The Opioid Epidemic: How We Got Here and What We Can Do

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00:01 Rachel Jantz: In undergrad, I volunteered at a harm reduction organization in Grand Rapids called The Grand Rapids Red Project. The Grand Rapids Red Project is a syringe exchange program in Grand Rapids. They also are dedicated to testing for and reducing the prevalence of HIV and hepatitis C in our community. I remember somebody coming into the syringe exchange program, and they were feeling pretty downtrodden that day and they just wanted to be able to help themselves. And they said to me, "People think that we don't care about our health because we're injecting drugs. People think that we just don't care about our lives, we don't care about our families, we don't care about our friends, but it just happens that I have a disease that I am addicted to opioids."

00:51 RJ: It was that conversation that, while I had been volunteering there for a while, it really made me remember that these are all individuals too. And being on the epidemiological side of things, it can sometimes be easy to turn people into numbers and to look at people as percentages or to look at them as a line on a chart that just continues to increase, and we say, "That is so terrible, look what's happening." But we forget that all of those people who are making up the increase in that chart, those are people that we see everyday on the street, who we go to church with, who we go to school with, people that we know and should get to know.

01:34 Speaker 2: More than two million Americans have an opioid use disorder. Each day, more than 130 people die from an opioid overdose. That's nearly 50,000 people per year, on par with the number of Americans who die each year from the flu and pneumonia combined. Researchers are asking, "How did we get here? And what can we do to help stop this epidemic?"

02:00 S2: Hello and welcome to Population Healthy, a podcast from the University of Michigan School of Public Health. Join us as we dig into important public health topics, stuff that affects the health of all of us at a population level. From the microscopic to the macro-economic, the social to the environmental. From neighborhoods to cities, states to countries, and around the world.

02:22 RJ: My name is Rachel Jantz and I'm a public health epidemiologist at the Kent County Health Department. I specialize in the opioid epidemic there. I graduated from the University of Michigan School of Public Health with my Masters of Public Health degree in Epidemiology in 2014. Kent County and Michigan in general have not been immune to the opioid epidemic that we have seen nationally. We know that since 1999, the number of people who have died from an opioid overdose has increased, and we're seeing that same kind of increase in Michigan and in Kent County in general. Between 2016 and 2017, parts of the nation did see a decrease in the number of opioid-related overdose deaths, but the Midwest was one particular region that did continue to see an increase, and so Michigan and Kent County are looped in with that as well. Between 2016 and 2017, in Kent County in particular, there was a 60% increase in the rate of opioid-related drug overdose death, as well as particular increases in heroin and fentanyl that were also seen in the rest of the nation.

03:48 RJ: Opioids are a class of medication that are commonly known as pain relievers, prescription pain medication. They can be natural, synthetic, or semi-synthetic. And when we're talking about natural opioids, that's like our morphine and heroin. The semi-synthetic opioids would be something like oxycodone or hydrocodone. And then we have our fully synthetic opioids, which would be something like fentanyl. Opioids bind to the Mu opioid receptor in the brain, and these receptors are located in a pain-regulating region of the brain. So when opioids bind to these receptors, there is a release of endorphins and general sense of analgesia and well-being that the person experiences. So when an individual continues to use opioids over time, the body doesn't produce as many endorphins, so a greater dosage of opioid is necessary to continue to feel that same level of well-being. We know that opioids are safest when used as prescribed from a doctor, typically for acute pain that would be for a duration of three days or less. What we run into is when individuals are using prescription pain medication in a way that is not prescribed by their doctor, for example using a greater dosage of pain medication, snorting or injecting the pain medication, and this can lead to dependency, which could lead to addiction over time.

05:31 RJ: There have been three distinct waves of the opioid epidemic. In the early 1990s, there was an increase in prescribing practices of physicians due to marketing of prescription pain killers as not being addictive. So there was this sense that we were not treating pain well in this country, and so physicians started overprescribing pain medications. Likewise, we saw an increase in opioid overdose deaths involving prescription pain medication around 1999, early 2000s. And from 1999 until about 2010, the majority of those opioid overdose deaths involved prescription pain medication. At about 2010, we started seeing the increase in the rate of opioid overdose deaths involving heroin. And then as of about 2013-2014, we're now seeing that there has been an increase in fentanyl-related opioid overdose deaths, and this isn't necessarily fentanyl that is prescribed by a doctor, but illicitly-manufactured fentanyl.

