Addressing the opioid epidemic: What the research says

The JR Guide to the 2020 Democratic Policy Proposals

Photo illustration of 2 milligrams of fentanyl, a lethal dose in most people / DEA
Photo illustration of 2 milligrams of fentanyl, a lethal dose in most people / DEA
By

December 9, 2019

In the lead-up to the 2020 elections, the Journalist’s Resource team is combing through the Democratic presidential candidates’ platforms and reporting what the research says about their policy proposals. We want to encourage deep coverage of these proposals — and to do our part to help deter horse race journalism, which research suggests can lead to inaccurate reporting and an uninformed electorate. Our criteria for the proposals we’re covering is simple: We’re focusing on proposals that have a reasonable chance of becoming policy, and for us that means at least 3 of the 5 top-polling candidates say they intend to tackle the issue. Here we look at candidates’ proposals to address the opioid epidemic. Candidates are divided in their approaches; while nearly all favor increasing funding for and access to treatment for opioid use disorder, fewer candidates support harm reduction policy interventions, such as safe injection sites and needle exchanges. A few candidates incorporate broader criminal justice-level changes or physician-level interventions into their policy proposals.

Candidates favoring increased funding for and access to treatment

Michael Bennet*, Joe Biden, Cory Booker*, Pete Buttigieg, John Delaney*, Amy Klobuchar, Bernie Sanders, Tom Steyer, Elizabeth Warren, Marianne Williamson*, Andrew Yang*

Candidates favoring harm reduction interventions

Michael Bennet, Cory Booker, Pete Buttigieg, Amy Klobuchar, Bernie Sanders, Elizabeth Warren

Candidates favoring action against pharmaceutical companies

Michael Bennet, Cory Booker, Pete Buttigieg, John Delaney, Tulsi Gabbard, Amy Klobuchar, Bernie Sanders, Elizabeth Warren, Andrew Yang

Candidates favoring interventions that target physician prescribing behavior

John Delaney, Amy Klobuchar, Andrew Yang

Candidates favoring decriminalization of possession of opioids

Pete Buttigieg, Andrew Yang

What the research says

Access to treatment: Medication-assisted treatment is an evidence-based treatment for opioid use disorder; it has been shown to reduce the risk of overdose death for people who use opioids. Methadone, buprenorphine and naltrexone are types of medication-assisted therapy for opioid use disorder. These medications reduce symptoms of craving and withdrawal. A systematic review and meta-analysis of medication-assisted treatment find that people receiving such treatment were less likely to die of an overdose or other causes than their peers with opioid use disorder who did not receive medication-assisted treatment.

Harm reduction: Harm reduction initiatives attempt to reduce the risks associated with using drugs. Such initiatives include needle exchange programs, widespread distribution of the opioid overdose antidote naloxone and supervised injection facilities. Supervised injection facilities, also known as safe injection sites or supervised consumption facilities, are not legal in the U.S. They exist legally in other countries, such as Canada and Australia, however.

Several studies have demonstrated a positive link between safe injection site use and entry into treatment. Safe injection sites also provide benefits to people who use drugs in the form of sterilized equipment and supervision to mitigate the dangers of overdose.

Over a dozen studies have linked needle exchanges with lower rates of hepatitis C and HIV infection among people who inject drugs.

A systematic review of research on take-home naloxone programs, which provide people at risk of opioid overdose with kits including the antidote, concludes that “there is overwhelming support of take-home naloxone programs being effective in preventing fatal opioid overdoses.”

The pharmaceutical industry: Big Pharma’s role in marketing opioids spurred physicians to prescribe more opioids, research shows. This, in turn, fueled the opioid epidemic the country faces today. Policies targeted toward Big Pharma include proposals to hold industry players liable for their role in the opioid epidemic with criminal penalties and fines.

Decriminalization: The rationale behind decriminalization of the personal use of narcotics is that criminal penalties essentially criminalize substance use disorder. Proponents of decriminalization argue that such drug use should, instead, be met with evidence-based treatment. There is not much research on the effects of decriminalization because it’s rare. However, in 2001, Portugal decriminalized personal acquisition, possession and use of illicit drugs. Research indicates that drug-related deaths have fallen since the southwestern European country decriminalized illicit drugs.

Physician-level interventions: These interventions target prescriber behavior. Examples include physician education programs, guidelines or restrictions on the quantity of opioids physicians can prescribe, and prescription monitoring programs that allow physicians to view patients’ prescription history to avoid overprescribing or illegitimate prescribing. While education and prescribing policies have curtailed prescribing habits, prescription monitoring programs have been less successful, studies indicate.

