April 17, 2018

Public Health

Follow the Data Podcast: A Prescription for Hope in the Opioid Epidemic

In the United States, over two million people are addicted to opioids and an average of 115 people die every day from opioid overdoses. It is a complicated issue that requires multifaceted solutions, with engagement and action from many stakeholders.

In this episode, Dr. Kelly Henning, Bloomberg Philanthropies’ Public Health Program Lead, speaks with Dr. Joshua Sharfstein, Vice Dean for Public Health Practice and Community Engagement at the Johns Hopkins Bloomberg School of Public Health. He is also director of the school’s Bloomberg American Health Initiative, which was launched with a $300 million gift from Bloomberg Philanthropies.

Dr. Henning and Dr. Sharfstein dive deeper into the opioid epidemic, addressing the factors that contributed to increased opioid use in America, harm reduction strategies and treatment options that can be implemented in American healthcare systems, and lessons-learned by American and global communities.

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Full Transcript

KATHERINE OLIVER: Welcome to Follow the Data. I’m your host, Katherine Oliver.

In the United States, over two million people are addicted to opioids and an average of 115 people die every day from opioid overdoses. All American communities feel the impact – rich, poor, urban and rural – and the epidemic is undermining America’s well-being and economic development. For the first time in 100 years, American life expectancy has decreased two years in a row and opioids are estimated to cost the US economy $500 billion per year.

It is a complicated issue that will require multifaceted solutions, with engagement and action from many stakeholders – ranging from public health workers and physicians to police, insurance companies, drug companies, and government officials.

In this episode, Dr. Kelly Henning, director of Bloomberg Philanthropies’ Public Health Program, speaks with Dr. Joshua Sharfstein, vice dean for public health practice and community engagement at the Johns Hopkins Bloomberg School of Public Health. He is also director of the school’s Bloomberg American Health Initiative, which was launched with a $300 million gift from Bloomberg Philanthropies.

The Initiative focuses on five areas affecting public health – obesity and the food system, violence, adolescent health, environment challenges, and drug addiction including tackling opioid addiction in America. A recent research study by Johns Hopkins researchers found that using low-cost test strips to check drugs for fentanyl – a synthetic opioid laced into street drugs, making them even more deadly – could help reduce overdoses.

KELLY HENNING: Thank you for joining us, Dr. Sharfstein. I want to start off by just asking you to set the scene for us. What’s the extent of this opioid epidemic in the United States and what is its impact?

JOSHUA SHARFSTEIN: Thanks for having me. The opioid epidemic is really a challenge, the likes of which the United States really hasn’t seen before. It is affecting millions of Americans, millions of American families, and the consequences range from the overdose and fatal overdose problem which is claiming more than 40,000 lives a year to all the consequences of addiction, people losing their jobs, losing their homes, broken families. It’s an astonishing toll. The economic consequences reach into the hundreds of billions of dollars.

HENNING: Do you think this epidemic is actually having an impact on how long people are living in the United States? Is that one of the pieces that we should know about?

SHARFSTEIN: One of the amazing things is for two years in a row the life expectancy in the United States, the average life expectancy, has dropped. And that hasn’t happened, I think, since the 1950s. U.S. life expectancy is somewhere around 31^st in the world and it is projected to fall even further and opioids really are the lead reason why.

HENNING: So, really you’re saying that opioids are shortening the number of years that people live, essentially.

SHARFSTEIN: For some people it’s shortening by quite a lot. People are dying in their twenties, their thirties, their forties, decades before their time and overall looking at the whole population it’s dragging down life expectancy as well.

HENNING: How did we get here? What brought us to this point that we’re talking about right now?

SHARFSTEIN: Most people trace the origins of this current opioid epidemic to the 1990s, when the culture of medicine changed with respect to treating pain and there are some good reasons and some not so good reasons for why the culture of medicine changed.
People started paying more attention to the fact that their patients were in pain. There were concerns that certain groups of patients didn’t get adequate treatment for pain, and there were concerns that pain in general was increasing because people were living longer with the results of injuries and chronic illnesses and they were more likely to have pain. And so, there was a whole movement to take pain more seriously, to rate patient’s pain, to treat pain until patients didn’t have pain anymore. Then that was fueled by the pharmaceutical industry, which was developing new medicines for pain.

