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Introduction
Opioids can help people manage severe pain, but they can be problematic if used for more than two or three days. Balancing medical use with the risks of prolonged intake is a complex problem. But it can be tackled. And in one Massachusetts seaside area, people on the front lines are tapping into facts and figures to come together and make a difference.
Chapter 1: Understanding the crisis
Opioids are powerful pain relievers and range from the less potent formulations like codeine to stronger drugs like morphine and fentanyl, which are typically used to treat cancer pain. They suppress discomfort and induce feelings of relaxation. See how opioids work and learn how — for some people — this can become problematic.
"Decades ago, opioids were reserved for catastrophic circumstances: patients coming out of major surgery, serious cancer and pain associated with end-of-life circumstances. There was a more balanced understanding within the medical community of the potential risks versus benefits of opioid therapy."
Dr. Sumit Dutta,
Chief Medical Officer, OptumRx
How opioids work
Opioids cause intense physical and emotional changes. Health care providers note that any individual can easily progress from taking them for pain relief to misusing them.
Pain relief
- Opioids attach to receptors on nerve cells in the brain and body.
- In the limbic system—which controls emotion—opioids induce relaxation and euphoria.
- In the brain stem—which controls automatic functions like heart rate—opioids suppress breathing and reduce discomfort.
- In the spinal cord, opioids can decrease the sensation of pain.
Building tolerance
- When the body becomes used to high levels of opioids, receptors on nerve cells become less responsive and more opioids are needed to relieve pain.
Addiction
- Opioids flood the brain with dopamine and overstimulate the reward center. This leads to an intense happy feeling some users become fixated on attaining.
- Addiction happens when the brain is altered by chronic opioid use. The changes cause patients to struggle with cravings and the desire to avoid withdrawal symptoms. Some of the brain abnormalities reverse during recovery, but others can be long term, or even permanent.
Withdrawal
- When opioids are no longer in the body, there’s a surge in noradrenaline, a hormone that counteracts their effects. This can trigger jitters, anxiety, muscle cramps, diarrhea and other uneasiness.
The beginning of a crisis
Historically, opioids were used to treat severe pain after surgery or during end-stage cancer. But by the 1990s, prescribers' clinically-based pain-management approaches changed. In 1996, pain was designated “the fifth vital sign,” along with temperature, blood pressure, pulse and respiratory rates. This new clinically-based prescriber philosophy created a demand for instant relief and rates of opioid prescriptions surged. So did misuse.
"In the early ‘90s, you began to see a shift in prescribing patterns where prescribers began to treat pain more aggressively."
David Calabrese
Chief Pharmacy Officer, OptumRx
Faces of the epidemic: Alexa
In high school, Alexa was an active student and cheerleader. She was first prescribed opioids after suffering an injury. But after a year of using them, her situation took a turn for the worse.
The toll of the crisis is profound
Families, friends, workplaces and communities are being decimated by opioid addiction. See how the crisis is impacting four key areas of everyday life.
Human
4.5 Million
Number of Americans estimated to have an addiction to opioid prescription pain killers
Health
58 percent
Surge in the average cost of an ICU overdose admission
Work
$2.5 billion
Estimated annual loss to employers caused by the misuse of prescription painkillers
Justice
$7.7 billion
Annual criminal-justice-related costs associated with the opioid crisis
Faces of the epidemic: Jillian
Jillian started out using opioids casually, then one day, she realized she couldn’t function without them.
Rise in opioid-related deaths across America 1999–2016
Alexa and Jillian are just two faces of a nationwide crisis. In 2016, 65,000 people died of an opioid overdose.
"Using today’s powerful data and analytics, we are not only able to understand the opioid epidemic in a more comprehensive way, but we can quickly identify what’s working most effectively to combat this crisis and bring those solutions to scale across the health system."
Dr. Darshak Sanghavi
Chief Medical Officer, OptumLabs
Chapter 2: From understanding to collaboration
The sheer number of people who have been hurt by the opioid crisis is disturbing, but might also contain a solution. Optum®, a health services company, is analyzing the data and joining forces with various partners to bring the most effective evidence-based care to life. Here is a seaside area of Massachusetts benefitting from the work.
"It's about bringing everyone to the table, getting rid of the separate silo approach. So having behavioral health, the medical community, the hospitals, law enforcement, the insurance companies all at the same table working together is the only way to make a dent in this epidemic."
Peter Monaghan
Eastern Region Area Director, CleanSlate
One method that's working is collaboration. Law enforcement,
treatment providers and others on the front lines are joining forces to make a difference.
