Prescription opioids are still getting much of the blame for the current opioid overdose crisis, yet heroin and synthetic opioids—fentanyl, carfentanil, and tramadol—have become the leading causes of opioid overdose deaths. The death rate from heroin and synthetic opioids other than methadone rose by more than 72% from 2014 to 2015, while overdose deaths linked to prescription opioids have leveled off or declined since 2011.
What would be a better way to deal with the opioid crisis? Three groups offer suggestions.
The Research-Oriented Approach
An article by Drs. Nora Volkow and Francis Collins in the New England Journal of Medicine urges stepping up research in three areas: overdose reversal: additional interventions and better formulations of naloxone; addiction treatment: new medications and technologies aiming at novel molecular targets; and pain management: safe, effective, nonaddictive treatments for chronic pain.
A Less-Conservative Approach: Legalizing Marijuana
Most states and Washington, D.C. have legalized marijuana use for medical purposes. But lacking substantial data to support medical marijuana’s effectiveness and safety, the broader medical community is calling for well-designed studies before lending its support.
In the Middle: The Drug Policy Alliance
The Drug Policy Alliance (DPA), a national nonprofit organization, describes itself as supporting drug reform and seeking to promote drug strategies “grounded in science, compassion, health and human rights.”
The focus of this AT Forum article is a policy paper the DPA released in April. Only 12 pages long, the paper includes dozens of recommendations, presented as suggestions for consideration.
The authors begin their policy paper by emphasizing patients’ legitimate need for access to pain medications, pointing out that “over 87 percent of people who used prescription opioid pain relievers in the past year did not misuse them.” They caution that “we must not widen the net and criminalize legitimate medical use of opioids, overstate the potential dangers of prescription opioid use and reduce access to needed pain medications, or stigmatize the people who use them.”
Some believe that the DPA overly favors marijuana, heroin, and harm-reduction interventions. As for marijuana and heroin, the DPA policy paper calls for safe drug consumption services, specifying “a pilot program” to clarify the heroin issue, and “additional research” to help resolve the marijuana question. It takes a stronger position on harm reduction.
Harm Reduction
(In harm reduction, individuals who have a substance use disorder but are not ready for rehab find ways to minimize the risks they incur.)
The DPA policy paper recommends setting up safe injection facilities (SIFs) and safe drug consumption services through local health departments or community organizations. While the paper was being written, proposals or legislation to establish such sites had already been introduced in California; Maryland; Ithaca, New York; and King County in Washington State.
The policy paper points out that studies in other countries have shown that SIFs reduce overdose deaths; provide an entry to treatment, even abstinence; reduce risky injection practices and disease transmission; reduce public injection practices; are cost effective; and do not increase the incidence of local crime, or encourage additional drug use.
Bottom line: some health care providers consider harm-reduction programs extreme; others believe they have potential benefits, and favor learning more about them, with well-designed clinical studies a necessary first step.
Medication-Assisted Treatment
The DPA covers medication-assisted treatment (MAT) at length, and includes many recommendations opioid treatment programs (OTPs) will favor. Among them: increasing access to MAT by such means as providing office-based treatment.
Establish an Expert Panel on Treatment Needs. A panel in each state would address treatment needs and opportunities, while considering the following tasks:
- Evaluate existing barriers to treatment
- Identify ways to address gaps in treatment
- Make recommendations to the state legislature
- Set evidence-based standards of care
- Identify treatment components and recovery services to include
The paper notes that access to MAT is limited in U.S. treatment facilities.
Increase Insurance Coverage for MAT. Plans in some states do not cover methadone or buprenorphine, 
and only about a quarter of patients treated for opioid use disorders at Veterans Health Administration (VHA) facilities are treated with methadone or buprenorphine.
Provide Office-Based Opioid Treatment for Methadone. Several states have limited the availability of methadone by establishing moratoriums on new OTPs. Office-based methadone would help make treatment broadly available, and could help reduce the stigma still associated with MAT.
Offer MAT in Hospitals, Jails, and Prisons. About 25% of incarcerated people are opioid-dependent. They are up to 130 times more likely to die of an overdose soon after release from incarceration than are opioid-dependent people in the general population. For the newly incarcerated, continuation of MAT should be mandated, the DPA believes; and for those who lack MAT, but need it, MAT should begin before their release from confinement.
Other Options: Helping Those Refractory to Treatment
The DPA suggests considering two options:
▬ A heroin-assisted pilot
▬ A program evaluating marijuana as an opioid substitute, or as an adjunct, in patients with chronic pain
Naloxone
The document provides good coverage of naloxone. It notes that great progress has already been made to increase access to this opioid overdose antidote—although access and protections vary widely among the states.
Criminalization, Syringe Sales, Diversion Programs, Decriminalization
The publication also recommends ending criminalization of syringe possession; lowering barriers to over-the-counter syringe sales; and allowing direct prescriptions for syringes (some states have already taken such steps); establishing an expert panel on prescribing practices, by states; mandating specific educational courses for degree-granting institutions; and developing an evidence-based curriculum for schools.
Two additional key recommendations found in the report: establish programs to help individuals with substance use disorders meet their basic needs; and decriminalize drug possession—that is, remove criminal penalties for possession of small amounts of controlled substances for personal use.
Conclusion
Although its approach is not as conservative as some would like, the paper offers many timely recommendations concerning MAT and naloxone. It also emphasizes a key requirement, sometimes overlooked—the need for policymakers to evaluate the benefits of “potential harm reduction, effective treatment, and prevention interventions—all backed by rigorous science—and to shift the focus of their efforts to implementing policies that actually have the power to save and improve lives [emphasis added].”
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References
Rudd RA, Seth P, David F, Scholl L. Increases in Drug and Opioid-Involved Overdose Deaths— United States, 2010–2015. MMWR Morb Mortal Wkly Rep 2016;65:1445–1452. doi: http://dx.doi.org/10.15585/mmwr.mm655051e1.
Centers for Disease Control and Prevention. Opioid Overdose Data. Opioid Data Analysis. Categories of Opioids. https://www.cdc.gov/drugoverdose/data/analysis.html#contentArea. Accessed August 10, 2017.
Volkow N, Collins F. The role of science in addressing the opioid crisis. N Engl J Med. 2017; [Epub ahead of print]. May 31, 2017. doi: 10.1056/
The Drug Policy Alliance. A Public Health and Safety Approach to Problematic Opioid Use and Overdose. April 18, 2017. http://www.drugpolicy.org/resource/public-health-and-safety-approach-problematic-opioid-use-and-overdose. Accessed August 10, 2017.