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The Rosenthal Report - April 2017

Rosenthal Reports

CONFRONTING THE OPIOID EPIDEMIC

This month’s Rosenthal Report examines new efforts announced by New York City and the State of New Jersey to stem the escalating opioid crisis, as well as the impact of opioid rationing and monitoring programs. Both are urgently needed as the opioid death toll escalates: 52,401 Americans died from overdoses in 2015, including more than 20,000 from opioid pain relievers and nearly 13,000 from heroin or heroin synthetics.  

It would be unfair to directly compare the two initiatives, since states (mostly with federal funds) provide, by far, the greatest amount of substance abuse service. Both, however, are responding to mounting numbers of overdose fatalities in different ways: New York City with a limited, narrowly focused approach and New Jersey with a broader and more comprehensive one. Reducing the number of fatalities however will not necessarily reduce the number of overdoses, because it is only by successfully addressing addiction itself can we curb the crisis. 

New York City Mayor Bill de Blasio Announces Anti-Opioid Initiative

Faced with a surge of opioid overdose deaths, de Blasio outlined a new initiative to combat the crisis and pledged $38 million annually to reduce the number of opioid deaths by 35 percent over the next five years. An estimated 1,300 New Yorkers died of drug overdose in 2016—the highest number on record. More than 1,075 of those died from opioid pain pills or opiates like heroin and the powerful synthetic opioid fentanyl, which accounted for 90 percent of opiod drug deaths last year compared to fewer than 5 percent from fentanyl before 2015. 

The Mayor’s plan, called HealingNYC, includes a reliable mix of prevention, outreach, professional training and supply reduction. To reduce overdose deaths, the city will distribute 100,000 naloxone kits to treatment centers, homeless shelters and pharmacies. And, for the first time, all 23,000 NYC Police Department patrol officers will carry the overdose reversal drug and be trained to use it. 

Also on the agenda are public awareness campaigns; more mental health clinics in high-need schools with a disproportionate share of suspensions and mental health issues, which can be precursors to substance abuse.  According to a City Hall statement, education programs for clinicians to reduce overprescribing are part of the initiative, as are doubling to 600 the number of inmates receiving methadone on Rikers Island, and the creation of police “Overdose Response Squads” that will target dealers in high-risk neighborhoods and “disrupt the supply of opioids before they come into the city,” according to a City Hall statement.

Another key element is providing medication-assisted treatment (MAT) for addiction to an additional 20,000 New Yorkers by 2022. Ten NYC hospital emergency departments will establish buprenorphine induction (the first phase of treatment to find the patient’s ideal daily dose of the drug) and what is called “care management” through the stabilization and maintenance phases. 

A Health Department spokesperson told the Rosenthal Report that HealthyNYC intends to make “the full spectrum of evidence based drug treatment” available to New Yorkers, including rehab beds and counseling at overdose programs and outpatient clinics. Still, the Mayor’s initiative is intensely focused on “increasing the availability and use of buprenorphine,” the spokesperson said, noting that the drug is currently underutilized in the city’s drug programs. 

 

First of a series: The States Take Action

NEW JERSEY
Entering his last year in office, two-term governor Chris Christie announced a comprehensive opioid emergency plan this past January. It establishes a broad framework for tackling the epidemic from a patchwork of programs already in place, including equipping emergency responders with overdose reversal drugs and training former drug users as counselors to drug addicts admitted to hospital emergency rooms.  

Christie’s plan followed a grim year for drug deaths in the state: overdoses from heroin and other opiates, including the powerful synthetic opioid fentanyl, claimed the lives of 1,600 drug users in New Jersey—a 20 percent increase over the previous year’s total. The governor’s first step was to declare a public health emergency, which gives him additional resources to battle the epidemic, and launch a television ad—with himself as pitchman—urging viewers to use a new one-stop website and telephone hotline to learn about addiction resources. 

The initiative includes substantive measures covering education and prevention, opioid prescription monitoring, and insurance coverage. In addition, there are regulations that limit physician prescriptions of opioids to a five-day supply instead of a 30-day one; rule changes that consider 18- and 19-year olds to be children to reduce waiting lists for treatment beds; proposed legislation that would require private insurers to pay for at least six months of drug treatment; and expanded education programs, starting in kindergarten, about avoiding opioid abuse.  

Democratic lawmakers in the state generally embraced the plan, but it already faces resistance from a physicians lobbying group, the Medical Society, which said it would be “cruel” to patients to limit prescriptions as well as an “intrusion” on medical practice.  Christie’s initiative got a reprieve when the GOP’s healthcare plan, which would have jeopardized Medicaid funding to the states and substance abuse programs, was withdrawn. And with Christie named to lead an anti-opioid drug commission within the White House’s new Office of American Innovation, his influence may also be felt at the federal level – and with the backing of President Trump.

