President, you actually have a great plan that has been formulated by your Opioid Commission that was convened early on in the Trump administration.

That commission drew upon a number of reports that had been put together before including, you know, the report I had published on addiction and a number of others. They reiterated a lot of those conclusions but, essentially, emphasized the fact that we actually know what we need to do.

We have a strategic vision in place that focuses on prevention, that focuses on different aspects of preventions around prescribing, changing prescribing practices around harm reduction, around public education.

We have—that strategic plan also includes a focus on treatment, specifically, an expansion of medication-assisted treatment with methadone, buprenorphine, and naltrexone. There’s a part of that strategy that also involves the wide dissemination and accessibility of naloxone, a medication which can save people during moments of—during episodes of overdose but which is far too inaccessible and is still far too expensive for many communities to afford.

And we would also say that there’s a key part of that strategy emphasized in mine and many reports that says that we also have to shift our culture when it comes to addiction and shift how we think about addiction as a country, which involves recruiting and engaging community leaders and partners to start thinking about, talking about, and sharing about addiction in a way that’s different from what they’ve done—all of this combined, of course, with what we just mentioned, which is the role—critical role of law enforcement in helping to address the supply of opioids.

So the key elements of the strategy are there. The challenge that we have had, Glen, is that we have—we have seen a piecemeal approach to implementing this strategy and what we know is that this is not like an infectious disease epidemic where you can say, OK, you know, we’re going to put a whole bunch of money into getting the right medicine on the shelf and then just get it out to everybody through existing—an existing delivery system.

This is not like that. This requires action on many fronts to truly be effective. If we tinker around with a modest expansion of treatment, you know, this year and the next year we, you know, fiddle around a little bit with, you know, prescription drug monitoring programs and hope that we can reduce prescribing practices, we may see progress in the long run. But every year that we wait, we are losing tens of thousands of people.

So I would say as important as the facets of the strategy is how comprehensively and consistently that strategy is, in fact, implemented. The last thing I’ll say about this is the role of the government itself, which is I don’t think that this is a problem that can be solved solely by government.

I think the role of the medical and public health community, the role of the public, including employers, is essential when it comes to educating—shifting how people think about this illness and getting people into treatment.

But with that said, with an issue that’s as big and urgent as this, you do need an entity that can step up and say, this is our vision for where we have to go—these are our targets for where we need to be—these are the methods through which we are going to create transparency around the progress that we’re making or not making so that we and the public can hold ourselves accountable.

This is actually what you would do in any business. If you realized that you had a problem in a business, you would say, OK, we’re going to develop a strategy, a timeline, and we’re going to have clear results and measures by which we hold ourselves accountable. If we don’t hit those, we’re going to either shift strategy, you know, also shake up our team—we’re going to do some things differently.

But for reasons that you can probably understand, we haven’t seen that, you know, coming out at a government level because there’s risk in doing that. The risk is that you may fail to hit your targets. But in the absence of having that kind of clear and compelling vision, targets, timeline, and leadership, we have many people throughout the country who are just saying, you know what—there are 50,000 recommendations that I hear—maybe I’ll just do whatever makes sense to me here—whatever is easy here.

It doesn’t feel strategic, and that’s a place where I do think the government has a unique role to play. That’s where I would urge, you know, our current president, any future presidents, to really think hard and to take a bold stance on providing that kind of leadership and vision.

DENTZER: And I think, just to close that out, Vivek, isn’t it also the case that the funding has followed a nonstrategic path?

MURTHY: Yeah.

DENTZER: Particularly in the last year and a half it’s been a question of shoveling funding out to the states and letting them decide what to do with the money, as distinct from setting some very clear targets at the federal level.

MURTHY: That’s right, because the money has to—I mean, there are two critical things about the money. It has to be deployed in a way that’s efficient and if it takes a year or year and a half where states ultimately go through a grant process to get the money, that’s not efficient. But the other thing is the money has to be deployed in the right place.

So what you've seen is you've seen a lot of the money go toward law enforcement measures, toward treatment expansion. Good. This is good. But if you ask the question, do we know if there are prevention programs that work and are we funding them, the answer is yes and no. There are extraordinary community-based prevention programs, many of which we detailed in our report, which are extraordinarily cost effective, some of which save $64 and reduce health care costs, criminal justice costs, and lost productivity costs for every $1 you invest.