So, now we get into the not so good reasons. There was an enormous push, not only to encourage people to prescribe opioids for pain, but to convince people that really there weren’t any real risks for addiction, and that included marketing materials that were later determined to be illegal. It included paying bonuses in the tens of millions of dollars in aggregate to salespeople. It included a whole range of activities that wound up changing the way that doctors think about pain and the way they treat pain, and not just one group of doctors, but specialists, primary care doctors, dentists, the whole medical profession really changed. And what you got in the United States was a three to four fold increase in prescribing for pain that put us way above any other country.

HENNING: I want to circle back to this idea of too many prescriptions, too much opioid prescribing, but it’s not just that, right?

SHARFSTEIN: This recent huge surge began as prescription drug overprescribing and a lot of people getting addicted. And then what happened was the epidemic shifted and around 2010/2011 we saw the rise of heroin.

There were so many patients who became addicted to prescription opioids who suddenly had challenges getting prescription opioids. Either it could be too expensive or people didn’t want to prescribe to them anymore. And now there was an enormous access to heroin, which is an opioid that can be injected and it very much, satisfies people’s addiction, so, we saw this huge rise in doubling and tripling the number of heroin deaths.

As that was happening, there was really a third wave, which was Fentanyl, which is a synthetic opioid. It’s manufactured very, very potent, at the end of 2013, the beginning of 2014, Fentanyl started to appear first in heroin, then in counterfeit prescription drugs, as well as in cocaine, and other illicit drugs, and it is just incredibly deadly. People can die with just the tiniest little bit of Fentanyl and that has caused just an enormous surge in deaths. So, what started with prescription drugs then shifted into heroin and most recently has become a Fentanyl problem — with the majority of deaths in some areas because of Fentanyl.

HENNING: You mentioned that there was a zealous use, of opioid prescribing back in the nineties or so. What is it like today? Is that still going on? Do you think that that’s being addressed: who’s prescribing and who’s getting it, what’s that look like today?

SHARFSTEIN: There have been declines in prescribing of opioids since about 2010/2011. It’s come down about 20%. I think that is reflective of the fact that the medical profession realized that things had gotten a bit out of hand. Suddenly you had new guidelines. You had people expressing concern about addiction. Some of the products get reformulated which made them less easy to divert for inappropriate use. If you look at where the excessive use is happening, it’s probably in three categories. The first is people who have relatively simple surgical procedures, just getting too many pills when they leave the office or the hospital.

HENNING: How many pills should they get?

SHARFSTEIN: (um) Most people say that for most things three days is probably sufficient. But people very commonly will wind up at 30 days and for their stories—

HENNING: That’s a lot of extra pills, three days versus 30 days.

SHARFSTEIN: The second group is the use of opioids for chronic non-cancer pain. That was really where this push from patient advocacy groups, some physicians, and certainly fueled by the industry happened in the 90s to say actually, it’s really important for you to prescribe opioids for chronic non-cancer pain. These patients are really suffering and so, a lot of doctor’s changed, and this is where the bulk of the increase prescribing happened, and this is where I think, to a certain extent, the culture of medicine changed. People felt like opioids were really the thing to give someone with chronic lower back pain.

But getting doctors from where they were reaching for the prescription pad to where they are really following the CDC Guideline is a really important step there.

HENNING: Can I just interrupt you for a second to ask, What are some of the things you could do that wouldn’t be opioid based? What are some of the things that doctors might offer patients that wouldn’t really be about prescriptions for opioids to alleviate their pain?

SHARFSTEIN: Well, the field of pain medicine has many different options. So, there’s everything from physical therapy, which can be helpful for certain conditions. Acupuncture, which has proven effective for certain types of conditions. There are non-opioid pain medicines, which can work quite well for many patients. So, there is a range of things. There are certain types of injections, for example, in the right spot for a certain type of condition that can be very localized treatment, rather than have to treat the whole patient with the huge whopping dose of opioids. One of the things that’s become clear is that often those aren’t reimbursed by insurance and so, it’s not just that the doctor found it easy to write a prescription, but the insurer found it easy to pay for the prescription, and that’s really got to change to get at that second bucket.

