The statistics describing America’s prescription drug abuse epidemic are startling, to say the least. Here are just a few statistics from the Centers for Disease Control and Prevention: In 2009, prescription painkiller abuse was responsible for nearly half a million emergency department visits — a number that doubled in just five years. Of the more than 41,000 drug overdose deaths in the U.S. in 2012, more than half were related to pharmaceuticals. In 2012, U.S. health care providers wrote enough painkiller prescriptions — 259 million — to provide every, single American adult with their own bottle of pills. Prescription painkiller abuse cost the nation more than $55 billion in 2007 alone.
While pharmaceutical companies are making billions in painkiller profits, it’s the public sector that ends up bearing the burden and cost of the widespread fallout that accompanies skyrocketing sales of highly addictive prescription opioids. Law enforcement, criminal justice, health and behavioral health care systems, and state and local public health departments are now on the front lines of an addiction and overdose crisis that continues to spiral out of control. And in addition to the painkiller problem, many state and local officials are reporting spikes in the use of another, more notorious opioid: heroin.
A handful of those frontline responders came together for a congressional briefing on the opioid epidemic in September and called on federal policy-makers to take a more concerted and coordinated effort to address a problem that, on more than one occasion, has been described as a public health crisis. Organized and hosted by the Big Cities Health Coalition (BCHC), the Sept. 16 briefing — “The Opioid Epidemic: Reporting from the Front Lines of America’s Big Cities” — featured insights and remarks from Barbara Ferrer, who until recently served as executive director of the Boston Public Health Commission; Bechara Choucair, commissioner of the Chicago Department of Public Health; and Mary Travis Bassett, commissioner of the New York City Department of Health and Mental Hygiene.
All three described their city’s experience in grappling with the opioid epidemic — click here to watch a video of their remarks. Chicago, in particular, has taken direct action against the pharmaceutical companies that manufacture painkillers. In June, the city filed a claim against five drug companies seeking compensation for damages and for the companies to forfeit revenue stemming from fraudulent marketing claims that pharmaceutical opioids are rarely addictive.
During the briefing, the BCHC members called for three specific federal actions. The first is passage of a federal Good Samaritan Law, which would among other measures, give legal protection to those who intervene in a drug overdose. The second is increasing access to naloxone, a drug that can effectively reverse the effects of an opioid overdose and can be easily administered by first responders as well as friends and families of those struggling with opioid addiction. The third action is the creation of a federal interagency task force to address insurance barriers to addiction treatment. (Increasing funding for addiction treatment services may be a particularly challenging goal. A recent study found that the public has significantly negative views of drug addiction, with 43 percent of adults in a nationally representative survey saying they oppose insurance parity for drug addiction.)
Below is a Pump Handle (PH) Q&A with two public health officials at the forefront of the opioid epidemic within America’s big cities: Choucair of the Chicago Department of Public Health and Hillary Kunins, assistant commissioner at the New York City Department of Health and Mental Hygiene.
PH: Opioid use and overdose has been at crisis levels for some time now. Why did the BCHC decide to host a congressional briefing now? Are we at a particularly critical point in the epidemic?
Choucair: Cities have been on the front lines of the opioid crisis for more than a decade. Despite our best efforts, prescription opioid abuse is still raging out of control. In Chicago, we work to help residents in recovery, but we are also looking upstream to help stop the problem before it starts. We know drug companies have engaged in deceptive practices and downplayed the risk of addiction when it comes to prescription opioids — leading many good, law-abiding people to become addicted to prescription drugs or turn to the streets to seek out heroin. This is why Mayor (Rahm) Emanuel and Chicago have filed suit against Big Pharma to require all companies to accurately represent the risks of these drugs and ensure doctors and patients can make informed choices about their care.
Even with these innovative steps, there is still a huge challenge ahead of us. Just (recently), the CDC reported 17,000 annual deaths from overdoses and a rise in heroin use, linking these numbers directly to prescription painkillers. Cities can’t fight this battle alone. We need all hands on deck if we are going to win, including increased leadership from the federal government.
PH: Is federal action to expand access to naloxone preferred to state and local action? Or do we need a combination of both? Are you concerned that federal action may prevent local health officials from designing and tailoring a naloxone program to fit their community’s needs?
Choucair: We need all hands on deck if we are going to win, with cities, states and the federal government working together. Expanding access to naloxone is a vital and life-saving step. In Chicago, fire fighters and emergency medical technicians are armed with naloxone, which has been proven to save lives. Action on the federal level can sidestep two barriers some municipalities face: cost and outdated attitudes towards addiction. The first, cost, reflects the sad reality that local health departments are more likely than state and national health agencies to be restricted to incredibly tight budgets that might not allow for the addition of naloxone purchases. The second, outdated attitudes towards addiction, results in municipal governments refusing to support the use of naloxone out of the mistaken belief that the existence of a lifesaving antidote will encourage abusive drug behavior. This theory has been thoroughly debunked by scientific research, and we hope that national action will erase gaps in medical coverage for both overdose and addiction treatment.
