News clip: This morning we’re looking at the opioid crisis.

Dan Gorenstein: Remember all the way back to 2019? Stories about opioids dominated the headlines.

News clip: The opioid epidemic.
News clip: Opioids
News clip: Opioid overdoses
News clip: Opioid abuse
News clip: The opioid crisis is getting worse.

DG: Then this year that other public health crisis sucked up all the oxygen.

News clip: The coronavirus outbreak declared a global pandemic.
News clip: In New York today, the governor compared the pandemic to September 11th.

DG: Leaving the opioid epidemic in our blindspot.

Data trickling in suggests 2020 may set record highs for opioid-related overdose deaths. 

Today, where we are going wrong and how we can change the tides.

From the Annenberg Studio at the University of Pennsylvania, I’m Dan Gorenstein and this is Tradeoffs.

MB: My name is Michael Barnett. I’m an assistant professor of health policy management at the Harvard T.H. Chan School of Public Health. I’m also a primary care physician at Brigham and Women’s Hospital.

DG:  So Michael, you have set out to understand the opioid crisis and help steer policy in a better, more evidence-based direction. Over the past 15 years or so, we’ve seen a host of policies at the state and federal level to help curb opioid use and expand treatment access. Can you just give us an overview, sort of a state of play, of these policies? 

MB: So I think of the the key policies for addressing the crisis in three big buckets. I’d say the first is really insurance access and the most important policy there is the Affordable Care Act and Medicaid expansion. The second bucket is another whole raft of policies to restrict or regulate how physicians prescribe opioids. And the third bucket is the set of policies and regulations around access to medications to treat opiate use disorder.

DG: So let’s take each of these one by one to understand their effectiveness and the impact and we’ll start where you started, which is Obamacare. Thirty five-plus states now have actually chosen to expand Medicaid. What has that actually meant for people who are struggling with opioid use disorder?

MB: So Medicaid expansion is really a lifeline for people who have opioid use disorder, because opioid use disorder is really concentrated among people in that range. So some of the evidence that’s out there has shown that in states that expanded Medicaid after 2014, there’s about a 10% reduction in the rate of opioid-related hospitalizations versus other states. Also, there’s a 36% increase in the people entering treatment for substance use disorder. So we’re really pushing the needle by 10 to 20% in outcomes that we care about, like access to treatments, hospitalizations or overdoses. 

What this teaches us is, I think, the relatively straightforward concept that having insurance and having access to health care means that people with addiction are going to access health care that will improve their health.

DG: Ok, let’s move to your second bucket, a raft of policies restricting physician prescribing of opioids. What kinds of policies have been most common here?

MB: Yeah, this is a group of policies I have some strong feelings about called prescription drug monitoring databases And the idea behind these databases is that patients with addiction may engage in something called doctor shopping, where they go from physician to physician or emergency room to emergency room and get different opioid prescriptions as part of their addiction And before having these databases, there was really no way for physicians to figure out how many opioid prescriptions people were filling across the states. And these databases were basically just a repository where a physician could look up all the prescriptions for opioids or other controlled substances that patients had been filling in the past couple of years.

DG: Why are you not such a big fan of these databases? Have they had any positive impact?

MB: The evidence suggests that these databases have probably had a decent impact on reducing high risk prescribing and have maybe cut down on this notion of doctor shopping. But I guess the reason I have strong feelings about these databases is that they’ve gotten so much policy attention and it’s just not really clear this is the major way we’re going to move the needle on the real crisis that we face, which is that people are dying. 

DG: That brings us to your third and final bucket, Michael, the set of policies and regulations surrounding access to medications to treat opioid use disorder, and there’s a growing awareness that methadone and buprenorphine are really the gold standard medications for people struggling with opioids. At a high level, what are the key policies around prescribing these?

MB: So this is a group of laws and regulations that are a bit all over the place because there hasn’t been much of a coordinated state or federal response. One of them is Medicaid programs at the state level realizing that if they’re going to tackle opioid use disorder, they need to make it easier and more attractive to prescribe these medications.

DG: Studies have found buprenorphine and methadone reduce opioid deaths by about half.

Yet, 80% of people who could benefit from medication-assisted treatment don’t get it. 

Doctors and other medical professionals need a special license to prescribe buprenorphine treatments, and many face caps on how many patients they can treat and for how long. 

Methadone is also highly regulated.

Michael says these sorts of restrictions speak to the persistent stigma that surrounds this type of treatment.