Then there is the third bucket, which is really kind of fraudulent prescribing, and that goes by the name sometimes “pill mills,” where you basically would show up and if your heart was beating, you’d get an opioid prescription.

So, I think of the three there’s definitely been a lot of enforcement activity on pill mills. I think we’re seeing some reductions in those initial prescriptions. In the middle category, the really big category, I think that’s the biggest challenge. So, one of the things that has become very difficult is figuring out how to implement a new set of standards for writing a pain medicines without really causing a lot of problems for the people who are in treatment now and are doing basically okay.

HENNING: Why don’t we turn for a minute to people who are already addicted and what’s available for them. what do you think about treatment options? Where is the science headed in that regard?

SHARFSTEIN: When people are on opioids for pain, they may be doing fine and the right thing to do may be to leave them if they’re getting their pain relief, if they’re able to live their lives without any problem. But some people get into trouble. What does that trouble look like? That trouble looks like they’re requesting ever increasing doses, that they may be stealing to get more. They can be not doing their jobs anymore, particularly well, or it’s influencing their family relationships.

So, somebody whose life is going fine and they’re getting a stable dose they may be just okay, but somebody who is really out of control, that is a problem, and that is a problem for them in their lives.

HENNING: That’s really addiction. That’s really the definition.

SHARFSTEIN: That’s one of the core aspects of the definition of addiction, I think it’s important to point out that it’s not so easy to predict when you start people on medicines who’s going to have a problem with addiction. We know that people who are getting heavier doses for longer periods of time are at greater risk. There are also some genetic predispositions, also relates to what is going on in people’s lives and the stress that they have. It’s complicated, but then once people get into that problem they really are in trouble. They’re in trouble from many different directions. Their lives are really cracking, and it’s very important to be able to offer them treatment

HENNING: So, they could really be buying drugs off the street. They can really shift into a bigger problem.

SHARFSTEIN: Right. So, what can you offer someone who has either gotten into trouble with prescription opioids or has started on illicit opioids and is coming in having a big problem with heroin, for example? The medicines that have been approved by the U.S. Food and Drug Administration really aim to address some of the biochemical imbalances in the brain that have developed. There are two treatments that are called opioid agonists, methadone and buprenorphine. They basically provide a very stable amount of opioids. It doesn’t allow someone to get euphoric, to get sort of the sensation of being high, but at the same time it addresses some of the biochemical changes that are in the brain and the patients report that it really reduces their cravings for opioids.

Other aspects of treatment include counseling. People have to put their lives back together. They have to think about how they can live their lives without the relief or whatever they’re feeling that’s driving them without that urge to use opioids, and then sometimes are very concrete things that they need to be able to live a life of sobriety, which include a more stable living arrangement, a job, things like that.

There is a third medicine I should just mention which is called Depot Naltrexone. It’s a blocker of the opioid receptor and it also is approved for opioid use disorder. There is a lot of evidence to support effective treatment with medicines. There’s evidence that it can dramatically reduce overdose risk, particularly from methadone and buprenorphine. There is evidence that it helps people get jobs, reduces their risk of committing crimes, reduces their chance of HIV and Hepatitis C, and basically allows them to go back to living the life that they want to live. it’s not at all the case that it’s hopeless for someone. I think the key is to be able to connect people with treatment when they’re really there in front of you and one of the most promising strategies right now is to rapidly help people get access to treatment.

HENNING: That is encouraging. And I know there’s been a fair amount written in the press and in other venues about the acute event of overdose and what can people do about that, and what are some of the strategies and naloxone or Narcan is talked about fairly often. Is that a good strategy?