06:44 RJ: Working at the local level, we know that collaboration is absolutely necessary when we're dealing with the opioid epidemic. And of course, not every strategy is going to work in every community because every community has its own local flavor of culture, of funding available, of resources that are already available with law enforcement and treatment centers and social service agencies, and in addition, momentum around the issue, so the way that people think and talk about the opioid epidemic. So when we get everyone at the table, we have these people all talking together: What are you seeing? What is working? What isn't working? What are some of the evidence-based strategies that we have seen nationally that we might be able to implement here locally? 

07:36 RJ: We know that addiction to opioids can happen to anyone. Addiction to opioids can really cause a breakdown in family trust because of some of the behaviors that are associated with addiction, for example if somebody is lying or stealing as a way to continue to source their addiction. And sometimes behaviors related to addiction can cause financial stress on a family. It can be traumatizing for children. We know that trauma is associated with the propensity for becoming addicted to something, and so we see this cycle where there may be children who are traumatized, and then they're at greater risk for becoming addicted themselves in the future because of this trauma. Family members may also be at a loss for how to help an individual because of barriers due to financing treatment, insurance barriers to accessing treatment, and sometimes family members aren't receptive to that help. Somebody may feel that they wanna help somebody who is in crisis, but that individual isn't at a state of behavior change, isn't ready to accept that help, and so these negative behaviors continue.

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09:00 S2: It's clear that this is a complex epidemic without a straightforward solution. That's got some researchers thinking about addressing one of the root causes of this epidemic, treating pain with prescription drugs. What if there were safer and even more effective options? 

09:18 Mary Janevic: I'm Mary Janevic. I'm an Assistant Research Scientist in the Department of Health Behavior/Health Education at the University of Michigan School of Public Health. So I should preface this by saying that I'm not a neuroscientist, I'm a community health researcher, but just to describe things on a very basic level, scientists now know that pain is a very complex experience in the brain. From imaging studies, we know that a variety of brain regions are involved in pain, so not just the area in the brain that's responsible for sensation, but also the areas that process emotion and attention, so that's the feeling and the thinking parts of the brain. The emotion is the suffering part of pain, and that's really the part that makes us dislike pain so much. This also means that things that you think and things that you feel can affect your pain, and in a way that's really good news because those are things that we have some control over. So strategies like relaxation, distraction, changing how we think about pain, all of those things can help to reduce pain and suffering.

10:24 MJ: Because of the opioid epidemic, there's more interest than ever in these non-pharmacological treatments. Although cognitive behavioral approaches to pain management are not new and they've long been included in clinical practice guidelines, they've really been kind of bumped up recently in priority, and they're now recommended as first-line treatment for common painful conditions like chronic low back pain. I think it's really important to think about the differences between acute and chronic pain. Acute pain is something that we're all unfortunately familiar with. It comes on quickly; we touch a hot cookie sheet, we have an infection, we stub our toe, and the pain can be pretty severe, but thankfully, it usually only lasts a short time. And I think a key point is that that type of pain has a purpose, it's a warning, it's an alert, a cue to action. We do something as a result of that pain, we take our hand off the cookie sheet, or if we have a pain in our lower abdomen, we get checked out for appendicitis.

11:22 MJ: For acute pain, the treatment goals are healing and complete relief of the pain, and medications usually work well for acute pain. Chronic pain is different. Chronic pain is usually defined as ongoing or recurrent pain that lasts beyond the usual course of acute illness or injury. And chronic pain has a few features that really make it distinct. First, it doesn't have any value in terms of warning that something is wrong in the way that acute pain does. In fact, for a lot of people with chronic pain, when they do imaging of the affected part of the body, it actually looks perfectly normal. It looks like it's been healed, and yet the person still feels pain. Then the second feature of chronic pain is that it often takes place in the context of changes in the central nervous system that make it more sensitive to pain, so the nervous system kinda gets revved up, it starts to amplify pain more. And I think the third feature of chronic pain is that it's a biopsychosocial phenomenon. And that's a long word, but it basically means that factors in all three of those categories, biological, psychological, and social, can affect the pain experience, as well as be affected by it. And this often unfortunately takes the form of a vicious cycle. So for example, having pain can lead to feelings of depression, which then can lead to poor sleep, and that can lead to increased pain. So it's a little bit of a downward spiral for some people.

