Scholarly thoughts about the Opioid Crisis

[jennistarr1]

Back in 2013 I applied to a Public Policy (Health Policy) Ph.D. program and my intent letter discussed how I was to focus on prescription drug abuse. As I started the program, I would choose this as my topic for all my papers. Initially, I was lucky to find a handful of articles to pull my research from.

Since then, the topic has exploded. As it has claimed more and more victims it's a prominent issue discussed by local, state, and national politicians. THERE IS SO MUCH RESEARCH to comb through.

I'm now the stage of needing to find a dissertation topic which has to be 2 things mainly: a very specific, narrow focus amongst this vast problem area AND something new, different, or a fresh take on work already done.

I was wondering if you guys could help me brainstorm some ideas. Give me anything you got because I promise it will be helpful in just getting my mind to narrow down the possibilities.

[Bad Dingo]

Not sure if this is what you are looking for, what about how opioid use/addiction/death is increasing in the teenage population, but parents are in denial and won't seek treatment?

I attended a meeting in the fall and someone working with treatment facilities for adolescents said that they have many open beds, despite the need for treatment.

Something that is being explored a lot so isn't really a new or fresh topic is treatment outcomes. Outcomes are significantly better if an individual is treated in their home/community using peer support (usually recovering addicts themselves).

Oh, I thought of one more, the increasing prevalence of treatment centers in FL that are costing insurers astronomical amounts of money. Due to the(very necessary) Mental Health Parity act, insurers may be forced to cut benefits across the board in order to deter their insured from using these facilities.

[hocus2]

So you can focus on safe zones where people can do drugs. Their controversial but effective at preventing overdoses. You could also write about how oxycodone and similar drugs play a big role as gateway drugs.

I'd also consider writing about how drug use policy and the national conversation has changed because the folks who are abusing drugs has perceived to have changed. Back under Regan/Bush Senior/Clinton the language of drug use was very criminal in nature and drug abuse was largely seen as an urban issue. However now the is rising in the midwest and southwest and the language is more disease or even policy based in nature. Every state that is dark purple/high prescription area on the map in the link below went for Trump and ameliorating the issue is now seen as a Republican issue which i feel is new.

www.cbsnews.com/news/the-states-with-the-worst-prescription-painkiller-problem/

[gummybear]

So, I am trying to put together pieces of information based on my own personal anecdotal experience.

My brother's ex-GF worked to get the Rx drug tracking program established here, we are one of the last states (of not THE last).
I am wondering if widespread use of the tracking program (via Drs and pharmacies) results in a lower rate of overdose for the actual medications, and if so, does that translate over into a lower use/overdose of fentanyl and heroin OR, are people more apt to switch over faster bc the Rx drugs and pills are less readily available and thus increase use and overdose of the illegal substances. Am I making sense?

This may not be fresh. I just wonder about it.

[jennistarr1]

Bad Dingo, hocus2,
Both of these are great!!! Thank you!

[toutsuite]

I'm sure something like this is probably out there but is there any way to compare rates of opioid misuse in states where marijuana has become legalized versus a state where it is not? I'm wondering what impact, if any, legalization would have on opioid abuse.

Otherwise, the only other things I can think of deal on an international level and I suspect would not be helpful...must be focused on u.s. Health policy correct?

[mrsn052408]

Working in a hospital, I see babies born to opioid addicts. I'm very rural. There are ethical issues and increased compassion fatigue issues related to the health care workers caring for the mom and baby. There are financial issues related to their care. Just some thoughts.

[Deleted]

Oh man I have a lot of ideas! The big this is that the mandatory prescribing history checks went into place a few years back - so a doctor couldn't prescribe opioids until they checked whether you had other opioid prescriptions out there. Now that the databases are out there - and states are working to get them to be interoperable with each other - pill shopping is way down. It's harder to get a prescription which has led to a rise in illegal drugs, specifically heroin.

