The Opioid Epidemic: Practice, Policy, and

Legislative Overview

Sharon A. Morgan

MSN, RN, NP-C

Senior Policy Advisor

October 21, 2017

IntNSA

2

Objectives• Where are we today and how did we get here?

• Definitions

• Chronic Pain

• Poor Pain Management & Barriers to Effective Care

• National Pain Strategy

• Prescribers as Gatekeepers

• Removing Treatment Barriers

• SUD in Nursing

3

Where Are We Today?

(newea.org)

• 91 Americans die every day from an opioid overdose

• At least half of all opioid overdoses involved a prescribed medicine

• Sales of prescription opioids in the U.S. nearly quadrupled from 1999 to 2014, but the overall amount of pain Americans report has not changed

• In 2014, an estimated 1.9 million people had an opioid use disorder related to prescription pain relievers and an estimated 586,000 had an opioid use disorder related to heroin use.

• Men were more likely to die from overdose, but the mortality gap between men and women is closing

• Heroin-related overdose deaths have more than tripled since 2010

(CDC, 2016; SAMSHA, 2015)

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Heroin Use

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The Interplay

(newea.org)

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Definitions

• Use: Taking a substance as prescribed

• Misuse:

• Using a substance for a purpose other than

intended reason

• Taking a substance not prescribed to

oneself

• Abuse: Taking a substance for a pleasant or

euphoric feeling

• Avenues for misuse and abuse

• Crushing, chewing, grinding solids

• Injecting

• Insufflating (nasal)

• Smoking(FDA, 2010; 2016)

ANA Stock Photo

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Definitions

(newea.org)

• Tolerance: Reduced response to a drug with repeated use

• Physical dependence: Adaptation to a drug that produces symptoms of withdrawal when the drug is stopped

• Addiction: A chronic, relapsing brain disease that is characterized by compulsive drug seeking and use, despite harmful consequences

• Substance Use Disorder: occurs when the recurrent use of alcohol and/or drugs causes significant clinical and functional impairment, such as health problems, disability, and failure to meet major responsibilities at work, school, or home

• Withdrawal: symptoms that occur after long-term use of a drug is reduced or stopped abruptly

• Restlessness

• Muscle and bone pain

• Insomnia

• Diarrhea

• Vomiting

• Cold flashes(CDC, 2016; FDA, 2016)

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How Did We Get Here• 3400 BC: Sumerians

• Cultivated the opium poppy— “Hul Gil” “Joy Plant”

• Assyrians����Egyptians����Alexander the Great����India����Asia

• 220 AD forward:

• Chinese surgeon Hua To documented use of opium and cannabis

extracts to minimize pain

• Substances used for pleasure and spiritual purposes

• Silk Road: series of interconnected routes that ran from Europe to

China

• 1800’s:

• Morphine extracted from opium

• Opium Wars; US expansion����Chinese labor����opium dens

• Opium marketed freely, best pain treatment option during the

Civil War

• Late 1800's 2/3 of those with opioid addiction were middle and

upper class women, due to over-prescribing the drugs for “female

troubles.”

(Atlantic, nd; BPM, 2014; DEA,nd)

olddesignshop.com

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How Did We Get Here• Late 19th/early 20th century

• Bayer develops heroin, marketed as cough

elixir—made illegal 1924

• Legislation enacted to curb use of opiates

• 1916: Oxycodone synthesized

• Most clinicians during 20th century acknowledged

addictive risk when using opioids to treat chronic

pain

• Late 20th century

• Oxycodone (Percocet® or Percodan®)

increases in popularity

• 1960’s: Vietnam War�heroin resurgence

• 1970’s: pain is not being controlled

• 1990’s: Oxycontin approved

• Video "I Got My Life Back"

• TJC: “Pain is assessed in all patients”(BPM, 2014; CNN, 2016; TJC, 2016)

deamuseum.org

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Recipe for Epidemic?

(newea.org)

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A Growing Epidemic of Pain

• IOM Report, 2011

• Pain is a warning sign

• Subjective, unique

• Complex

• Biological: factors that affect pain tolerance

or thresholds

• Psychological: pain represents something

worse than it does

• Social: response of significant others to the

pain

• Types

• Acute:

• Sudden onset, short duration

• Recurrent: episodic

• Chronic:

• Lasting > several months

• Maladaptive, debilitating(IOM, 2011)

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Chronic Pain by the Numbers

• 100 million—approximate number of U.S. adults with common chronic pain

conditions

• $560 to 635 billion—conservative estimate of the annual cost of chronic

pain in America

• $99 billion—2008 cost to federal and state governments of medical

expenditures for pain

• 10 to 50 percent of patients with postsurgical pain develop chronic pain

• 2011 survey of U.S. soldiers returned from deployment, 44 percent

reported chronic pain and 15.1 percent reported recent use of opioid pain

relievers(IOM, 2011; JAMA, 2014)

