We Cannot Treat the Dead

No single policy solution has stymied the maelstrom of societal ills spun out by the opioid epidemic. Our state government legislatures are now pulling policy levers at a frantic pace to identify some combination of prevention and treatment that will slow the increases in opioid overdose mortality, cases of opioid use disorder (OUD), diversion of prescription opioids, and uptake in heroin and fentanyl.

DYNAMIC COMPARTMENTAL MODELING

In this issue of the AJPH, Pitt et al. (p. 1394) apply an epidemiological tool for modeling infectious disease trajectories, known as dynamic compartmental modeling, to characterize and project hypothetical outcomes resulting from different combinations of extant and potential opioid policy interventions. An individual enters into the model within a compartment (e.g., a baseline compartment may consist of “a person with chronic pain who does not use opioids”), then may transition to other compartments (e.g., move into the compartment for “a person with chronic pain who receives opioid prescriptions”), where the likelihood of transition between each compartment is based on a transition state probability. The authors derived the probabilities of transition between compartments from the literature when available or from expert opinion when evidence was lacking. For example, they used the calculated per-month overdose mortality rate for persons not in medication-assisted therapy to assign a transition probability between the “person with severe OUD who is not in medication-assisted therapy” compartment and the “death from overdose” compartment.

A total of 11 opioid policy interventions, individually and in combination, are engaged within the model to manipulate the probability of an individual’s transition between each compartment; however, it should be noted that the magnitude of effect size for each of the 11 opioid policy interventions is assumed. The authors then calculated several outcomes at five and ten years following each model iteration of the hypothetical opioid policy intervention(s): quality-adjusted life years, overdose deaths (pills, heroin, all opioids), and prevalence of OUD or heroin use disorder. So, where do the findings from this modeling exercise leave us?

NO SINGLE OPIOID POLICY LEVER

No single opioid policy intervention, in the modeling exercise and in reality, has demonstrated a silver bullet solution for all opioid sequelae. However, one portfolio of policies highlighted by the authors yielded a promising series of outcomes in the form of reduced deaths and increased quality-adjusted life years. This policy portfolio contained three of the familiar elements long advocated for by the public health community: to (1) address demand (i.e., medication-assisted treatment of OUD), (2) engage in harm reduction (i.e., increase naloxone availability and needle exchange), and (3) prevent new cases (i.e., reduce initiation of new opioid prescriptions). These findings are bittersweet and somewhat frustrating. Decades of public health research have demonstrated the net benefit of harm reduction policies such as needle exchange,¹ and yet harm reduction policies such as increasing naloxone availability remain politically unpopular with the public² and hence with policymakers.

Meanwhile, policy solutions that address demand in the form of expanding funding for evidenced-based OUD treatment have been similarly unpalatable for policymakers in cash- and resource-strapped state governments, so the most recent wave of policy levers pulled by state governments have trended back toward supply-side restrictions. In fact, from 2016 to the present, 28 states have enacted limitations on daily supply of opioid prescriptions per patient or total morphine milligram equivalents of new opioid prescriptions,³ with more states considering similar proposals. Such policies could possibly reduce new cases of OUD and perhaps even overdose. However, legislative supply limitations coupled with payer-driven restrictions placed by Medicare and other major payers, along with the ongoing confusion regarding the Centers for Disease Control and Prevention’s 2016 opioid prescribing guidelines,⁴ may leave pain patients high and dry (or, perhaps, low and dry). One wonders whether the marked recent increase in US suicide rates may be related to inadequate pain treatment—in 2015, a reported 22% of suicides occurred among persons with documented physical health problems.⁵

POLICYMAKERS ARE LISTENING, BUT WHAT NOW?

The opioid epidemic as we know it has evolved into a syndemic, which leaves our individual policy levers less capable of across-the-board reductions in opioid-related mortality and morbidity. These other, “downstream” opioid sequelae are numerous and complex, with each likely requiring its own portfolio of policy interventions. Downstream opioid problems include spread of infectious diseases resulting from shared needles, increased burden on child welfare services resulting from incarcerated parents with opioid possession or diversion convictions, the increased rate of infants born with neonatal abstinence syndrome, an overwhelmed legal and judicial system dealing with the rapidly evolving circumstances of opioids and analog products, and even decreases in US labor force participation.⁶

We cannot treat the dead, and so public health practitioners must make harm reduction and public health–focused policies more palatable to policymakers and the public by clarifying policy intent. There are many tools available to communicate the benefits of public health–focused, evidence-based opioid policies, and continued efforts in coalition building between health care providers, public health officials, and the public will be the pathway by which we employ these tools. We start among ourselves, where negative attitudes and avoidance of medication-assisted therapies for OUD in the medical community are concerningly common.⁷

The consensus building necessary for implementing effective opioid policies will require communication from the public health community by formal means (through dissemination of research findings and policy evaluations) as well as informal means. In other words, talk to your colleagues, your neighbors, your family, and your friends. Keep the opioid epidemic and its sequelae rooted in the attention of policymakers and the public. Lessons from public health history can be applied here, where media coverage of the heroin crisis in the 1980s was abandoned long before those public health problems were addressed and a decade before the dismissive and cruel phrase “hillbilly heroin” entered our collective vocabulary. From there, our attention shifted from prescription opioid abuse in rural communities to the crisis level of prescription opioid overdose deaths in the country as a whole, then again from prescription-issued pill supply to diverted pills, to heroin, to fentanyl and other synthetics, ad infinitum. When our attention is brief and our memory is short, it is crucial that we redouble communication regarding effective policy interventions for the current generation of opioid sequelae. We know the levers: address demand with treatment, reduce harm, prevent new cases; let’s pull them.