Chapter 3: Using data to drive meaningful change
How fact-based insights are helping experts understand and treat the epidemic.
"Despite all the recent attention, the data tells us that about half of all prescriptions written fall outside of the 2016 CDC guidelines."
Dr. Darshak Sanghavi
Chief Medical Officer, OptumLabs
Evidence drives action
Data can help sum up the social, economic and human devastation of the opioid epidemic. But Optum believes it provides critical insights into the most effective ways to prevent opioid misuse and addiction, deliver effective treatment and offer recovery support to those who are struggling. See three ways data and analytics have helped make a difference.
Better prevention: part 1
In March 2016, the Centers for Disease Control and Prevention (CDC) came out with guidelines for using opioids to manage chronic pain outside of certain circumstances, like cancer treatment or end-of-life care.
Per CDC Guidelines, Opioid prescriptions should:
- Not be first-line treatment for chronic pain
- Be short duration for acute pain
- Be the lowest effective dose to start
- Not be used with benzodiazepines
- Have dose escalation minimized
- Include an offer for medication-assisted treatment (when a patient has opioid use disorder)
Better prevention: part 2
A data-driven dashboard was developed to offer a better understanding of what was happening at the prescribing level. Then, coordinating efforts with prescribers, pharmacies and partners across the entire care continuum led to increased alignment with the CDC guidelines.
The results:
decrease in total opioid prescription volume
reduction in average morphine equivalent dose (MED) across opioid prescriptions
decrease in first fills for more than a seven-day supply
compliance with CDC guidelines for first-fill opioid prescriptions less than 50 mg MED
Treatment where it’s needed
Using advanced analytics, Optum partnered with care providers to identify where they were most needed by geo-mapping its members.
The results:
increase in Optum MAT
network locations since 2013
of Optum members are within
20 miles of a MAT provider as of 2017
Long-term support
Opioid use disorder is a chronic medical condition, like diabetes or hypertension. A combination of evidence-based treatment and strong support tailored to each patient’s needs increases the chances for long-term recovery. Medication-assisted treatment (MAT) is one example of this type of treatment, that’s offering some people struggling with addiction a chance at a new beginning—by making changes that have lasting benefits.
"Studies have shown that individuals who receive MAT are 50% more likely to remain free of opioid misuse compared to those who received detoxification or psychosocial treatment alone."
Dr. Martin Rosenzweig
Chief Medical Officer, Optum Behaviorial Health
Understanding Medication-Assisted Treatment (MAT)
MAT is an evidence-based, holistic approach to treating opioid use disorder that helps people by treating their physical symptoms along with the behavioral aspects of addiction.
What is it?
It's a method of treatment for opioid use disorder that uses FDA-approved medications such as methadone and buprenorphine.
They block opioid uptake, alleviate cravings and withdrawal.
This helps to adjust the chemical imbalance in the brain that develops during addiction.
But is there more to MAT treatment?
No. Agonists help treat the physical symptoms of opioid use disorder without affecting a patient's cognitive abilities.
At the same time, patients get counseling and therapy, a critical part of staying healthy for the long-term.
Is MAT effective?
Yes. Studies have shown that individuals who receive MAT are 50% more likely to remain free of opioid misuse, compared to those who receive detoxification or psychosocial treatment alone.
"What needs to happen is we need to make more options available to patients and providers for the treatment of pain. We also need to educate providers on the variety of treatments and educate patients on a healthier approach to pain management."
Dr. Robert Saper
Director of Integrative Medicine, Boston Medical Center Department
Chapter 4: Starting over
Alexa and Jillian and are both benefitting from treatment programs driven by facts, figures and partnership.
Alexa
Alexa participated in a multidisciplinary addiction program that allows people to get treatment instead of going to jail.
Jillian
Jillian received treatment at a CleanSlate center over two years ago. CleanSlate’s locations are based on clusters of opioid misuse. Jillian is now drug-free, married and raising a child.
Conclusion: Hope for the future
Across this nation, we have the tools to tackle the opioid crisis. We can prevent misuse by using data about prescriptions to minimize overuse and supply. Those struggling with opioid use disorder— a chronic medical condition like cancer or diabetes — can be helped with compassionate, evidence-based treatment. And long-term support can be local and accessible. We all have a stake in this. We don’t have to work alone. Through partnership and collaboration, things can get better.
"There is no question that this epidemic is as complex as it is heartbreaking. With the promising results we are seeing from newly enacted programs and partnerships, I see bright spots and reasons to believe our health system can solve this crisis."
David Calabrese
Chief Pharmacy Officer, OptumRx
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