Annual Check-up: Is the Opioid Crisis Any Better?

It is estimated that in 2016, 11.8 million individuals or approximately 4% of the U.S. population misused opioids and over 42 thousand individuals died of opioid overdoses – more than firearm homicides, car crashes, or H.I.V. at its peak – making the opioid crisis the deadliest epidemic in American history⁽¹⁾. As a follow-up to our 2017 blog post on this topic, we were eager to perform an annual check-up and dig a layer deeper to explore the root causes of the problem, while highlighting a few innovative companies delivering potential solutions and taking inventory of other efforts underway to address this massive, incredibly complex and deeply human issue.

Background
Late last year, the U.S. government estimated that, in just a single year, the opioid epidemic cost the U.S. economy more than $500 billion⁽²⁾. However, there has been little action from legislators to stop the spread of this epidemic as only $6 billion has been budgeted over the next two years for education, preventative treatment, and increased law enforcement action – far less than experts project it will take to solve the problem⁽³⁾.

Aside from the economic burden, opioids are also having a tremendous humanistic impact on our society. This problem affects the entire socioeconomic spectrum from construction workers who are injured on the job to businessmen, expectant mothers, stay at home parents, and the elderly who become addicted to opioids after a surgery. It is also a problem that disproportionately impacts the most vulnerable members of our society – 25% of people with Opioid Use Disorder (OUD) are on Medicaid, and these Medicaid individuals have double the relapse rate of other populations⁽⁴⁾.

As we dug deeper into these types of eye-opening statistics, we began to wonder: how and why opioid use and addiction got out of control? What are the current treatment options and resources available to those who currently have OUD? And, what else can we be doing as community members, social workers, parents, providers and payers to prevent, mitigate, and ultimately solve the problem?

How did we get here?
There are multiple socioeconomic factors and structural shortcomings of our healthcare system that have contributed to the opioid epidemic.

• Culture of Impatience & Instant Gratification: It is no secret that in the age of smart phones, social media, same-day shipping, streaming videos, etc., the need for instant gratification has become a common trait for modern Americans. While this “impatience” can be harmless in many scenarios, from a healthcare / wellness perspective, it can be a contributing factor to mental health and addiction issues. Why take the time and energy to follow a physical therapy program for pain management when a pill may dull the pain temporarily?

• Over Prescribing by Doctors & Alternative Treatments Options: In 2012, providers wrote 259 million prescriptions for opioids in the U.S. This equates to almost one bottle for every adult in the U.S.⁽⁵⁾ However, a recent study demonstrated that pain can be treated just as effectively using a combination of Tylenol and Advil in an emergency department setting⁽⁶⁾. Perhaps too many of our physicians are meeting less resistance and receiving better reimbursement to treat symptoms rather than the underlying, root cause of the medical condition? Other non-drug pain management methods such as chiropractic services, physical therapy, yoga, cognitive therapies, and regular exercise are also effective methods for preventing and treating pain. As such, a health plan or employer would certainly prefer to pay for five physical therapy sessions at $150 per visit as opposed to the medical expenses associated with an opioid addiction. So what are the barriers to these alternative treatment options?

• Impact of the Recent Economic Downturn: Studies have shown that during times of recession, the use of drugs (including opioids) increases drastically. A paper published by the National Bureau of Economic Research found that as unemployment increased by one percentage point, the opioid death rates rose 3.6 percent⁽⁷⁾. This dynamic may be compounded by the fact that people with less income often do not have the resources to pursue healthier alternatives to stress relief and depression, both of which can lead to a higher rate of opioid addiction.

• Co-Occurring Mental and Physical Health Conditions: A recent study found that one third of the individuals that died from an opioid overdose had a dual diagnosis of chronic pain and a mental health disorder⁽⁸⁾. While OUD is usually associated with physical pain, this statistic highlights the need for a more holistic approach to care, inclusive of any co-occurring mental and physical conditions.

• Reimbursement Gap for the Most Vulnerable Population: Less than 70% of state Medicaid plans cover physical therapy and less than 50% cover chiropractor services⁽⁹⁾. Even when these treatments are covered, there are very few states that have policies or procedures that mandate or encourage their use, subjecting Medicaid members to increased risk of opioid addiction.

