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The opioid epidemic has been worsening in the United States. There were 33,091 deaths involving an opioid in 2015, the most recent year from which the Centers for Disease Control and Prevention has data. Addiction to prescription opioids like Percocet and OxyContin has led to an increase in addiction to heroin and fentanyl.
Here & Now’s Jeremy Hobson talks with Dr. Caleb Alexander, co-director of the Johns Hopkins Center for Drug Safety and Effectiveness, about what can be done to solve the opioid epidemic.
On where to start when looking for solutions to the opioid crisis
"I think there's two things that we need to focus on. One is prescribing fewer opioids. That is, decreasing the volume of prescription opioids in the circulation. And the other is identifying and treating those that have opioid addiction."
On the prescription of opioids in the U.S. and efforts to limit the volume
"It does help. Rates of injuries and deaths from these products have increased in lockstep with the volume of opioids in circulation. So these types of measures, such as quantity limits that restrict the volume of opioids that patients can get on a first prescription, are an important step.
"I think both patients and clinicians have tended to systematically overestimate the effectiveness of prescription opioids for the treatment of chronic non-cancer pain, and also underestimated their risks. So let's be clear: Prescription opioids are invaluable for caring for patients at the end of life and patients that may have severe, acute pain. But all too often we've seen over the past decades that they've been used increasingly for patients with chronic non-cancer pain, and these are the patients where there's a particularly unfavorable risk-benefit trade-off in many cases.
"There are dozens of tools in the toolbox, and we've been far too quick to reach for prescription opioids, rather than using a variety of prescription drugs and non-prescription treatments for pain. I think that we've tended to view opioids as the first-best treatment for many types of chronic non-cancer pain, when nothing could be further from the truth. I think it's for clinicians and patients in particular to recognize the varieties of different treatment approaches that there are for managing pain."
On prescriptions other than opioids for treatment
"Well with respect to prescription drugs, there are a variety of alternative prescription drugs than opioids. But even over-the-counter medicines such as non-steroidal anti-inflammatory drugs, things like ibuprofen or naproxen, acetaminophen or Tylenol, are often good places to start."
"I think that we've tended to view opioids as the first-best treatment for many types of chronic non-cancer pain, when nothing could be further from the truth."Dr. Caleb Alexander
On getting access to opioids through friends or family members with prescriptions
"It's true that many patients get prescription opioids friends or family, but these friends or family are receiving these prescriptions in turn from licensed prescribers. So I think it's important to realize that the vast majority of prescription opioids that are ultimately used by people with opioid use disorders originate from licensed prescribers."
"I think clinicians play a very important role because they ultimately are prescribing the vast majority of opioids which are used by individuals with opioid use disorders."
On addiction to heroin and fentanyl
"Since 2010, we have seen soaring rates of deaths from heroin and fentanyl. This fentanyl is not fentanyl which is prescribed and obtained through pharmacies. It's fentanyl that's made on the black market and often imported from overseas. And this is another face of the same epidemic. It is important for people to realize, however, that the vast majority of individuals that use prescription opioids, even those who are addicted to them, do not go on to use heroin or fentanyl. We've seen a remarkable change in the face of the heroin epidemic over the past 20 or 30 years, where now the vast majority heroin users report that prescription opioids were their first opioid of abuse."
On effective treatment
"Medication-assisted treatment is evidence-based when it's delivered as it's intended to be delivered. But it's very important that these patients are engaged and kept in care. We recently published a study looking at individuals receiving buprenorphine, which is one treatment for opioid dependence. And we found that a remarkable number of patients that were receiving buprenorphine also were receiving other prescription opioids either during or following periods of buprenorphine receipt. This type of evidence raises concern about the comprehensiveness and the quality of care that patients are receiving who are enlisted in medication-assisted treatment."
On the 'last resort' treatment naloxone
"Well, it's a tragedy that we need naloxone as much as we do, but you're right that it can be life-saving. But once someone is receiving naloxone, the horse is out of the barn. I mean this is a very important medicine, and I think it's important that we identify further ways to reduce its price, because it is very, very costly, and to make it more available to health systems and to municipalities and local government. But with that being said, naloxone is treating the end-result of opioid use disorders, namely overdose. And while I support increased efforts to distribute naloxone, I also think it's vital that we focus further upstream. That is, prior to opioid dependence developing, and identifying and treating those with opioid use disorders that may not yet have overdosed."
On opioid addiction in rural areas
"These areas are areas that have been hard hit by the economic recession, and where there are high rates of unemployment. And these types of factors create a vulnerability. And prescription opioids have been widely prescribed in many of these settings and fueled the epidemic enormously. One doesn't have to look far to find someone that's been affected directly by this epidemic. And injuries and deaths from opioids have skyrocketed in red states and blue states alike. This is a bipartisan issue, and it should be one where there's clear agreement on all sides of the table regarding what we need to do to address it."
This segment aired on April 18, 2017.