no words requirments due tomorrow

Journal.pdf

Home >Business & Finance homework help >Management homework help >no words requirments due tomorrow

Point/Counterpoint Theodore Joyce, Editor

PERSPECTIVES ON THE OPIOID EPIDEMIC: CAUSES, CONSEQUENCES, AND RESPONSES

There are over 100 deaths per day associated with the opioid crisis. Opioid fatal- ities now exceed those from automobile crashes and the upward trend shows no signs of abating. In this Point/Counterpoint, experts from the fields of public health and economics use their disciplinary insights to explain the causes of the epidemic, what is sustaining it, and what responses might be most effective. However, unlike traditional Point/Counterpoint exchanges, our experts largely agree on broad as- pects of the crisis. Their differences are chiefly ones of emphasis; Brendan Saloner and Colleen Barry, both professors from Johns Hopkins’ Bloomberg School of Public Health, focus on the demand for opioids, while the economists, Rosalie Pacula and David Powell, from the RAND Corporation, emphasize supply-side factors. Given general agreement that the best approach for tackling the epidemic is a comprehen- sive strategy including supply and demand considerations, we decided on a unique format for the Counterpoint. Instead of challenging each other’s points, both sets of authors posed questions for the other authors to address. The result is a deeply insightful discussion by leading experts in the health and social science of addiction.

Journal of Policy Analysis and Management, Vol. 37, No. 2, 430–451 (2018) C© 2018 by the Association for Public Policy Analysis and Management Published by Wiley Periodicals, Inc. View this article online at wileyonlinelibrary.com/journal/pam DOI:10.1002/pam.22045

Point/Counterpoint / 431

ENDING THE OPIOID EPIDEMIC REQUIRES A HISTORIC INVESTMENT IN MEDICATION-ASSISTED TREATMENT

Brendan Saloner and Colleen L. Barry

INTRODUCTION

The opioid epidemic is an unprecedented public health crisis that has rapidly spread across the United States. In the late 1990s, illicit opioid use was a phenomenon clus- tered in Appalachian communities where people trafficked in prescription pills and in the inner cities of the northeast where predominantly minority populations in- jected heroin. Today, the epidemic has spread across American cities and rural areas, as well as to more affluent suburban communities. Opioids officially account for more than half of all drug overdoses, and this underestimates their true contribu- tion, as opioid overdoses are undercoded in mortality data (Ruhm, 2017). Overdoses are the leading cause of injury death in the United States, accounting for one and a half times more deaths than motor vehicle crashes (Rudd et al., 2016). More people now die of overdoses every day than died of HIV at the height of that epidemic in the mid-1990s and the opioid deaths are contributing to reversals of life expectancy gains (Dowell et al., 2017).

Causal explanations of the epidemic tend to focus on two interrelated factors. The first is the overprescription of opioid pain relievers. The U.S. is an outlier in the quantity of opioids legally prescribed for pain relief (Kolodny et al., 2015). The acceleration of opioid prescribing reflects the role of drug makers exaggerating the safety and effectiveness of their products. For example, OxyContin was brought to market under the premise that its long-acting formulation would reduce misuse, but the manufacturer was aware that the medication was susceptible to abuse (Van Zee, 2009). Many individuals who misuse opioids began with legitimately prescribed pain relievers and then become addicted following long-term use (Kolodny et al., 2015). Moreover, rising prescription opioid use has created a secondary market in diverted medications. While opioids are recognized to have medical benefits, they are of limited use in treating chronic pain and growing evidence suggests that many would be better served with nonopioid alternatives. However, individuals seeking nonopioid alternatives for chronic pain relief have found it difficult to obtain effective treatments such as physical therapy, as these treatments are sometimes not covered by insurance (Volkow, Benveniste, & McLellan, 2017).

The second factor emphasized more recently is the rise of potent alternatives to prescription opioids. Surging overdose death rates have been linked to heroin and fentanyl, a departure from the 1990s and early 2000s when prescription pain relievers were the main driver of the epidemic (Frank & Pollack, 2017). These two dynamics are related, as individuals dependent on prescribed opioids often shift to the street market when prescription drugs become difficult to obtain (Compton, Jones, & Baldwin, 2016). Some commentators have speculated that this shift may actually be accelerated by policies that crack down on prescribed opioids. These policies are heterogeneous, making it difficult to summarize their effects. For example, laws intended to close “pill mills” appear to not increase heroin mor- tality (Kennedy-Hendricks et al., 2016), but there is some evidence that the 2010 reformulation of OxyContin that made it more difficult to crush pills led to

Journal of Policy Analysis and Management DOI: 10.1002/pam Published on behalf of the Association for Public Policy Analysis and Management

432 / Point/Counterpoint

more heroin use (Alpert, Powell, & Pacula, 2017). Research on prescription drug monitoring programs similarly yields mixed evidence on unintended consequences (Buchmueller & Carey, 2017; Lin et al., 2018; Meara et al., 2016). Even if these poli- cies have successfully reduced prescription opioid misuse, the epidemic likely would have become more lethal because of the rising purity of heroin and the potency of fentanyl. Making matters worse, consumers lack information about whether street drugs contain fentanyl, limiting their ability to use drugs in a safer manner.

In sum, the opioid epidemic would never have achieved scale without prescription opioids and it would not be sustained today without heroin and fentanyl. However, we regard these supply-side factors as necessary but not sufficient to account for the scope of the epidemic. We argue that the epidemic has persisted in large part because of the failure to reduce demand for opioids among the two million people who meet clinical criteria for opioid use disorder (OUD) and who are most susceptible to overdose (Han et al., 2017). Making medication-assisted treatment more widely available would save lives by reducing opioid misuse in this population, and is one of the few proven strategies to do so over the long term.

BROADER ACCESS TO MEDICATION-ASSISTED TREATMENT TO COMBAT THE EPIDEMIC

The case for scaling up treatment is supported by the effectiveness of opioid agonist medications (i.e., methadone and buprenorphine) as long-term maintenance thera- pies. These medications address the core physiological symptoms of OUD—the crav- ing for opioids and the experience of withdrawal during periods of nonuse, without creating the experience of euphoria. The potential of agonist therapies for long-term treatment was first demonstrated in landmark studies on methadone in the 1960s, and has since been replicated in randomized controlled trials comparing treatment with either methadone or buprenorphine to nonmedication treatment programs (Mattick et al., 2009, 2014). Individuals on agonist medications are less likely to misuse opioids and more likely to be retained in treatment, and may experience improved life expectancy and reduce criminal justice involvement (Connock et al., 2007). Counseling interventions, such as cognitive behavioral therapy, have gener- ally been shown to improve outcomes with medication-assisted treatment (Dugosh et al., 2016).

There is more limited evidence related to naltrexone, an opioid antagonist that works by repelling opioids from the brain’s opioid receptors. Some research is equivocal about the benefits of naltrexone for OUD, but at least one recent clinical trial indicates that naltrexone is noninferior to buprenorphine over a short-time period (Tanum et al., 2017). Naltrexone is costlier than methadone and requires full withdrawal before initiating treatment, but may be a useful medication for some specific populations who do not desire, or cannot gain access to, opioid agonists (Murphy & Polsky, 2016).

Despite the strong evidence supporting medication-assisted treatments, only about one-fifth of individuals with OUD receive treatment of any kind (Saloner & Karthikeyan, 2015). Many individuals in treatment are steered away from med- ications and toward treatments that have little or no evidence supporting their effectiveness. For example, there has been a proliferation of medication-free resi- dential treatment programs, despite the lack of evidence supporting this as a strategy for long-term recovery (Connery, 2015). A dearth of medication-assisted treatment reflects structural barriers such as a lack of treatment programs that offer medi- cations. Even if all current opioid treatment programs and all physicians who pre- scribed buprenorphine operated at full capacity, there would only be adequate slots in treatment programs to serve half the population with OUD (Jones et al., 2015). In fact, very few physicians with a waiver serve close to their maximum capacity

Journal of Policy Analysis and Management DOI: 10.1002/pam Published on behalf of the Association for Public Policy Analysis and Management

Point/Counterpoint / 433

(Stein et al., 2016). Regulation limits the supply of treatment options: methadone used to treat OUD can only be prescribed through opioid treatment programs and buprenorphine can only be prescribed by physicians who hold a federal waiver, and these physicians are capped in their maximum patient volume.

