While the U.S. has been battling Covid-19 it’s gotten lost in the shuffle that the nation had record numbers of drug overdose-related deaths in 2020; approximately 93,000. In addition, from May 2020 through April 2021, the figure rises to 100,000. These numbers of fatalities constitute significant year-to-year increases.
Contrary to public perception, the problem of misuse, abuse, and diversion of prescription opioids has been much less of a factor in recent years. A picture of a bottle of prescription painkillers often accompanies articles on drug overdose deaths, which creates an erroneous impression.
And so it’s important to properly distinguish between the role of illicit and prescription opioids in the current crisis. Heroin and illicit synthetic fentanyl account for the vast majority of drug overdose-related fatalities, with fentanyl being far and away the biggest driver.
The opioid crisis has been called the “most consequential preventable public health problem in the U.S.” Arguably, it is. In October, without much fanfare, the Biden Administration proposed new measures to curb the rise in drug overdose deaths.
There’s a building consensus around expanding federal support and coordinating certain harm reduction strategies for people actively using illicit drugs; for example, wider distribution of fentanyl test strips, which help users avoid street drugs contaminated with the deadly synthetic opioid.
More controversially, perhaps, the Biden Administration’s plan also embraces expansion of needle exchange programs, which for several decades have demonstrated effectiveness in reducing the spread of contagious diseases such as HIV and hepatitis.
At the municipal level, we’re already seeing implementation of comprehensive programs designed to reduce harms in those who are using illicit drugs. New York City is authorizing the establishment of two supervised injection sites for drug users in Manhattan.
The facilities will provide clean needles and administer medication, such as naloxone, to reverse overdoses. Users will also be offered options for addiction treatment.
The city’s health commissioner, Dave Chokshi has called the overdose crisis a “five-alarm fire in public health in New York City and nationally … Overdose prevention centers are a key part of broader harm reduction.”
Role of Prescription Opioids
During the opioid crisis, the role of misuse and abuse of prescription opioids has been hotly contested. At roughly just past the peak of prescription opioid prescribing, in 2013, more than a third of the 44,000 drug overdose deaths reported were attributable to inappropriate use of prescription opioids.
Since 2013, the percentage of drug overdose deaths that can be traced to inappropriate use of prescription opioids has diminished, in part because fewer are being prescribed. This follows reductions in prescribing, based on restrictive regulatory policies instituted in individual states and counties, as well as guideline recommendations put forth by the Centers for Disease Control and Prevention in 2016.
Some experts have suggested that curbs on prescribing opioids has caused the pendulum to swing too far in the direction of severely limiting prescription opioids – even forced tapering – as such medicines do have legitimate uses for persons suffering from pain.
Nevertheless, there’s no denying that prescription opioids can be misused, abused, and diverted. And here the problem is complex and involves multiple stakeholders, from the pharmaceutical industry, to regulators, to physicians, to payers, to pharmacies, to wholesalers, to patients.
Recent court decisions indicate that pinning the blame on drug makers can be tricky. After all, regulators approved prescription opioids, doctors prescribed them, and payers reimbursed. Simply manufacturing and marketing the products doesn’t prove culpability. Last month, in a $50 billion court case in California, a judge ruled that manufacturers of opioids did not create a public nuisance. Similarly, the Oklahoma Supreme Court overturned a $465 million judgment against Johnson & Johnson in a lawsuit alleging the company fueled the opioid crisis through deceptive marketing of painkillers and created a public nuisance.
Litigation has mostly focused on the pharmaceutical manufacturers, pharmacies, and wholesalers. Payers, whether in the commercial, Medicare, or Medicaid spaces, have been ignored. Yet, their role as facilitators can’t be brushed aside.
A Department of Health and Human Services report from the Pain Management Best Practices Inter-Agency Task Force on gaps in pain treatment concluded that insurers often don’t pay for non-opioid therapies that are more expensive than (generic) opioids. The group America’s Health Insurance Plans countered by saying that the report oversimplified the issue. The large insurer UnitedHealthcare went further by stating that the task force must not recommend broader reimbursement for pain non-opioid treatment and management.
Though insurers have pushed back against the report’s main findings, they haven’t denied not covering non-opioid pain management therapies or favoring generic prescription opioids over alternative treatments as can be inferred from formulary positioning.
Indeed, in the post-operative pain market, non-opioid pain treatments – such as Exparel (bupivacaine liposome) and Zynrelef (bupivacaine/meloxicam) – are often given non-preferred positioning on the formulary, or excluded altogether. Moreover, acupuncture and other alternative methods to alleviate pain face high reimbursement hurdles, which prescription opioids – especially generics – rarely face.
There are opportunities for public and commercial payers to recalibrate the role of prescription opioids in pain management, while, where appropriate, expanding access to opioid alternatives through coverage and reimbursement policies. This will take a concerted effort on the part of all stakeholders to strike a balance when it comes to pain management.
Here, government policymakers must redouble efforts to target the current drivers of the opioid crisis, namely, illicit fentanyl and heroin, while reframing preventive approaches in place to curb misuse and abuse of prescription opioids.
The opioid problem is complex. It’s a crisis that requires a partnership among multiple stakeholders to respond with effective clinical and public health strategies.