The Critical Role of Health Systems in the Nation’s Response to the Opioid Crisis

The opioid epidemic, two decades in the making, is worsening. The gravest projections forecast a significant increase in annual opioid-related deaths in the next decade, reaching 93,000 in 2027. Based on the average of 10 forecasts from public health experts at leading universities, it is projected that the nation will suffer 500,000 deaths from opioid abuse in the next 10 years. ^c

To convey the tragic consequences of opioid abuse at a human level, the March 5 issue of TIME was entirely devoted to this topic. For the first time in the magazine’s 95-year history, it featured only one photographer’s work, graphic black and white photographs by James Nachtwey of various people impacted by this epidemic—addicts, their relatives and friends, social workers, healthcare providers, and law enforcement officials.

In addition to the loss of life, the impact on the economy of the opioid crisis is staggering. The Council of Economic Advisers estimates that the economic cost of the opioid crisis was $504 billion in 2015, equal to 2.8 percent of the nation’s gross domestic product. ^d

Public Policy Countermeasures

The Consolidated Appropriations Act, 2018, an omnibus spending bill for the U.S. federal government for FY18, was passed by both houses of Congress with bipartisan majorities and was signed into law by President Trump on March 23. The law specifies nearly $4 billion to address the opioid crisis, with more than half of that amount designated for treatment and prevention, as follows:

• $1 billion for grants to states and Native American tribes to address the opioid epidemic
• $476 million to the Centers for Disease Control and Prevention for increased opioid overdose surveillance and prevention
• $500 million to the National Institutes of Health for research on opioid addiction support
• $117 million to the Office of National Drug Control Policy to bolster federal drug control programs ^e

At the state level, prescription drug monitoring programs (PDMPs)—which have been implemented or are being implemented by all 50 states, the District of Columbia, and Guam—are electronic databases that help geographic entities track controlled-substance prescriptions. New Jersey Governor Chris Christie, chairman of the President’s Commission on Combating Drug Addiction and the Opioid Crisis, has explained how PDMPs can be used: “For example, doctors can use PDMPs to check patient records, while law enforcement can use PDMPs to identify prolific opioid prescribers, and public health agencies can use it to identify and intervene in a potential victim pool before overdoses occur—different, but all valuable uses of the same data.” ^f

Community Responsibility

Although public policy moves by the federal and state governments can be helpful, the high degree of geographic variation that characterizes the opioid epidemic ultimately means the battle must be waged on a community level. Commenting on a report issued by the state of Maine’s task force on the opioid crisis, Maine Attorney General Janet Mills emphasized, “Our communities need to remember the report of this task force doesn’t get the job done alone, that every community needs to come together and address this problem and take care of their own.” ^g

The Role of Health Systems

According to market research firm IMS Health, opioid prescriptions rose from 112 million in 1992 to a peak of 282 million in 2012. ^h This upward trend in provider opioid prescribing has unquestionably contributed to the opioid epidemic. 

Recognizing this causal relationship, a survey by healthcare improvement company Premier Inc. found that about 90 percent of C-suite leaders from Premier’s member health systems are prioritizing strategies to curb opioid use, including altering the prescribing practices of physicians and developing and recommending alternative forms of pain management. ⁱ These preventive initiatives, coupled with physician education, can help facilitate the needed changes in prescribing patterns.

Penobscot Community Health Care (PCHC), headquartered in Bangor, Maine, is a health system that has made progress in this regard. In 2013, PCHC was fully engulfed in the prescription opioid crisis. Patients’ opioid doses were startlingly high, and measures to ensure that prescriptions were being used as prescribed and not diverted, were being underutilized. In response, PCHC developed a comprehensive approach to controlled substance stewardship, a coordinated effort to promote the appropriate use of controlled substances (including opioids), improve patient outcomes, reduce misuse and abuse, and decrease patient morbidity and mortality tied to these high-risk medications. Since the program was established, the number of PCHC patients receiving chronic opioids has decreased by 67.2 percent and continues to drop. A review of premature deaths to identify associations with opioids prescribed at the time of death showed a decline of 50 percent from 2013 to 2015. ^j

In addition to prevention and pain management, health systems are a major provider of opioid use disorder treatment—including opioid dependency medications and opioid overdose prevention medication (naloxone)—and they are often called on to drive and coordinate community outreach, including training on how to administer naloxone. 

Although every health system should employ a multifaceted interdisciplinary approach to respond to the opioid crisis, prevention, pain management, opioid use disorder treatment, and community outreach all require leadership from the pharmacy department. Pharmacists have the unique combination of education, training, knowledge, expertise, and skills to drive and execute these initiatives.

It is not an overstatement to say that every hospital and health system in the United States has been affected by the opioid epidemic. Public awareness of the significance of the opioid crisis is rising, there is bipartisan concern in Washington, and federal and state funding to ameliorate the problem is available and increasing. Because of all that preventing and treating opioid use disorders entails, healthcare providers have the opportunity—what some have called a leadership moment—to play a critical role in addressing this serious blight on society. 

Footnotes

a. Trump, D., “ President Donald J. Trump’s State of the Union Address,” The White House, Jan. 30, 2018.
b. Lee, M., “ The Numbers Behind the Opioid Crisis,” Social Capital Project, November 2017. 
c. Blau, M., “ STAT Forecast: Opioids Could Kill Nearly 500,000 Americans in the Next Decade,” STAT, June 27, 2017.
d. The Council of Economic Advisers, “ The Underestimated Cost of the Opioid Crisis,” November 2017.
e. House Committee on Appropriations, “ FY 2018 Omnibus: Fighting the Opioid Epidemic,” March 21, 2018.
f. Slobodkin, G., “ Prescription Monitoring Programs Crucial to Fighting Opioid Epidemic,” Health Data Management, Nov. 29, 2017.
g. Thistle, S., “ Task Force on Maine’s Opioid Crisis Urges Lawmakers to Take Action in 2018,” Portland Press Herald, , Dec. 12, 2017.
h. “ Opioid Crisis Fast Facts,” CNN, March 2, 2018.
i. Pugliese, G., “ Premier Survey Finds Majority of C-suite Leaders Prioritizing Opioid Safety Strategies,” Premier Safety Institute, Jan. 22, 2018.
j. Homsted, F.A.E., Magee, C.E., and Nesin, N.,, “ Population Health Management in a Small Health System: Impact of Controlled Substance Stewardship in a Patient-Centered Medical Home,” American Journal of Health-System Pharmacy, September 2017.