It's the last episode of our four part update on opioids. With support from the National Institute for Healthcare Management Foundation, we've talked about the crisis and new regulations are affecting the healthcare system, its workers, and the patients it serves. We've talked about deaths of despair and how they've contributed to decreased life expectancy in the United States. And we've talked about how marijuana might not be the answer we once thought it might be. In this last episode, we'll shine a light on where we're still failing to stop the crisis, and what the data say about our ability to turn that around. That's the topic of this week's Healthcare Triage.

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We're still largely failing to stem the opioid crisis. This failure is happening on many levels, not the least of which is lack of access to medication assisted therapy, or MAT. MAT is the use of drugs such as methadone, naltrexone, or buprenorphine to treat opioid use disorders. These are well-established treatments that are associated with significantly improved opioid abstinence and decreased mortality.

But access barriers are rampant. For starters, we aren't turning to MAT when addicted patients show up at the hospital. When compared with opioid-dependent patients placed on a detoxification regimen upon admission, those placed on a buprenorphine induction protocol and treatment upon discharge reported significantly less illicit opioid use six months later. Other data suggests that initiating buprenorphine treatment at hospital admission significantly reduces the chances of both 30- and 90-day re-admissions. But despite these and other data, a 2016 study reported that among 102 patients hospitalized with heart infections related to injection drug use, fewer than 25% were given addiction consultations and fewer than 8% were discharged with a plan for MAT. 

This could be due in part to low MAT availability. Medication for opioid addiction is offered at fewer than half of US addiction treatment facilities. In addition, there are huge portions of the United States where there are too few to no doctors that can prescribe buprenorphine, leaving an enormous number of addicted individuals without this treatment option.

It seems like there's tighter regulation of the medications that treat opioid use disorder than there are of the medications that cause it. Physicians with licenses from the Drug Enforcement Administration can write prescriptions for oxycodone and fentanyl, but they need extra training before they're given a waiver that allows them to prescribe buprenorphine. Among other things, physicians cite this 8-hour training is a significant barrier to being an MAT provider.

Addiction specialists have argued against the waiver requirement, citing outcomes in countries like France, where a substantial decrease in opioid deaths was seen after regulations on buprenorphine administration were eased. As of now, though, the waiver remains a requirement here in the United States.

Other moves have been taken to address barriers to MAT. The California BRIDGE program is working to make hospitals and emergency rooms primary access points for addiction treatment, and a handful of universities and medical centers are working to ensure in-hospital addiction treatment.

Let me be clear, though, that a lot more effort is required. To repeat something I said just a minute ago, the majority of addiction treatment centers in the United States do not offer MAT, and effective, evidence-based treatment for addiction. This could be due, in part, to stigma. We'll discuss that in just a minute, but first we want to talk about policy.

A paper released in 2018 used a modeling approach to project addiction-related deaths in the United States in response to potential policy fixes to the opioid epidemic. They examined policy changes aimed at preventing new cases of opioid use disorder, like reducing prescription rates, expanding opioid disposal programs to reduce inappropriate use of leftover prescriptions, and reformulation of opioids to deter tampering and abuse. They also examined policy changes aimed at existing cases of opioid use disorder, like expanding availability of MAT, psychosocial treatment, naloxone availability, and needle exchange programs, which prevent deaths from things like HIV contracted via needle sharing. They also projected the effects of enhancing provider access to and use of prescription drug monitoring programs to support appropriate prescribing and to identify misuse among patients. 

Over a ten-year period, changes to opioid prescription policies related to acute pain were projected to prevent around 9,000 deaths, whereas changes related to chronic pain and prescription monitoring programs were actually projected to increase deaths.

As we discussed in the first episode of this series, it's critical to change the way we prescribe opioids, but caution and awareness of individual circumstances will also be critical to avoid making things worse. The projected number of lives saved due to drug reformulation was 3,900. Disposal of excess opioids accounted for a projected 2,400. Expanding needle exchange programs was projected to save almost 6,000 lives, and expanding psychosocial treatment could save another 7,500. Expanding access to MAT was projected to save 12,500 lives, and expanding naloxone availability made the biggest impact at a projected 21,200 lives saved over the ten-year period. 