But if I was looking for a narrowly tailored policy topic I would talk about the lack of practitioners focusing on pain management. We had a doctor get indicted and he had thousands of patients in his pain clinic who were all of a sudden cut off. And all the area doctors were inundated with new patients and were afraid to treat them. There is a host of reasons but a lot of the restrictions put into place to prevent pill shopping make it harder to treat legitimate pain.  And policymakers are stuck trying to differentiate between "chronic pain" and "acute pain." It's a hard issue to navigate.

[isabel]

Feb 6, 2017 10:27:18 GMT -5 @notquiteblushing said:

Oh man I have a lot of ideas! The big this is that the mandatory prescribing history checks went into place a few years back - so a doctor couldn't prescribe opioids until they checked whether you had other opioid prescriptions out there. Now that the databases are out there - and states are working to get them to be interoperable with each other - pill shopping is way down. It's harder to get a prescription which has led to a rise in illegal drugs, specifically heroin.

But if I was looking for a narrowly tailored policy topic I would talk about the lack of practitioners focusing on pain management. We had a doctor get indicted and he had thousands of patients in his pain clinic who were all of a sudden cut off. And all the area doctors were inundated with new patients and were afraid to treat them. There is a host of reasons but a lot of the restrictions put into place to prevent pill shopping make it harder to treat legitimate pain.  And policymakers are stuck trying to differentiate between "chronic pain" and "acute pain." It's a hard issue to navigate.

I think this is pretty interesting. My mom has fibromyalgia and struggled for a long time to find someone who would work with her to get her the right combination of medications for pain, sleep issues, etc. Luckily, she has a great doctor now and has for years, but she was diagnosed when I was 7, so 21 years ago. It was a long road for her and very challenging to find the right kind of specialist. I know she had issues in some cases because doctors didn't want to overprescribe to her.

Seems like this topic has the potential to branch out into alternate pain management practices, but that may not be where you want to go. Regardless, I think a focus on physicians who specialize in pain management and how the opioid epidemic has impacted their ability to practice could be interesting.

[mich1]

Why don't you go from the chronic pain patient stand point?

This is where the collateral damage is coming in with all the hoopla about getting prescriptions. As a result, many, many patients in my hip group are being horribly under treated for their pain and they can no longer work. As a result, many are moving to pot, which is going to have a whole 'nut her set of repercussions for those who have to deal with random drug tests as a condition of employment.

As someone who spent almost a solid year on massive doses of narcotics, it scares the crap out of me that if I ever have another infection (and my risk is higher now) that I will have my pain under treated.....despite the fact that when my pain went away, I tapered off all narcotics with no repercussions.

[Deleted]

I've read some news articles recently about the marketing of prescription opioids, particularly Oxycontin, and the problems that has caused. And now the drug companies are looking to expand overseas. The relationship of prescription drug marketing to the opioid epidemic is one I find fascinating and horrifying.

[livinitup]

Have you looked at the " Harm Reduction" model versed the "Abstinence" model? Treatment has almost exclusively been funded for only programs that require 100% abstinence- which only works for patients who are ready/willing to be non-users. So, anyone 'using' is cut entirely out of any type of connection or support along their recovery path. This is especially true for folks who not only get booted out of programs but get sent back to jail for using. This drives them further into their addiction, and risk of overdose/death. The harm reduction model literally accepts people "where they are at" to keep them as safe/connected as possible until THEY are ready to abstain.

For my agency, this means access to free needles/works, education on how to do the least amount of harm to yourself (smoke vs injection) (never get high alone), advocacy for laws that protect folks from prosecution for calling 911 to report an overdose, Narcan training and Narcan kits in the community (parents, cousellors, cops), and prevention/access to treatment programs when they are ready. Our needle-exchange program is usually the only safe place where users can admit they are using, get help/education to stay as safe as possible in their addiction, and be trusted by the user as a safe place to admit their addiction and get placements in treatment when ready. The needle/exchange program not only prevents the spread of STDs, HepC and HIV, they provide hundreds of referrals for treatment beds.

My agency is getting so many calls from community groups - including police, for Narcan training. Even though it is a a KNOWN intervention to keep people alive, there is no funding for it.

The whole idea is to re-look at treatment as a continuum where users are kept alive long enough - and kept connected to services long enough - to be able to get clean.

