Tag Archives: opioids

Is There an Answer to Opioid Crisis?

What a difference two words make.

Last week, President Trump declared the opioid epidemic a “national public health emergency.” The declaration will speed up how quickly specialized personnel can be hired, expand access to treatment for some addicts and make some HIV/AIDS programs more flexible.

But many people wish he’d left out the words “public health.” That’s because a “national emergency” would have freed up money, and lots of it. The Public Health Emergency Fund at Health and Human Services currently contains only $57,000. And the president did not ask Congress to refill it.

But we shouldn’t entertain the idea that the federal government, or any other entity, is going to “fix” the opioid epidemic, just as you can’t pin blame for the crisis on a single entity. The epidemic is all-encompassing, far-flung and complex, and it unfolded over two decades and millions of bad decisions.

See also: 6 Shocking Facts on Opioid Abuse  

Pharmaceutical manufacturers are partly to blame because they marketed opioids as safe when taken as prescribed. Doctors and medical institutions compounded the problem because they didn’t adequately question and research these false claims. Drug distributors shipped massive amounts of drugs to places that obviously didn’t need them, and pharmacists looked the other way when filling prescriptions that were clearly too large. The Drug Enforcement Administration allowed manufacturers to make more and more opioids, even as overdose death rates skyrocketed. And many patients and drug users didn’t take responsibility for their own health.

There’s no one person or organization responsible for the crisis, and there’s no easy fix, no magic bullet.

I was disturbed by the recent reports that the Trump administration was “scrambling” to formulate an opioid plan. This epidemic didn’t have simple causes, and the response to it should not be rushed out. Meaningful change will require a response that recognizes millions of addictions have been created that aren’t going anywhere.

Each of the parties that took part in creating of this epidemic must be a part of the solution.

For instance, doctors and medical schools need to develop drastically different prescribing protocols to avoid creating addictions. Their far-more-challenging task will be to develop ways to deal with all of the patients who have been prescribed high doses of opioids for many years and are understandably terrified that they will be taken off their meds, even though the drugs are probably sapping their lives of vitality. How do you treat those patients so they don’t turn to street drugs?

The federal government does have one big stick in its arsenal that hasn’t been used, which is the fact that the DEA is in charge of setting manufacturing quotas for all controlled substances. The DEA could use this power to force drugmakers to better track where their opioids are ending up. This hasn’t happened, and in fact, the DEA permitted hike after hike in manufacturing quotas, finally cutting the rates only in the last two years.

See also: Opioids: Invading the Workplace  

In the end, I think the gathering tsunami of lawsuits against the drug companies may prove to be more effective than the federal government’s response. The eventual settlements could dwarf the $206 billion in Big Tobacco settlements from 1998. We need to make sure that any settlement provides lots of money for research and treatment.

But neither the federal government nor plaintiffs’ lawyers are going to “solve” this epidemic. Addictions, once created, don’t die easily. The opioid crisis is going to be a part of life in the U.S. for a long time.

Big Opioid Pharma = Big Tobacco?

Have you noticed that big opioid pharma (BOP), manufacturers and distributors of prescription opioids are under attack? I have.

In fact, I’ve written about it for awhile. You can read “Suing Big Opioid Pharma – The Next Big Thing?” from 3/13/17, “780,069,272 Pain Pills” from 12/20/16, “Suing Big Opioid Pharma” from 9/27/16 and “Patients Sue Physicians’ and Pharmacists” from 5/22/15.

As I’ve followed the strategic initiative, it reminds me of big tobacco. As a refresher, it was accused (informally, at first, and then collectively, over time) of knowing that tobacco was dangerous and addictive but kept it a secret. In November 1998, attorney generals from 46 states entered into the Tobacco Master Settlement Agreement (MSA) with the four major tobacco companies:

The states settled their Medicaid lawsuits against the tobacco industry for recovery of their tobacco-related health-care costs, and also exempted the companies from private tort liability regarding harm caused by tobacco use. In exchange, the companies agreed to curtail or cease certain tobacco marketing practices, as well as to pay, in perpetuity, various annual payments to the states to compensate them for some of the medical costs of caring for persons with smoking-related illnesses. In the MSA, the original participating manufacturers (OPM) agreed to pay a minimum of $206 billion over the first 25 years of the agreement.