And these programs not only have reduced addiction rates but they help reduce teen smoking, teen pregnancy, suicide rates. They improve grade point averages and graduation rates. They do a lot of multifactorial benefits. But these programs are minimally invested in in communities and part of the reason is that they take—they don’t deliver results tomorrow. They take on the order of months to years to deliver results.

But when they deliver them, they’re powerful. But we need to make that investment now. That’s not where you see these investments going. And that’s what I—when I said that when you think about that larger strategic vision and plan that we actually already have in reports, that needs to be funded evenly. It has to be implemented evenly and consistently, and if not, then we’re not going to get our handle around this crisis.

DENTZER: Great. And we want to make sure we take advantage of the expertise of Susan and Alan. So if there are questions particularly directed at them we’d like to hear those.

OK. Let’s take one more in the back there and then we’ll come forward.

Q: Thanks so much. So, for Susan, if you could just quickly explain what Alan raised about the nonaddictive opioids or—

SHERMAN: Abuse deterrent.

WHITE: Abuse deterrent opioids.

Q: Thank you. I just, myself, wasn’t too clear about what that is. And then, Alan, could you unpack a little bit more the economic analysis in terms of does it include some count of crime associated with this? Does it include—and how much does it differ across geographies within the United States?

It strikes me that when—one of the things that’s most surprising about this epidemic is how it’s in low resource settings and so but if a state approaches and to what it—what is indicated, how do you work on the demand side in a sub-regional way?

DENTZER: OK. Susan, do you want to take the first part of it?

SHERMAN: I do. I’m going to take the privilege of sitting up here and respond a little bit to what we can do in interventions because I’ll feel remiss if we don’t—I don’t say the words harm reduction myself—I appreciated that you said that—and talk a little bit about drug checking.

I just want to say it’s—part of what’s challenging about this epidemic is that we actually have to think about the well-being of people personally who might have done—taken stuff from you—you know, people who use drugs in your family or people who have caused family pain or shame or are stigmatizing.

And we often talk about prevention and we talk about treatment, but we forget that 80 percent of people who are using drugs at any given time and many of them even with best treatment available are not ready for treatment. And the road to recovery, so treatment and beyond, is really paved by lots of different relationships and lots of different positive interactions, and that’s really the world I work in. Needle exchange is an example. Drug checking is an example. Safe consumption spaces, which is in every other Western industrialized country including all over Canada, is an example that’s not here yet. So—

DENTZER: And just say a phrase more about what that is.

SHERMAN: So drug—well, I’ll start with—so drug checking actually—and this is the study that Susan referred—we validated against the gold standard three technologies where you could test a sample of street drugs in the Rhode Island crime lab—Baltimore City police lab.

We obtained street samples—204 street samples—and looked at strips that are being used in Canada and now actually are being used throughout the U.S.—a dollar. They tell you yes or no fentanyl. We found them to be very sensitive, very specific, so they can tell if fentanyl is or is not there and also a very small level of detection—the smallest of the three technologies we tested.

Everyone doesn’t have the same tolerance. It doesn’t tell you how much fentanyl. But it is used in a way—so if a whole market has fentanyl that some people say—and I just read this in an article this morning I was quoted in—a health commissioner said, but, you know, people need to have naloxone—people need to assume that everything they’re using—

DENTZER: And just say what naloxone is for those who—

SHERMAN: It prevents—it literally covers your opioid receptors so they can’t take any more opioids—and Vivek mentioned naloxone—so that people—if you talk to people who’ve seen someone administered naloxone it’s like someone comes back from the dead. They’re overdosing and then they’re—they sit up and they don’t know what happened. So and that is—it’s very expensive. Some states, like Maryland, has invested in it. Our health commissioner has distributed it.

There’s—people are allowed to get it. There’s a blanket prescription. It’s a really important intervention but it’s not the—and everyone should have it. In West Virginia, it’s promoted to all different kinds of people because people—lots of people have stories of people on the side of the road they’re worried that have overdosed. I mean, and that’s—so people who aren’t using drugs carry it, et cetera. Naloxone is really important.