 

COMMENTARY

All efforts to address the opioid crisis ravaging America’s urban and rural communities are to be applauded. Both the New York City and New Jersey initiatives include excellent ideas and effective policies, but the blueprint they offer is incomplete. The orientation (especially in New York) on curbing overdose deaths represents a short term, medication-based emergency response plan rather than a comprehensive long-term strategy that would lead patients to full recovery. 

That approach would require more than Mayor de Blasio’s planned $38 million expenditure. By comparison, he has allocated $1.6 billion for the Vision Zero safe streets initiative to eliminate traffic injuries and deaths. “We have made a commitment to decisively confront the epidemic of traffic fatalities and injuries,” the Mayor has said. The same should hold true for substance abuse and drug addiction. What about a Vision Zero for the addiction epidemic? It’s time to think bigger and bolder about bringing this crisis under control.   

A CLOSER LOOK: The Risks and Rewards of Opioid Rationing 

In one form or another, rationing opioids is now a reality.  Every state except Missouri has special prescription limitations, and the Center for Disease Control (CDC) has issued voluntary pain management guidelines backed by the surgeon general intended mainly for primary care physicians treating patients for non-cancer chronic pain. 

The motivation for rationing and monitoring is clear: prescription painkillers can be a gateway to addiction and abuse.  A paper published in the current Annals of Surgery, reported that three out of four recent heroin users say they were introduced to opioids by prescription medications. Unconsumed opioid pills remained in four out of five filled prescriptions, and one out of every five “opioid-naïve” surgical patients “continue to require opioids long after their surgical care is complete.”

A recent CDC study found that that risk of addiction for a representative sample of “opioid-naïve” cancer-free patients increased with each day of medication – starting with day three. Only six percent of the 1.3 million patients in the sample who were given a one-day supply were using opioids a year after their initial prescription. That number doubled to 12 percent for those given a six-day supply and to 24 percent if that first supply was for 12 days. 

February’s Rosenthal Report told how ER doctors are cutting back on narcotic painkillers. Dentists are also heeding this advice. They prescribe about 8 percent of all opioid drugs—and more than 30 percent of those given to patients aged 10 to 19. Last year, the American Dental Association recommended that dentists consider over-the-counter pain relievers as “first-line therapy for acute pain management.”

Now, surgeons are testing painkiller rationing. A Washington Post story highlighted a study at Dartmouth-Hitchcock Medical Center in New Hampshire that limited opioid prescriptions to a specific number of pills for five of the most common outpatient surgical procedures (for example, five pills for a partial mastectomy, and ten for a lymph node biopsy.) In addition, patients were counseled in the use of non-narcotic, over the counter pain relievers such as ibuprofen to manage pain.

A follow-up survey confirmed the efficacy of rationing: the total number of pills fell to under 3,000 from more than 6,000 for the 224 patients in the study. Moreover, a smaller sample of 148 patients was found to have taken only about half of the pills that were prescribed. Although only one patient returned to the medical center for a refill prescription, others may have sought additional pain medication from their primary care physicians, who write close to half of all opioid prescriptions. 

For those in favor of opioid rationing, the definitive factor in the explosive over-prescription of pain medication was the promotion of a high-potency, time-release opioid painkiller (OxyContin) in the late 1980s and early 1990s as well as the notion that addiction due to prescribed opioid pain management is rare. But, while promotion of that new painkiller did indeed play a key role, so did the long-time under-treatment of pain that preceded today’s concern for patient satisfaction.

The organization, Physicians for Responsible Opioid Prescribing (PROP), is a leader in the rationing campaign. It argues that while prescribed narcotics can lead to addiction, too much attention is given to how severely a patient’s chronic condition hurts. Reducing the intensity of pain, PROP maintains, should not be the goal of treatment for chronic pain. “Willingness to accept pain, and engagement in valued life activities despite pain, may reduce suffering and disability without necessarily reducing pain intensity,” the organization insists.

While PROP’s position enjoys support within the medical community, many doctors find the rationing campaign and “opioid phobia” troubling because opioids also clearly help some patients. A previous Rosenthal Report cited the example of Dr. Sean Mackey, head of Stanford University’s pain management program, who described a patient on an opioid regime for a severe foot injury who was able to continue working. 

To be sure, physicians must carefully consider the risks and rewards.  The monitoring programs have had a significant impact on prescribing practices, and have reduced “doctor shopping” – when patients seek out doctors who will prescribe more opioids. Nevertheless, the number of opioid deaths continues to rise; many patients are driven to illicit drugs; and although the rate of fatalities from the use of commonly prescribed opioid medications has flattened, the rate of death from heroin and heroin synthetics is increasing.

Equally important, critics say the CDC guidelines ignore the needs of the individual patient and lack compassion for their pain. Many patients feel like addicts or criminals when they require more painkillers after other medical interventions have failed. The tragedy is that doctors cannot agree on an approach to pain medication that recognizes both the need to control levels of opioid prescribing and the obligation to relieve patient pain.

4th April 2017
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