Opioids

HHS official: Better pain treatment a key to ending opioid crisis

Utilizing a rapid delivery, Brett P. Giroir, MD, gave his physician audience a status report on the opioid crisis and how it is morphing into a poly-drug, multi-problematic phenomenon, but also provided some glimmers of hope and a progress report on implementation of a five-point federal strategy to combat the epidemic.

Two things that must be addressed are treating pain and transitioning the response away from a “crisis framework” financed by grants and toward an integrated and sustainable system with predictable funding, said Dr. Giroir, the Health and Human Services (HHS) assistant secretary for health and an admiral in the Commissioned Corps of the U.S. Public Health Service. He spoke Feb. 13 to physicians attending the AMA National Advocacy Conference in Washington, D.C.

About 11.4 million people in the U.S. misused opioids in 2017 with 2.1 million of them having an opioid-use disorder (OUD), Dr. Giroir said, citing statistics included in National Survey on Drug Use and Health (NSDUH) released last September.

More than half of the survey’s 70,000 respondents said they obtained the last pain reliever they misused from a friend or relative, and 62.6 percent cited pain as a reason for misusing opioids.

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Dr. Giroir suggested that, to solve the opioid crisis, the pain crisis needed solving as well. His office led the HHS Pain Management Best Practices Inter-Agency Task Force that issued a draft report to Congress in late December. A final report is expected later this year.

Calling it “the most critical public health challenge of our time,” Dr. Giroir told how the U.S. had 70,237 drug-overdose deaths in 2017, with 47,600 of those related to opioids.

Deaths from heroin, pills, and methadone were down, while deaths from fentanyl and cocaine were up—with opioids detected in more than 70 percent of cocaine deaths. Dr. Giroir told of how Customs and Border Patrol agents recently seized 254 pounds of fentanyl found in a truck trailer loaded with cucumbers and noted that amount of fentanyl was sufficient to kill more than 50 million people.

Consumption of alcohol, marijuana and opioids was growing among pregnant women, and Dr. Giroir said epidemiologists are learning about long-term neuro-cognitive disorders the children of these women face and a growing number of incidents of gastroschisis where their babies are born with intestines outside their abdomen.

Consequences being seen for adults included more blood-borne infections resulting in more cases of HIV, hepatitis C, hepatitis B, endocarditis (inflammation of the heart’s chambers and valves inner lining), and skin, bone and joint infections.

Positive signs include drops in pharmacy-dispensed opioids of more than 25 percent. This continues the trend noted in the AMA Task Force to Reduce Opioid Abuse’s 2018 Progress Report which noted that the number of opioid prescriptions written between 2013 and 2017 fell by 55 million.

There were also significant jumps in prescribing buprenorphine and naltrexone for medication-assisted (MAT) treatment of OUD and of naloxone used to reverse opioid overdoses. Also, the numbers of individuals misusing pain relievers and of first-time heroin users have gone down.

The HHS’ five-part strategy to combat opioid abuse, misuse and overdose was outlined by Dr. Giroir. It includes better:

  • Prevention, treatment and recovery services.
  • Data to find out what is happening and where.
  • Pain management.
  • Targeted distribution of naloxone.
  • Research.

The strategy includes providing evidence-based treatment—particularly MAT using naltrexone, buprenorphine or methadone. But other important aspects of treatment include psychosocial therapy and recovery services—with Dr. Giroir noting that people rebuilding their lives need to be accepted without stigma.

Some clinicians who receive the Drug Enforcement Agency waiver to prescribe buprenorphine have yet to prescribe it while others are not seeing as many patients with OUD as they could, Dr. Giroir said, though he added that research shows “lack of patient demand” has been one reason for this.

Similarly, he said physicians were not co-prescribing naloxone enough for patients at risk of overdose, and—of those patients who were co-prescribed naloxone—too many were not picking it up.

Other positive developments Dr. Giroir noted were:

  • Passage of the Substance Use-disorder Prevention that Promotes Opioid Recovery and Treatment (SUPPORT) for Patients and Communities Act.
  • Development of a Maternal Opioid Misuse alternative payment model to provide comprehensive care, MAT and support services for Medicaid beneficiaries.
  • Building of an infrastructure to track, study and improve outreach for services.

Infrastructure plans also include opioid rapid response public health teams that are available to communities in the aftermath of the removal of “pill mills” or other major illicit suppliers of opioids, Dr. Giroir said.

In terms of improving outreach efforts to fight against both the opioid and HIV epidemics, Dr. Giroir noted that, “We have to reach people who are difficult to reach.”

He also encouraged physicians to “keep working with us in every forum.”