The U.S. Opioid Epidemic: Tackling Misuse and Addiction from the Inside

Widespread misuse of both prescription and non-prescription opioids led the Department of Health & Human Services to declare a public health emergency last year. Opioid overdoses accounted for more than 42,000 U.S. deaths in 2016, more than any previous year on record. Furthermore, an estimated 40 percent of those deaths involved a prescription opioid.

“A patient-centered approach is vital to improve opioid safety.”

At the 2018 Centers for Medicare & Medicaid Services (CMS) Quality Conference, health care quality leaders from across the nation made it their mission to work together to combat this crisis from within the system.

With 12 breakout sessions and a large part of the first-day plenary focused solely on fighting the opioid epidemic, attendees were able to hear from patients, physicians, CMS leadership, advocacy organizations and others on the impact and pervasiveness of opioid misuse and addiction in the U.S. It’s a topic that hits close to home for many, with opioids largely impacting aging and underserved populations with acute or chronic pain, meaning many Medicare and Medicaid beneficiaries.

And throughout all of the sessions, a common thread was clear: a patient-centered approach is vital to improve opioid safety.

Anita Thomas, CMS’s Quality Improvement Organization (QIO) Program Patient Safety lead, began one of the first breakouts on the topic—focused on patient-centered approaches to improve opioid safety—with a statement of hope.

“I think at CMS, we are poised for our networks to make a difference, particularly the Quality Innovation Network-QIOs, who work directly with the most in-need communities,” Thomas said. “Now is the time to better understand the complexity of this crisis and identify solutions together.”

Advancing Pain Management

During that same session, David Andrews, a Campaign for Meds Management (CMM) core team member and beneficiary advisor, said that pain management is a necessary conversation topic for addressing the larger issue at hand.

“I’ve been prescribed opiates in many cases—most I don’t take because of my high pain tolerance, developed at an early age by visiting the dentist without novocaine,” Andrews said. “Sometimes I do [take them], but find you can still feel the pain,” he said, adding, “No one in my medical history has ever asked me, ‘How do you deal with pain?’”

Other panelists agreed that this is a question that the healthcare community needs to start asking.

Another recurring topic was the taboo nature of opioid misuse in the U.S., often meaning that patients avoid having a conversation on the topic with loved ones and even their physician. At the conference, QIN-QIOs working on Special Innovation Projects discussed how building a relationship between providers and patients is essential to produce valuable interactions for both parties.

Addressing Rural Communities

Opioids affect every community across the nation, often with high concentrations of addiction in rural areas. One conference session was dedicated entirely to comprehensive care management strategies to address the opioid emergency in rural health care settings, where access may be an issue.

The Centers for Disease Control and Prevention (CDC) played a large role in the conference, with Jan Losby of the Prescription Drug Overdose Health Systems and State Support Team setting the stage by detailing the three waves of the opioid epidemic. The first, in 1999, saw an increase in deaths involving prescription opioids. That was followed in 2010 with an increase in heroin-involved deaths, and, finally, in 2013, with more deaths involving synthetic opioids like illicitly manufactured fentanyl.

Losby explained how chronic pain is one of the most common causes of visiting a provider, and half of opioids on the market are for the treatment of chronic, non-cancer pain. Thus, the CDC is focusing its work, including the RX Awareness Campaign, on determining when to initiate or continue opioids for chronic pain, and selecting opioid dosage, duration and discontinuation. To do so, it provides a number of educational materials for patients and providers.

Tony Campbell of the Center for Substance Abuse Treatment at the Substance Abuse and Mental Health Services Administration (SAMHSA), added that improving access to treatment and recovery services in rural communities is vital.

“There are a lot of individuals who need, but don’t have, access,” Campbell said. “On another note, unfortunately, addiction has a negative stigma, and people may not want treatment in their backyard.”

Shifting the Focus from Addiction to Disease

The treatment of opioid addiction was another key topic during the conference.

Judy Bartlett, Project ECHO program operations director, said, “Opioid addiction is a chronic disease, just like hypertension and diabetes. To stabilize and have recovery, we need medication and treatment, not just prevention.”

“A misconception is that we’re swapping drugs for drugs. Well, we’re swapping a debilitating drug for a lifesaving drug,” Bartlett continued.

One of these treatment medications is methadone. Unfortunately, as Campbell explained, methadone has a stigma associated with it. Utilizing naloxone or buprenorphine will solve this issue, Bartlett explained. The bigger issue, reducing the stigma itself, will be another, larger effort—starting with training on person-first language to reduce stigmatizing behavior.

Bartlett also looked at the crisis through the lens of primary care settings, which, as she explained, have special and important roles to play in medication-assisted treatment. She mentioned that QIN-QIOs are working with clinics on screening, harm reduction and treatment, but commitment to continuous quality improvement must start at the top.