Jul 9, 2018, 9:27 PM ETPanel, Conference Presentation

Combatting the Crisis of Opioids

Root Cause: The crisis originated from a well-intentioned healthcare initiative to treat the 100 million Americans suffering from pain, driven by a lack of non-opioid alternatives and overconfidence in opioid efficacy.
Clinical Misconception: Physicians initially underestimated the risk of addiction, operating under the false belief that patients using opioids for legitimate pain management would not develop substance use disorders.
The Three Waves: The epidemic has evolved through three distinct phases:
- Phase 1: Over-prescription of pharmaceutical opioids created a supply for diversion and addiction.
- Phase 2: As prescription rates fell, users transitioned to cheaper, more accessible heroin.
- Phase 3: The rise of synthetic opioids, specifically fentanyl, which is cheaper to synthesize, easier to smuggle, and requires smaller volumes due to extreme potency.
Fatality Trends: Fentanyl-related fatalities have surged from approximately 200–300 seven years ago to 20,000 currently.
Broader Context: While opioids are the focus, fatal overdoses from cocaine are also rising rapidly, indicating a need for a holistic national drug strategy rather than an opioid-only approach.

Personal Tragedy: Admiral Winnefeld lost his son, Jonathan, a 25-year-old EMT and college student, to a relapse four days after completing 15 months of recovery.
Admiral Winnefeld's Seven Lines of Operation:
- Public Awareness: Combating stigma and building political support for recovery.
- Prevention: Full-spectrum prevention across schools, colleges, and workplaces.
- Prescription Management: Addressing irresponsible prescribing by doctors, dentists, and the pharmaceutical industry.
- Law Enforcement & Medical Response: Integrating "warm handoffs" from overdose scenes to treatment and focusing on the fact that 85% of drug arrests are for possession.
- Treatment & Recovery: Addressing the critical shortage of affordable, high-quality treatment.
- Family Support: Supporting families during the high-risk transition from inpatient care to community reintegration.
- Community-Level Action: Promoting "Safe Communities" and "Safe Campuses" to decentralize solutions from the federal level.

Committee Investigations: The Energy and Commerce Committee is investigating the "epicenter" of West Virginia, where millions of hydrocodone pills were distributed to towns with populations in the hundreds (e.g., 9 million pills in Kermit, WV, a town of 406 people).
Socioeconomic Reach: The crisis affects all demographics, with New Hampshire ranking second only to West Virginia, proving the issue transcends economic status.
Legislative Output: Over 60 pieces of legislation have emerged from committee discussions, with 56 bills already marked up.
Enforcement Priorities:
- Addressing the entry of synthetic fentanyls through the US Postal Service.
- Updating laws to stay ahead of chemists creating new synthetic molecules faster than regulatory schedules can classify them.
Healthcare Reform: Legislation aims to treat addiction as a chronic disease rather than a crime, breaking down silos in data sharing between providers and expanding access to Medication-Assisted Treatment (MAT) via telemedicine.
Medicaid/Medicare Evolution: Proposals to modernize funding structures to support newer treatment modalities like telemedicine and expanded Suboxone prescribing.

Cigna's Holistic Approach: Cigna integrated behavioral, medical, and pharmacy programs to treat substance abuse as a chronic condition, resulting in a 25% reduction in opioid prescriptions among their physician network.
Paradoxical Increase: Despite reducing prescriptions by 25%, Cigna recorded a 19% increase in overdoses last year; notably, only 40% of these overdose patients had a Cigna prescription for opioids on file.
Naloxone Access: Cigna advocates for deploying Naloxone (Narcan) at all locations with Automated External Defibrillators (AEDs) and has already successfully utilized a citizen-administered dose to revive a passenger on a commercial flight.
Data Gaps: Dr. Nora Volkow highlighted critical missing data regarding the distinction between overdose deaths caused by intentional suicidal behavior versus accidental overdose in pain management.
Quality Metrics: There is currently no standardized data on treatment program outcomes, leading to a proliferation of low-quality programs; quality metrics are needed to incentivize better care.

Communication Gaps: Messaging often fails to resonate with specific demographics:
- 18–25 Year Olds: Almost entirely missed by prevention campaigns despite being the peak age of initial opioid experimentation.
- Rural Communities: Receive messaging tailored to urban contexts, ignoring their specific conceptualization of the crisis.
- Over 45s: Engage with the topic primarily through the lens of chronic pain.
Stigma Dynamics: Stigma is more prevalent among older generations; younger generations (Millennials/Gen Z) are more willing to discuss addiction openly and seek help.
Language Matters: Shifting terminology from "addict" and "clean/dirty" to "person with a chronic illness" changes physician attitudes and improves patient follow-up care.
The "College Cliff": A critical gap exists in prevention and support systems for the transition from high school to college, where opioid uptake significantly increases.
Family-Centric Treatment: Emerging models, such as those in Denver, allow mothers to receive treatment while keeping their children, removing a major barrier to seeking help.

Preventive Strategies: Effective prevention requires alignment of the right message, messengers, mediums, timing, and audience; current efforts are failing to reach the specific "moments of need" in a user's journey from pain to addiction.
Alternative Pain Management: Evidence suggests traditional anti-inflammatories (e.g., Tylenol) can be as effective as opioids for pain, yet physicians are still incentivized to prescribe opioids due to outdated cultural norms and lack of reimbursement for non-opioid pain management.
Prescription Tracking: Legislation is advancing to improve Prescription Drug Monitoring Programs (PDMPs), enable e-prescribing, and allow pharmacists to refuse filling suspicious prescriptions.
Community Action: Successful local models include "turn-in-and-treat" programs at sheriff's offices (e.g., Illinois) and fire departments (e.g., New Hampshire) that guarantee immediate transport to treatment upon surrendering drugs.
Call to Action: The crisis requires a shift from punitive justice to a public health model, demanding individual community involvement, better data transparency, and a rejection of the "siloed" approach to treatment.