See also: Misconception That Leads to Opioids  

Throughout 2017, I have saved every article I read on the subject of the opiod problem (see below). You are more than welcome to read the entire article, but I think the date (constant throughout the year), source (wide variety of publications) and headline (provocative and descriptive) provide a sweeping perspective on the scope of this activity:

The full scope of the opiod crises includes an investigation by Congress; lawsuits by individual states, counties and cities around the country (and in Canada); collaboration among attorney generals; and class action lawsuits. (And maybe others). The initiation of most of this action is not academic, it is personal.

Take Mike Moore, the former Mississippi attorney general who was the first to sue Big Tobacco using a then-unproven legal strategy. His nephew started with Percocet as prescribed by a doctor in 2006. By 2010, he was using street fentanyl. Moore saved his nephew from an overdose by taking him directly to the hospital.

As he’s watched the tobacco victory pay off in declining smoking rates, he’s also seen easy access to powerful pain medication spark a new deadly crisis. He’s convinced this is the moment to work the same mechanisms on the drug companies that forced the tobacco industry to heel — and he’s committed himself to making that happen. “It’s clear they’re not going to be part of the solution unless we drag them to the table.”

The primary argument against BOP is the same as the one against Big Tobacco. BOP knew the dangers of their product, but they misled consumers (in this case, prescribers) by purposefully obfuscating the truth.

See also: Opioids: Invading the Workplace  

If you look at the evidence (anecdotal and factual), it appears as though there was a strategic effort to hide the truth. Of course, all of this in large part is still alleged — not proven in a court of law — and BOP will have an opportunity to make their arguments.

Except… In May, Purdue Pharma settled a class-action lawsuit in Canada for $20 million. But of course, settlements always include the language “no admission of guilt.” As I stated in a post:

$20 million (or 0.064% of OxyContin revenue) to settle? This is a rounding error for Purdue Pharma. But not to those who became dependent/addicted and lost anything from an active lifestyle to life itself. Fair and equitable? That was a rhetorical question — I don’t believe it is either fair or equitable. Not so much the dollar amount, but the fact that it will not hurt Purdue at all in the pocketbook. If the goal of a lawsuit is to change behavior because it’s too painful not to, then this probably didn’t hit the mark.

Whether you believe the opioid epidemic is real or not (I do), or whether you think at least some of the deaths from illicit street heroin and fentanyl are a consequence of over-prescribing prescription opioids (I do), I think we can all agree it’s wrong for a company to tell its customers there is no danger when there really is (and when the company knows it). In this case, it can be deadly.

So if BOP wants to know where this is heading, they just need to refresh their memories about what happened with Big Tobacco. What happened then is about to happen again.

Misconception That Leads to Opioids

No physician wants to create an addicted patient. In almost all cases, they simply want to mitigate patients’ pain. Good intentions with a bad strategy.

The breakdown in the system stems from a poor understanding of pain and how to diagnose and classify it correctly. In effect, you have to match the treatment to the patient’s condition, which means you need to possess a reliable method of diagnosing pain.

Human beings experience three types of pain: 1) thermal pain — quite rare and only produced in the very ill and systemically sick patients; 2) chemical or inflammatory pain — pain that is mediated through a release of chemicals at a site of injury (this pain lasts five to seven days, occurs when trauma happens and is only present in 2% to 5% of all patients in pain); and 3) mechanical pain — pain that is mediated through/by distortion or pressure on tissue (90%-plus of all pain that humans experience).

Bend your finger back as far as you can until pain is produced, and you have just experienced mechanical pain in its purest form. A bulging or herniated disc in 95% of all patients produces pain because the wall of the disc is being distorted or strained just like your finger was when it was hurting.