SHARFSTEIN: Sure. So, what’s going on chemically in the brain of someone who is overdosing is that they’re taking an opioid, the opioid is stimulating a particular receptor in their brain and one of the side effects of that receptor is that it tells the body to stop breathing. That is obviously very serious and if you take enough of certain kinds of opioids, you stop breathing. Naloxone is a blocker at that receptor. It kicks the opioid off it. It immediately restarts the breathing. As long as the person is alive they will wake right up, and it is essential to saving a lot of people’s lives and I think there are some very good data that when communities began distributing naloxone that the overdose fatality rate declined. But it doesn’t do anything for the underlying addiction. People suddenly are in withdrawal and they will want to use again to avoid going all the way into withdrawal. So, you have these situations where people are being resuscitated again and again, and that can cause some compassion fatigue as they say among the EMTs who are providing the naloxone and so, I think that the general feeling is people should have access to an array of services, not just naloxone. Naloxone is very important in life-saving. And then you want to be able to help people take a step closer to recovery and for some people that may be getting them all the way into treatment. There are emergency departments that offer treatment right there. There’s programs that send out peers to connect people into care after an overdose. Those are the kinds of promising programs that are paired up with naloxone.

HENNING: You’ve made a strong case, I think, for medication assisted treatment for people who have an opioid addiction and also some discussion about Narcan and its really life-saving attributes. Can you–can you talk a little bit about harm reduction? Can you talk about what role that might have and what some of those strategies might be and why they’re important, potentially?

SHARFSTEIN: Sure. Harm reduction means a lot of different things to different people. For me, harm reduction is the idea that we want to help people move towards recovery. We want to help people, no matter where they are on the spectrum of drug use. We want them to be able to be functional and with their families, doing the things that they want to be doing.

It has many different components. So, most people would say that Narcan is a harm reduction technique, because Narcan and naloxone reverses the overdose, keeps someone alive and allows them to take whatever that next step might be. Syringe exchange is another type of harm reduction activity. It basically not only provides for reduced risk for HIV, by making sure people are using clean needles if they’re injecting, but it also gives an opportunity to connect with someone and talk to someone when they’re trading their used needles for the clean needles. They can talk about what they’re doing to get food, what they’re doing to get shelter, how they’re trying to protect themselves, and ultimately what opportunities are there for people to get into treatment,

HENNING: So, given all these various facets of the epidemic and the ways of addressing it, could you comment on whether there are any countries or maybe states within the U.S. who’ve been doing a particularly good job at addressing this epidemic?

SHARFSTEIN: Sure. So, I did mention Europe a bit and the fact that in certain countries, Portugal for example, Spain is another example, treatment is pretty easy to come by. That there is an array of services for people at different stages of drug use and this ability to kind of go upstairs and get treatment and really put their lives back together. And I think one of the other hallmarks is that the drug use itself is not overly criminalized and there is such a vicious cycle that kicks in when people who are just non-violently using drugs wind up arrested.

In the United States, I’ve been particularly impressed with Rhode Island. Rhode Island has reconfigured its response to the opioid epidemic over the last few years, focusing very strategically on a few major initiatives.

On prescribing, they focused a lot on the dangers when opioids are used with this other class of medicines called benzodiazepines. The health commissioner there, the health commissioner from Baltimore City led a national petition that was granted to put a black box warning on all the medications to try to dissuade doctors from using these two classes of medicines together because they’re more likely to cause an overdose. And then they’re tracking the co-prescribing. One of the most creative things that they’ve done is that they’ve decided to offer treatment to everyone who comes into the jail or prison in Rhode Island with opioid use disorder with an opioid addiction, with any one of the three FDA approved medicines, methadone, buprenorphine, and depot naltrexone.

It’s easy for them to do, I should say relatively easy, because there is only one jail and one prison in Rhode Island, and they’re located next to each other, but they have created a very comprehensive approach to treatment with the support of the governor and the General Assembly and the results of that have been quite good because previously, people who had an addiction to opioids would go in to jail and they would basically have to withdraw off and maybe they got a little bit of medicine so the symptoms of withdrawal weren’t so bad, but the result was they were off. They were often consumed by craving. They weren’t getting any real treatment and as soon as they got out, which could be a couple of days to a week to a month, soon as they got out, they would want to use again and they were at such high risk of dying, particularly with the Fentanyl problem that Rhode Island, has seen.