The authors project that, without intervention, we would see upwards of 500,000 opioid-related deaths over ten years. When combining the appropriate policy approaches, they project we could reduce that by around 11%. That's a lot.

The important takeaway is that no single approach will do it. Rather, a combination of the most effective policies is the key to saving a significant number of lives. Multifaceted problems require multifaceted solutions. We need to take action where possible to halt addiction before it starts, reducing unnecessary exposure to opioids, and taking steps to screen for and safeguard at-risk individuals, including the steps mentioned in our episode on deaths of despair.

But we won't catch everyone there. And some are already past that point. So we'll need more nets. We must plan for both the immediate and long-term needs of those affected by addiction. We need naloxone to save lives in the most desperate moments. After that, we need evidence-based treatments like MAT and psychotherapy to help affected individuals move forward. We need those treatments to be easily accessible on all levels.

Building up this kind of system will also require a lot more money than we've been giving it. But many people disagree with their tax dollars being spent on something like methadone treatment. Which brings us to stigma.

Addressing this crisis will require us to address it in a big way. There's no shortage of stigma when it comes to addiction, and its presence leads to a decrease in both treatment availability and likelihood of addicted individuals to seek treatment when it is made available. Addiction is commonly regarded as a moral failing rather than a disease, and treatments like MAT are seen as just replacing one drug for another.

As an excellent Vox article points out, these beliefs lay bare a misunderstanding of how addiction works. Americans use drugs all the time. They partake in substances like caffeine and alcohol, while receiving far less backlash than individuals using opioids. Opioids put an individual at high risk of overdose and of severe withdrawal that often leads to poor and/or unacceptable behaviors that negatively affect themselves and those around them.

Using appropriate medications, we can alleviate the cravings that lead to these risks and behaviors without producing a high, helping to ameliorate the outcomes that make opioid use such a problem. We use this approach with other modes of addiction as well: for example, when we offer drugs like Chantix or alternate methods of nicotine exposure to help people quit smoking.

For improved opioid policies to be passed and become useful, we must work towards reducing stigma by educating policymakers and the public at large about opioid addiction, withdrawal, and successful treatment. We need to help them understand that behaviors exhibited by addicted individuals stem from physical changes in the brain and body caused by the drug, not from some kind of character flaw leading them to make choices that destroy their relationships, income, and security.

We may also need to address perceptions within the medical community about who handles this disease and how.

Physicians report a lack of formal or informal training in addiction treatment as well as a general perception that this type of treatment is relegated to outpatient settings with psychiatrists.

And last but not least, we'll need to remove financial barriers including those related to insurance. Lack of insurance coverage, or rules that make coverage especially difficult, are often reported as barriers to treatment. There's a great lack of parity when it comes to addiction treatment and insurance - meaning insurance companies have different rules for covering addiction than they do other diseases and disorders. Coverage can be delayed or denied based on specific requirements for prior authorization, or accessory services like drug tests or attendance of 12-step programs. Some insurance programs exclude medications for substance use disorders altogether. Complicated rules for addiction treatment plague programs like Medicaid, which is of particular concern given that individuals with opioid-use disorder are often reliant on public programs and funding for help.

If not covering this seems reasonable to you, consider that we don't make heart insurance coverage contingent upon individuals proving they haven't been smoking or that they've been to see the dietitian and joined a weekly exercise program. We don't complicate their medical care because we assume they made bad choices. We assume that whatever factors are relevant to their situation will be dealt with between them and their doctor. In the meantime, we save their lives.

We hope you enjoyed this episode and we hope you enjoy these other episodes that are part of this series. We'd  especially also like it if you liked and subscribed down below and if you'd consider going on to patreon.com/healthcaretriage where you can help make the show bigger and better. We'd especially like to thank our research associates Joe Sevits, Joshua Gister, and James Glasgow, and of course our surgeon admiral, Sam.