12:49 MJ: I think a good example of a non-pharmacological therapy for chronic pain is cognitive behavioral therapy, or CBT. CBT really works on a person's thoughts, emotions, and behaviors. So for example, people are given skills that they can distract themselves and move their thoughts away from pain, because we know that the more people focus on pain, the greater pain sensation they'll feel. It also gives strategies and techniques for getting people to break this cycle of inactivity that often happens with chronic pain. What happens is that people who are in pain are afraid to move sometimes because it makes their pain worse, and then they become deconditioned, which leads to even more pain. And so cognitive behavioral therapy gives them some tools to break through that cycle, become more active again, which usually has positive repercussions in terms of their pain.

13:51 MJ: There are a huge number of non-pharmacological options for chronic pain. Some of them involve practitioners or formal treatments and others involve skills or behaviors that people can do on their own. I think the important thing to keep in mind is that there is no magic bullet when it comes to chronic pain, whether it's a drug treatment or a non-drug treatment. The effects of medication on chronic pain are actually not particularly impressive when they're actually studied in rigorous research. I think the most we can say, even about medications, is that they can help some people, but usually not that much and sometimes not at all. I think what's almost certainly going to turn out to be the case as more research continues to be done on non-pharmacological treatments for pain is that the effects are going to be fairly individualized. So that is to say what works for one person might not work for another person. And I think moreover, what sometimes people will say about exercise, that the best type of exercise is the one that you'll actually do, is also true of non-pharmacological pain management. So it's really also a matter of personal preference.

14:57 MJ: Well, talking about the risks of these approaches, I think they really are a strong contrast to opioids because opioids have side effects that can range from mild to devastating. So one of the wonderful things about most of the psychological or behavioral approaches to pain management is that they're very low risk. So maybe mindfulness or relaxation doesn't work as well for you as it does for another person, but it's not gonna hurt you either.

15:23 MJ: Unfortunately, there's many barriers to people actually using these approaches. For one thing, many of the cognitive and behavioral approaches to pain require more effort on the part of the patient than just taking a pill. So doing tai-chi or walking a lot or cognitive behavioral therapy, all require time and motivation, sometimes skills, sometimes money. And pills often don't require any of those things. The fact is that many people have busy stressful lives with all kinds of constraints, and a yoga class just isn't gonna happen. Sometimes even just finding a quiet place or time to do a mindfulness exercise is just not possible. And then I think also providers are often not aware of these treatments, or at least of how their patients can access them, so they might know that they exist, but they don't really have any idea where they would send a given patient to access training or other resources to engage in some of these therapies. And unlike medications, which are usually covered by insurance, few of these behavioral or so-called alternative treatments are covered by insurance.

16:35 MJ: Last, I think sometimes patients have a resistance to engaging in psychological or mind-body treatments for pain because they think that the implication is that their pain is somehow not real, when the reality is that they perceive it as a very physical thing in their body. The thing to keep in mind is that the mind-body dichotomy is really artificial, and treatments that work on your thoughts and your emotions are actually affecting your brain chemistry, just as drugs affect your brain chemistry. And there are behavioral ways of affecting those brain chemicals, like exercise, that are so much safer than drugs because they tap into the body's natural opioid systems.

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17:22 S2: As of July of 2019, 33 states plus the District of Columbia have legalized marijuana for medical purposes. But that doesn't mean it's free from stigma, and it is still illegal at a federal level. But one researcher with a personal history of chronic pain is taking a look at whether cannabis could be a safer alternative to opioids for managing pain.

17:43 Kevin Boehnke: My name is Kevin Boehnke, I'm a research investigator in anesthesiology in the Medical School here at University of Michigan. I did my PhD in the School of Public Health here at the University of Michigan in Environmental Health Sciences and graduated in 2017. I have a personal stake in this idea of chronic pain and chronic pain management because it's something that I deal with on a personal level as well. When I was 20, I started having pain in my hands that quickly spread throughout my whole body, and after 13 months of uncertainty and fear and doubt about where this was coming from and how it was going to affect my life moving forward, I was diagnosed with fibromyalgia, which is a lifelong chronic pain condition.