Kunins: Both federal and state action is needed to increase access to naloxone for those at high risk of witnessing an overdose. A federal law that allows laypersons to carry and use naloxone, as we have in New York state, would increase access to naloxone greatly. In addition, (a) Good Samaritan law, which we are fortunate to have in New York State and which protects individuals from drug-related prosecutions in the setting of a drug overdose, should be adopted nationally. Finally, over-the-counter access to naloxone would be another way to facilitate access to and availability of naloxone to reverse overdose. These federal policies would help, not hinder, local health officials to prevent overdose in their communities. Knowledge of the local context, including opioid overdose trends and stakeholders, could be used in a synergistic way to tailor naloxone programs to the community’s needs.
PH: Some communities that have successfully curbed the illicit flow of prescription painkillers have experienced an increase in heroin use. A few months ago, I interviewed a local health official who told me that after successfully restricting the flow of painkillers, there was a nearly 100 percent switch to heroin among clients at the local needle exchange. What does a story like this tell us about the importance of addressing the opioid epidemic in a comprehensive way instead of focusing on either painkillers or heroin separately?
Choucair: Addiction to prescription painkillers and addiction to heroin are one and the same — both in terms of the chemical effects and their ability to ruin lives, tear families apart and kill the individuals using them. We are very concerned about individuals moving from prescription painkillers to heroin in response to either the lower price or the reduced availability of prescription drugs, which is why both the Big Cities Health Coalition and the City of Chicago have made addiction treatment such a high priority. Unless our public health and health care agencies are able to successfully intervene and rehabilitate an individual misusing prescription drugs, we will be turning addicts out onto the street in search of other alternatives.
Kunins: Using a comprehensive strategy to address the public health crisis related to opioids is very important. In New York City, we have taken a multi-pronged, public health response, including developing an innovative drug surveillance system, promoting safe and judicious opioid prescribing, promoting overdose prevention with naloxone, improving access to addiction treatment and conducting public education media campaigns. Although we have seen an increase in heroin overdose deaths the past three years in New York City, our data do not suggest that initiatives to limit opioid analgesic prescribing caused this trend, given that heroin overdose deaths began to increase prior to implementing these prescribing initiatives. Additionally, we are conducting real-time qualitative studies in the community to better understand this problem and we are finding that several patterns of new heroin users exist (not only those who transition from opioid analgesics to heroin). This is a complex story that is unfolding. A comprehensive public health response will help to understand and reduce overdose deaths.
PH: In efforts to prevent the diversion of prescription painkillers and refine prescribing practices, how can we ensure that legitimate chronic pain patients don’t get caught in the middle? Are you concerned that fewer and fewer doctors will be willing to prescribe painkillers to those who need them?
Choucair: I am a family physician, and I will be the first to say that we do not want painkillers to be banned or made unavailable for those patients for whom it is appropriate. We have gone too far in one direction by making prescription painkillers the first, most common, and often only method of pain management. Prescription painkillers should be used to address temporary pain in conjunction with other treatments, like physical therapy. Prescription painkillers are not appropriate for long-term or chronic pain in individuals who are not terminally ill, and physicians need to be more rigorous in screening for abuse risk factors.
Kunins: It is important to address patients’ concern for pain in a comprehensive and safe way. Although there is still a role for opioid analgesics in certain painful conditions, they are not always the appropriate treatment. In fact, for chronic pain that is not related to cancer, there is insufficient evidence for pain relief or improved function from long-term opioid use; however, there is a substantial risk for addiction and overdose. Efforts to promote safe and judicious opioid prescribing should be evidence-based and should encourage prescribers to carefully weigh the serious risks of opioid analgesics against possible benefits to the patient. In New York City, we urge consideration of non-opioid therapies to treat pain, whenever possible. However, if after thorough consideration of the risks versus benefits, opioids are prescribed, they should be for evidence-based indications, shorter durations and lower doses. This approach limits unnecessary exposure to opioid analgesics on the population level, preventing addiction and overdose, yet supports safe and appropriate treatment of pain.
PH: Public health officials are on the forefront of addressing the opioid use and overdose epidemic, yet we seem to hear little from the medical community, which is a key player in this problem. Are you hearing from physicians in your community who want more education and resources to help them responsibly prescribe painkillers? Do physicians in your community seem eager to help solve the problem?
Choucair: I am a physician and I can tell you I am concerned. Furthermore, physicians from around the country have reached out to me and expressed support for our efforts in Chicago. If you haven’t heard much from medical institutions yet, I expect you will soon. Public health officials and physicians are partners in this effort, as are policy-makers and community leaders — at every level.
Kunins: In New York City, we conducted office-to-office educational visits with more than 1,000 health care providers in Staten Island, our hardest-hit county. During these visits, we promoted our guidelines for safe and judicious opioid prescribing, provided resources and tools to implement these guidelines and received feedback. Providers were enthusiastic about our educational guidelines and were motivated to learn strategies to help address this serious problem.
To learn more about the Big Cities Health Coalition and its efforts to address prescription drug abuse as well as to access video from the September congressional briefing, click here. To learn more about the nation’s opioid epidemic, visit the Centers for Disease Control and Prevention.
Kim Krisberg is a freelance public health writer living in Austin, Texas, and has been writing about public health for more than a decade.