MB: There’s a sense that people with addiction have a moral problem or a self-control problem and not a medical issue and that we can’t trust them or somehow they’re not clean, and that if they use medications that actually have opioids as part of their mechanism, that somehow they’re kind of cheating.

DG: What’s the one data point to suggest that maybe the tide is turning, that buprenorphine and methadone are becoming more accepted and will become truly the part of standard treatment?

MB: One of the metrics that I look at is how many providers out there are getting the buprenorphine waiver. The rate at which doctors and NPs and PAs are getting these waivers has really been exploding over the past several years. And I find that really encouraging that doctors are increasingly aware that this is really just a standard part of medical practice, especially younger physicians.

DG: Ok Michael, you’ve walked us through three buckets of policies—expanded access to treatment thanks to Obamacare, a raft of policies aimed at limiting physician prescribing and a patchwork of regulations surrounding methadone and buprenorphine treatments. 

Despite some progress, overall the opioid death toll is still climbing. What grade would you give the United States before the pandemic hit?.

MB: I would give the country either a D plus or C minus. The amount of money and effort that we have to throw at this problem hasn’t really approached even close to what we really need. I guess the reason it’s not a failing grade is because there is progress being made in a lot of sectors. But we have so much progress to make.

DG: Since the pandemic hit, much of the nation’s attention obviously has shifted to the virus. And we’ve heard a lot less about the opioid crisis. Yet in an issue brief from earlier this month, the American Medical Association says more than 40 states have reported a jump in opioid related deaths. 

News clip: One of the hidden epidemics in the coronavirus pandemic has been an increase in drug overdoses with suspected cases spiking significantly in March, April and May.

DG: Michael, can you give us a sense of what has happened since March in the United States as it pertains to the opioid situation?

MB: First of all, there’s a huge economic recession levels of mental illness and symptoms of depression, anxiety are through the roof  and of course, there’s a lot more social isolation and I think all of this is really a recipe for depression, loneliness and the kind of despair that really can feed the cycle of addiction. 

DG: As tough as the pandemic landscape may be, there’s also been an unexpected bright spot. Michael, we’ve talked about how methadone and buprenorphine have been regulated. That’s changed a bit, right? 

MB:  The pandemic triggered kind of a previously unthinkable loosening of a lot of the regulations that we’ve talked about around prescribing medications for opioid use disorder and addiction. So, for instance, enabling doctors to prescribe buprenorphine to people for the first time without seeing them in person, by a phone call or a video visit. 

News clip: Consulting patients through videoconference has opened up a new world for the addiction specialist.

Clip: It’s been the biggest game-changer that I have had in my time in addiction medicine.

MB: Or really loosening the restrictions around how people can get treated with methadone, which usually many patients have to show up every single day to get their methadone dose. But federal regulations around that were significantly loosened so that more and more folks could actually acquire methadone for many days at home.

DG: Do you think these changes will last beyond the pandemic? 

MB: It will really feel quite inhumane to go back to the way things were prior to the pandemic. I think we will see that the sky is not falling and we don’t have some huge epidemic of buprenorphine or methadone abuse as we loosen these restrictions.

DG: Another approach with promise, Michael says: Simply pay health care providers more to treat opioid use disorder and integrate these resources into primary care.

DG: So pre-pandemic, you gave the country a C minus, D plus grade.

Do you feel more hopeful today in October than you did before the pandemic?

MB: I do feel more hopeful that more people, more policymakers know how we can best tackle this problem, there are some policies we haven’t even talked about yet, things like expanding access to naloxone, which is the medication you can use to reverse overdose or harm reduction approaches, things like safe injection sites and needle exchanges. Issues like this that were previously pretty toxic politically, I think have become much more widely accepted, including understanding medications for opiate use disorder.

DG: But you’re clearly not pulling out the “we nailed it” banners yet. 

We’re still seeing a rise in overdose deaths and facing unprecedented economic and personal distress because of the pandemic. What are you most concerned about moving into election season and beyond? 

MB: We have such divisive politics right now and so many other issues that take up all of the available oxygen and media coverage. This is a population that doesn’t advocate for itself in the same way that maybe airlines asking for federal relief. So I worry about the ability to just get political momentum behind this, even though everyone might agree it’s important. 

DG: We have seen some slow progress in our efforts to tackle the opioid crisis, but tens of thousands of Americans continue to die each year.  

A big question: is our growing understanding of the epidemic going to help us build enough political momentum to  reduce the stigma and the barriers to care?  

I’m Dan Gorenstein, and this is Tradeoffs.