See also: Opioids: Invading the Workplace  

You can’t treat mechanical pain with a chemical intervention ( pills and injections). You can’t treat chemical pain with a mechanical intervention. Makes sense, right?

The problem is that we have a system built around using chemicals to manage pain and providers who receive less than two weeks of education in medical school around how to adequately assess and diagnose patients in this space.

The evidence is overwhelming. There are dozens of studies that show little influence on back or joint-related pain (less than one point on a 10-point pain scale, and that’s in only 30 % of the cohort) when using opioids, analgesics, muscle relaxants and steroids, yet every PCP and specialist in the land has them as the first stop off for MSK (musculoskeletal) patients. When the simple analgesics and muscle relaxants don’t work, then escalate to opioids.

Numerous studies show that less than 5% of patients experience any change in back pain when epidural steroids or transformational injections are used to put the medicine at the supposed source of symptom. Why are these studies struggling to find treatment effect on patients in pain with some of the best-trained examiner/physicians in the world conducting the study? It’s simple. We don’t train them to assess patients in a reliable way and to match chemical patients with chemical interventions and match mechanical patients with mechanical interventions (surgery and movement-based strategies).

See also: 6 Shocking Facts on Opioid Abuse 

90% of opioids are prescribed for back or chronic joint pain. The solution to the crisis is to teach providers to reliably sub-group patients into their appropriate pain group. Mechanical patients only get mechanical solutions, and chemically dominant or inflammatory patients get chemical treatment.

Our failure to do this has allowed us to continue to use treatment methods long ago determined to be ineffective in this population and also forces providers to become inventive. We blame the patient; we claim they are gaming the system; we think the problem is psychosomatic or a construct in their mind — when in reality we are not applying the right treatment to the right patient to the right body part at the right time.

6 Shocking Facts on Opioid Abuse

What is your most pressing employee health issue today?

It’s not cholesterol, weight, sitting or probably anything else you are prioritizing. Instead, by far the major health menace facing your employee population is the opioid epidemic — which, according to Harvard Medical School psychiatrist John Kelly, has reached “DEFCON 5.”

DEFCON 5 is right. There is roughly one opioids prescription written for every adult in the U.S., and the total addiction rate is estimated at 4.6%, which makes it higher than alcoholism and roughly comparable (in the employed population) to diabetes.

Here are five things you need to know:

  1. Opioid abuse has jumped 500% in the last seven years.
  2. The price per milligram of morphine-equivalent paid by employees has declined about 75% in the last 15 years. This is due to more generous coverage (by you!), more use of the formulary and, most distressingly, more pills per prescription. There is virtually no product whose use doesn’t increase as the price falls. And there are very few products whose price falls that much.
  3. The $78 billion all-in cost in the U.S. of opioid use, abuse and treatment works out to about $756 per employee per year. To put that in perspective, that’s about 10 times what you spend on heart attacks and diabetes events (not that those aren’t important, too!).
  4. Workers’ compensation claims costs are 10 times higher when long-acting opioids are involved.
  5. Your ER visit claims coded to opioid issues have probably increased threefold since 2003.

(Yes, we know, that is only five facts. and we promised six. Keep reading…)

How do you solve an opioid problem within your organization?

You can’t look to your wellness vendor to solve this problem. If biometric screens included drug-testing, the employees who need to submit to them wouldn’t. (The legality of the testing would be very questionable anyway.) Asking a health risk assessment question: “Are you addicted to painkillers or heroin?” would generate — at best — the same level of candor wellness vendors observe when they ask about drinking and smoking. You can’t address an addiction that an addict won’t admit to having in the first place.

However, a health literacy vendor – ideally, my firm, Quizzify – can raise awareness of the hazards of opioids in your employee population. Because health literacy quizzes don’t require personal health information, there is no opportunity to lie, no one is being singled out and no one needs to worry that the results aren’t confidential. It’s simply, purely education. The answers are pure facts. (And in our case have passed review by doctors at Harvard Medical School.)