[childofhiphop]

What about the pharmacies who are refusing to fill legitimate prescriptions? Here in California, it is becoming a problem. It doesn't seem to matter if the patient has been getting their prescription filled at a particular store for years.

This happened to my Mom who has chronic health issues. I ended calling the pharmacy and reminding them that it is a violation of the Americans with Disabilities Act and that deliberately delaying or denying filling her prescriptions was unprofessional and had to say I would file a complaint with the Boards of pharmacy in order to get her script refilled.


ETA: (to bring my thoughts back to topic)  The opioid crisis and abuse is also affecting genuine patients in need of medicine.

[Deleted]

Feb 6, 2017 11:29:19 GMT -5 @aliciaroset said:

I'm interested in the legislation around the medications which can be used to wean addicts. They seem very unavailable.

Actually buprenorphine should become more available really soon as SAMHSA just changed their rules on prescribing limits recently. Providers just have to take the required training first.

[bittybomb]

Feb 6, 2017 11:06:17 GMT -5 @angryharpy said:

I've read some news articles recently about the marketing of prescription opioids, particularly Oxycontin, and the problems that has caused. And now the drug companies are looking to expand overseas. The relationship of prescription drug marketing to the opioid epidemic is one I find fascinating and horrifying.

Me too.  So scary.  I was just talking with a friend of mine who is a PA.  She met her husband in PA school, and one of her husband's very good friends from PA school met and fell in love with another PA once he started working in a hospital.  They have four children together.  The wife had some type of back surgery, and was put on prescription opioids, and got hooked.  Now she is a full fledged heroin addict, their marriage has been decimated and he is seeking sole custody of their four small children.  Terrifying.

[Deleted]

Feb 6, 2017 11:45:30 GMT -5 @aliciaroset said:

Feb 6, 2017 11:43:34 GMT -5 @notquiteblushing said:

Actually buprenorphine should become more available really soon as SAMHSA just changed their rules on prescribing limits recently. Providers just have to take the required training first.

That's great. What about suboxone? That's one I have heard a person trying to get and not being able to. (anecdote)

Suboxone is the brand but buprenorphine is the drug.

Here's an article about the limits:

www.npr.org/sections/health-shots/2016/07/06/484843560/obama-administration-eases-restrictions-on-doctors-who-treat-opioid-addiction

But finding doctors is still challenging because they have to get a waiver first.

[readyin07]

Have you thought about presenting it from the other side - the crisis it has caused for people who legitimately need pain medication and are facing extreme difficulty getting it due to increasing regulations because of abuse?

My mom is one of those people. When she was in her mid 40s she was diagnosed with degenerative disc disease and spinal stenosis. I remember walking through the mall with her and coming home sobbing bc she was walking like an old woman bc of her pain. Because of severe osteoporosis she was not a candidate for surgery, epidurals did not help. Taking some pretty heavy duty opioids, while not ideal, gave her her life back.

We are in south Florida so prime "pill mill" area. Pharmacies are limited on what they can sell. You cannot just walk up to cvs with an opioids rx and get it filled. Her independent pharmacy got into some trouble last year and was unable to fill opioids rx leaving her to scramble for a new pharmacy. You have no idea how many places she had to call and visit to get her rx filled. And they would tell her for every opioid rx you fill (she has 2 plus she takes adderall) you have to fill another non opioids rx here. She now has to drive 25 mins to her pharmacy, which being non affiliated with a store, is open traditional 9-6 hours which is hard for her as someone who works full time to get to. It breaks my heart for her that she is stigmatized like this/

[winnies]

As an OB nurse, I can tell you that this addiction crisis having a huge effect on growing families. Narcotic abuse is huge in my area, followed closely behind by meth. I take care of babies going through the withdrawl process for weeks. Often times the parents stop visiting completely, I have seen babies abandoned once CPS becomes involved. There is also the difficult task of managing surgical pain in those who abuse narcotics

[childofhiphop]

Feb 6, 2017 11:57:13 GMT -5 readyin07 said:

Have you thought about presenting it from the other side - the crisis it has caused for people who legitimately need pain medication and are facing extreme difficulty getting it due to increasing regulations because of abuse?