From a population perspective, the effectiveness of medication-assisted treat- ments in lowering the overdose rate depends on how well it gets to populations in need of treatment. There are some cases where access to agonist treatment was rapidly expanded to in-need populations. In the mid-2000s, the Baltimore buprenor- phine initiative increased slots in formerly drug-free outpatient treatment programs. A time series analysis (without a comparison group) indicates that implementation of the initiative was associated with declines in heroin overdoses (Schwartz et al., 2013). In France, buprenorphine was made widely available to office-based physi- cians in the mid-1990s with fewer regulations than in the United States, after which time there was similarly a reduction in overdose deaths (Fatseas & Auriacombe, 2007). More recently, Rhode Island implemented a statewide plan to increase ac- cess to methadone and buprenorphine, including offering treatments to individ- uals in detention facilities and beginning buprenorphine treatment in emergency departments.

Beyond increasing access to medication in conjunction with counseling or other behavioral therapies, changing treatment requires a well-integrated system ap- proach that manages the medical and social needs of individuals with OUD, in- cluding challenges related to housing, employment, criminal justice involvement, and comorbid physical and mental health issues. Managing the often complex health and social service needs of individuals with OUD is important for successful treat- ment and long-term recovery. Historically, there has been weak linkage between drug treatment programs, social services, and general medical care, leading many vulnerable individuals to fall through the cracks of different service systems. The future success of treatment programs depends on building models to allow indi- viduals easier access to medical care and wraparound services (e.g., employment assistance) alongside evidence-based drug treatment services.

The scientific evidence supporting the effectiveness of pharmacological treatment for OUD is not controversial among medical researchers, yet there remains deep- seated societal resistance to medication-assisted treatments, particularly opioid ag- onists. This includes a pervasive misrepresentation that because opioid agonist ther- apies are themselves opioids that they simply “substitute one opioid for another” (Olsen & Sharfstein, 2014).

APPROACHES TO BROADEN USE OF PHARMACOLOGICAL TREATMENTS FOR OUD

We argue that it will be impossible to turn the corner on the opioid epidemic without a major transformation in the treatment system for individuals with OUD. To do so, it will be critical to develop policies to build a robust evidence-based treatment sector and to overcome the barriers that prevent individuals with OUD from receiving long- term services. Both will require substantial new expenditures and strong leadership from a diverse set of decisionmakers.

Building the Treatment Sector

Recent federal initiatives have aimed to increase the addiction treatment workforce and extend the capacity of existing medication-assisted treatment providers. For example, the Comprehensive Addiction Recovery Act (CARA) of 2016 authorizes— but does not appropriate—funds to support medical training in addiction medicine and grant programs for medication-assisted treatment. The 21st Century Cures Act

Journal of Policy Analysis and Management DOI: 10.1002/pam Published on behalf of the Association for Public Policy Analysis and Management

434 / Point/Counterpoint

provides $1 billion in grants to states over two years to increase the number of individuals in treatment programs, providing leeway for states to determine how to achieve this goal (Clark, 2017). Finally, regulatory changes have increased options for accessing buprenorphine treatment, as the cap on maximum number of patients has been lifted from 100 to 275 patients and non-physician mid-level providers can now be granted authority to prescribe buprenorphine. The declaration of a public health emergency under the Trump Administration in 2017 also allows more leeway in implementing telemedicine for buprenorphine prescribing.

Though helpful, these efforts are insufficient for two major reasons. First, they do not provide enough resources to comprehensively engage the majority of people with OUD who are currently disconnected from evidence-based services. Tools such as helplines are useful, but the more fundamental problem is that most individuals with OUD report that they are not seeking treatment (Ali, Teich, & Mutter, 2015). Much more must be done to proactively identify, connect, and engage individuals with OUD with comprehensive, high-quality treatment services at critical junctures (e.g., following a non-fatal overdose, arrest, or pregnancy diagnosis). Strategies to better integrate evidence-based drug treatment services and other service sectors are critical. For example, Rhode Island has initiated comprehensive opioid agonist treatment in detention and buprenorphine initiation in the emergency department. Second, current initiatives do not adequately address the problem of poor retention in treatment. For example, more than half of individuals beginning buprenorphine treatment do not persist in treatment for more than six months (Saloner, Daubresse, & Alexander, 2017). As OUD is a chronic disease with common relapse, treatment should be focused on models for long-term disease management, and providers should be offered incentives for improving functioning and reducing overdose risk beyond the acute treatment episode that often precipitates first contact with treat- ment. Efforts are needed to develop new performance metrics to reward providers able to maintain a sizable share of their patient populations in longer-term evidence- based treatment (Pincus et al., 2016).

Improving Insurance Coverage and Financing

Financial incentives can drive increases in access and motivate quality improve- ments. However, there are few strong incentives in the current system to drive the system toward improved access to high-quality evidence-based addiction treatment. Underfunding is a legacy of the historical marginalization of drug treatment, where limited funding for treatment has come primarily from state and local funding grants rather than insurance programs (Buck, 2011). The 2008 Mental Health Par- ity and Addiction Equity Act in tandem with Affordable Care Act of 2010 have had the positive effects of increasing the number of individuals in addiction treatment financed through health insurance through private insurance or the Medicaid pro- gram (Saloner et al., 2017). These recent policy changes have also facilitated broader access to evidence-based treatment for OUD through regulatory changes in benefit design (Horgan et al., 2016).

However, there remain sizeable holes in the insurance market that need to be addressed. Although insurers are obligated to provide drug treatment at parity with physical health care, interpreting this standard has proven difficult and there re- mains a lack of clarity as to what an “adequate” benefit for OUD in public and private insurance should cover. For example, burdensome prior authorization stan- dards continue to limit access to opioid agonist treatments under private insurance. The 2017 Congressional efforts to repeal the Affordable Care Act and to cap Medicaid would have left millions without drug treatment coverage (Friedmann, Andrews, & Humphreys, 2017). Though these efforts have failed for the time being, the health

Journal of Policy Analysis and Management DOI: 10.1002/pam Published on behalf of the Association for Public Policy Analysis and Management

Point/Counterpoint / 435

care law was weakened through the effective repeal of the individual mandate in the 2017 tax reform legislation. This could destabilize the individual insurance market through which many obtain drug treatment coverage.

Broadening use of medication-assisted treatment requires expanding rather than retracting financing options under private- and public-sector insurance. Thirty-two states and the District of Columbia have expanded Medicaid as of late 2017, and many of the remaining uninsured individuals in the United States are poor adults who would qualify for Medicaid, a population that has elevated rates of substance use disorders (Busch et al., 2013). If non-expansion states reversed course and opted for expansion, they would gain a powerful funding stream for connecting individ- uals with OUD to medication-assisted treatment, primarily financed through fed- eral dollars. This investment might even produce offsets in areas like law enforce- ment given emerging evidence that the newly insured commit fewer crimes (Wen, Hockenberry, & Cummings, 2017).

Additionally, the Medicaid benefit package may be used to provide more compre- hensive drug treatment services. All states should offer methadone and eliminate burdensome restrictions on buprenorphine. Other strategies might include using the Medicaid home health option to finance services for individuals with OUD not typically paid for through insurance, including case management and peer-recovery coaching services (Clemans-Cope et al., 2017). Similar innovations may be possible in private insurance.

CONCLUSION

The opioid epidemic is commonly understood to be a problem of oversupply, and much attention has focused on curtailing the flow of narcotics through both licit and illicit markets. National efforts to reduce inappropriate prescribing and to cut off the market for illicit opioids could be effective in decreasing the number of newly addicted individuals. But, we have argued that altering the course of the epidemic further requires a serious strategy focused on reducing long-term overdose risk and improving the quality of life of the millions of individuals who already have OUD. Supply-side crackdowns, without an adequate consideration of the treatment needs of people in the already-affected population could have the unintended consequence of pushing these individuals into even more dangerous behaviors.

A feasible demand-side solution exists: vigorously reach out to high-risk individu- als, offer them access to evidence-based treatments (and especially to medications) in the most proximate settings possible, and link them to a variety of services to address their long-term needs. Moving away from the use of treatment options with a poor evidence-base (i.e., residential treatments without medication, other stand-alone behavioral therapies) also will be critical. Though feasible, we believe that achieving this goal requires marshalling more resources, political will, and leadership than has been put forward thus far. As we noted, this solution requires straightforwardly confronting lingering stigma about the safety and efficacy of opi- oid agonist medications. Although these medications are already saving lives, their full potential has not been realized because of the lack of a coherent system to refer and retain populations in treatment and ongoing misperceptions about medica- tions. These changes require upfront investment, likely requiring billions of dollars to reach maximal effectiveness. On the other hand, there may be cost savings if treatment expansion averts other medical and social expenses—to say nothing of the saved human potential.