See also: The True Face of Opioid Addiction  

For employees not already using pain meds:

Firstly, employees who are not currently using prescription painkillers need to be made aware of the risks of starting. If there is one health literacy risk worthy of attention — meaning one risk where curing a knowledge deficit (as opposed to trying to change behavior, as with smoking cessation or eating habits) matters — it’s in opioid addiction prevention.

A few facts:

  • It can take as little as three days of use before the first signs of addiction occur. To put this into perspective, even something as minor as prophylactic wisdom teeth removal (not generally recommended by Quizzify anyway) can generate three days of painkiller medication.
  • If you use a 10-day supply as directed, you have a 20% risk of becoming a long-term user.
  • Dose matters. A lot. A high dose for a short duration is 40 times as likely to cause an opioid use disorder as a low dose.
  • Employees’ kids are taking prescription pain meds in numbers far exceeding those of previous generations. This is because they believe them to be safer than street drugs and are easier to get hold of (often from the parents’ medicine cabinets).

For employees already using pain meds:

As mentioned, the percentage of employees using pain meds, 4.6% on average, is roughly the same as the percentage with diabetes. The cost of treating those on pain meds – and their productivity losses (not to mention the possibility to pilferage or other crimes to support the habit) – is much higher than diabetes.

Further, employees are unlikely to seek help on their own. Use of medications designed to treat opioid addiction has grown only about a fifth as fast as opioid use itself. And many employees either don’t know where to turn or are concerned that their EAP conversations are not confidential. Fear of job loss or having a criminal record also impede the likelihood of seeking help. Your health literacy vendor should be able to create the education for you to overcome these natural impediments.

Quizzify’s opioid abuse education includes:

  • Specific contact information for the EAP.
  • “What if I think a coworker is opioid-dependent?”
  • “Are there resources for family members?”
  • “Can I get or renew pain meds from the on-site clinic?”
  • “Is opioid treatment a covered benefit?”
  • “Will human resources find out I am getting opioid treatment?”
  • “What are signs that my children are abusing painkillers?”

What can you do to help?

Your budget allocation for health and wellness should be in proportion to the priorities for health and wellness. As of now, you are likely spending less on educating employees on opioids (not to mention on other health literacy imperatives) than on, for example, weighing employees.

Likewise, employees are probably spending more time figuring out how to cheat on their weigh-ins than on understanding the hazards of opioid use. It’s time to reconfigure these priorities. Teach employees how to avoid, manage and treat opioid addiction before it is too late.

See also: Opioids: Invading the Workplace  

And by “too late” we mean #6 of the facts you need to know:

Far exceeding diabetes and heart attacks, overdoses are the leading cause of death for employees under 50.

We invite you to take Quizzify’s Opioids Awareness Quiz and share it with the top executives, HR administrators and wellness champions within your organization. Your awareness that something needs to be done now will increase. Quizzify offers educational quizzes about opioids for employees. That might be a good place to start.

Opioids: Invading the Workplace

America’s employers are facing a serious drug problem. A 2015 survey of 200 Indiana-based companies conducted by the National Safety Council and the Indiana Attorney General’s Office indicated that a staggering 80% of the state’s employers have had problems with employees abusing prescription opioids such as Vicodin and OxyContin.

“We would expect very similar results in many states,” said Deborah Hersman, president and CEO of the National Safety Council. The Illinois-based nonprofit organization focuses on preventing injuries and deaths at work and in the community. “This is not a local problem. This is a national problem, and it’s very important for employers to understand that this is an issue that they need to pay attention to and not put their heads in the sand.”

Prescription painkiller abuse has reached epidemic proportions across the United States. In addition to endangering the health and well-being of millions of employees, opioid abuse is costing employers billions of dollars in absenteeism and lost productivity, and growing evidence suggests that opioid abuse also affects many unemployed individuals.

“Beyond the loss of productivity, prescription drug abuse can cause impairment, injury and may lead employees to bad choices, such as theft and embezzlement from the employer,” said Indiana Attorney General Greg Zoeller in a news release about the December 2015 study.

