Disease, Health Policy, Healthcare Reform, opioids, Recommendations, Substance Dependence

Opioid Policy

Continuing this week’s focus on opioids, we discuss some of the policies that have been attempted to stem the tide of the opioid epidemic. Check them out below!

Local and non-Governmental.

Lock-in Programs. Insurance companies, hoping to limit the staggering financial burden the opioid crisis has placed on them, have implemented several strategies to prevent the overuse of opioid medications. One such strategy is called patient review and restriction or Lock-in. This strategy requires that patients suspected of misusing opioids and other controlled substances use a single prescriber or pharmacy to obtain their controlled substance prescriptions. These programs look to have significant cost savings and may be more widely implement in the future.

Take-back Events.­­ Many municipalities have introduced drug take-back events that encourage patients to properly dispose of unused medication. States have sponsored messaging campaigns about the safe storage and disposal of opioids. These interventions are designed to educate patients on the dangers of keeping unused opioids and to make it easier to dispose of them. Evidence on their effectiveness is mixed.

Education.  Other interventions have been aimed at changing knowledge and attitudes related to SUD. These interventions range from handing out pamphlets to intensive counseling programs. While many of these programs appear to be effective, they are by nature small in scope and resource intensive to scale up.

Safe Injection Facilities. Safe injection facilities are places where individuals can inject drugs in a safe location, typically with treatment services located nearby and with medical personnel available to treat any issues. These facilities reduce drug related mortality and needle-borne infections. They currently face zoning restrictions, legal challenges, and community disapprobation. However, because of their effectiveness, some states are creating policies that support their creation.

State and Federal.

Naloxone. One change that has proven successful at decreasing deaths from opioid- induced respiratory depression (OIRD) is making naloxone, a medication that reverses OIRD, more easily available. Current recommendations suggest that naloxone be co-prescribed with opioids, especially when patients have a history of opioid misuse. As of 2016, forty-seven states had passed legislation designed to increase lay-person access to this life saving drug. These laws take on three forms. First, they may provide naloxone prescribers, dispensers, and administrators with protection from criminal and civil lawsuits related to the drug. Second, allowing naloxone to be prescribed by providers to individuals outside of their practice. This may mean that providers can prescribe to third parties or that there are standing orders making the drug available without a prescription. Third, Good Samaritan laws provide protection to individuals who seek emergency help for some experiencing overdose. Because many people who witness an overdose may be engaging in illegal behavior themselves, they may be hesitant to contact emergency responders in the case of an overdose. These laws provide limited immunity from prosecution for minor drug-related offenses.

MAT. Medication assisted treatment—MAT—is the most effective treatment for opioid use disorder. MAT combines traditional counseling approaches with the use of certain opioids—methadone, buprenorphine, and naltrexone. Despite its effectiveness, MAAT faces stigma, legal limitations, and a lack of prescribers. Patients who can find providers willing and able to treat OUD may be unable to afford the treatment. Historically, very few insurance plans have provided coverage for MAT, especially those for lower income individuals. The Affordable Care Act (ACA) attempted to address these issues, but treatment is still limited and the ACA’s future is unsure.

PDMPs. Prescription Drug Monitoring Programs (PDMPs) are one solution that states are using to try and monitor who is providing opioids and who is receiving them. These programs are designed to both prevent physicians from over-prescribing and to prevent patients from doctor shopping. Currently, 49 states, Washington D.C. and Guam have operational PDMPs. Data on PDMP effectiveness varies, but suggests that they are effective at reducing controlled substance prescribing. After implementation of PDMPs, doctor shopping has decreased by at least 41%, prescribing either leveled off or decreased, and overdoses, overall, have dropped.

ESOOS. In addition to monitoring prescriptions, many states are implementing enhanced monitoring of drug overdoses. Starting in 2016, the CDC funded 32 states to participate in the Enhanced State Opioid Overdose Surveillance (ESOOS) program. The ESOOS collects hospital billing data to determine overdose visits. While the data gathered thus far shows mixed results in state efforts to decrease opioid overdose, the ESOOS has created a national database of information and encourages state accountability.

Outside the U.S.

The opioid epidemic extends beyond national borders. Many western countries are dealing with the new proliferation of opioids and the associated increase in OUD. There are two major policies that have been enacted by countries outside of the United States in order to stem the increase in opioid misuse.

Marketing Limits. In Western European countries, marketing of drugs is strongly regulated compared to the United States. Specifically, pharmaceutical companies are not allowed to offer any kinds of benefits to physicians or the organizations that govern them. This is a broad regulation that prohibits not only the direst transfer of funds or presents, but also things like the all-expense paid conferences that were an important part of marketing in the U.S. This policy is enforced by both governments and medical associations, and has resulted in significantly less heavy marketing of prescription drugs.

Decriminalization. Many of the harms associated with drug addiction come not from the addiction itself, but from the stigma attached to it. This stigma has been codified through laws that punish addicts. Changing the law—or its enforcement—to decriminalize the use of opioids is one policy that attempts to address this problem. Various forms of decriminalization have been enacted throughout the globe, including Australia, Portugal, the UK, Canada, and the U.S. When these changes have been made, there has been no increase in the use of controlled substances, but significant drops in the rates of overdose and overdose death.

Have you seen other policies implemented to address opioids? Which ones do you support?

For more information, check out these sources:

  1. Haegerich TM, Paulozzi LJ, Manns BJ, Jones CM. What we know, and don’t know, about the impact of state policy and systems-level interventions on prescription drug overdose. Drug and Alcohol Dependence. 2014;145:34-47. doi:10.1016/j.drugalcdep.2014.10.001.
  2. Gostin LO, Hodge JG, Gulinson CL. Supervised Injection Facilities. Jama. 2019;321(8):745. doi:10.1001/jama.2019.0095.
  3. Davis CS, Carr DH. The Law and Policy of Opioids for Pain Management, Addiction Treatment, and Overdose Reversal. Indiana Health Law Review. 2017;14(1). doi:10.18060/3911.0027.
  4. Questions and Answers. State Prescription Drug Monitoring Programs. https://www.deadiversion.usdoj.gov/faq/rx_monitor.htm. Accessed April 16, 2019.
  5. Prescription Drug Monitoring Program Center of Excellence at Brandeis. Briefing on PDMP Effectiveness.http://www.pdmpassist.org/pdf/COE_documents/Add_to_TTAC/Briefing on PDMP Effectiveness 3rd revision.pdf. Published September 2014. Accessed April 16, 2019.
  6. CDC’s Enhanced State Opioid Overdose Surveillance (ESOOS) Program, 32 states and the District of Columbia reporting, https://www.cdc.gov/drugoverdose/pdf/data/CDC_ESOOS_April2018_508.pdf. April 2018.
  7. Vokinger KN. Opioid Crisis in the US – Lessons from Western Europe. The Journal of Law, Medicine & Ethics. 2018;46(1):189-190. doi:10.1177/1073110518766033.