What are Common Treatment Plans for those with an Opioid Addiction?
Since the early 2000s, treatment centers have seen their admissions for prescription drug use increase 500%⁽¹⁰⁾. Over this period, two primary schools of thought have developed for the treatment of OUD: traditional abstinence and Medication Assisted Therapy (MAT).

MAT is a more recently developed treatment option that utilizes counseling / behavioral therapies to support, teach, and heal in combination with medications, such as methadone or buprenorphine, which help reduce or eliminate withdrawal symptoms and cravings. This treatment methodology has been shown to have improved outcomes for patients over the standard abstinence-only model⁽¹¹⁾. Despite being more effective, MAT is frequently misunderstood and carries a moralistic stigmatization that has led to many healthy debates. Those that oppose MAT argue that using drugs to cope with withdrawal symptoms does not solve the underlying issue; MAT just replaces one addiction with another. This viewpoint could be waning, however. In 2012, The Hazelden Betty Ford Foundation, historically a strict believer in abstinence treatment programs, announced it would begin offering MAT, representing a big shift from its abstinence only model. “This is a huge shift for our culture and organization,” Marvin Seppala, Chief Medical Officer of Hazeldon, said at the time. “We believe it’s the responsible thing to do.” While this form of treatment is new to addiction, it isn’t new to medicine. How is it different than replacing cigarettes with nicotine gum or a patch? Perhaps our society is just letting its moral compass interfere with a treatment methodology that has shown to cut all-cause mortality rates among addiction patients by more than half. As the scientific evidence in favor of MAT continues to grow and other prominent organizations continue to embrace MAT, we are hopeful the moralistic stigmatization will continue to fade, providing individuals with better access to the most-effective care.

A recent opioid treatment provider startup, Groups, is using MAT-based treatments along with providing positive peer groups to combat the crisis. The Company’s goal is to provide opioid treatment services to the millions of people in communities where treatment is not readily available while keeping expenses at a rate that almost anyone can afford. The Company understands the social determinants that lead to addiction, recovery, and relapse and believes that support from a community of physicians, counselors, and recovering opiate users is a critical component of the recovery journey. According to the Company’s website, “People at different stages of recovery learn from each other, build collective wisdom, and hold each other accountable.” Groups’ approach seems to be working as the Company broadcasts impressive success rates – after six months at Groups, 95% of patients attend weekly counseling and 85% are totally abstinent from opiates.

While rehab treatment centers are a key part of helping those with OUD, what happens after a patient successfully completes a rehab program is equally as important. It is critical that patients have access to a supportive, drug-free community. This is another reason why Groups is so successful at meeting the epidemic head-on. Its care model provides the ongoing community support and accountability that individuals need. To help bring the real personal, social and environmental challenges of recovery to life, we recommend listening to two podcasts released by Bessemer Venture Partners and Oxeon Partners:

• “When a Dose Isn’t Healthy: Talking Opioids & Heroin with People Who Have Battled Them”, which provide powerful first-hand accounts of individuals that have suffered from OUD

• “Jeff DeFlavio, CEO of Groups”, which provides perspectives from the CEO of Groups, Jeff DeFlavio

axialHealthcare is another example of an innovative company helping to change the way providers, patients, and insurers fight the opioid crisis. Founded in 2012, axialHealthcare counts .406 Ventures, Oak HC/FT, Sandbox Advantage Fund, and BlueCross BlueShield Venture Partners among its investors. The company aggregates data from over 100 million lives to provide data-driven solutions for payers, providers, and patients. Payers use axialHealthcare’s database and proprietary software to identify the best and worst performing pain care and medication-assisted treatment providers. With this information, payers can direct patients to the highest quality care providers, reducing the risk of long-term opioid addiction and increasing positive patient outcomes. For providers, the company offers pain treatment pathways to help avoid the initial prescription, alerts for the most at-risk patients, and intervention plans to support better care across the continuum of opioid use. For patients, the company offers an app that collects self-reported data that is used to support personalized care plans, encourage alternative therapies for pain management, and help patients better manage symptoms and side effects. The provider- and patient-facing solutions are supplemented by access to axialHealthcare’s clinical care team. By leveraging technology and analytics in combination with human engagement, axialHealthcare is educating all major constituents on pain management alternatives and avoidance strategies and demonstrating its ability to deliver a significant impact. axialHealthcare’s recent partnership with Highmark provides some impressive and promising results in a state severely affected by the opioid crisis.

