1. Kim Krisberg

• Copyright The Nation’s Health, American Public Health Association

Confronting an opioid overdose epidemic that kills nearly 100 Americans every day takes a combination of interventions across sectors. But a common thread throughout, says Andrew Kolodny, MD, should be viewing the problem not as an epidemic of abuse, but as an epidemic of addiction.

“If you refer to it as an abuse problem, it leads people to believe the problem is a lot of folks behaving badly and abusing drugs,” said Kolodny, co-director of opioid policy research at Brandeis University. “But that’s not at all what’s going on. The majority of deaths happen in people suffering from opioid addiction — these are people who aren’t taking opioids for fun but to avoid feeling the agonizing pain of withdrawal.”

In fact, Kolodny sees the opioid addiction crisis as similar to a disease outbreak — “you have to contain the outbreak by preventing new people from becoming infected and make sure everyone already infected gets the best possible care so they don’t die from infection,” he told The Nation’s Health.

Preventing further “infection,” or new cases of opioid addiction, he said, boils down to one overarching strategy: more cautious prescribing.

“For a while now, CDC has been pointing out that the rise in deaths has corresponded with a rise in prescribing,”said Kolodny, who also serves as executive director of Physicians for Responsible Opioid Prescribing. “And now we see much greater recognition that it’s overprescribing that’s driving this epidemic.”

The Centers for Disease Control and Prevention reports that drug and opioid-related overdose deaths keep rising in the U.S., with rates up among men and women and among all racial and age groups. In the U.S., more than three of every five drug overdoses involve an opioid, with overdose deaths due to both prescription opioids and heroin quadrupling since 1999. According to data published last year in CDC’s Morbidity and Mortality Weekly Report, opioid-related overdose deaths increased by 14 percent between 2013 and 2014, including a sharp increase in deaths associated with the synthetic opioid fentanyl. Such findings, the researchers wrote, “indicate that the opioid overdose epidemic is worsening.”

At public health departments nationwide, prevention is guiding work to stem the overdose epidemic, with efforts focused on both avoiding addiction in the first place and preventing fatal overdoses in people already addicted. On the addiction side, changing the way medical professionals prescribe highly addictive opioid painkillers is a key intervention point, with CDC releasing its “Guideline for Prescribing Opioids for Chronic Pain” in 2016. Noting that opioid prescriptions went up 7.3 percent per capita from 2007 to 2012, the evidence-based guidelines recommend prescribers consider nonpharmacologic and nonopioid therapy for chronic pain, concluding the “clinical evidence review found insufficient evidence to determine whether pain relief is sustained and whether function or quality of life improves with long-term opioid therapy.”

The guidelines recommend prescribers fully discuss the risks and benefits of opioids with patients, start patients on the lowest effective dose if opioids are needed and assess a patient’s risk of opioid-related harm, among other measures. In an article accompanying the new guidelines and published in the Journal of the American Medical Association, researchers with CDC’s National Center for Injury Prevention and Control concluded that “of primary importance, nonopioid therapy is preferred for treatment of chronic pain.” Kolodny said the CDC guidelines marked a substantial shift in how to address the role of prescribing in rising opioid addiction.

Since their release last year, the CDC guidelines have become a frontline tool in public health efforts to stem opioid addiction and overdose risk. Also on the frontline are prescription drug monitoring systems, which are often administered by health departments and allow prescribers to view a patient’s prescription drug history. In fact, the CDC guidelines recommend prescribers use such systems when prescribing opioids. The systems, which can serve as an early warning of addiction and risky drug behaviors as well as highlight signs of drug sharing, operate in every state and Washington, D.C., except Missouri, though the state’s legislature was considering a bill to create such a system earlier this year.

Research finds that prescription drug monitoring programs can impact opioid prescribing. For example, a 2015 report prepared for the Kentucky Cabinet for Health and Family Services found that since the state began requiring prescribers to register with and use such systems in 2012, opioid prescriptions have decreased with no negative impact on patients who need opioids for chronic cancer pain. Findings from Pennsylvania’s monitoring system, which began in 2016, showed that doctor-shopping, in which patients visit multiple doctors to procure medications, fell by 94 percent.

“Prescription drug monitoring systems have emerged as a very useful tool (in confronting the opioid epidemic),” said Peter Kreiner, PhD, principal investigator of the Prescription Drug Monitoring Program Training and Technical Assistance Center at Brandeis University, which assists local officials in implementing and enhancing their monitoring systems. “And because they’re run at the state level, it fosters a lot of innovation and allow states to specifically respond to what’s happening in their own communities.”

Besides shifting prescribing practices, Kreiner said monitoring system data also let public health practitioners track trends and patterns over time, which helps officials know where and when to deploy proactive prevention efforts. For instance, he said, the data can reveal areas of a state where providers need more education on the latest prescribing guidelines or communities where expanded access to naloxone could stem fatal overdose rates. Naloxone is a prescription medicine that can reverse an overdose.

Kreiner said work is underway in many states to make the systems easier for prescribers to use, such as connecting the data to electronic health records and generating daily opioid dosages across a patient’s multiple prescriptions. He also noted that in communities without access to addiction treatment services, monitoring systems data may be particularly useful in identifying patients who need greater engagement with their medical providers.

“These programs are a major public health asset,” Kreiner told The Nation’s Health.

In addition to better linking public health and physicians, the monitoring systems also connect public health to pharmacists. Heather Free, PharmD, a practicing pharmacist in Washington, D.C., and spokesperson for the American Pharmacists Association, emphasized that the systems are not for “policing” patients, but for identifying those who need help. The data, she said, alert her to patients who need more information on nonopioid therapies and those who should have naloxone on hand as a precaution.

Free noted that many states allow pharmacies to have a standing order to dispense naloxone, which is nonaddictive, as part of efforts to reduce fatal overdoses. Pharmacists can also help with the diversion of opioids for nonmedical use, such as partnering with law enforcement to install secure take-back boxes outside of pharmacies. Free said she recently began dispensing a new tool to prevent diversion: a small, biodegradable bag that neutralizes painkillers’ active ingredients when water is added and allows for the safe disposal of opioid medication at home.

Of course, because the opioid epidemic is such a complex problem, one of public health’s greatest tools is its expertise in convening multisector solutions. In 2016, the Los Angeles County Department of Public Health helped convene and launch Safe Med LA, a cross-sector coalition that includes local health and law enforcement agencies, health insurers and health care providers and organizations. An overarching mission of the coalition is to carry out the public health agency’s five-year plan to reduce prescription drug overdose deaths by 20 percent by 2020.

Gary Tsai, MD, medical officer and science officer in the agency’s Substance Abuse Prevention and Control program, said Safe Med LA allows for a more coordinated response to the problem.

“One of public health’s real strengths is seeing things from a population perspective,” he said. “So when we have complicated problems like this, we know the solutions needs to be similarly sophisticated.”

For more information, including links to opioid-related prevention tools, visit www.cdc.gov/drugoverdose/epidemic.