Finally, a focus on treatment is likely to be most effective when combined with other pillars of drug control. For example, there is value in preventing harmful opioid use, including among individuals who misuse but do not yet meet clinical

Journal of Policy Analysis and Management DOI: 10.1002/pam Published on behalf of the Association for Public Policy Analysis and Management

436 / Point/Counterpoint

criteria for use disorders. Harm reduction efforts likewise provide a valuable means of keeping the most vulnerable individuals alive, even when they do not currently intend to reduce their drug use. Evidence-based harm reduction approaches include distribution of naloxone (the overdose reversal drug), syringe exchange, rapid street testing for fentanyl in purchased drugs, and supervised consumption facilities where individuals can use drugs in the presence of medical personnel. The long-term goal of keeping people alive today is to provide them with a chance to receive treatment tomorrow, and to experience recovery and well-being into the future.

BRENDAN SALONER is an Assistant Professor in the Department of Health Policy and Management at Johns Hopkins Bloomberg School of Public Health, 624 N. Broadway, Room 344, Baltimore, MD 21205 (e-mail: [email protected]).

COLLEEN L. BARRY is the Fred and Julie Soper Professor and Chair of the Department of Health Policy and Management at Johns Hopkins Bloomberg School of Public Health, 624 N. Broadway, Room 403, Baltimore, MD 21205 (e-mail: [email protected]).

ACKNOWLEDGMENTS

The authors gratefully acknowledge research support from the National Institute on Drug Abuse (Saloner: K01DA042139 and Barry: R01DA03521).

REFERENCES

Ali, M. M., Teich, J. L., & Mutter, R. (2015). The role of perceived need and health insurance in substance use treatment: Implications for the Affordable Care Act. Journal of Substance Abuse Treatment, 54, 14–20.

Alpert, A., Powell, D., & Pacula, R. L. (2017). Supply-side drug policy in the presence of substitutes: Evidence from the introduction of abuse-deterrent opioids. National Bureau of Economic Research, w23031. Retrieved January 19, 2018, from http://www.nber.org/ papers/w23031.

Buchmueller, T. C. & Carey, C. (2017). The effect of prescription drug monitoring programs on opioid utilization in Medicare. National Bureau of Economic Research, w23148. Retrieved January 19, 2018, from http://www.nber.org/papers/w23148.

Buck, J. A. (2011). The looming expansion and transformation of public substance abuse treatment under the Affordable Care Act. Health Affairs, 30, 1402–1410.

Busch, S. H., Meara, E., Huskamp, H. A., & Barry, C. L. (2013). Characteristics of adults with substance use disorders expected to be eligible for Medicaid under the ACA. Psychiatric Services, 64, 520–526.

Clark, H. W. (2017). Health reform and the substance use disorder treatment system: A time of change. Journal of Psychoactive Drugs, 49, 51–54.

Clemans-Cope, L., Wishner, J. B., Allen, E. H., Cafarella Lallemand, N., Epstein, M., & Spill- man, B. C. (2017). Experiences of three states implementing the Medicaid health home model to address opioid use disorder. Journal of Substance Abuse Treatment, 83, 27–35.

Compton, W. M., Jones, C. M., & Baldwin, G. T. (2016). Relationship between nonmedical prescription-opioid use and heroin use. The New England Journal of Medicine, 374, 154– 163.

Connery, H. S. (2015). Medication-assisted treatment of opioid use disorder: Review of the evidence and future directions. Harvard Review of Psychiatry, 23, 63–75.

Connock, M., Juarez-Garcia, A., Jowett, S., Frew, E., Liu, Z., Taylor, R. J., . . . Taylor, R. S. (2007). Methadone and Buprenorphine for the management of opioid dependence: A systematic review and economic evaluation. Health Technology Assessment, 11(9), 1–171.

Journal of Policy Analysis and Management DOI: 10.1002/pam Published on behalf of the Association for Public Policy Analysis and Management

http://www.nber.org/papers/w23031

http://www.nber.org/papers/w23148

Point/Counterpoint / 437

Dowell, D., Arias, E., Kochanek, K., Anderson, R., Guy, G. P., Losby, J. L., & Baldwin, G. (2017). Contribution of opioid-involved poisoning to the change in life expectancy in the United States, 2000–2015. Journal of the American Medical Association, 318, 1065– 1067.

Dugosh, K., Abraham, A., Seymour, B., McLoyd, K., Chalk, M., & Festinger, D. (2016). A systematic review on the use of psychosocial interventions in conjunction with medications for the treatment of opioid addiction. Journal of Addiction Medicine, 10, 93–103.

Fatseas, M. & Auriacombe, M. (2007). Why Buprenorphine is so successful in treating opiate addiction in France. Current Psychiatry Reports, 9, 358–364.

Frank, R. G. & Pollack, H. A. (2017). Addressing the Fentanyl threat to public health. The New England Journal of Medicine, 376, 605–607.

Friedmann, P. D., Andrews, C. M., & Humphreys, K. (2017). How ACA repeal would worsen the opioid epidemic. The New England Journal of Medicine, 376, e16.

Han, B., Compton, W. M., Blanco, C., Crane, E., Lee, J., & Jones, C. M. (2017). Prescription opioid use, misuse, and use disorders in U.S. Adults: 2015 National survey on drug use and health. Annals of Internal Medicine, 167, 293.

Horgan, C. M., Hodgkin, D., Stewart, M. T., Quinn, A., Merrick, E. L., Reif, S., . . . Creedon, T. B. (2016). Health plans’ early response to federal parity legislation for mental health and addiction services. Psychiatric Services, 67, 162–168.

Jones, C. M., Campopiano, M., Baldwin, G., & McCance-Katz, E. (2015). National and state treatment need and capacity for opioid agonist medication-assisted treatment. American Journal of Public Health, 105, e55.

Kennedy-Hendricks, A., Richey, M., McGinty, E. E., Stuart, E. A., Barry, C. L., & Webster, D. W. (2016). Opioid overdose deaths and Florida’s crackdown on pill mills. American Journal of Public Health, 106, 291–297.

Kolodny, A., Courtwright, D. T., Hwang, C. S., Kreiner, P., Eadie, J. L., Clark, T. W., & Alexander, G. C. (2015). The prescription opioid and heroin crisis: A public health approach to an epidemic of addiction. Annual Review of Public Health, 18, 559– 574.

Lin, H.-C., Wang, Z., Boyd, C., Simoni-Wastila, L., & Buu, A. (2018). Associations between statewide prescription drug monitoring program (PDMP) requirement and physician pat- terns of prescribing opioid analgesics for patients with non-cancer chronic pain. Addictive Behaviors, 76 (Supplement C), 348–354.

Mattick, R. P., Breen, C., Kimber, J., & Davoli, M. (2014). Buprenorphine maintenance versus placebo or Methadone maintenance for opioid dependence. The Cochrane Database of Sys- tematic Reviews, no. 2:CD002207-CD002207. Retrieved January 19, 2018, from https://doi. org/10.1002/14651858.CD002207.pub4.

Mattick, R. P., Breen, C., Kimber, J., & Davoli, M. (2009). Methadone maintenance therapy versus no opioid replacement therapy for opioid dependence. The Cochrane Database of Systematic Reviews. Abstract. Retrieved January 19, 2018, from http://onlinelibrary. wiley.com/doi/10.1002/14651858.CD002209.pub2/abstract.

Meara, E., Horwitz, J. R., Powell, W., McClelland, L., Zhou, W., O’Malley, A. J., & Morden, N. E. (2016). State legal restrictions and prescription-opioid use among disabled adults. The New England Journal of Medicine, 375, 44–53.

Murphy, S. M. & Polsky, D. (2016). Economic evaluations of opioid use disorder interventions. PharmacoEconomics, 34, 863–887.

Olsen, Y. & Sharfstein, J. M. (2014). Confronting the stigma of opioid use disorder—and its treatment. Journal of the American Medical Association, 311, 1393–1394.

Pincus, H. A., Scholle, S. H., Spaeth-Rublee, B., Hepner, K. A., & Brown, J. (2016). Quality measures for mental health and substance use: Gaps, opportunities, and challenges. Health Affairs (Project Hope), 35, 1000–1008.

Rudd, R. A., Aleshire, N., Zibbell, J. E., & Gladden, R. M. (2016). Increases in drug and opi- oid overdose deaths—United States, 2000–2014. MMWR. Morbidity and Mortality Weekly Report, 64, 1378–1382.

Journal of Policy Analysis and Management DOI: 10.1002/pam Published on behalf of the Association for Public Policy Analysis and Management

https://doi.org/10.1002/14651858.CD002207.pub4

http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD002209.pub2/abstract

438 / Point/Counterpoint

Ruhm, C. J. (2017). Geographic variation in opioid and heroin involved drug poisoning mortality rates. American Journal of Preventive Medicine, 53, 745–753.

