The opioid crisis, which affects millions of people across the country, shows no signs of stopping. Indeed, the pace of addiction and death is so fast in some locations that the statistics are more overwhelming than helpful. Pioneering, effective interventions are needed — but they will only get us so far. The complexity of the opioid crisis requires medical, legislative, behavioral, educational, and legal changes, and it requires that these changes be made in coordination with each other, at the same time.
States and communities will succeed only if they engage and align all actors to create systems that can prevent new individuals from becoming dependent on opioids, while supporting the recovery of those who already are. Failing to take such an approach will result in burnout among those working individually to improve the current situation and a rate of progress that is too slow to keep up with the velocity of this crisis and the power of opioid addiction.
Fortunately, important actions are being taken at the national level and within some states to both prevent individuals from becoming addicted and to treat those who already are. For example, the Center for Disease Control and Prevention’s (CDC) recent guidelines will help millions of physicians prescribe opioids appropriately and responsibly. The Department of Health and Human Services’ proposed rule to increase the patient limit for physicians who prescribe buprenorphine (an effective medication used to treat opioid addiction) from 100 to 200 patients will allow more individuals to receive the treatment they need to end their dependence on opioids.
States are implementing drug courts; narcotics detectives and emergency medical technicians (EMTs) are becoming trusted case managers helping guide individuals to treatment rather than arresting them; and some medical examiners are serving as physician educators when overdoses occur. Again, although these efforts are necessary, they are not sufficient to reverse this crisis.
We work for the Institute for Healthcare Improvement, an organization that specializes in approaching even the most devastating health crisis as a systems problem requiring a coordinated, comprehensive response. In our study of the opioid crisis, including the myriad efforts being put in place across the country to save lives and the successes and failures that accompany these efforts, we find the systems perspective more important than ever. It will take a community-wide effort and work at the national, state, and local levels to adequately address the problem. We have identified six key components to develop a system-wide community solution.
Recognize that everyone in your community has a role to play
If you produce or prescribe opioids, if you treat addiction, if you enforce the law, if you are an educator, if you are a family member, if you’re an individual taking opioids — you have a role to play. We cannot rely on “someone else” to solve this crisis. Table 1 shows the high-level and specific actions, along with the actors, required to implement a coordinated, systematic approach across a community.
Communities are often resource rich and coordination poor. Resources—financial, human, programmatic—are precious, and given the extent of this crisis, we cannot waste them. Unlikely collaborators must learn to work together, communicate continuously, and think beyond the perceived boundaries of their role in the community. Well-intentioned providers need to work together across areas, which likely means moving beyond the borders of their institutions and traditional roles to create new relationships and pathways in order to provide coordinated services to those in need.
Work on multiple parts of the system simultaneously
Many efforts focus only on one part of the crisis. We cannot focus just on prescribing guidelines, just on naloxone distribution, just on increasing access to treatment, just on preventing diversion. We need to focus on them all, and all at once, because a multi-faceted problem requires a multi-faceted solution. Think of the response to a natural disaster: we don’t focus only on housing, or food, or infrastructure — all pieces need to come together. The same is true of the opioid crisis; preventing a fatal overdose through the administration of naloxone is important, but addressing the ongoing addiction requires a system approach.
Be unambiguous about the risks of prescription opioids
Let’s be clear: approximately 75 percent of heroin users started on the road to addiction with prescription drugs. Let’s change the conversation with patients from a footnote that prescription opioids can be dangerous if abused, to a frank discussion about how prescription opioids and heroin affect the brain and body in the same way.
Let’s tell patients and their family members that the majority of people who become addicted to prescription opioids were not engaged in drug-seeking behavior or recreational use, and were simply taking a medication to relieve pain as prescribed by their physician. Let’s use opioids when they are the only option or for palliative or cancer care. Let’s be appropriately afraid of prescription opioids and treat them like the lethal drug they can be.
Re-train the medical community
Physicians received misinformation about the risks and benefits of prescription opioids for treating chronic pain, and we know that changing practice takes time. However, we do not have the benefit of time with 44 individuals dying each day. Prescription guidelines are important, but physicians need to be re-trained in how they treat patients with all kinds of pain. There are effective alternatives for chronic pain management; providers need to use them and payers need to adequately reimburse for them.