See also: How to Attack the Opioid Crisis  

Employers Feel the Pain

On average, opioid misuse costs the U.S. economy $55.7 billion a year, according to the American Society of Addiction Medicine. Employers bear the burden of nearly half of that cost, with an average of $10 billion lost every year from missed work and decreased productivity alone.

Prescription drug abuse has two effects on an employee’s medical costs. First, employees who abuse opioid drugs have significantly higher costs for pharmaceuticals than non-opioid users. Costs for opioid painkillers rose 11.5 percent in 2014, according to pharmacy benefit manager Express Scripts Holding Co. As a result, workers’ compensation claim payers spent an average of $1,583 per injured worker for prescription drugs in 2014.

Furthermore, opioid abusers have significantly higher healthcare costs than non-abusers — $10,627 higher annually — according to a research article in the Journal of Managed Care & Specialty Pharmacy.

The Illusion of Relief

While highly effective in the short term, opioids are also dangerously addictive. This is because opioids produce a sense of pleasure due to their effect on brain regions involved in reward mechanisms. Adding to their danger is the fact that opioids tend to induce tolerance, which means that over time larger and larger doses are needed to achieve the initial effect.

A 2015 Healthentic study on the cost of painkiller abuse borne by U.S. companies found that for pain related to common workplace injuries such as soft-tissue injuries (bruises and musculoskeletal problems that affect muscles, bones and joints), opioids are no more effective at reducing pain than over-the-counter alternatives such as Tylenol, Advil or generic ibuprofen.

Less risky treatments for pain include nonsteroidal anti-inflammatory drugs, nerve blockers and other medicines including anti-seizure drugs and antidepressants which have pain-relieving properties. Other important options for managing the pain of workplace injuries include physical therapy, massage and acupuncture. It is also vital to treat any concomitant depression in the injured worker, as depression makes pain feel more acute and causes the sufferer to feel hopeless and helpless.

Steps Employers Can Take

Employers have a variety of options to ensure the long-term health of employees while improving productivity and lowering employment costs. The first is to demand adherence to evidence-based prescribing guidelines for pain treatment from all participating providers in their medical, workers’ compensation and occupational health programs. There is technology available now that can alert payers to providers who prescribe according to current treatment guidelines and those who don’t.

Employers also should educate employees about the risks of opioid drug use to help prevent drug misuse. For example, employees should know that a substantial subset of opioid users become addicted with their very first prescription, so care is warranted to ensure that patients with chronic pain know both the advantages and disadvantages of taking opioids right from the start.

Lastly, employers should provide confidential access to treatment for employees who find themselves in a position of opioid dependency. Employee Assistance Programs (EAPs) or wellness programs should be able to connect employees with effective treatment programs for their opioid use disorder, their depression and whatever else is impeding their ability to full productivity.

See also: The True Face of Opioid Addiction  

The Connection With Unemployment

A new study suggests unemployment also might be one of the factors behind the dramatic rise in opioid use disorder. The paper, published by NBER, finds that as the unemployment rate increases by one percentage point in a given county, the opioid death rate rises by 3.6 percent, and emergency room visits rise by 7 percent.

Rather than more people getting injured when jobs are scarce, the authors suspect that the increased use of painkillers is a “physical manifestation of mental health problems that have long been known to rise during periods of economic decline.” Depression and pain go hand-in-hand, in other words: “Not only does depression make people more sensitive to pain,” they note, but also, “opioids have been shown to help relieve depressive symptoms.” Pain, opioids and depression are all interrelated and all must be managed to achieve what both injured workers and payers would regard as success.

One can conclude from all of this evidence that opioid use disorder is increasingly rampant among both employees and those who are unemployed. Opioid misuse now may be a national problem, but the solution needs to start locally. Employers are uniquely positioned to demand accountability from providers and to join with their neighborhood social service agencies and nonprofits focusing on the opioid issue collectively to intervene in and reduce the prevalence of this debilitating epidemic.