Saloner, B., Bandara, S., Bachhuber, M., & Barry, C. L. (2017). Insurance coverage and treatment use under the Affordable Care Act among adults with mental and substance use disorders. Psychiatric Services, 68, 542–548.

Saloner, B., Daubresse, M., & Alexander, G. C. (2017). Patterns of Buprenorphine-Naloxone treatment for opioid use disorder in a multistate population. Medical Care, 55, 669–676.

Saloner, B. & Karthikeyan, S. (2015). Changes in substance abuse treatment use among indi- viduals with opioid use disorders in the United States, 2004–2013. Journal of the American Medical Association, 314, 1515–1517.

Schwartz, R. P., Gryczynski, J., O’Grady, K. E., Sharfstein, J. M., Warren, G., Olsen, Y., Mitchell, S. G., & Jaffe, J. H. (2013). Opioid agonist treatments and heroin overdose deaths in Baltimore, Maryland, 1995–2009. American Journal of Public Health, 103, 917–922.

Stein, B. D., Sorbero, M., Dick, A. W., Pacula, R. L., Burns, R. M., & Gordon, A. J. (2016). Physician capacity to treat opioid use disorder with Buprenorphine-assisted treatment. Journal of the American Medical Association, 316, 1211–1212.

Tanum, L., Solli, K. K., Latif, Z.-e-H., Benth, J. S., Opheim, A., Sharma-Haase, K., Kra- jci, P., & Kunøe, N. (2017). The effectiveness of injectable extended-release Naltrexone vs daily Buprenorphine-Naloxone for opioid dependence: A randomized clinical noninferior- ity trial. JAMA Psychiatry, 74, 1197–1205.

Van Zee, A. (2009). The promotion and marketing of Oxycontin: Commercial triumph, public health tragedy. American Journal of Public Health, 99, 221–227.

Volkow, N., Benveniste, H., & McLellan, A. T. (2017). Use and misuse of opioids in chronic pain. New England Journal of Medicine, 374, 1253–1263.

Wen, H., Hockenberry, J. M., & Cummings, J. R. (2017). The effect of Medicaid expansion on crime reduction: Evidence from HIFA-Waiver expansions. Journal of Public Economics, 154 (Supplement C), 67–94.

A SUPPLY-SIDE PERSPECTIVE ON THE OPIOID CRISIS

Rosalie Liccardo Pacula and David Powell

INTRODUCTION

Between 2001 and 2015, more than 530,000 Americans died from drug overdoses (National Institute on Drug Abuse [NIDA], 2017). In 2015 alone, the death toll in the United States from drug overdoses (52,404) exceeded that attributable to HIV/AIDS in the peak year of that epidemic (Humphreys, 2017) and the total number of U.S. fa- talities from both the Iraq and Afghanistan wars combined (Department of Defense, 2017). The substantial death rate from drug overdoses, primarily among those be- tween 45 and 54 years of age, has translated into the first decline in life expectancy for white, non-Hispanics (males and females) in decades (Case & Deaton, 2017). Deaths alone do not fully capture the breadth of harms; we have also witnessed unprecedented rises in poisonings (Warner, Hedegaard, & Chen, 2014), emergency

Journal of Policy Analysis and Management DOI: 10.1002/pam Published on behalf of the Association for Public Policy Analysis and Management

Point/Counterpoint / 439

department visits (Centers for Disease Control and Prevention [CDC], 2010) and opi- oid use disorder and addiction (Han et al., 2015). While the crisis was initially driven by prescription opioids, many of the harms observed today are due to a transition in consumption to heroin, fentanyl, and other black market opiates (Alpert et al. (forthcoming); Warner, Hedegaard, & Chen, 2014). In light of the changing opioid problem, as well as the unprecedented duration of it, it seems critical to re-assess strategies for solving the current epidemic.

The opioid crisis is a complex, multifaceted, and dynamic problem requiring a comprehensive strategy for dealing not just with the stock of addicted users who are at risk of overdosing, but also considering the flow of new initiates and escala- tors in abuse. We had a limited understanding of the best approaches for tackling these issues when it was a prescription opioid problem; our understanding of ef- fective levers in the current situation is even more limited. In the past two years, substantial attention and funding has been given to efforts to expand naloxone dis- tribution and access to substance abuse treatment, two very important components of a comprehensive strategy. Prior to this, supply-side interventions dominated the policy landscape. Initial conflicting evidence of the effectiveness of supply-side in- terventions and the ongoing rise in overdoses despite widespread adoption of such policies, has led to pessimism about the potential of supply-side strategies. Criti- cisms about these approaches when dealing with black markets further abound. Ignoring the supply side of the equation at this stage, however, particularly the potential reactions and innovation of suppliers in these markets, would be a mis- take and could further generate unintended consequences to well-meaning demand reduction strategies just as they did with well-meaning supply-side strategies. We explain below how ignoring the motivation and innovation of suppliers, both in the legal or illicit market, got us to this point in the opioid crisis, and how ignoring their continuing role could be even more devastating.

WHAT WE DO KNOW: THE ROLE OF SUPPLY-SIDE FACTORS IN THE INITIAL DRAMATIC RISE OF THE OPIOID CRISIS

The United States has had a persistent insatiable demand for intoxicating sub- stances, legal and illegal, as is evidenced by the heroin epidemic in the late 1960s, the cocaine/crack epidemic of the 1980s, and the methamphetamine epi- demic of the 2000s. However, defaulting to the argument that this is just the latest manifestation of “an insatiable demand for drugs” reduces the role that unchecked supply has clearly played in the current epidemic. Prescription opi- oids serve a legitimate medical function and, in fact, are rather effective pain management tools supplied in regulated markets. The combination of the med- ical utility and addictiveness potential of opioids alone could create a signifi- cant addiction problem. The crisis we see today, however, resulted because these factors were compounded by at least three aspects of the U.S. health care sys- tem that enabled these drugs to be overly supplied in both medical and black markets.

First, health insurance subsidizes the cost of prescription drugs, including opi- oids, by including them as a covered benefit. Expanding coverage for prescription opioids coupled with declining average prices of this medication, due to the expi- ration of patents, has led to a tremendous decline in the cost to the consumer of this powerful intoxicant. One study, using data from the Medical Expenditure Panel Survey (MEPS), shows that the average consumer out-of-pocket spending on opi- oids per 100 morphine milligram equivalents fell from $4.40 in 2001 to $0.90 in 2012 (Zhou, Florence, & Dowell, 2016). Declining costs of prescription opioids to patients pushed the epidemic forward in two important ways. First, the lowering of patient

Journal of Policy Analysis and Management DOI: 10.1002/pam Published on behalf of the Association for Public Policy Analysis and Management

440 / Point/Counterpoint

0 5

10 15

M or

ph in

e Eq

ui va

le nt

D os

es P

er C

ap ita

2 3

4 5

6 7

O pi

oi d

D ea

th s

pe r 1

00 ,0

20 00

20 01

20 02

20 03

20 04

20 05

20 06

20 07

20 08

20 09

20 10

20 11

20 12

20 13

20 14

20 15

Year

Opioid Mortality Total Morphine Equivalent Doses Oxycodone Morphine Equivalent Doses

Sources: Drug Enforcement Agency’s ARCOS System (opioid distribution) and CDC’s National Vital Statistics System.

Figure 1. Trends in Opioid Mortality and the Distribution of Opioids, Measured in Morphine Equivalent Doses.

cost induced a standard demand-side response of increased utilization, thereby in- creasing risk of addiction from prolonged exposure. Second, the difference between patient cost and manufacturing cost made for an immediate economic opportunity for anyone willing to divert medication to the black market. As new actors engaged in diversion in pursuit of economic profits, they also created bridges to the black market for newly addicted patients who pursued illegal channels when their access was reduced in medical markets.

Second, the U.S. health care reimbursement system, until very recently, has gener- ally rewarded providers for the volume of services given rather than the appropriate- ness of these services. Because of this, some providers were incentivized to inappro- priately prescribe opioid medications to medication-seeking patients through “pill mills.” While pill mills have received broad attention, the incentives exist even for less extreme, though still inappropriate, prescribing behavior in traditional medical settings.