18:25 KB: The main thrust of my work at this point is focused on cannabis and cannabinoids in the chronic pain setting. So we do survey studies in which we interview or send online surveys to people who are using cannabis for chronic pain and we ask them if they found it effective, we ask them how they use it, we ask them how long they've been using it and how it's interacted with things like pain or anxiety, etcetera; people who are experienced at using cannabis as well as people who are new to cannabis, and following those people who are new cannabis over time, so we can really see that trajectory in people who don't have this type of experience with it. We do more epidemiological studies in which we've looked at the medical cannabis registries that are put in place for each state with these laws to see why people are using cannabis, and indeed, we found that chronic pain is the most common reason that people say that they'll be using cannabis.

19:24 KB: So at this point there's not very good evidence in terms of clinical trials of people using cannabis as a opioid substitute, but that's in part because there's a big limitation on the type of evidence that has been allowed to be collected, because cannabis is a Schedule 1 substance under the Controlled Substances Act, which means that by definition, it has a high potential for abuse and no accepted medical use. That being said, at this point, there are numerous, numerous studies from states all over the US, from Canada, from Israel, where people using cannabis for pain or other conditions have said, "I have substituted cannabis for opioids and for other pain medications for that matter, and I've done so because it provides better symptom management and fewer negative side-effects."

20:13 KB: And so this is the type of thing that we obviously have a lot of interest in because if it's possible to have people using a substance that doesn't cause lethal overdose, then it's possible that we could leverage that to provide people with better and safer chronic management care. That being said, there's still a lot of science to be done, and at this point, because cannabis still remains Schedule 1, we are seeing a lot of that work going on in other countries.

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20:48 KB: So at this point, there's still quite a bit of opposition to the use of cannabis in a therapeutic context. Some of the concerns are around the fact that it is possible to abuse. About 9% of people who get exposed to cannabis have a dependence or an addiction issue with it, and that's something that of course we wanna be concerned about. And then I think the biggest health concern besides changes in brain structure and respiratory issues from smoking, is people getting behind the wheel of a car, especially if they're mixing that with alcohol. With those things in mind, we really wanna be certain that cannabis is used in a responsible way.

21:28 KB: Some of the other opposition to cannabis is cultural. Not only do we have this situation where it's a banned Schedule 1 substance for 50 years, which has totally influenced the education system, what doctors and other medical practitioners are taught about cannabis, there is also the fact that it's been culturally stigmatized through the escalation of the war on drugs and the way that that has really targeted a lot of communities of color and underrepresented communities in the US. So we have this really ugly situation where we have a substance that we're not allowed to research very effectively, we demonize its use, often for racist or xenophobic issues, and we punish people, typically people of color and people who are of low socioeconomic status for using this, and we don't teach physicians on how to safely and effectively use it.

22:25 KB: So the confluence of all these factors means that we're really in a difficult situation culturally and countrywide of how to deal with this, and this is now in opposition to many advocates and people who have used cannabis successfully for these different therapeutic indications saying, "Wait a second, there is actually a body of literature about this. Also, it's been effective for me, and I might be dead now if I wasn't using this." Obviously, there's different interpretations that people have of those personal anecdotes and stories, but they've been very effective in driving policy, and one of the reasons that we have over 30 states that have legal medical cannabis now.

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23:15 S2: Of course, alternative pain treatments are not the only way to address this crisis. From databases that monitor drug prescribing to laws governing medication-assisted addiction treatment, there are many policy considerations that can play a role in curbing this epidemic.

23:31 Rebecca Haffajee: My name is Rebecca Haffajee. I'm an Assistant Professor of Health Management and Policy at the University of Michigan School of Public Health. Our rates of prescribing of opioids vastly dwarf those in other countries. And even since we've seen reductions nationally and in most states at this point in opioid prescribing, we're still at levels that are in multiples of what we see in other countries. Prescription drug monitoring programs are electronic databases that store, monitor, and analyze controlled substance dispensing information. Prescribers, pharmacists, law enforcement officers, and state medical boards typically can get access to these data. They will have an aggregate view of what a patient is being prescribed within a state. Sometimes states share their data as well. You also can see a prescriber, so you could look at a particular prescriber and see what their pattern of prescribing is as well.