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Poor Pain Management

(newea.org)

• How Pain Occurs Poorly Understood• The relationship between injury and pain is not

consistent• Location of pain and tissue damage are sometimes

different• Pain can persist long after tissue healing

• Nature of pain and its location can change over time• Individuals respond to a given therapy

• Variable Data Collection• Experience of pain is subjective• Few standardized, validated self-reporting tools

• Varying assessment by location• Meeting a standard vs comprehensive patient

assessment

• Clinician education varies

• Misperceptions about misuse and abuse of opioids• Comprehensive education lacking• Education does not translate to competency

(IOM, 2011)

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Barriers to Effective Pain Management

• System-level barriers:

• Clinical services (and research endeavors)

organized along disease-specific lines

• Pain management belongs to everyone and

therefore, belongs to no one

• Clinical (and research) silos prevent cross-

fertilization of ideas and best practices

• Clinician-level barriers:

• Practitioners not well educated current best

practices

• Unable to ID or engage other clinicians skilled

at treating chronic pain(IOM, 2011)

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Barriers to Effective Pain Management

• Patient-level barriers:

• Societal stigma

• Is the pain real?

• Drug or disability benefit–seeking behavior?

• Religious or moral judgements

• Popular culture: suck it up; no pain, no gain

• Insurance and third-party payer level barriers

• Payers do not encourage interdisciplinary team care

• Payers frequently limit reimbursement

• CAM therapies not covered(IOM, 2011)

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National Pain Strategy

(newea.org)

• National effort of public and private organizations to transform how the nation understands and approaches pain management

• Six key areas:

• Population research

• Prevention and care

• Disparities

• Service delivery and payment

• Professional education and training

• Public education and communication

• Specifics:

• Develop metrics to improve the prevention and management of pain

• Support a system of patient-centered integrated pain management practices

• Take steps to reduce barriers to pain care; improve care for vulnerable, stigmatized and underserved populations

• Increase public awareness of pain; increase patient knowledge of treatment options and risks; help develop a better informed health care workforce

(NIH, 2016)

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Population Research

• 2011 IOM underscored the impact of pain on the health,

productivity, and well-being of the U.S. population

• Core responsibility of public health agencies is assessing

the significance of health problems in the population

• Data collection needs to improve

• Improved data will drive federal and state initiatives

• Objectives:

• Estimate the prevalence of chronic pain and high-

impact chronic pain

• Refine and employ standardized electronic health

care data methods to determine use and costs of care

• Develop a system of metrics to track changes in

prevalence, impact, treatment, and costs(NIH, 2016)

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Prevention and Care

• Preventable causes of acute and chronic pain are not

addressed throughout the health care delivery system

• People who have pain do not receive appropriate

assessments or evidence-based care that is coordinated

across providers and personalized

• Poor understanding of the factors that cause pain to

become persistent

• Objectives:

• Articulate the benefits and costs of current

prevention and treatment approaches

Develop nation-wide pain self-management

programs

Develop standardized, consistent, and

comprehensive pain assessments and outcome

measures(NIH, 2016)

arthritis.org

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Disparities

(newea.org)

• Vulnerable/marginalized populations due to conscious and unconscious biases about higher-risk groups or about pain itself:

• English as a second language

• Race and ethnicity

• Income and education

• Sex and gender identification

• Age group

• Geographic location

• Military veterans

• Cognitive impairments

• Cancer patients

• EOL

• Objectives:

• Reduce bias and its impact on care

• Improve access to high-quality care for vulnerable groups

• Facilitate communication among patients and providers

• Highlight data on the impact of pain on high risk populations(NIH, 2016)

floridahealth.gov

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Service Delivery and Payment

• Commonly used single-modality treatments often fail as

first-line therapies for chronic pain

• Insurance limitations affect consumer choices of

treatments and their adherence to treatment regimens

• CAM poorly covered, takes time and repeated Rx

• Providers constrained in the time they can spend with

individual patients

• Objectives:

• Define and evaluate integrated, multimodal, and

interdisciplinary pain care

• Enhance evidence for care

• Incentivize payments for quality care based on

integrated, cost-effective, and comprehensive

models(NIH, 2016)

consumerreports.org

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Professional Education and Training

• IOM report found education key to the needed cultural

transformation to effective pain management

• Most health care professions’ education programs devote

little time to education and training about pain and pain

care

• Preventive approaches are underutilized almost

universally

• Practitioners often experience negative emotions in

caring for people with pain

• Objectives:

• Develop and update core competencies for pain care

education, licensure and certification at the

undergraduate and graduate levels

• Develop a pain education portal that contains a

comprehensive set of materials to enhance curricula(NIH, 2016)

luc.edu

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Public Education and Communication