Finally, the U.S. health care system permits direct promotion of pharmaceuti- cals to physicians and patients with little oversight. Long-acting opioids, therefore, could be heavily promoted to medical professionals, medical and hospital boards, and even to patients for their pain management effectiveness—and they were — despite reliance on misleading evidence about their addictiveness, let alone their effectiveness (Kolodny et al., 2015). A 2003 General Accounting Office Report doc- uments an extensive marketing campaign using multiple promotional approaches undertaken by Purdue Pharma between 1996 and 2002 to promote the use of their OxyContin product for the management of chronic non-cancer pain (U.S. GAO, 2003). This promotion appears to have been successful, as evidenced by the rising medical distribution of oxycodone and total opioid morphine equivalents per capita shown in Figure 1.1

1 OxyContin represents about 70 percent of all oxycodone available on the market (Van Zee, 2009).

Journal of Policy Analysis and Management DOI: 10.1002/pam Published on behalf of the Association for Public Policy Analysis and Management

Point/Counterpoint / 441

These market factors, coupled with a tradition within the medical profession not to monitor or discipline professionals for unscrupulous behavior or inappropriate care, created an environment where financial incentives dominated patient safety and the health of the nation. While some have tried to attribute the opioid crisis to a rise in the prevalence of musculoskeletal and other chronic pain problems, scholars conducting international comparisons have demonstrated comparable prevalence rates of these clinical conditions in other countries (Fischer et al., 2014). However, the United States is the leading consumer of opioid pain relievers, consuming more than twice as much per capita as the second largest consumer, suggesting that the root causes are more likely health care system incentives unique to the United States.

WHY HAS THE PRESCRIPTION OPIOID CRISIS GONE ON AS LONG AS IT HAS?

Overprescribing of opioids by physicians, encouraged by misleading evidence on effectiveness and risks, is widely understood to be a major reason for the continuous rise in opioid mortality through 2010. As can be seen in Figure 1, opioid mortality rates generally paralleled opioid distribution per capita through 2013, suggesting a possible relationship between the growth in supply and the rise in overdoses.

It began with a push to treat pain as the “Fifth Vital Sign” first by individuals, then by medical and patient associations financed by the pharmaceutical industry (Kolodny et al., 2015). By 2001, it had become a formal recommendation within the Veteran Affairs health system and the Joint Commission on Accreditation of Healthcare Organizations (JCAHO). Then, in 2005, Medicare modified how it would reimburse hospitals, tying inpatient payments to participation and reporting of Hos- pital Consumer Assessment of Healthcare Providers and Systems, which included as one of its seven primary measures of performance “management of pain.” When the Affordable Care Act passed, value-based incentive payments to hospitals were tied to the value of these patient experience performance measures, which included pain management scores as a core component.

Although initial evidence suggested that overprescribing was largely a function of a few specialized areas of medicine (Betses & Brennan, 2013), subsequent evi- dence has shown that opioid prescribing is distributed across many different types of providers, including and perhaps especially, general practitioners (Chen et al., 2016). Moreover, the greater prescribing among general practitioners has demon- strated far less geographic variability than prescribing of other medications. As general practitioners lack training on the addictive potential of these drugs and strategies to avoid dependence in patients, they did not have the knowledge base on which to question misinformation provided by the industry (Kolodny et al., 2015). They further lacked training and information on effective alternative methods for managing pain, and had no incentives from patients to explore alternative pain management techniques given that such therapies were far less likely to be covered by health insurance.

Starting in 2010, the opioid epidemic went through a pivotal transformation, which is reflected in fatal overdoses. Instead of prescription opioids, since 2010, overdoses increasingly involved heroin and synthetic opioids, particularly fentanyl. From 2010 to 2015, fatal heroin overdoses more than quadrupled. The transfor- mation has been traced back to the reformulation of OxyContin, the most major supply-side intervention to date, which caused dependent users to search for a substitute. Other research has found similar, though more modest, substitution ef- fects in response to other supply-side interventions, such as pill mill closures and prescription drug monitoring programs (PDMPs) (Meinhofer, 2016). The smaller effects associated with these policies likely suggest that they did not eliminate the supply of prescription opioids entirely, just one source. Reformulation, however,

Journal of Policy Analysis and Management DOI: 10.1002/pam Published on behalf of the Association for Public Policy Analysis and Management

442 / Point/Counterpoint

eliminated the supply of the drug of choice for many nonmedical users nation- ally (Cicero, Inciardi, & Muñoz, 2005), nudging users to either quit altogether or switch to different drugs. Because of the bridge to illegal markets created by those engaged in diversion from the medical market, illicit options were easily accessed.

This shift to abuse of black market opioids has considerable implications for thinking about effective policy in the future. No longer can policymakers simply be concerned about overprescribing and inappropriate prescribing of highly addictive pain medications in medical markets; attention must also be given to treating those currently addicted and cutting off supply of substitutes in illicit markets. To the extent that demand-side interventions, such as increased access and quality of sub- stance abuse treatment, can reduce dependence, then they could have substantial benefits. But it is necessary to couple these strategies with supply-side interventions because, as noted in Saloner and Karthikeyan (2015), utilization of substance abuse treatment among those with an opioid use disorder is low and has not increased despite recent efforts to expand access to treatment. Moreover, relapse is common among those in treatment (McLellan et al., 2000), meaning that access to and supply of opioids will remain important.

Our ability to monitor availability of illicit opioids in black markets has been dramatically reduced over the past decade, which also contributed to the ability of consumers to shift to black markets. Budget cuts eliminated key agencies re- sponsible for monitoring these markets (e.g., the National Drug Intelligence Cen- ter) as well as important surveillance systems covering them (e.g., Arrestee Drug Abuse Monitoring program and Drug Abuse Warning Network). The lack of data on emerging black markets, coupled with technological innovation in how retail sellers and users interact, made it difficult for law enforcement to stay ahead of the curve.

WHAT ARE THE UNINTENDED CONSEQUENCES OF THIS SHIFT?

While we cannot ignore that prescription opioids are still present in many overdoses, the transition to illicit opioids poses a number of new challenges that policymakers must consider. First, new users of street drugs tend to be unsophisticated and thus are at elevated risk of overdosing, particularly because illicit markets are prone to greater variance in drug purity. Second, all consumers in black markets can be exposed to cutting agents that make use of a given drug even more dangerous, as we have seen recently with fentanyl and carfentanil. As shown in Figure 2, suppliers of these cutting agents, once they enter the market, do not think merely about penetrating just one drug market; they diversify. Synthetic opioids, which include fentanyl and carfentanil, have been involved with an increasing share of overdoses, not just for opioids but also for cocaine. We also see a surprising increase in the fraction of alcohol poisoning involving synthetic opioids.

A third consequence of the transition to illicit opioids that has received less at- tention is the shift in route of administration from oral misuse to injection. Drug injection is associated with costly and fatal infectious diseases such as hepatitis C virus (HCV) and HIV infections. In fact, reported HCV infections have increased at a rate proportional to the rate of heroin overdose deaths since 2010 (CDC, 2017). Hepatitis C is associated with substantial direct and indirect costs and a reduction in life expectancy of 15 years (Mahajan et al., 2014). Thus, the rise in HCV infec- tions associated with the opioid epidemic will have longer-lasting effects that are not reflected in the contemporaneous overdose rate. As policies become effective at reducing mortality associated with dependent use, our focus must turn to treating these infectious diseases.

Journal of Policy Analysis and Management DOI: 10.1002/pam Published on behalf of the Association for Public Policy Analysis and Management

Point/Counterpoint / 443

Source: National Vital Statistics System, CDC.

Figure 2. Trend in the Fraction of Drug Poisonings Involving Synthetic Opioids.

POLICY RECOMMENDATIONS

As policymakers consider mechanisms to address the opioid epidemic, it is impor- tant to be sensitive to the situation as it exists today, as well as to be forward thinking in considering how the situation could evolve as suppliers and users adapt to poli- cies that are imposed. Both the supply and demand sides of the market need to be considered. While supply-side interventions alone were inadequate in addressing the early stages of the epidemic, and may have even worsened the overdose rate in the short run (Alpert, Powell, & Pacula, forthcoming), they were narrowly ap- plied to a specific opioid or specific supply source. Broader supply-side policies that consider the full market, if coupled with effective treatment, are likely to be more effective and robust to substitution effects. With this in mind, we offer the following recommendations.

Reduce Overprescribing, Inappropriate Prescribing, and Non-Medical Use of Opioid and Other Pain Medications

Efforts to reduce both overprescribing and inappropriate prescribing through adop- tion of evidence-based dosing and best-practice guidelines along with comprehen- sive education to prescribers can be effective, can reduce introduction of new ini- tiates, and reduce rates of dependence and overdoses (Gellad, Good, & Shulkin, 2017). “Must access,” real-time PDMPs, can also deter overprescribing and reduce doctor shopping (Buchmueller & Carey, forthcoming). Continuation of these and related efforts that monitor the supply of medications delivered to patients, possibly expanding them to include other addictive medications, is important for reducing the flow of new initiates and the number of patients who become addicted. To deal with the large number of individuals already hooked on these medications for man- aging pain, alternative pain management therapies need to be considered and tried so reliance on opioids is reduced.