My mom is one of those people. When she was in her mid 40s she was diagnosed with degenerative disc disease and spinal stenosis. I remember walking through the mall with her and coming home sobbing bc she was walking like an old woman bc of her pain. Because of severe osteoporosis she was not a candidate for surgery, epidurals did not help. Taking some pretty heavy duty opioids, while not ideal, gave her her life back.

We are in south Florida so prime "pill mill" area. Pharmacies are limited on what they can sell. You cannot just walk up to cvs with an opioids rx and get it filled. Her independent pharmacy got into some trouble last year and was unable to fill opioids rx leaving her to scramble for a new pharmacy. You have no idea how many places she had to call and visit to get her rx filled. And they would tell her for every opioid rx you fill (she has 2 plus she takes adderall) you have to fill another non opioids rx here. She now has to drive 25 mins to her pharmacy, which being non affiliated with a store, is open traditional 9-6 hours which is hard for her as someone who works full time to get to. It breaks my heart for her that she is stigmatized like this/

This is my Mom's story too.

I am SO SORRY you and your Mom have to go through this! It is so demoralizing when all you want is to have the closest to "normal" life that you can with the pain.

[InBetweenDays]

I would love to see more research (or more synthesis of research) on safe/supervised injection sites. Our county health board just gave them the green light - I think the first in the US? - and there has been much reference to a study from Vancouver. But that study was done based on data from 2001 - 2005. I'd love to see a synthesis of more recent data - not only on how the sites have affected overdose rates, but how have they affected public drug use in general, people entering treatment, the ability of law enforcement to enforce drug laws, etc.

[rageragerage]

I'd be curious to see more about how the rise in addiction has contributed to the strain on the child protective agencies.

[berbles]

Feb 6, 2017 12:38:44 GMT -5 kooshball said:

Another angle... the use of Naloxone by non-medical people. Ie, our police carry it and post a blog about using it every time.

spdblotter.seattle.gov/2016/03/15/spd-announces-initiative-to-prevent-overdose-deaths/

Most interesting to me would be how many repeat? percentage of deaths from another incident? 

This is what I was going to suggest. I have read a little about the controversy regarding allowing non-medical people carry/administer this drug and I find it very interesting.

[jennistarr1]

you guys are so smart!!! Anyone want to be on my dissertation defense committee?

[mnp555]

Not sure if this has been mentioned, but I just read an article about how the pharma co that distributes the anti-overdose meds for heroin (nalaxone) increased their prices astronomically. Maybe something about the ethical/fiscal responsibility of the state/first responders to revive ODs in a world where that drug can cost as much as $2,500

Article link:
www.scientificamerican.com/article/massive-price-hike-for-lifesaving-opioid-overdose-antidote1/

[Que?]

Feb 6, 2017 11:23:13 GMT -5 livinitup said:

Have you looked at the " Harm Reduction" model versed the "Abstinence" model? Treatment has almost exclusively been funded for only programs that require 100% abstinence- which only works for patients who are ready/willing to be non-users. So, anyone 'using' is cut entirely out of any type of connection or support along their recovery path. This is especially true for folks who not only get booted out of programs but get sent back to jail for using. This drives them further into their addiction, and risk of overdose/death. The harm reduction model literally accepts people "where they are at" to keep them as safe/connected as possible until THEY are ready to abstain.

For my agency, this means access to free needles/works, education on how to do the least amount of harm to yourself (smoke vs injection) (never get high alone), advocacy for laws that protect folks from prosecution for calling 911 to report an overdose, Narcan training and Narcan kits in the community (parents, cousellors, cops), and prevention/access to treatment programs when they are ready. Our needle-exchange program is usually the only safe place where users can admit they are using, get help/education to stay as safe as possible in their addiction, and be trusted by the user as a safe place to admit their addiction and get placements in treatment when ready. The needle/exchange program not only prevents the spread of STDs, HepC and HIV, they provide hundreds of referrals for treatment beds.

My agency is getting so many calls from community groups - including police, for Narcan training. Even though it is a a KNOWN intervention to keep people alive, there is no funding for it.