(newea.org)

• High-quality, evidence-based communications:

• Increase public awareness of the complexity of chronic pain

• Change cultural attitudes about chronic pain, debunking stereotypes

• Foster coalitions

• Objectives:

• Develop and implement a public awareness campaign about the impact of chronic pain to counter stigma and misperceptions

• Develop and implement an educational campaign encouraging safer medication use, especially opioid use for patients with pain

(NIH, 2016)

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Prescribers as Gatekeepers

• Interventions to improve safe and appropriate

prescribing must balance the legitimate need for

opioids with the need to curb dangerous practices

• 2016 CDC Guideline for Prescribing Opioids for

Chronic Pain

• Articulation of National Pain Strategy

• Objectives:

• Determine when to initiate or continue

opioids for chronic pain

• Select right dosage, duration, follow-up

and discontinuation

• Assess risk and address harms of opioid

use (CDC, 2016)

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Prescription Drug Monitoring Programs

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Do PDMPs Work

• A PDMP with a mandate

(registration or use) was associated

with a 9 – 10% reduction in

prescriptions for Schedule II opioids

by Medicaid enrollees

• Issues: • PDMPs do not all collect the same

data

• It can be difficult to identify the

correct individual

• Each PDMP has a unique mandate

from the state

• Changing a PDMP to allow a change

in provider access or data sharing

may require the passage of new

legislation

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The Science of Addiction

(newea.org)

• Drugs change the brain

• Reasons to use

• To feel good

• To feel better

• To do better

• To fit in

• How does addiction occur

• More need to just feel normal

• More needed to feel old high

(NIDA, 2014)

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The Problem with Tough Love

• Remember, addiction includes compulsive

drug seeking and use, despite harmful

consequences

• Addiction as a chronic disease

• From quick, reactive to slow,

continuous

• Treatment in specific stages of

intervention

• Includes self-management component

• can utilize a wide range of treatments

(including medication) during each

phase(ASAM, nd)

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Treatment Options

• Treatment Options

• Individual and group counseling

• Inpatient and residential treatment

• Intensive outpatient treatment

• Partial hospital programs

• Case or care management

• Medication

• Recovery support services and 12 Step

• Peer supports

• FDA approved medications available to treat opioid addiction

• Methadone (Dolophine®)

• Naltrexone: Oral (ReVia®, Depade®); ER injectable (Vivitrol®)

• Buprenorphine/naloxone (Suboxone®, Zubsolv®)

• Buprenorphine (Subutex®)(ASAM, nd; SAMSHA, 2016)

thefix.com

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Removing Treatment Barriers

(newea.org)

• Addiction treatment system

• Separate from mainstream health care

• Built on infrastructure and financing models that treat addiction under an acute care model

• Public and private insurers levy prescribing restrictions against medications to treat opioid addiction

• Medication-Assisted Treatment (MAT)

• With counseling, most effective form of treatment

• Issues:

• A paucity of trained prescribers

• Negative attitudes and misunderstandings about addiction medications held by the public, providers, and patients

• Replacing one addictive medicine with another

• Need for concomitant counseling

(ANA,nd)

drugrehab.org

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Expanding Treatment Access• Drug Addiction Treatment Act of 2000 (DATA 2000)

• Permits qualified practioners to treat opioid dependency with FDA approved

narcotic medications

• Required training and obtaining a special DEA license

• Patient limits

• Care could not be delegated

• Barriers:

• Inadequate reimbursement by insurance plans

• Detailed training and treatment protocols

• Access to referral agencies

• “Undesirable” clientele

• The Recovery Enhancement for Addiction Treatment Act (TREAT Act, S.1455)

• Revise the definition of a "qualifying practitioner" to include NPs and PAs

• Amend the Controlled Substances Act to increase the number of patients that

a qualifying practitioner can treat from 30�100

• Naloxone

• Immediate reversal of opioid

• Expand access to first responders, family, friends, and caregivers(ANA, nd)

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SUD in Nursing

• No higher than national average�8-20% combined use/abuse

• Top 4 risks for nurses to develop SUD in the workplace

• Access

• Attitude

• Stress

• Lack of education about SUD

• Signs of SUD

• Job performance

• Personality and mental status changes

• Diversion of drugs

• ANA advocates for comprehensive and consistent access to alternative-to-

discipline programs

• All States, DC, and Territories have some form of Peer Assistance or Chemical

Dependency program(AANA, nd; ANA, nd; NCSBN, 2011)

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ANA Opioid Website

http://www.nursingworld.org/MainMenuCategories/W

orkplaceSafety/Healthy-Work-Environment/Opioid-

Epidemic

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References

(newea.org)

American Association of Nurse Anesthetists. (n.d.) AANA Peer Assistance Resource Directory. Retrieved from http://peerassistance.aana.com/directory.asp?State=All