Key context

In late 2017, the U.S. Department of Health and Human Services declared the nation’s opioid crisis a “public health emergency.” The problem has been building for over a decade, spurred by sharp increases in prescriptions for opioids, commonly used to treat both short-term and chronic pain.

About 233.7 million opioid prescriptions were filled each year, on average, from 2006 to 2017, according to a March 2019 study in JAMA Network Open that looks at opioid prescriptions filled in retail pharmacies across the U.S.

Prescription painkillers have a high risk of abuse — across the academic literature, rates of misuse among patients taking opioids for chronic non-cancer pain average between 21% and 29%. Research indicates that as of 2013, more than 2 million people in the U.S. had prescription opioid-related opioid use disorder.

Prescription opioids can also pave the way for illegal drugs like heroinEighty percent of people who have used heroin have previously misused prescription opioids, according to an August 2013 analysis of national survey data collected from 2002 to 2011.

As opioid use and misuse has increased, deaths linked to the drugs have increased. In 2017, opioids were involved in 47,600 drug overdose deaths, accounting for nearly 70% of all overdose deaths nationwide that year.

Recent research

Access to treatment:

A review of randomized controlled trials comparing medication-assisted treatment of opioid use disorder to placebo or no medication finds that medication-assisted treatment “at least doubles rates of opioid-abstinence outcomes.”

A study of 151,983 adults in England treated for opioid dependence between 2005 and 2009 finds that the risk of fatal drug overdose more than doubled for individuals who received only psychotherapy compared with those who received medication-assisted treatment.

Harm reduction:

Two reviews — one published in Drug and Alcohol Dependence in 2014, and one published in Current HIV/AIDS Reports in 2017 indicate that supervised consumption facilities promote help people access treatment. The more recent review looks at 47 studies published between 2003 and 2017 on supervised drug consumption facilities. The authors find a handful of studies that demonstrate a positive link between safe injection site use and starting treatment.

One of these studies compared enrollment in detoxification programs among those who used Vancouver’s supervised injection facility the year before and after it opened in 2003. Researchers find the facility’s opening was linked to a 30% increase in detox program use, which, in turn, was linked to pursuing long-term treatment and injecting at the facility less often. A later study of the injection facility focused on use of detox services located at the facility. It finds that 11.2% (147 people) used these services at least once over the two years studied. The authors conclude that supervised injection facilities might serve as a “point of access to detoxification services.”

A 2006 study of 871 people who injected drugs finds no substantial increase in rates of relapse among former users before and after the Vancouver site opened. However, the researchers also find no substantial decrease in the rate of stopping drug use among current users before and after the site opened. Another study of 1,065 people at this facility published in 2007 finds that only one individual performed his or her first injection at the site.

Though supervised injection sites are illegal in the U.S., one opened underground in 2014. Researchers interviewed those who used the underground site during its first two years of operation and their findings were published in 2017 in the American Journal of Preventive Medicine. The site’s users were asked the same set of questions about their use patterns every time they injected drugs at the site. The authors conclude that the site offered several benefits, including safe disposal of equipment, unrushed injections and immediate medical response to overdoses. The authors add that if the site were sanctioned, it might be able to offer additional benefits, including health care and other services.

Big Pharma:

Research suggests that physicians targeted with marketing from pharmaceutical companies prescribe opioids at higher rates than doctors not exposed to their marketing.

Several studies use data from the Centers for Medicare and Medicaid Services’ Open Payments database, which tracks payments made by drug and medical device companies to physicians. That information is used to analyze how relationships between physicians and drug companies are linked to prescriptions written.

These studies define opioid-related payments as cash payments — for example, speaking fees associated with promoting a drug — and payments-in-kind — free meals pharmaceutical representatives provide to doctors’ offices, for instance. These studies find that physicians who receive opioid-related payments tend to prescribe more opioids.

A study in PLoS One from December 2018 looks at physicians who received opioid-related payments, some in 2014 and some in 2015, compared with doctors who never received such payments. The authors find that physicians who received opioid-related payments had a larger increase in the number of daily doses of opioids dispensed, as well as in total opioid expenditures, prescribing pricier opioids per dose.

Another study looking at the same data offers further detail. The study, published in Addiction in June 2019, focuses on 865,347 physicians across the country who filled prescriptions for Medicare patients from 2014 to 2016. “Prescribers who received opioid-specific payments prescribed 8,784 opioid daily doses per year more than their peers who did not receive any such payments,” the authors write.

Other research geographically links opioid marketing and opioid-related overdose mortality. The paper, published in JAMA Network Open in January 2019, analyzes county-level prescription opioid overdose deaths and county-level opioid marketing payments.