But something else that can be useful is that of these fentanyl strips where people receive them from needle exchanges, from drug treatment programs, from public health authorities, different venues, and they take them, and although everyone should assume that any sample that they put in their body has an adulterant like fentanyl or one of its analogs, it still is a way to stop for a second and think. It’s, like, whatever you put on the refrigerator or an app on your phone that beeps before lunch to have a conversation with you about remember, don’t eat that piece of bread, or whatever it is. (Laughter.)

So although we know and we all have the tools, I mean, it’s—you know, for exercise and for food, it’s a way to stop for a second and add something else to that ritual of drug use—that if you’ve had a conversation from the provider who’s given it to you about how are you using—are you tasting your drugs—are you ingesting them slowly, it actually has, you know, are you going to a different supplier once you find fentanyl—are you using with other people—do you have naloxone on hand. It actually provides an opportunity for a conversation you might not have. That was my tangent. Alan really would be better, and I can tell you what abuse deterrent drugs but since he studied it and I just took my soapbox, I’m going to let you have the moment.

WHITE: OK. Sure. So I’m not, obviously, a medical expert but I can—I can at least, based on my layman’s understanding, try and explain what these abuse deterrent opioids are and if Vivek or Susan hears something that is completely wrong, you’ll jump and correct me.

But, essentially, my understanding, based on sort of data I’ve looked at, the three methods by which abusers typically abuse opioids are snorting, injecting, or sort of chewing and swallowing—so, you know, drawing up the active ingredient into a syringe, injecting into the bloodstream, snorting it through nostrils, and chewing.

So abuse deterrent opioids are opioids that have sort of technology built into them that make those routes of abuse more difficult. So it’s much more difficult to crush the active ingredient and then draw it up into a syringe. So that's sort of what an abuse deterrent opioid is, and the intention is to prevent or reduce, and prevent is probably a too strong word but reduce abuse through intended routes of administration. So that is what those drugs are.

With respect to your question on urban or geographic differences in abuse, absolutely. I mean, I think that the data do suggest that there are pockets of the country where abuse rates are higher than others. One sort of striking example, at least for me, based on the study I did a few years ago is there is quite a striking difference in abuse rates in Medicaid populations compared with privately-insured populations and, you know, one example that does come to mind is the state of New Mexico, where I had done some work in the past few years. New Mexico, a state of approximately 2 million persons and about half of the state is Medicaid based, and in the state of New Mexico they were experiencing very high rates of abuse among the Medicaid population.

Your last question on unpacking the criminal justice piece, most of it—our cost estimate—focused on apportioning—of all the arrests in the U.S. what percentage can be attributed to drug-related arrests and what’s the cost of, essentially, housing a convicted felon in prison for a certain period of time. Doesn’t really cover costs associated with, you know, running the DEA and the various government initiatives to, essentially, stay on top of the drug problem more generally. Hope that helps.

DENTZER: And I neglected to ask all of you, please, let’s limit ourselves to one question each so that we can get through more questions. So let’s come here to the front.

Q: Thank you. Selen Ustun. I’m the director of government propositions at Thomson Reuters.

So if we go back to the states, I believe states have access to prescription information, right?

WHITE: Yes.

Q: So how well are the states using this information to identify anomalous prescribers or pharmacies that distribute too many opioids and how well are the states sharing information with other states?

DENTZER: That is—we should hear more about this but this—I will—I’ll just jump in and say my organization has just completed a major study about this and the PDMPs, as they’re called—prescription drug monitoring programs—are so highly variable among the states. There is no standardization and there is no systematic exchange of information among states with respect to one PDMP to another, let alone to a physician in another state who might have a patient that they’d be wondering about—might make an inquiry about whether a patient has been prescribed opioids in another state and is, in effect, doctor shopping.

So it’s a—it’s a huge and serious problem. There’s no consistency at all, and it goes back to Vivek’s point about if we had a national strategy, frankly, we would probably have a national PDMP, and we don’t. Do you want to add more than that?