While prescribing behavior should always consider the benefits and costs to the patients, the prescribing of opioids should involve additional considerations because of the potential externality they pose on the broader population. The externality stems from their intoxicating properties which makes them desirable nonmedi-

Journal of Policy Analysis and Management DOI: 10.1002/pam Published on behalf of the Association for Public Policy Analysis and Management

444 / Point/Counterpoint

cally, and hence easy targets for diversion. Prescribing such medications in high volumes facilitates greater opportunities for diversion. Quantifying such externali- ties and incorporating them into prescribing guidelines or using them as a basis for prohibiting their promotion by pharmaceutical companies are important steps for reducing spillovers.

Maintain Efforts to Limit Supply in Black Markets

Serious efforts and resources must be given to developing improved monitoring and tracking tools for illicit drug markets and effectively intervening in them in a manner that reduces supply, given such a large group of new addicted consumers have shifted to these markets. Investments in alternative methods of surveillance, data collection, and drug identification are needed to keep up with the evolving supply and delivery methods and could assist in interdicting new supplies. Efforts to track and intercept precursor chemicals or technology that can be used to detect the development of new synthetic opioids are also desperately needed.

Reduce the Harms Experienced by Those Currently Dependent

While harm reduction policies do not address the root of the problem, they can save lives in the short-run and could have other long-term benefits. Improving naloxone access, through pharmacies and other community organizations, is one example that should reduce fatal overdoses, and may be even more effective if coupled with mandatory treatment for anyone receiving a dose. Other programs that encourage injection drug users to use clean syringes and get tested for HCV and HIV, are also important at this stage of the epidemic to reduce the risk of spreading infectious diseases that will lead to long-term public health challenges. New and innovative strategies for tackling the problem of contaminated drugs also need to be considered. Media campaigns are helpful for raising awareness in specific communities when deadly adulterants are being mixed with drugs, but they have not stopped addicts from using street drugs. Bolder strategies, such as providing testing facilities for drugs purchased on the street and safe injection rooms, could be considered in particularly hard hit communities as a way of saving lives in the short run.

Address the Affordability of High Quality Treatment, Including Medication-Assisted Therapies (MAT)

While there has been a huge push to increase the number of treatment providers and access to MAT, little consideration has been given to the cost of this treatment to patients over its full duration. There was a presumption that insurance coverage would simply keep costs down for patients. Effective treatment may last months, far longer than insurance benefits cover. Any serious attempt to expand treatment needs to seriously address the affordability of a full episode of treatment to the patient.

Finally, most discussions about policy recommendations in this arena center around identifying the most cost-effective methods to reduce opioid-related harms given limited funding. However, the level of resources dedicated to fighting the opioid epidemic should itself be open to discussion. The economic burden of the opioid epidemic has been estimated to be $78.5 billion per year (Florence et al., 2016). Applying the lower bound willingness-to-pay measure to reduce mortality of $5.4 million2 from Viscusi and Aldy (2003) to the 22,598 lives lost to opioid pain

2 Adjusted to 2017 dollars.

Journal of Policy Analysis and Management DOI: 10.1002/pam Published on behalf of the Association for Public Policy Analysis and Management

Point/Counterpoint / 445

relievers in 2015 implies an additional annual burden of over $122 billion. In re- sponse, federal and state governments have dedicated substantially fewer resources. Given the above calculations, even small changes in abuse rates due to these policies would generate significant benefits relative to cost, suggesting that we should not hesitate to extend more resources to address this crisis.

ROSALIE LICCARDO PACULA is a Senior Economist at the RAND Corporation and the National Bureau of Economic Research, 1776 Main Street, Santa Monica, CA 90407 (e-mail: [email protected]).

DAVID POWELL is a Full Economist at the RAND Corporation, 1200 S. Hayes Street, Arlington, VA 22202 (e-mail: [email protected]).

ACKNOWLEDGMENTS

This paper was written with research support from the Pardee RAND Alumni Impact fund and the National Institute on Drug Abuse (R21DA041653-01). Several of the opinions reflected in this paper were shaped by previous work and discussions with numerous colleagues, including Abby Alpert, Beau Kilmer, Rosanna Smart, Brad Stein, and Erin Taylor.

REFERENCES

Alpert, A., Powell, D., & Pacula, R. L. (Forthcoming). Supply-Side drug policy in the pres- ence of substitutes: Evidence from the introduction of abuse-deterrent opioids. American Economic Journal: Economic Policy.

Betses, M. & Brennan, T. (2013). Abusive prescribing of controlled substances—a pharmacy view. New England Journal of Medicine, 369, 989–991.

Buchmueller, T. C., & Carey, C. (Forthcoming). The effect of prescription drug monitoring programs on opioid utilization in Medicare. American Economic Journal: Economic Policy.

Case, A. & Deaton, A. (2017). Mortality and morbidity in the 21st century. Brookings Papers on Economic Activity, pp. 23–24.

Centers for Disease Control and Prevention (CDC). (2010). Emergency department visits involving nonmedical use of selected prescription drugs—United States, 2004–2008. Mor- bidity and Mortality Weekly Report, 59, 705–709.

Centers for Disease Control and Prevention (CDC). (2017). New hepatitis C infec- tions nearly tripled over five years. Retrieved from https://www.cdc.gov/media/releases/ 2017/p-hepatitis-c-infections-tripled.html

Chen, J. H., Humphreys, K., Shah, N. H., & Lembke, A. (2016). Distribution of opioids by different types of Medicare prescribers. JAMA Internal Medicine, 176, 259–261.

Cicero, T. J., Inciardi, J. A., & Muñoz, A. (2005). Trends in abuse of OxyContin R© and other opioid analgesics in the United States: 2002–2004. Journal of Pain, 6, 662–672.

Department of Defense. (2017). Operation Iraqi Freedom (OIF) U.S. Casualty Status Retrieved from https://www.defense.gov/casualty.pdf

Fischer, B., Keates, A., Buhringer, G., Reimer, J., & Rehm, J. (2014). Non-medical use of prescription opioids and prescription opioid-related harms: Why so markedly higher in North America compared to the rest of the world? Addiction, 109, 177–181.

Florence, C. S., Zhou, C., Luo, F., & Xu, L. (2016). The economic burden of prescription opioid overdose, abuse, and dependence in the United States, 2013. Medical Care, 54, 901–906.

Gellad, W. F., Good, C. B., & Shulkin, D. J. (2017). Addressing the opioid epidemic in the United States: Lessons from the Department of Veterans Affairs. JAMA Internal Medicine, 177, 611–612.

Journal of Policy Analysis and Management DOI: 10.1002/pam Published on behalf of the Association for Public Policy Analysis and Management

https://www.cdc.gov/media/releases/2017/p-hepatitis-c-infections-tripled.html

https://www.defense.gov/casualty.pdf

446 / Point/Counterpoint

Han B., Compton, W. M., Jones, C. M., & Cai, R. (2015). Nonmedical prescription opioid use and use disorders among adults aged 18 through 64 years in the United States, 2003–2013. Journal of the American Medical Association, 314, 1468–1478.

Humphreys, K. (2017). Avoiding globalisation of the prescription opioid epidemic. Lancet, 390, 437–439.

Mahajan, R., Xing, J., Liu, S. J., Ly, K. N., Moorman, A. C., Rupp, L., . . . Holmberg, S. D. (2014). Mortality among persons in care with hepatitis C virus infection: The Chronic Hepatitis Cohort Study (CHeCS), 2006–2010. Clinical Infectious Diseases, 58, 1055–1061.

McLellan, A. T., Lewis, D. C., O’Brien, C. P., & Kleber, H. D. (2000). Drug dependence, a chronic medical illness: Implications for treatment, insurance, and outcomes evaluation. Journal of the American Medical Association, 284, 1689–1695.

Meinhofer, A. (2016). The war on drugs: Estimating the effect of prescription drug supply-side interventions. Working Paper. Retrieved from https://ssrn.com/abstract=2716974

National Institute on Drug Abuse (NIDA). (2017). Overdose death rates. Retrieved from https://www.drugabuse.gov/related-topics/trends-statistics/overdose-death-rates

Saloner, B., & Karthikeyan, S. (2015). Changes in substance abuse treatment use among indi- viduals with opioid use disorders in the United States, 2004–2013. Journal of the American Medical Association, 314, 1515–1517.

U.S. GAO (General Accounting Office). (2003). OxyContin abuse and diversion and ef- forts to address the problem. GAO-04-110. Washington, DC: GAO. Retrieved from http://www.gao.gov/new.items/d04110.pdf

Van Zee, A. (2009). The promotion and marketing of OxyContin: Commercial triumph, public health tragedy. American Journal of Public Health, 99, 221–227.