The authors find that deaths from prescription opioid overdoses increased with each standard deviation increase in opioid marketing as measured by dollars spent per capita, number of payments to physicians per capita and number of physicians receiving payments per capita. Standard deviation indicates the variation of a given value from the average. “Opioid prescribing rates also increased with marketing,” the authors write. They note that the higher prescription rate might be why overdose deaths increased.

Physician-level interventions:

An August 2018 study published in Science highlights the role physician education might play in addressing the nation’s opioid crisis. The intervention was simple: When a patient died of an opioid overdose, the county medical examiner sent the prescribing physicians a letter notifying them. The authors conducted a randomized trial of 861 physicians whose patients overdosed. The intervention group received the letter, which included a safe prescribing warning consisting of these recommendations:

  • Avoid co-prescribing an opioid and a benzodiazepine.
  • Minimize opioid prescribing for acute pain.
  • Taper long-term users off opioids.
  • Avoid prescriptions lasting for three consecutive months or longer and prescribe naloxone, an opioid overdose antidote.

The control group received no communication.

Physicians in the intervention group cut their opioid prescribing by 9.7% — as measured by milligram morphine equivalents in prescriptions filled — in the three months after the letter was sent. These physicians also started fewer patients on opioids and wrote fewer high-dose prescriptions than the control group.

Prescribing policies and guidelines also have successfully curbed physicians’ distribution of opioids.

In October 2017, the Michigan Opioid Prescribing Engagement Network released opioid prescribing guidelines for nine surgical procedures to clinicians participating in the Michigan Surgical Quality Collaborative, a statewide initiative to improve surgical care.

Researchers compared opioid prescribing before and after these guidelines were released, analyzing data from 11,716 patients across 43 hospitals collected from February 2017 to May 2018. They find that prescriptions declined, on average, from 26 pills to 18 pills per month after the guidelines were released.

Patients also took fewer of the pills they were prescribed. As measured by patient-reported survey data, opioid consumption following surgery dropped from 12 pills to nine, “possibly as a result of patients anchoring and adjusting their expectations for opioid use to smaller prescriptions,” explain the authors of the August 2019 New England Journal of Medicine study. Although patients received smaller prescriptions and used fewer pills after the guidelines were published, there were no substantial changes in the patients’ satisfaction and pain scores.

Similar to the study of Michigan’s opioid prescribing guidelines is a February 2018 study in the American Journal of Emergency Medicine that tracks the effects of an emergency department opioid prescribing policy. The policy resulted in declines in opioid prescriptions. Compared with the control emergency department, the two intervention hospitals had a more pronounced decline in opioid prescribing. The authors conclude that emergency department-based policies might help reduce opioid prescribing.

Prescription drug monitoring programs, which allow physicians to view patients’ prescription history to avoid overprescribing or prescribing opioids to people who don’t actually need them, have been shown to be less effective. A January 2018 study of national data published in Addictive Behaviors finds that there were not statistically significant differences in the likelihood that physicians would prescribe opioids for chronic pain when comparing states with prescription drug monitoring programs with those without.

Further reading

General overview

Modeling Health Benefits and Harms of Public Policy Responses to the US Opioid Epidemic

Allison L. Pitt, Keith Humphreys and Margaret L. Brandeau. American Journal of Public Health, October 2019.

The gist: “Policies focused on services for addicted people improve population health without harming any groups. Policies that reduce the prescription opioid supply may increase heroin use and reduce quality of life in the short term, but in the long term could generate positive health benefits. A portfolio of interventions will be needed for eventual mitigation.”

Safe injection sites

Attendance at Supervised Injecting Facilities and Use of Detoxification Services

Evan Wood, Mark W. Tyndall, Ruth Zhang, Jo-Anne Stoltz, Calvin Lai, Julio S.G. Montaner and Thomas Kerr. New England Journal of Medicine, June 2006.

The gist: A study of Vancouver’s supervised injection facility finds “an average of at least weekly use of the supervised injecting facility and any contact with the facility’s addictions counselor were both independently associated with more rapid entry into a detoxification program.”

Injection Drug Use Cessation and Use of North America’s First Medically Supervised Safer Injecting Facility

Kora DeBeck, Thomas Kerr, Lorna Bird, Ruth Zhang, David Marsh, Mark Tyndall, Julio Montaner and Evan Wood. Drug and Alcohol Dependence, January 2011.

The gist: “These data indicate a potential role of SIF [supervised injecting facilities] in promoting increased uptake of addiction treatment and subsequent injection cessation.”

“A Little Heaven in Hell”: The Role of a Supervised Injection Facility in Transforming Place

Ehsan Jozaghi. Urban Geography, May 2013.