So, you go from that situation where the evidence is probably a ten-fold increase in risk of overdose. Now you use that jailing as an opportunity and you say well, we’re going to actually get you into treatment. You’re not going to go into withdrawal. And that’s in accordance with a lot of evidence saying that that’s not only good for you, but it’ll reduce the chance you have to commit a crime again or you do commit a crime again. And what they’ve seen is a 60% decline in opioid overdose deaths year over year from before when they implemented this new approach to afterwards. And that’s responsible for a statewide decline in overdose deaths, even as the percentage of Fentanyl deaths has increased. I think it sends a signal that there are things that can be done.

HENNING: That is indeed encouraging. I’d like to really say that we’ve learned a lot from our conversation about the opioid epidemic in the United States. It’s a complex challenge. It requires a lot of action on many levels, but it is possible to address it and your comments are really very well received. I wonder if in summary, you would like to mention what you think the primary steps are that should be taken nationally to address the epidemic.

SHARFSTEIN: First, I think it’s important for the country as well as states and localities to have access to better data so that whatever they’re trying, they can assess very quickly whether it’s working or not.

Second, I think it’s important to pay attention to the over prescribing of opioids and I personally support helping doctors adhere to guidelines like the CDC Guidelines on chronic non-cancer pain which really are thoughtful and talk about the need to try other things first, use opioids as a last resort, and provide some clinical judgment, and aren’t so arbitrary that they could wind up hurting a lot of patients who are doing okay on opioids for pain.

Related, I think it’s important that there be support for non-pharmaceutical approaches to pain management and that really is important for insurance companies. Insurance companies have to be able to cover the other types of treatments. Otherwise, all that’s left is the prescription and that’s kind of what caused the problem in the first place.

Beyond the overprescribing, increasing access to treatment is really important, and some of the most promising approaches are to give access to treatment rapidly to people right there when they’re right in front of caregivers or others, so that includes in the emergency room, it includes in criminal justice systems.

Part of that is countering the stigma that’s associated with methadone and buprenorphine. There is a lot of stigma on addiction. There’s extra stigma on the treatment. It’s really important for people to understand that the important thing is for people to be in recovery and to be able to live the lives they want to live, somebody who got a job, got their family back, looking like, you know, anybody else on the street doing fine, if they’re taking a medicine, that’s totally okay. It’s not a sign of weakness; it’s a sign of strength to be taking your medicine and to be doing well in your life.

People may ask, how do you pay for this? There is a lot of need for more treatment. There’s a lot of need for education of physicians, and one promising route is to hold the pharmaceutical companies accountable, because some of their marketing and activities in creating this problem we’re very much responsible for it and the lawsuits that are going on hopefully will end with some extra resources that can be used to help a lot of people.

And then finally I would say that is important for there to be some innovation in the response, particularly with Fentanyl. We don’t know yet everything to do because this is a new problem. Is there something that can be done to keep the Fentanyl from coming into the country at all? Once it’s here, are there new tools that can be used? And we have been involved in testing different technologies to see whether people who use drugs can know whether Fentanyl is in those drugs and use that information to protect themselves in different ways and have that tool be a tool of engagement to help move people along.

I think, you know, in the end, we have to see this as a problem that in fact can be solved, that we can make progress on it. That we can take people who are deep into addiction and move them along towards recovery. We can prevent people from getting addicted in the first place, and we can follow the evidence to have an impact on one of America’s greatest public health challenges.

HENNING: Thank you again, Dr. Sharfstein, for being with us today.

SHARFSTEIN: Thanks for having me.

OLIVER: We hope you enjoyed this episode of Follow the Data, and many thanks to Dr. Joshua Sharfstein for joining us. If you’d like to learn more about the Bloomberg American Health Initiative, check out the American Health Podcast, which can be found on iTunes or Google Play. You can also visit AmericanHealth.jhu.edu

If you haven’t already, be sure to subscribe to Follow the Data podcast. This episode was produced by Ivy Li, Electra Colevas, and Jean Weinberg, with music by Mark Piro. Special thanks to David Sucherman.

As our founder Mike Bloomberg says, if you can’t measure it, you can’t manage it. So until next time, keep following the data.

I’m Katherine Oliver, thanks for listening.