MURTHY: That’s—I mean, that’s, I think, most of the answer there. Part of our challenge—we have two data issues. One is that we don’t always get the right data and the second is once we have it, we don’t always deploy it in a timely way to the people who need it.

So here’s a case scenario I’d give you. I’m a doctor sitting in a clinic. I have a patient who comes to me and says, I am in pain—I haven’t seen you before—but I’ve been traveling—I’m visiting here for the week and I’m usually on 10 milligrams of oxycontin, you know, like, three times a day and—or twice a day, in that case, and I just ran out of my prescription—I need a refill—can you help me, right.

What I want to know—and it’s 4:30 p.m. and let’s say it’s about closing time—what I need to know very quickly is do—are you really on that dose—have you been to other doctors—like, did you just come from another doctor’s office where you got a prescription and you’re going to go ahead and fill this and several others. I need to know that information, and the problem that we have right now—the challenge with prescription drug monitoring programs. And these are—for those of you who are not familiar, PDMPs or PMPs, as they’re sometimes called—are systems that allow a clinician to see the other prescriptions that their patient is actually getting, and the challenge is that these aren’t always up to date or real time. There’s often a week, sometimes even longer, delay in getting those—the data in.

The second issue is that those systems aren’t always integrated with the electronic medical record, right, so that creates another barrier to entry. So if you’ve got 10 minutes per patient, what’s the likelihood that you’re going to, like, remember your login, go to another system, log in, et cetera? You should do that, but the difference between you should and what’s practical is sometimes quite large.

And then the other piece is that communication between states. So more states are starting to develop hubs where, with neighboring states, they will share data so that if I’m on the border of Kentucky and Ohio, you know, if I’m, say, in Cincinnati, for example, that I can get data from both states. But the problem is that that isn’t happening consistently everywhere. And we know now that people can now easily travel from—like, take New England, for example, where I lived prior to coming to D.C. You know, if I’m sitting in Boston, Massachusetts, I can have patients driving from Connecticut, from Rhode Island, from Vermont, from New Hampshire, all—and from New York State all fairly easily within a short period of time. So this is where I think the need for a national system that is integrated with the EMR that is also up to date in terms of real-time data is really, really essential.

And, lastly, when you think about the bigger data problem beyond what doctors need, we actually need to know how many people are being impacted by the opioid sort of situation. We need to know how many people are actually struggling with opioid use disorders. We need to know how many people have experienced opiate overdose—overdoses whether they led to death or not and where those overdoses are happening. That data is far more spotty than you might recognize and there’s also a much greater lag. So that here we are, sitting in May of 2018, and we don't have the full report on 2017 data yet, right, which seems—sorry?

SHERMAN: (Inaudible.)

MURTHY: Yeah, which would seem—seems bizarre in an age where we seem to be able to get real-time information on just about everything else from stock quotes to, you know—you know, how your children are doing in school to a whole bunch of other data metrics.

So if we don’t close that gap, it also makes it harder to target our efforts most easily. Now, there’s some places that have tried to have—come up with solutions on their own, like in the Baltimore area, for example, that law enforcement officials have—I believe they have their own app that they use where they will input where an officer responds to an overdose situation and others can see that overdose map.

But we shouldn’t have to rely on localities to try to come up with homegrown solutions like that. This is where, you know, national leadership and strategy and solution sharing is essential.

DENTZER: OK. Let’s take a question here and then we’ll come over to this side of the room.

Q: Hi. You talked very compellingly at the beginning about the many perfect storms leading to this. I was wondering—and then also about the sort of compelling strategic vision, going forward. I was wondering if you could just take a look back and say were there any specific missed opportunities for marshalling a more effective policy response to this epidemic. Is there a reason—

DENTZER: How much time do you have? (Laughter.)

Q: Or maybe the top two. I mean, other than the sort of, you know, general inertia, it’s complex, political will. But, like, is there—were there specific moments or missed opportunities where we could have changed this trajectory?

MURTHY: You want to start us off, Sue?

SHERMAN: I think scale-up of services. We were talking before lunch. When you think about—my entry into this world was through HIV. I lived in San Francisco in the early ’90s, and HIV really brought me to the world of public health and working with people who use drugs because they were so impacted.

