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How America Can Effectively Fight the Opioid Crisis

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Stanford University

Over the past 15 years, the American death rate from opioid-related overdoses has increased by more than 200%. Each year, more people now die from overdose deaths than those that died of AIDS at the peak of that epidemic. The human cost of addiction and overdose is accompanied by a substantial financial price – an estimated $78.5 billion in 2013 alone to pay for opioid use, abuse, and overdose treatment.  

Solving the U.S. opioid epidemic requires coordinated efforts. The federal government, opioid manufacturers and distributers, and health insurance agencies all must work together to improve data collection systems, monitor prescriptions, and account for unfinished prescriptions. These tasks are expensive and difficult, but if they are not jointly accomplished the epidemic will continue to rage at great expense to American society and taxpayers.  

An Urgent Need for Better Government Data

Policymakers need accurate data in order to craft effective solutions, but good data are missing about U.S. heroin use, the primary driver of the growth in overdose mortality since 2014. Research suggests that the heroin death rate is actually 22 percent above the government’s official figures. A frequently-cited U.S. estimate of 591,000 people suffering from a heroin use disorder comes from the federal government’s annual National Household Survey on Drug Use and Health. But before the crisis exploded in 2010, that survey could only identify 60,000 of the one million Americans who met criteria for this disorder. 

This survey has two serious flaws. It excludes people who are incarcerated and those who are living on the street, two groups with very high rates of drug use. And it relies on self-reports, even though many people are understandably reluctant to disclose their use of heroin to government surveyors. Furthermore, recent Congressional cuts in federal spending have forced many government agencies to curtail their research capacities. In 2011 the budget ax hit national programs that gathered substance use data from emergency room patients, and the same happened in 2014 to data collection from people entering jails. Unless state and federal governments invest in better data collection, the nation will continue to fly blind on the heroin epidemic, unable to determine the effects of current policies for better or worse.

Manufacturers and Distributors Must Facilitate Drop-Off Locations

Most of the roughly 200 million opioid prescriptions dispensed annually in the United States are not finished by the patient for whom they are intended. An enormous reservoir of excess pills fuels the epidemic, as these pills let people experiment with drug use or fall into the hands of addicted individuals and dealers. Efforts to remove this threat have fallen short.

  • The Drug Enforcement Administration instituted prescription take-back days that allow anyone to drop off pills at designated locations with no questions asked. This is an effective strategy but happens too infrequently to make much of a dent in the supply of unused opioids.
  • In 2010, Congress passed useful legislation authorizing pharmacies, hospitals, clinics that dispense opioids to operate prescription drop-off locations throughout the year, but only 2.5 percent of eligible organizations are participating.

The key barrier is financial because maintaining the safe-like prescription drop-off container, training staff to follow relevant regulations, and destroying the returned medications are all expensive steps, and most public and private sector organizations are unwilling or unable to absorb the costs. Opioid manufacturers should be required to bear this burden. They have earned billions of dollars in revenue and at least some of them played a significant part in starting the epidemic. Mandating opioid manufacturers to pay patients and drop-off location operators a few dollars for every returned bottle of pills may be a useful approach toward making the return of leftover medication as automatic and prevalent in America as recycling cans and bottles.

Medicaid is Not to Blame – But Insurers Do Have an Important Role to Play

Some politicians like Wisconsin Republican Senator Ron Johnson have blamed the opioid crisis on the expansion of Medicaid coverage under the Affordable Care Act. Such politicians claimed that expanded insurance made an excess of opioids available and inexpensive – but the evidence suggests otherwise. The Act’s expansion of Medicaid never reached all U.S. states and did not begin until 2014 – well after the 15-year-long quadrupling of prescription painkiller overdoses deaths from 4,030 to 16,234. Since 2014, furthermore, black market heroin, much of it laced with fentanyl, is much more responsible for the growth in overdose mortality than any expanded access to the health-care system. Oregon’s Medicaid Experiment found that Medicaid had no effect on the likelihood that patients would get opioid prescriptions. Rather than causing the crisis, Medicaid reduces overdose deaths as the lead payer for heroin addiction treatment.

Enrollees of all private and public insurance programs may receive unnecessary opioid prescriptions – either because they intentionally fake pain or because their physician prescribes inappropriately. To prevent this, insurance programs should use education and take protective steps. In fact, insurance companies are uniquely positioned to fight “doctor shopping” through which almost three million Americans receive prescriptions from five to as many as 20 different physicians. Doctors do not know about the multiple visits, but insurers have a patient’s full information and can collate separate billings and use “reimbursement lock-in” to allow the enrollee’s prescriptions for opioids to be covered only if written by a single provider. Medicaid has already initiated effective lock-in programs; North Carolina, for instance, has reduced controlled substance prescriptions by 17 percent among Medicaid enrollees suspected of doctor shopping. If done with care, locking patients with many previous prescriptions into single providers not only lowers risks of overdoses but also reduce costs for employers or taxpayers. 

In sum, there is no single magic solution, but America can tackle the opioid crisis with increased funding for programs known to be effective. Improved funding for accurate data collection will, in turn, support wiser policymaking, allow opioid manufacturers and distributors to set up drop-off locations along with effective services, and help insurers implement and improve reimbursement lock-ins. All Americans will benefit if these steps are jointly implemented.

Read more in Peter Friedmann, Christina Andrews, and Keith Humphreys, “How ACA Repeal Would Worsen the Opioid EpidemicNew England Journal of Medicine 376no. 10 (2017): e16.