The whole idea is to re-look at treatment as a continuum where users are kept alive long enough - and kept connected to services long enough - to be able to get clean.

This is worded far better than I could have done so I'll just quote you.
OP could extrapolate from this and research region/demographic specific cases as a means of comparing models.

[litskispeciality]

I haven't had a chance to read over all of the comments so I apologize if these are repeates:

1. Lack of funding for treatment. My friend's family started a campagin to the state after their son OD'd.
    Edited to expand: funding from the state to build treatment centers. If the state "shouldn't" pay for this who should? Does     insurance cover funding? Could/would increase funding decrease use and/or the number of deaths?
2. Pros and cons of easy access to narcan (sp?) Many say this may create more drug use because you can use this if you OD.
    Are there populations (civil service, civilians) who should or shouldn't have access - liability issues
    etc.
3. Is there any research about mandating counseling/therapy when you're on an opiod? Many prescriptions for depression require counseling. Would there be any benefit or reduction in addiction?

Interesting topic, good luck!

[atarianna]

What about availability of narcan and if having it available to family members increases the likelihood of drug use.

[ashbridemd]

PDQ

At the tender age of 27, I have DDD, Spinal Stenosis, A cyst on my spine, hip damage due to a bad car accident, Fibromyalgia, and Rheumatoid Arthritis. I also have a hernia and a condition that is causing my ab muscles to separate and tear. After years of suffering and countless surgeries that weren't helping, I resigned to pain management. I am on a daily dose of Oxycodone for breakthrough pain, and I also wear a Fentanyl patch for long term pain control. I absolutely DO NOT abuse my meds, in fact, I take them LESS than prescribed. This is good because I get kidney stones ALL the time, but I usually have a decent amount of my pain meds left at the end of the month so I can stock pile them and save them for when I do get an attack and I don't have to go through the rigamarole of going to the ER to be pumped full of pain meds and fluids.

When I first started going to PM, getting my scripts filled was a NIGHTMARE. I would spend 12+ hours traveling the MD/VA/WVA/PA roads in search of a pharmacy willing to fill them. I always got the same response.. "Sorry we don't stock these" or "They're on back-order" or even "We won't fill prescriptions for these because you'll just sell or abuse them". One day, I walked into a Target about 50 miles from my home, completely exhausted and handed them my scripts already knowing they wouldn't have them....And they didn't. But the Pharmacist was SO caring and compassionate that she offered to order them for me every month as long as I got all my prescriptions filled there. I have been with them ever since. About a year ago, CVS bought out Target pharmacies and it worried me because CVS was always a pharmacy that said no way. But they have continued to order my meds for me with no problem. I was blessed to walk in there.

However- I am what you would call chemically dependent on the medication. I don't abuse them AT ALL. But I've been on them for so long that my body will go into withdrawal if I don't take any for a day or 2. Some days are better than others and some days I feel I dont NEED to take any medication. But then I'll cut my pill in half and only take a tiny bit to keep my body from going into withdrawal. It's such a balancing act and it's exhausting. But my life without the medications would be spent confined to a bed unable to even turn over without any help.

[kirra]

Another vote for how regulations affect chronic pain patients who aren't terminal. I won't take opiates because I have the gene that makes you metabolize them faster than normal, which would require a higher dose, and I don't want to risk having to go through withdrawal if my physician changes or I can't find a pharmacy to fill it.

The irony is if I went to the ER every time I dislocated a joint, they'd write prescriptions without hesitating. But I don't want to spend my life in the ER.

I have acute pain, chronic pain, muscle pain, and nerve pain. For now I'm barely getting by with gabapentin, Tylenol, Advil, trigger point therapy, a tens unit, ice, and heat. But insurance doesn't cover tens units, has a strict cap on physical therapy, and will only cover trigger point therapy if it's part of physical therapy. So I spend a huge percentage of my paycheck on pain relief. But without the pain relief, I can't work.

[whitemerlot]

I'm very interested in this topic because I have a sister who is an addict and a close family member who requires a lot of pain medication to get through the day due to cancer. Will you share more with us along the way?

My sister started with prescription medication in her early 20s for endometriosis and other pain and has been an active heroin user for many years.