Recognize that addiction is a chronic disease, and treat it accordingly
The people who are addicted and dying in this opioid crisis cross all boundaries. They include high school athletes, middle-aged women, and high-functioning executives. They are individuals, not some amorphous group beyond help. Indeed, addiction in any form is not a moral failing; it is a physical and psychological disease that must be managed over time like any other chronic disease. Recovery from addiction is long and painful, and the stigma around addiction only prevents people from getting the help they need.
The statistics are staggering: in 2014, 28,647 individuals died from a drug overdose involving some type of opioid, a 14 percent increase from 2013, already the highest year on record. But we can’t let them overwhelm us. For the parents who just buried their daughter who became addicted to opioids after a sports injury, the baby born dependent on opioids, or the suburban mother accidentally overdosing when she became addicted to prescription painkillers after a car accident, the statistics are irrelevant. But even though their pain is singular, working in isolation cannot be the solution; states and communities need to provide the infrastructure for success.
Table 1. Actions and Actors to Address Key Drivers of the Opioids Crisis
|High-level Actions||Specific Actions||Actors|
|Decrease supply of prescription opioids||• Change prescribing practices (dose, duration, reason for prescribing, ceiling)|
• Change dispensing practices
• Prevent diversion
• Limit pharmaceutical production
|• Physicians, Physician Groups, CDC, national or state legislative action
• Pharmacists, Payers, legislation
• Patients, community organizations (locations for safe drug disposal)
• National legislative action, FDA, pharmaceutical companies
|Decrease supply of recreational opioids||• Enable prosecution of dealer by classifying overdose death as crimes rather than untimely deaths|
• Change classification of controlled substances
• Arrest and prosecute dealers
|• Attorney General
• Attorney General, legislation
• Law enforcement
|Increase availability of non-opioid forms of chronic pain management||• Change reimbursements|
• Educate providers on effective, alternative pain management strategies
|• Payers: private and public
• TBD: Requires academic detailing, guidelines, requirements, and education/implementation
|Educate about risks of prescription opioids||• Identify patients at greater risk for addiction|
• Educate the public about the risk of prescription opioids
• Education, Public Health
|Reduce stigma||• Provide education for:|
◦ Law enforcement
• Providers, education system, Public Health
• Law enforcement (treatment of disease, not just crime)
|Manage opioid-dependent population||• Taper patients from high dose, chronic use|
• Educate patients about pain management
• Increase availability and reimbursement of alternative pain management therapies
|Identify opioid-addicted individuals||• Assess for substance use (opioid use) disorder at physician visits|
• Use PDMP to identify opioid-seeking patients
|• Law enforcement, EMTs, Providers, Pharmacists
• Providers, Pharmacists, Public Health
|Enroll in detox + ongoing, comprehensive substance abuse treatment||• Increase availability of inpatient detox|
• Increase availability of outpatient detox
• Train providers to use Medication-Assisted Treatment (MAT)
• Increase availability of MAT
• Increase availability of Behavioral Health services (either integrated into Primary Care or separate)
|• Providers, law enforcement, EMTs, public health, payers|
|Link detox and ongoing treatment and recovery services||• Provide ongoing MAT when appropriate|
• Provide ongoing group therapy
• Implement drug courts
• Providers, payers, Peer support
• Attorney General, law enforcement
|Prevent death from opioid overdose||• Administer Naloxone|
• Increase availability of Naloxone in community
• Educate family/friends on signs of overdose and use of Naloxone
|• EMTs, clinicians, law enforcement
• Legislative, Individual, Provider
|Create learning and feedback loops||• Report opioid overdoses to any provider linked to the individual|
• Provide access for all to PDMP
• Use PDMP at each patient encounter
|• Medical examiner
• State legislation
• Medical societies, provider networks, Public Health
|Decrease demand for recreational opioid use||• Implement drug courts |
• Eliminate pre-authorization for SA treatment
• Build strong recovery system
|• Attorney General
• Attorney General, payers
• Public health, behavioral health services