American Nurses Association. (n.d.) The Opioid Epidemic: Addressing the Growing Drug Overdose Problem. Retrieved from http://nursingworld.org/DocumentVault/Health-Policy/Issue-Briefs/ANA-IssueBrief-Opioid-Epidemic.pdf

ANA. (n.d.) Substance Use Disorder in Nursing. In Work Environment. Retrieved from http://www.nursingworld.org/MainMenuCategories/WorkplaceSafety/Healthy-Work-Environment/Work-Environment/SubstanceUseDisorder

American Society of Addiction Medicine. (n.d.) Treating Opioid Addiction as a Chronic Disease. Retrieved from http://www.asam.org/docs/default-source/advocacy/cmm-fact-sheet---11-07-14.pdf?sfvrsn=0

The Atlantic. (nd). A Brief History of Opioids. Retrieved from http://www.theatlantic.com/sponsored/purdue-health/a-brief-history-of-opioids/184/

Better Pain Management. (2014). History of Opioid Use and Abuse. In Pain & Wellness Evaluation. Retrieved from http://testmypain.com/page5/page10/

Cable News Network. (2016, October 14). Opioid history: From 'wonder drug' to abuse epidemic. Retrieved from http://www.cnn.com/2016/05/12/health/opioid-addiction-history/

Centers for Disease Control. (2016, March 14). Guideline Information for Providers. In Injury Prevention and Control: Opioid Overdose. Retrieved from https://www.cdc.gov/drugoverdose/prescribing/providers.html

CDC. (2016, March 14). Opioid Basics. In Injury Prevention and Control: Opioid Overdose. Retrieved from https://www.cdc.gov/drugoverdose/opioids/index.html

CDC. (2016, June 21). Understanding the Epidemic. In Injury Prevention & Control: Opioid Overdose. Retrieved from https://www.cdc.gov/drugoverdose/epidemic/index.html

Drug Enforcement Administration Museum & Visitors Center. (nd). Opium Poppy: History. In Cannabis, Coca, & Poppy: Nature’s Addictive Plants. Retrieved from: https://www.deamuseum.org/ccp/opium/history.html

Institute of Medicine. (2011). Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education, and Research. Retrieved from https://www.nap.edu/catalog/13172/relieving-pain-in-america-a-blueprint-for-transforming-prevention-care

National Center for Biotechnology Information. (2008, October). Opioids and the Treatment of Chronic Pain: Controversies, Current Status, and Future Directions. In HHS Author Manuscripts. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2711509/#R17

National Council of State Boards of Nursing. (2011). Substance Use Disorder In Nursing. Retrieved from https://www.ncsbn.org/SUDN_11.pdf

National Institute on Drug Abuse. (2014, July). Drug Abuse and Addiction. In Drugs, Brains, and Behavior: The Science of Addiction. Retrieved from https://www.drugabuse.gov/publications/drugs-brains-behavior-science-addiction/drug-abuse-addiction

NIDA. (2015, August). What is withdrawal? How long does it last? In Frequently Asked Questions. Retrieved from https://www.drugabuse.gov/frequently-asked-questions#withdrawal

National Institutes of Health. (2016, March 16). National Pain Strategy. In The Interagency Pain Research Coordinating Committee. Retrieved from https://iprcc.nih.gov/National_Pain_Strategy/NPS_Main.htm

Substance Abuse and Mental Health Services Administration. (2015, October 27). Substance Use Disorders. In Mental and Substance Use Disorders. Retrieved from http://www.samhsa.gov/disorders/substance-use

SAMHSA. (2016, August 9). Treatments for Substance Use Disorders. In Behavioral Health and Treatment Services. Retrieved from http://www.samhsa.gov/treatment/substance-use-disorders

The JAMA Network. (2014, June 30). Research Letter Examines Reports of Chronic Pain, Opioid Use by U.S. Soldiers. In For the Media. Retrieved from http://media.jamanetwork.com/news-item/research-letter-examines-reports-of-chronic-pain-opioid-use-by-u-s-soldiers/

The Joint Commission. (2016, April 16). Joint Commission Statement on Pain Management. In Topic Details. Retrieved from https://www.jointcommission.org/joint_commission_statement_on_pain_management/

U.S. Food and Drug Administration. (2010, July). Combating Misuse and Abuse of Prescription Drugs. In Consumer Health Administration. Retrieved from http://www.fda.gov/downloads/ForConsumers/ConsumerUpdates/UCM220434.pdf

U.S. FDA. (2016, March). General Principles for Evaluating the Abuse Deterrence of Generic Solid Oral Opioid Drug Products Guidance for Industry. Retrieved from http://www.fda.gov/downloads/Drugs/GuidanceComplianceRegulatoryInformation/Guidances/UCM492172.pdf