“I actually don’t blame the pharmaceutical companies; I blame our healthcare system, which left an opening for industry, and they took the opening, ” said Reznikoff, assistant professor of medicine at the University of Minnesota in Minneapolis.
Countries other than the U.S. are handling the opioid crisis much differently than we are, said Reznikoff. For example, in 1995, France began allowing any doctor to prescribe buprenorphine for opioid use disorder (OUD); “Now the majority of patients [there] with OUD are receiving buprenorphine from their primary care physicians.” These changes led to a 10-fold increase in buprenorphine prescribing in France “and the overdose death rate dropped by 80%,” he added, noting that half of all people with OUD in France are on addiction medications, compared with 15% in the U.S.
In Portugal, the country shifted its approach toward opioid addiction in 2001 from a criminal justice approach to a public health approach; “They basically stopped incarcerating people with opioid addiction,” Reznikoff said. As a result, active heroin users dropped from 100,000 to 25,000. “Portugal had the highest rate of opioid death in Western Europe and they now have the lowest rate — and it’s 1/50th of the death rate in America.” In addition, new HIV diagnoses attributable to IV drug use dropped by 90%, he said.
Charles Reznikoff, MD, University of Minnesota (Photo by Joyce Frieden)
One thing that makes it easier for these countries to tackle this problem is that they all have universal healthcare, Reznikoff noted. In the U.S., with a more fragmented system, “we have efforts at mental health and addiction parity, but we have a long way to go. The ideal is that the patient, the doctor, the clinic, the insurer, public health, and the government all have incentives aligned, and that is not the case right now. But it’s easier to get that done when more people are covered and there is a more coherent healthcare policy.”
What is a good medication to make available to people at risk of addiction? It’s not naloxone — as many people may think — but buprenorphine or methadone, “because the literature for mortality is more robust” for those two drugs, Reznikoff said. What naloxone does do is delay an increase in mortality rates — “it stalls the deaths and gives us time to implement other policies; but it’s not going to turn the [upward] curve down.”
So why is naloxone so frequently used? “You can give naloxone to patients without changing the underlying systems of care,” he said. “It can be given to ambivalent patients, it’s easy for the busy provider, it avoids the stigma of medication-assisted treatment (MAT), and there is a perception that adding it makes a risky opioid regimen safer,” even though there’s actually no evidence for that, he said.
Reznikoff also faulted the U.S. for not using MAT with opioid–addicted patients who are incarcerated, as is done in other countries. “The risk of opioid use disorder-related death increases 20-fold after release from incarceration,” he said. “We are not going to get out of this [problem] without wrestling with that tough issue.”
Each state is also responding to the opioid crisis in its own way, said Rebecca Haffajee, JD, PhD, MPH, assistant professor of health management and policy at the University of Michigan in Ann Arbor. “A policy that’s working in one state doesn’t work in another,” she said. “States and localities are at the forefront and have been very active in the policy-making space.”
(l-r) Charles Reznikoff, MD, University of Minnesota; Rebecca Haffajee, JD, MPH, University of Michigan (Photo by Joyce Frieden)
Over 1,300 bills related to the crisis have been introduced in state legislatures, and more than 500 of those have been enacted, she said. The “heavy hitters” in this area include legislation around the use of prescription drug monitoring programs (PDMPs), funding for media campaigns about opioid abuse, and laws increasing access to naloxone, as well as “Good Samaritan” laws that hold people harmless if they call the police regarding someone who has overdosed. Regulation of pain clinics has also been enacted in 11 states; those laws have plateaued, likely because penetration of these clinics varies greatly from state to state, Haffajee said.
The best evidence for state policies that work has so far come from pain clinic regulation laws, which are usually combined with laws regulating PDMPs, she continued. “Those did seem to reduce opioids prescribed and dosages dispensed … We also find that drug supply management — which we define as something that limits opioid prescribing by quantity or dosages, or [requiring] prior authorization — particularly those prior authorization policies in Medicaid, those did seem to decrease higher-risk opioid prescribing and ‘doctor shopping’ as well. But other state policies: opioid prescription guidelines, doctor shopping laws, continuing medical education requirements, Good Samaritan laws, naloxone access laws — there’s really not good evidence to demonstrate their effects.”
State laws that limit the number of days a prescription can be written for or the dosage amount “are controversial because they’re very blunt instruments,” but their effects are still not known. “We have done some initial evaluations on earlier [such laws]; they don’t seem to be having a big effect, but it’s too early to make that determination,” she said. “We need to generate more evidence about these state policies.”
One barrier to getting more MAT is a workforce issue, Haffajee said. “What we’re hearing is that [people] need peer support — ‘I don’t want to be the only prescriber in my practice. I want back-up, and I want institutional support.’ How do we get healthcare systems and employers to foster these environments? We don’t have nearly enough addiction specialists.”