Another company at the forefront of fighting the opioid crisis is Cordant Health Solutions. Cordant serves payers, clinicians and agencies involved in addiction, criminal justice, and pain management through a network of toxicology laboratories and pharmacies. The company’s toxicology laboratories not only provide Prescription Drug Monitoring Program (PDMP) data and testing results that help providers gain further insight into their patients, but they also provide full-service pharmacies, specializing in management and dispensing of controlled substances. Additionally, to stop opioid related deaths and new OUD cases from starting, the company offers naloxone, a drug used to stop overdoses, and a take-back program designed to remove dangerous prescriptions from medicine cabinets and prevent powerful narcotics from falling into the wrong hands. Cordant Health Solutions recently published promising results showcasing the Company’s ability to help doctors provide the right care while alerting them of potential opioid abuse.

Work Left to be Done
The results of our “annual check-up” indicate that progress is being made, but we are still far from solving the problem. It will take a combination of changed societal norms, improved patient, provider and payer education, better access to the appropriate care, and intensified support from government programs for the situation to meaningfully improve. The good news is many of these parties are starting to put plans into motion:

• 16 national and region health plans have made a commitment to help fight the opioid crisis

• Since 2017, the government has established commissions, declared the epidemic a public health emergency, and increased education and funding on the issue

• WellCare Health Plans has implemented a pharmacy management pilot program that has reduced the amount of opioids prescribed to at risk populations by 50%

• United Health Group’s OptumRx has introduced an opioid risk management program and has made great strides in a short period of time

• On February 1, 2018, CMS announced changes to Medicare Advantage and Part D to provide new protections to combat the opioid crisis

• The FDA plans to expand access to MAT treatment by allowing pharmaceutical companies to sell medication that diminishes opioid cravings

In addition to these moves, both the Justice Department and Congress recently put new plans of action into place. On February 27th, the Justice Department announced that it will try to join a lawsuit against opioid drugmakers and distributors, seeking to “hold accountable those whose illegality has cost us billions of taxpayer dollars.” On the same day, Congress proposed a bipartisan bill, CARA 2.0 (named after its predecessor, the Comprehensive Addiction and Recovery Act), that aims to build off of what the original CARA bill started by:

• Imposing 3-day limits on initial opioid prescriptions for acute pain
• Increasing the availability for doctors to treat patients using buprenorphine and allowing PAs and nurse practitioners to prescribe buprenorphine with guidance from a physician
• Requiring prescription monitoring programs
• And authorizing spending for nearly $1 billion of the $6 billion budgeted in the most recent federal budget for slowing the opioid epidemic

With intensified efforts by payers, providers, consumers, and the government we are optimistic that we are heading down the right path toward stopping or at least slowing the deadliest drug epidemic in American history. Let us know what you think.

End Notes 
(1) https://www.cdc.gov/nchs/products/databriefs/db294.htm; https://www.samhsa.gov/data/sites/default/files/NSDUH-FFR1-2016/NSDUH-FFR1-2016.pdf; https://www.nytimes.com/2017/10/26/us/opioid-crisis-public-health-emergency.html
(2) https://www.whitehouse.gov/sites/whitehouse.gov/files/images/The%20Underestimated%20Cost%20of%20the%20Opioid%20Crisis.pdf
(3) https://www.vox.com/policy-and-politics/2018/2/8/16988236/congress-federal-budget-opioid-crisis
(4) https://www.macpac.gov/wp-content/uploads/2017/06/Medicaid-and-the-Opioid-Epidemic.pdf; axialHealthcare
(5) https://www.cdc.gov/vitalsigns/opioid-prescribing/index.html
(6) https://jamanetwork.com/journals/jama/article-abstract/2661581
(7) http://www.nber.org/papers/w23192
(8) http://cordantsolutions.com/study-correlates-chronic-pain-mental-illness-opioid-overdose/
(9) https://www.kff.org/state-category/medicaid-chip/
(10) http://www.hazeldenbettyford.org/treatment/models/mat-faq
(11) http://www.pewtrusts.org/en/research-and-analysis/fact-sheets/2016/11/medication-assisted-treatment-improves-outcomes-for-patients-with-opioid-use-disorder
(12) Image: http://ohiovalleyresource.org/2016/08/05/going-mat-government-science-back-medication-assisted-treatment-addiction/