Viscusi, W. K., & Aldy, J. E. (2003). The value of a statistical life: A critical review of market estimates throughout the world. Journal of Risk and Uncertainty, 27, 5–76.

Warner, M., Hedegaard, H., & Chen, L. H. (2014). Trends in drug-poisoning deaths involving opioid analgesics and heroin: United States, 1999–2012. NCHS Health E-Stat. Hyattsville, MD: National Centers for Health Statistics.

Zhou, C., Florence, C. S., & Dowell, D. (2016). Payments for opioids shifted substantially to public and private insurers while consumer spending declined, 1999–2012. Health Affairs, 35, 824–831.

RESPONSE TO PACULA AND POWELL: INVESTING IN HARM REDUCTION AND ALTERNATIVES TO COERCED TREATMENT

Brendan Saloner and Colleen L. Barry

Some believe harm reduction strategies only lower the barriers to continuing opioid use and reduce drug users’ willingness to seek treatment. Does implementation of harm reduction interact with or even work against the goal of expanding treatment?

Harm reduction refers to approaches to minimize negative health, social, and eco- nomic consequences of drug use for people unable or unwilling to stop using drugs.

Journal of Policy Analysis and Management DOI: 10.1002/pam Published on behalf of the Association for Public Policy Analysis and Management

https://ssrn.com/abstract=2716974

https://www.drugabuse.gov/related-topics/trends-statistics/overdose-death-rates

http://www.gao.gov/new.items/d04110.pdf

Point/Counterpoint / 447

Harm reduction can reduce overdose deaths, hepatitis and HIV transmission, and incarceration among individuals using drugs. Five approaches are worth highlight- ing. First, syringe services programs, which provide sterile equipment to injection drug users, have been shown to reduce blood-borne infections from needle-sharing (Wodak & Cooney, 2006). Second, naloxone, a quick-acting medication to reverse the respiratory effects of opioid overdose, is increasingly carried by first responders, drug users, and their family members and has been shown to reduce overdoses (Giglio, Li, & DiMaggio, 2015). Third, safe consumption sites are spaces where in- dividuals can legally use pre-obtained drugs under medical supervision. Currently operating in Canada and Western Europe, these sites have been shown to decrease overdose deaths, HIV and hepatitis C infection, and have not increased crime or drug use in their surrounding neighborhoods (Potier, Laprévote, Dubois-Arber, Cot- tencin, & Rolland, 2014). Several cities including Seattle, Baltimore, San Francisco, and Ithaca are considering establishing sites. Fourth, anonymous drug-checking technology can reduce fatal overdoses by providing individuals with information on whether their drugs contain adulterants like fentanyl, and have been implemented in various European countries where guidelines have been developed (Harper, Pow- ell, & Pijl, 2017). Fifth, harm reduction–oriented policing involves changing law enforcement responses to drug-related offenses that do not pose significant public safety risk (e.g., simple possession). For example, Seattle’s Law Enforcement As- sisted Diversion (LEAD) program involves law enforcement officers’ diverting low- level offenders engaged in prostitution or drug use from criminal justice settings (Collins, Lonczak, & Clifasefi, 2017).

Harm reduction approaches can facilitate, rather than deter, treatment entry. For example, safe consumption sites offer opportunities to connect individuals to services including withdrawal management, drug and HIV treatment, and primary health care and with social supports including housing and employment services. The LEAD program provides immediate case management and linkage to drug treatment, as well as other important supports that can facilitate eventual treat- ment entry including housing assistance, job training, legal advocacy, and coun- seling. LEAD case managers have access to funds to support other critical needs, including food, motel stays, and clothing. Harm reduction can thus provide an on-ramp to treatment and other supports through building trusting relationships between people using drugs and compassionate outreach staff, facilitating access and care continuity through co-locating treatment services with harm reduction facilities, and keeping people alive to receive treatment at the point they are ready and able to do so. Further facilitating linkages between harm reduction and drug treatment could save additional lives. For example, many individuals rescued with naloxone are not offered timely, evidence-based drug treatment. This increases the likelihood of a future overdose, which may reinforce anti-treatment stereotypes among first responders when they are called upon to repeatedly resuscitate the same individuals.

Although we view harm reduction as a stepping stone to treatment, it need not lead to treatment to be valuable. An underlying premise of harm reduction is that some individuals will not seek treatment. Drug use is a complex phenomenon involv- ing factors such as past trauma, poverty, racism, social isolation, and stigma—all of which can affect a person’s capacity and interest in embracing treatment and recovery. It will be impossible to stem the opioid epidemic without embracing harm reduction approaches alongside treatment approaches in a manner that is well- coordinated and grounded in the idea of meeting drug users “where they are at” with dignity and respect.

Evidence suggests that simply ensuring treatment access does not mean treatment will be utilized. Does treatment need to be coerced, and if so, for whom, and how?

Journal of Policy Analysis and Management DOI: 10.1002/pam Published on behalf of the Association for Public Policy Analysis and Management

448 / Point/Counterpoint

The vast majority of individuals in need of drug treatment do not seek it. According to data from the National Survey on Drug Use and Health (NSDUH), of the 22.5 million people in need of treatment for substance use in 2014, only 4.1 million received any treatment in the past year (Han et al., 2015). By far, the most common reason cited in the NSDUH among individuals in need but not receiving treatment for drug use was “not feeling a need” for it. Since drug use causes many individual and societal harms, it is reasonable to ask whether a person with a drug addiction who does not seek treatment should be compelled to receive it.

This question is in the spotlight in the context of efforts to combat the opioid epidemic. For example, Massachusetts provision Section 35 allows family members, doctors, and police officers to petition a judge to civilly commit an individual with substance use disorder in circumstances where there is likelihood of serious harm. About 33 states have similar statutes and these policies are increasingly viewed as a critical crisis response tool by states and family members searching for ways to help their loved ones. State involuntary commitment statutes vary along important dimensions; for example, in Massachusetts, an individual can be involuntarily held for treatment for up to 90 days.

We argue strongly against forcing treatment among individuals using drugs who have not committed a crime. We recognize that circumstances for people who are al- ready in the criminal justice system are different, as legally-mandated treatment may provide a viable alternative to time spent locked up. However, the available evidence suggests that coercion is typically not an effective method for getting people into treatment and facilitating long-term treatment continuity and recovery. A systematic review of compulsory drug treatment concluded that, while the literature is limited, available evidence does not support its effectiveness in reducing long-term drug use or lowering recidivism (Werb et al., 2016). Second, often individuals are forced to re- ceive treatments lacking a strong evidence-base; medication-assisted treatment, for example, is rarely offered in legally-mandated programs. Third, coerced treatment raises a range of civil liberty concerns. People with opioid use disorders can and should make treatment choices for themselves. Finally, a reliance on involuntary treatment as a means for families to keep their loved ones safe from overdose has the unintended consequence of shifting attention away from the pressing need to develop and fund non-coercive crisis response alternatives.

For these reasons, we recommend that policymakers interested in combating the drug epidemic invest in non-coerced alternatives to crisis response, evidence-based treatment entry and long-term recovery.

REFERENCES

Collins, S. E., Lonczak, H. S., & Clifasefi, S. L. (2017). Seattle’s law enforcement assisted diver- sion (LEAD): Program effects on recidivism outcomes. Evaluation and Program Planning, 64, 49–56.

Giglio, R. E., Li, G., & DiMaggio, C. J. (2015). Effectiveness of bystander naloxone adminis- tration and overdose education programs: A meta-analysis. Injury Epidemiology, 2, 10.

Journal of Policy Analysis and Management DOI: 10.1002/pam Published on behalf of the Association for Public Policy Analysis and Management

Point/Counterpoint / 449

Han, B., Hedden, S., Lipari, R., Copello, E., & Kroutil, L. (2015). Receipt of services for behavioral health problems: Results from the 2014 National Survey on Drug Use and Health. Rockville, MD: Substance Abuse and Mental Health Services Administration.

Harper, L., Powell, J., & Pijl, E. M. (2017). An overview of forensic drug testing methods and their suitability for harm reduction point-of-care services. Harm Reduction Journal, 14, 52. https://doi.org/10.1186/s12954-017-0179-5

Potier, C., Laprévote, V., Dubois-Arber, F., Cottencin, O., & Rolland, B. (2014). Supervised injection services: What has been demonstrated? A systematic literature review. Drug and Alcohol Dependence, 145(Suppl. C), 48–68.