24:28 RH: The idea is to flag high risk prescribing. This might be high dosages of opioids you're getting that are particularly risky for overdose. This might be polypharmacy, so using multiple opioids at the same time, or opioids and benzodiazepines for example. This might be patterns of patient behavior, so frequenting different pharmacies or different prescribers within a short period of time. So it's trying to track that risky behavior and provide that information to a clinician so that they can make the best informed decision when they're making the decision whether to prescribe a patient an opioid. They're particularly helpful for emergency department physicians or physicians that might not know the patient as well, but they're still helpful to a primary care physician, for example if they aren't getting the full information or having a long enough conversation to get all this information from a patient.

25:20 RH: So some of the controversy is who should have access to these data and under what circumstances, and that varies from state to state, so what those circumstances are. But typically, yeah, law enforcement and medical boards would be using the data more as an enforcement tool and a surveillance tool, so trying to see which prescribers or which patients are exhibiting risky behavior, and to help, in the law enforcement side, their investigations of that behavior and potentially making a case or shutting down a pain clinic or something like that. For medical boards, it would be more on the prescriber side. Maybe they're trying to monitor, "Who are outlier prescribers that we might need to look into and eventually perhaps sanction?" In my view, the goals of the program should be to reduce this high-risk prescribing. I also think another goal of the program, from a clinical side, is to provide the best care to patients, and if they are exhibiting some of these misuse, addiction types of characteristics, to use that information to actually refer patients to treatment.

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26:34 RH: Treatment for opioid addiction is an incredibly important element. We're in a situation where we created this big population that had a dependence and/or addiction to opioids, and now how do we help those people? And it's important to remember that addiction is a chronic health condition, it's not something that is going to be cured in a month or two or three months' time. We're looking at a year, perhaps your whole lifetime. It could be along the lines of diabetes and having regular treatment for the rest of your life. There's more evidence for the effectiveness of medications. We think that behavioral health therapy is an important component and coupling with that, but in my mind, if we're gonna do anything, we need to provide the medications for addiction treatment. If we can provide the counseling and therapy on top of that, that's great, but if we can't, it doesn't mean that we shouldn't do the medications, because those alone are very effective.

27:27 RH: Buprenorphine is one of the dominant forms of medications for medication-assisted treatment therapy, and it's really promising approach in my view because it can be provided in primary care offices and by non-addiction specialists. The most restricted is methadone, and that's highly effective but it's only provided in opioid treatment programs, and we have a severe shortage of those. A last component is insurers actually have a lot of barriers to covering those medications for addiction treatment as well. Recent studies have shown even if all Medicaid programs cover them, there are a lot of additional hurdles, so prior authorization, those sorts of things. A lot of these kind of policies related to access to these treatments need to change to try to get more providers providing the treatment and then get more patients access and then on the treatments.

28:28 RH: Naloxone is the opioid overdose reversal agent. It's basically an antidote to an overdose and can reverse it if it's administered very quickly after the substance is ingested. It's in the hands of first responders but needs to be even more so, but also family and friends. One policy that I favor is potentially making naloxone an over-the-counter medication. Right now it is only by prescription. There are a few standing orders and things where you can prescribe to either friends or family members or somebody who meets certain criteria instead of the actual individual. But being over-the-counter, so just like your ibuprofen that you can get at the pharmacy, would open up access, I think, to a lot more people.

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29:19 S2: Thank you for listening to this episode of Population Healthy from the University of Michigan School of Public Health. We're glad you decided to join us and hope you learned something that will help you improve your own health or make the world a healthier place. If you enjoyed the show, please subscribe or follow this podcast on iTunes, Apple Podcast, Google Play, Stitcher, Spotify, or wherever you listen to podcasts. Be sure to follow us @UMICHSPH on Twitter, Instagram, and Facebook, so you can share your perspectives on the issues we discuss, learn more from Michigan Public Health experts, and share episodes of the podcast with your friends on social media. You can also check out the show notes on our website, population-healthy.com for more resources on the topics discussed in this episode. We hope you join us for next week's episode where we'll dig further into public health topics that affect all of us at a population level.