Candace Saldarini, MD and Lisa Strouss, PharmD, published in Behavioral Health News on the opioid crisis.

1 November, 2017

Opioid overdoses led to more than 33,000 deaths in the U.S. in 2015—an average of 91 per day, according to the Centers for Disease Control. That national death toll is the “equivalent to America enduring another 9/11 attack every two-and-a half weeks,” says New Jersey Governor Chris Christie, newly appointed chairman of the President's Commission on Combating Drug Addiction and the Opioid Crisis. Addressing this epidemic is a top priority of The Centers for Medicare and Medicaid Services (CMS). Its strategy is built on four pillars:

  1. Implement more effective person-centered and population-based strategies to reduce the risk of opioid use disorders, overdoses, inappropriate prescribing, and drug diversion;
  2. Expand naloxone use, distribution, and access, as appropriate;
  3. Expand screening, diagnosis, and treatment of opioid use disorders, emphasizing increased access to medication-assisted treatment; and
  4. Increase the use of evidence-based practices for acute and chronic pain management.

These are laudable goals and we believe that significant public and private resources should be devoted to achieving them. However, it is important to step back and view opioid use disorders through a wider lens. To combat opioid misuse and promote programs that support treatment and recovery, the healthcare system must look holistically at individuals with opioid use and dependence issues.

That means seeing those individuals not solely as having an opioid problem, and focusing not only on their clinical needs arising from the substance abuse. Rather, we must also consider other health issues – such as co-morbid behavioral or physical health conditions – in conjunction with the disorder that may be an exacerbating factor.

People with a substance use disorder are more likely to have a mental disorder such as depression – and people with a mental disorder are more likely to experience a substance use disorder – when compared to the general population. Individuals who have both a substance use disorder and another mental illness often have symptoms that are more severe and resistant to treatment compared with those who have either disorder alone. And yet, only a tiny percentage of individuals presenting with co-morbid substance use and mental health disorders are enrolled in a comprehensive treatment program.

Additionally, healthcare professionals have an obligation to understand the economic and social challenges confronting individuals with a substance use disorder. Are they impoverished, living in and out of public housing, suffering from food insecurity or lacking transportation to keep a doctor’s appointment? Unless these kinds of conditions are addressed and, at least to some extent, alleviated, there is little likelihood that we can improve patients’ medication adherence and reduce opioid dependency.

In short: we need to examine the factors in an individual’s life that can be impacted in a positive manner to diminish opioid dependency. Taking a comprehensive view of individuals with opioid use disorder requires sharing of data among health plans and patients’ various providers at the point of care. However, current restrictions on health plans sharing opioid disorder claims or prescription data with providers, and providers sharing patient data with each other, impose a barrier to optimal treatment.

Providing necessary patient privacy safeguards, of course, must always be a top priority. But policy makers should consider reforming federal confidentiality regulations pertaining to substance use treatment to allow appropriate data exchange among healthcare professionals, while still protecting patient privacy.

State-based prescription drug monitoring programs are a step in the right direction. These electronic databases are designed to give providers access to patients’ controlled substance prescription history and help them identify opioid misuse. However, states have their own rules on what data to collect and share, creating an ineffective regulatory patchwork quilt. Many states, in fact, don’t share their data with other states at all.

Aggregating physical health, behavioral health and social determinants of health data can play a key role in assessing and treating opioid use disorder. Technology tools can help bring together disparate data to inform thoughtful interventions. For example, specific cohorts can be identified such as:

  • Individuals already identified as having an opioid use disorder
  • Individuals vulnerable to the disorder because of specific preexisting conditions such as depression
  • Providers who may be misprescribing opioids

Applying analytics to aggregated data can help identify risk factors that may suggest an individual’s vulnerability to opioid use disorder. These factors may include being male, unmarried or publicly insured, or having mental illness, chronic disease, lower back pain, hepatitis or a history of prior addiction. Certain patterns of care such as repeated emergency room visits may also be an indicator.

Consider the hypothetical example of John, a man in his twenties who transitions from taking prescription pills to injecting heroin and becomes infected with hepatitis C. His health plan refers him to a facility where he receives high quality psychosocial interventions plus medication-assisted treatment.

But John is unable to get to the pharmacy or keep his doctors’ appointments because he has no car and buses don’t service his rural neighborhood, and, living paycheck to paycheck, he sometimes doesn’t know when his next meal will be. For people like John, the struggle to meet life’s basic necessities like food and transportation invariably outweigh healthcare concerns.

So, despite the best intentions of his health plan and healthcare professionals engaged in his care, John is unlikely to adhere to his treatment regimen and his condition will worsen. In this case, the lack of a holistic approach has failed the patient.

If, on the other hand, the plan or his healthcare professionals had tools that provided comprehensive data - including social issues – demonstrating barriers to care, they could make referrals to social services agencies and food banks. Peer support programs referrals could also help individuals like John in their recovery journey. Peer support coaches access community resources, assist with transportation to medical appointments, encourage self-help efforts and generally serve as mentors. These relatively simple interventions can help John get his life on track, thereby enabling him to more actively participate in his treatment.

Combating this epidemic requires a comprehensive strategy that promotes safe, effective and appropriate treatment for those with opioid dependency. The Christie Commission’s final report, which will be released this fall, is expected to promote wide-ranging recommendations for a holistic approach. To succeed, this approach must be enabled by data aggregation and analytics tools which identify individuals in need and the best evidenced-based treatment to help them on their road to recovery.

By Candace T. Saldarini, MD, Medical Director; and Lisa Strouss, PharmD, Director, Field Medical ODH, Inc.

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