Werb, D., Kamarulzaman, A., Meacham, M. C., Rafful, C., Fischer, B., Strathdee, S. A., & Wood, E. (2016). The effectiveness of compulsory drug treatment: A systematic review. International Journal of Drug Policy, 28(Suppl. C), 1–9.

Wodak, A., & Cooney, A. (2006). Do needle syringe programs reduce HIV infection among injecting drug users: A comprehensive review of the international evidence. Substance Use & Misuse, 41, 777–813.

RESPONSES TO QUESTIONS ON POLICING AND INSURANCE BENEFIT DESIGN AS THEY PERTAIN TO THE OPIOID CRISIS

Rosalie Liccardo Pacula and David Powell

Law enforcement is charged with upholding drug laws to deter illicit markets. At the same time, communities are looking to police to assist users by offering naloxone and linking them to treatment rather than arresting them. Is there a tension between law enforcement’s deterrence and harm reduction roles?

From a law enforcement side, we do not believe the tension is that great or insurmountable for at least two reasons. First, police across the country have been proactively engaged in injury prevention activities for decades. As opioid overdoses are now the leading cause of injury death in the United States, police involvement in the distribution of naloxone, particularly as first responders on the scene, and linking the recipient to effective treatment is an obvious step toward injury prevention. When viewed as an “injury prevention” campaign rather than a “harm reduction” strategy, these activities tend to be better received by law enforcement, as indicated by evidence from interviews with police after being trained on how to use naloxone (Purviance et al., 2017; Ray, O’Donnell, & Kahre, 2015). Second, police agencies across the country are adopting innovative policing strategies that selectively let some offenders go, at least initially, in an effort to (1) focus limited law enforcement resources on more serious repeat offenders, and (2) entice low-end and first-time offenders to change their ways by giving them a one-time pass (explaining that much tougher and stricter penalties will be imposed if they do not). Examples include “focused deterrence” strategies, such as the High Point Drug Market Intervention (Corsaro et al., 2012) and Boston’s Ceasefire program (Braga et al., 2001), which have been replicated in other cities. None of these policing innovations has stopped police from aggressively pursuing high-level or repeat offenders of the specific crimes being

Journal of Policy Analysis and Management DOI: 10.1002/pam Published on behalf of the Association for Public Policy Analysis and Management

https://doi.org/10.1186/s12954-017-0179-5

450 / Point/Counterpoint

targeted, and research suggests they may have been effective at reducing crime. Within the context of these policing innovations targeting gangs, gun distribution, and drug markets, the current proposal targeting opioid users does not seem that unconventional or contentious. We recognize, however, that not all law enforcement agencies will agree. The fact that today more than 1,200 law enforcement agencies across 40 states choose to carry and administer naloxone when needed1 suggests that we are not alone in our thinking.

The perceived tension by bystanders and users is very important to address as well. It is critical in those communities willing to take such an approach that Good Samaritan Laws and similar policies removing criminal and civil penalties for those assisting overdose victims be passed and that their passage be widely disseminated throughout the community. Only when the perceived risk of arrest is removed will these laws be truly effective at saving lives.

Health insurance programs now have a dual mandate to reduce prescribing of opioid analgesics while increasing access to drug treatment. Should plans use different cost-sharing and oversight mechanisms to control access to opioid analgesics than they do to medications like buprenorphine for drug treatment?

The average out-of-pocket cost to patients for opioid analgesics in the United States has declined by 50 percent between 2002 and 2012, reaching a mean patient out-of-pocket cost of just $45 in 2012 (Stagnitti, 2015). The share of the total cost paid by patients has also been declining during this period, such that in 2012 patients paid just 20 percent of the total cost of these opioid analgesics on average (Powell & Pacula, 2017). In contrast, we found in recent work that the total average monthly patient cost per standard dose of generic buprenorphine used in treatment in 2012 was $129.60 (for those with private insurance), with patients paying 40 percent of the total cost charged (Maksabedian, Pacula, & Stein, 2017). The difference in the pharmaceutical cost of treating opioid dependence as compared to the cost of the opioid itself is astounding, as is the difference in the level of cost sharing. It is really difficult to justify these differences from a mortality risk perspective, as sustained buprenorphine treatment has been shown to decrease mortality risk (Sordo et al., 2017). As a partial opioid antagonist, the scope for abuse is lower, which probably explains its lower involvement in opioid overdose mortality, though diversion is still admittedly a concern (Lofwall & Walsh, 2014). Methadone, on the other hand, has played a larger role in overall opioid mortality. However, recent work suggests that much of the risk was driven by prescriptions for methadone related to chronic pain, as methadone-related mortality has been declining since 2006 when greater controls were placed on its prescribing for pain (Jones et al., 2016).

To the extent that we believe that the relative costs—monetary and non- monetary—of drugs should reflect possible negative externalities of access to them, then health insurance plans should make medication-assisted therapies used for addiction treatment less expensive and more accessible to the patient than other opioids that are prescribed on a long-term basis for chronic pain. However, we do fear a repeat of the mistakes of the past, in terms of expanding access to prescription opioids with insufficient oversight, leading to expansions in abuse and mortality. Consequently, we think that oversight mechanisms in place for opioids should also pertain to buprenorphine and other medication-assisted therapies while the costs

1 Source: North Carolina Harm Reduction Coalition. See http://www.nchrc.org/law-enforcement/us-law- enforcement-who-carry-naloxone/.

Journal of Policy Analysis and Management DOI: 10.1002/pam Published on behalf of the Association for Public Policy Analysis and Management

http://www.nchrc.org/law-enforcement/us-law-enforcement-who-carry-naloxone/

Point/Counterpoint / 451

to patients should reflect the reduced potency and risk of addiction as well as the possible gains to a useful source of treatment.

ROSALIE LICCARDO PACULA is a Senior Economist at the RAND Corporation and the National Bureau of Economic Research, 1776 Main Street, Santa Monica, CA 90407 (e-mail: [email protected]).

DAVID POWELL is a Full Economist at the RAND Corporation, 1200 S. Hayes Street, Arlington, VA 22202 (e-mail: [email protected]).

REFERENCES

Braga, A. A., Kennedy, D. M., Waring, E. J., & Piehl, A. M. (2001). Problem oriented policing, deterrence, and youth violence: An evaluation of Boston’s OperationCeasefire. Journal of Research in Crime and Delinquency, 38, 195–225.

Corsaro, N., Hunt, E. D., Hipple, N. K., & McGarrell, E. F. (2012). The impact of drug market pulling levers policing on neighborhood violence. Criminology & Public Policy, 11, 167–199.

Jones, C. M., Baldwin, G. T., Manocchio, T., White, J. O., & Mack, K. A. (2016). Trends in methadone distribution for pain treatment, methadone diversion, and overdose deaths— United States, 2002–2014. Morbidity and Mortality Weekly Report, 65, 667–671.

Lofwall, M. R. & Walsh, S. L. (2014). A review of buprenorphine diversion and misuse: The current evidence base and experiences from around the world. Journal of Addiction Medicine, 8, 315–326.

Maksabedian, E., Pacula, R. L., & Stein, B. D. (2017). Estimating the costs of substitution therapy for heroin and opioid addiction in the United States: Insights and challenges. In Drug treatment expenditure: A methodological overview, European Monitoring Centre for Drugs and Drug Addiction (Chapter 12). Insights 24. Luxembourg: Publications Office of the European Union.

Powell, D., & Pacula, R. L. (2017). Prescription opiates and opioid abuse: Regulatory efforts to limit diversion from medical markets to black markets in the United States. In E. Savona & M. A. R. Kleiman (Eds.), Dual markets—Comparative approaches for regulation (pp. 37–54). New York, NY: Springer.

Purviance, D., Ray, B., Tracy, A., & Southard, E. (2017). Law enforcement attitudes towards naloxone following opioid overdose training. Substance Abuse, 38, 177–182.

Ray, B., O’Donnell, D., & Kahre, K. (2015). Police officer attitudes towards intranasal naloxone training. Drug and Alcohol Dependence, 146, 107–110.

Sordo, L., Barrio, G., Bravo, M. J., Indave, B. I., Degenhardt, L., Wiessing, L., . . . Pastor- Barriuso, R. (2017). Mortality risk during and after opioid substitution treatment: System- atic review and meta-analysis of cohort studies. British Medical Journal, 26, 357.

Stagnitti, M. N. (2015). Trends in prescribed outpatient opioid use and expenses in the US civilian noninstitutionalized population, 2002–2012. Statistical Brief #478. Rockville, MD: Agency for Healthcare Research and Quality.

Journal of Policy Analysis and Management DOI: 10.1002/pam Published on behalf of the Association for Public Policy Analysis and Management