And countries where they had programs earlier like syringe exchange, distributing a—you know, 6.7-cent syringe really staved off the epidemic in Amsterdam. It always was under 5 percent where the first needle exchange started in 1989 and it scaled to kind of public health population level levels. In Scotland—I mean, in Dublin, Scotland, they’re—Dublin, Ireland, sorry.

WHITE: That’s OK. (Laughter.)

SHERMAN: Edinburgh—he’s Irish—he’s Scottish—Edinburgh, Scotland—

WHITE: I’m Irish.

SHERMAN: You’re Irish, and Canadian. (Laughter.) I’ve been to both places. I’m a little mortified with that.

Anyway, the HIV rates among people who inject drugs was under 5 percent. In Baltimore, it was consistently 22 percent. In New York, it was also in the teens. So early—implementing early prevention efforts for things that we know, and I’m talking about—obviously, I’m more—I don’t deal with physicians prescribing the PDMP that—or, you know, pharmaceutical companies.

In the world that I work, it’s evidence-based interventions that we don’t have a will to employ or scale up meaningfully. In West Virginia right now, there—if you—I mean, it’s just unbelievable. Needle exchanges have been closed in Charleston, West Virginia. You have a mayor who is—has his own AM radio station who goes on rants and really not well supported by the data, along with the police commissioner, who he’s friends with. They’re thinking of introducing—and, apparently, someone in the state is friends with the owner of the company—of retractable syringes so they only inject once and then they’re supposed to not work again. But there’s dead space and people have studied that to show they can be reused and they get jammed and they can get jammed in people’s arms.

So that’s to say that in my world, working with people who are actively using to prevent overdoses, really looking at things from cost-effective and public health impact, informing our decisions about how we and what we employ as interventions and not just this lens of morality which, sadly, has really—I mean, it’s real and we all know that’s true but the cost of thinking this is a moral failure is just extraordinary.

DENTZER: And I think it’s also true the country could have scaled up medication-assisted treatment—

SHERMAN: Yeah. Absolutely.

DENTZER: —much more quickly years ago and the evidence for the effectiveness of that has been in for quite some time.

SHERMAN: Absolutely.

DENTZER: And it’s a long story to explain why that hasn’t happened but it’s also been connected—

SHERMAN: Absolutely.

DENTZER: —I think, to this notion of stigma around addiction.

So let’s take—I think we have time for maybe just one more. So do you—do you want to do rock-papers-scissors to figure out who gets the question? (Laughter.) So OK. Why don’t we go—yeah.

Q: I want to kind of go back to the beginning. You brought up this sort of malaise that we’re in.

Oh. Lucas Koontz (sp), Joint Staff.

You brought up sort of a malaise that you're in and you brought up the depths of despair, which I think also include suicide and alcohol, if I remember right. But you also mentioned stress, loneliness, disconnect, and you were talking about Medicaid patients or I assume lower socioeconomic people experience this epidemic more strongly.

So is that group somehow more lonely, less connected, et cetera, like you were referring to with—or is there some other distinguishing factor that you’ve seen in your research that shows why that group would be affected more than others? Thank you.

DENTZER: Well, I think—I’ll just start out but I’d love to hear your perspective—I think the evidence shows that. Let’s just take—and to sort of not stigmatize Medicaid for a moment, to clarify the situation—so when Ohio expanded Medicaid under the Affordable Care Act, it added 500,000 people to the Medicaid rolls, 200,000 of whom went on opioid use disorder treatment because they were on Medicaid, right. So that tells you what an effective force Medicaid has actually been on addressing this problem as opposed to just being a cause of the problem. So I think—but it’s pretty clear that this—

Q: (Off mic)—where it surfaces up from. Why is that group more affected?

WHITE: Yeah. I think I could just comment on it based on research and maybe not to single out Medicaid or non-Medicaid populations specifically. One of the key things that I have come to appreciate over the past several years is it’s important not to only focus on the individual but the family unit as well.

And so one of the things that comes across very clearly in looking at sort of data over a longer period of time, the family history has a big piece to—an important piece to play in this opioid story and, in particular, family members with prior histories of substance abuse disorders in general, and that could be alcohol or other substances but also mental health conditions.