The gist: “Participants’ narratives indicate that attending InSite [Vancouver’s supervised injection facility] has had numerous positive effects in their lives, including changes in sharing behavior, improving health, establishing social support and saving their lives.”

Process and Predictors of Drug Treatment Referral and Referral Uptake at the Sydney Medically Supervised Injecting Centre

Jo Kimber, Richard P. Mattick, John Kaldor, Ingrid Van Beek, Stuart Gilmour and Jake A. Rance. Drug and Alcohol Review, May 2009.

The gist: Researchers conducted 1.5-year study at a supervised injection site in Sydney. They find that 16% of clients at the site referred to treatment by health and social welfare professionals went on to receive it, leading the authors to conclude that the center “engaged injecting drug users successfully in drug treatment referral and this was associated with presentation for drug treatment assessment and other health and psychosocial services.”

Inability to Access Addiction Treatment and Risk of HIV Infection Among Injection Drug Users Recruited from a Supervised Injection Facility

M.-J.S. Milloy, Thomas Kerr, Ruth Zhang, Mark Tyndall, Julio Montaner and Evan Wood. Journal of Public Health, September 2012.

The gist: Many who use supervised injection facilities have the desire to access treatment. This study surveyed 889 people who were randomly selected to be surveyed at Vancouver’s supervised injection facility. “At each interview, ∼20 percent of respondents reported trying but being unable to access any type of drug or alcohol treatment in the previous 6 months,” the authors write. The main barrier to access, respondents said, was waiting lists for treatment.

Big Pharma

The Promotion and Marketing of OxyContin: Commercial Triumph, Public Health Tragedy

Art Van Zee. American Journal of Public Health, February 2009.

The gist: In the first six years it was on the market, Purdue Pharma spent about six to 12 times more to promote OxyContin than it had to promote another long-lasting opioid. The paper describes various marketing strategies including promotional giveaways and Pharma-funded medical education programs.

Industry Payments to Physicians for Opioid Products, 2013-2015

Scott E. Hadland, Maxwell S. Krieger and Brandon D. L. Marshall. American Journal of Public Health, September 2017.

The gist: This study examines payments pharmaceutical companies make to physicians to market opioid products. The authors find that 375,266 opioid-related payments that weren’t related to research work were made to 68,177 physicians over the study period. The authors estimate that about 1 in 12 physicians in the U.S. received a payment from a pharmaceutical company to promote their opioid medications during the 29-month study period. The bulk of the money went toward speaking fees or honoraria, but the most common expense was food and beverages – 352,298 payments totaling $7,872,581.

Association of Pharmaceutical Industry Marketing of Opioid Products to Physicians with Subsequent Opioid Prescribing

Scott E. Hadland, Magdalena Cerdá, Yu Li, Maxwell S. Krieger and Brandon D. L. Marshall. JAMA Internal Medicine, June 2018.

The gist: “Whereas physicians receiving no opioid-related payments had fewer opioid claims in 2015 than in 2014, physicians receiving such payments had more opioid claims,” the authors write.

Physician-level interventions

Differences in Opioid Prescribing Practices among Plastic Surgery Trainees in the United States and Canada

David W. Grant, Hollie A. Power, Linh N. Vuong, Colin W. McInnes, Katherine B. Santosa, Jennifer F. Waljee and Susan E. Mackinnon. Plastic and Reconstructive Surgery, July 2019.

The gist: Plastic surgery trainees were asked about their opioid prescribing education, factors contributing to their prescribing practices and what they would prescribe for eight different procedures. The authors find that, of the 162 respondents, 25% of U.S. plastic surgery trainees received opioid-prescriber education, compared with 53% of Canadian trainees. For all but one of the eight procedures, U.S. physicians prescribed significantly more morphine milligram equivalents than their Canadian counterparts.

Subject experts

Caleb Alexander, professor and co-director of the Center for Drug Safety and Effectiveness, Johns Hopkins University.

Michael L. Barnett, assistant professor, Harvard T.H. Chan School of Public Health.

Chinazo Cunningham, professor, Albert Einstein College of Medicine.

Scott Hadland, assistant professor, Boston University School of Medicine

David N. Juurlink, scientist, Sunnybrook Research Institute.

Thomas Kerr, associate professor, The University of British Columbia.

For more, check out JR’s long read on the opioid prescribing problem, our summary of research on where opioids are prescribed the most and our tip sheet for reporting on fentanyl and synthetic opioids.

This piece adheres to suggestions offered by the National Institute on Drug Abuse’s media guide, which recommends language that avoids the potentially stigmatizing term “addict” in the context of substance use. It states: “In the past, people who used drugs were called ‘addicts.’ Current appropriate terms are people who use drugs and drug users.”

 

*Dropped out of race since publication date.

 

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