Clinicians Call for Federal Intervention in Opioid Epidemic

In a recent Viewpoint paper in JAMA, Andrew Kolondy, MD, and Thomas R. Frieden, MD, MPH, called on the US federal government to take 10 steps to address the problem of opioid addiction. Frieden is the former director of CDC.

The first 6 of the authors’ recommendations are aimed at both preventing more patients from becoming addicted to opioids and avoiding overdoses:

1. Improve surveillance of addiction to opioid treatments. The authors note that, currently, there exists no real-time assessment of data or trends in new opioid addiction, and that such a lack of information creates substantial difficulty in determining the trajectory of the epidemic. The Prescription Drug Monitoring Program (PDMP) and other data systems could be used to aggregate data for use in better understanding the incidence of addiction.

2. Improve reporting of and response to overdoses and fatalities. The authors call for the gathering and reporting of real-time data on opioid overdoses and fatalities in order to trigger automatic reports to patients’ health care professionals and state medical boards. Medical examiners and coroners may require additional resources in order to improve their response times.

3. Promote cautious prescribing of opioids for patients with acute pain. When post-surgical pain or serious injury necessitates opioid treatment, dosages should be low and the duration of treatment as brief as possible. Recommendations for duration of use should also be provided on drug labels to educate providers and patients about the risks of using opioids beyond a 3-day period.

4. Change labeling for chronic pain and restrict the marketing of opioids for this indication. The authors state that patients with chronic, non—cancer-related pain have been targeted by opioid marketing, and account for a large proportion of opioid consumption. The authors call for the FDA to narrow the on-label indications for opioids to discourage clinicians from prescribing these drugs in the long term.

5. Increase access to and coverage for alternative pain management. CMS should ensure full reimbursement for non-prescription analgesics for Medicare Part D and Medicaid beneficiaries in order to remove a financial disincentive for using drugs like acetaminophen. Lower or no copayments for physical therapy could also reduce medication use.

6. Interrupt the supply of heroin and other illicit opioids. If illegal opioids are more difficult to obtain, use should decrease. The legal system can also implement treatment programs as alternatives to incarceration.

The authors’ remaining 4 recommendations focus on providing treatment and reducing harm to current opioid users:

7. Identify addiction early and connect patients with treatment. Medically assisted treatment with products such as methadone should be offered routinely in primary care, as well as in emergency department and inpatient hospital settings. The criminal justice system, too, should offer such treatment. State health officials should actively identify patients who have opioid addictions, and should refer patients to treatment.

8. Expand low-threshold access to treatment. Patients will benefit from medically assisted treatment only if it becomes more attractive and accessible than continued use of opioids. The authors point to evidence from France, where deaths from opioid overdose decreased by 79% in the 6 years after widespread prescribing of buprenorphine.

9. Implement harm-reduction measures for current opioid users. Access to clean syringes and naloxone can help prevent injection-related infections and fatal overdoses. The authors also call for accelerated FDA approval of an over-the-counter naloxone product.

10. Consider removing ultra-high-dosage units of opioids from the market. Formulations that exceed the equivalent of 90 mg of morphine per day when taken as directed can cause a fatal overdose.

Kolondy and Frieden acknowledge the fact that widespread opioid addiction will take time to resolve, but suggest that the rapid implementation of their 10 recommendations could help to reduce the number patients who become addicted to opioids, and reduce the number of fatal overdoses.