So one of the things that is very important in terms of thinking about predicting who would be a likely at-risk person, it’s individuals who are exposed to or come from units with prior histories of mental health disorders and other substance abuse disorders.

DENTZER: And adverse child experiences and in particular for women—

WHITE: Yes.

DENTZER: —sexual abuse as children is a great predictor of addiction. Yeah.

MURTHY: If I could—

DENTZER: Vivek, do you want to close?

MURTHY: Yeah. Sure. Last time for me—is, you know, what I find really interesting about the demographics of the opioid epidemic is actually less, it seems—it’s less striking to me the differences between populations and more striking to me how every group seems to be impacted by this, because usually we think about most illnesses as predominantly impacting the poor or those who are marginalized because they lack access to resources and such in medical care and coverage.

But what’s really striking about this epidemic is it’s affecting people who are rich and poor people in rural and urban areas. It’s—you know, we’ve seen it originally has been written about as a disease, you know, that has predominantly affected white populations but we’re actually seeing that change now as more and more minority populations are seeing their—the rates of opioid overdose increase as well.

I do think that the—part of the reason for this is that I think that some of these deeper social factors that I think many of us are concerned about, factors which are causing, I think, pain in people’s lives, really are becoming more and more universal and that’s something that I saw when I was traveling the country as surgeon general is I saw that everywhere I went, while people didn’t say it explicitly, from their stories and from more private conversations I would have with them after events, you could tell that people were experiencing a great deal of pain.

And sometimes that pain came from living in poverty for years and from the stress and uncertainty of that. Sometimes it came from the experience of discrimination or abuse and trauma. Sometimes it came from feeling irrelevant in an economy where they felt that they—their skills were not useful anymore and particularly for many men that I encountered, who felt that their job and their ability to bring income into their family was at the core of their self-worth as a human being, that was a tremendous blow to them.

So this deeper pain that people are in I think is partly physical but is much greater. It’s a—there’s a nonphysical dimension of this pain, which I think is driving a whole set of behaviors that we are just starting to (uncover ?) now. One of those—(inaudible)—a few—a few months ago who told me that a few days after the tragic shooting in Newtown, Connecticut, at the school—at Sandy Hook Elementary School, she was talking to a group of New York City public school students and she asked them—she said, what do you think would lead somebody to do something so terrible to children, and you know what the students said automatically? They didn't think about it. They just raised their hand and they said, probably because he was lonely.

That was their first response, and these are—they were very striking and she said, why do you think that loneliness would make him do something like that. They said, well, because when we felt lonely, which has been often, it’s made us angry and we’ve lashed out at the people around us.

Now, this is the wisdom of elementary school students in a public school in New York City. But it’s actually borne out by a growing amount of data and science that tells us that loneliness, for example, does lead people not only to a chronic stress state but toward behaviors that lead, ultimately, to addiction—that their risk of addiction is actually increased.

It tells us the risk of violence, the risk of depression and anxiety, the risk of cardiovascular disease and premature death—all of these are actually increased when you’re lonely. And not just a little bit. Like, for example, the reduction in lifespan that you see with loneliness—that’s associated with loneliness is similar to the reduction that’s seen by smoking 15 cigarettes a day. It’s greater than the reduction in lifespan that you see with obesity.

And so there is something much deeper fundamental that’s happening in our society that’s leading and giving rise to and exacerbating the addiction crisis. You know, I’ve come to really believe that the most important social safety net that we have is the relationships we have with each other—the social fabric of our country—and right now my concern is that is fraying, and unless we strengthen that fabric, unless we take a comprehensive, much more thoughtful approach to this epidemic that goes beyond getting naloxone into people’s hands or expanding MAT, both really important—but unless we take that deeper approach, I worry that we will be nibbling around the edges and won’t be getting, ultimately, at the heart of this problem.

DENTZER: Well, and as Susan said so importantly, many, many, many perfect and far from perfect storms came together to produce this problem, and we appreciate your great interest and I’m afraid we do have to end it there.

Join me in thanking our three speakers for a terrific discussion. (Applause.)

(END)

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