Viewing the Opioid Crisis Through a Post-Pandemic Lens

June 4, 2021 Gary Call, M.D.

We were making progress.

It wasn’t much, but it was a significant milestone on an otherwise grim trajectory. From 2017 to 2019, the number of prescription opioid-related deaths declined, contributing to an overall decrease in drug overdose deaths for the first time in nearly 30 years.

Things were starting to look up. At the same time prescription opioid-related deaths fell, so too did deaths from many other leading causes. In 2018, life expectancy had increased for the first time in four years.

The decline in deaths coincided with a number of interventions at the federal, state and clinical levels between 2016 and 2018. These included opioid prescribing guidelines from the CDC, increased adoption and enhancement of prescription drug monitoring programs, substantial federal funding efforts and regulations mandating coverage for medication-assisted therapy (MAT) for opioid addiction. At the same time, adoption of MAT programs, which combine the use of medication with counseling and behavioral therapies, became more widespread.

What little progress had been made in the fight against the opioid epidemic was all but reversed in 2020, the year of death, despair and social isolation — all contributing factors to mental illness, opioid addiction and overdose. A paper published by the Opioid Response Network draws an important correlation: “The same populations already at risk for [substance/opioid use disorder] are also the people most impacted by COVID-19.”

Things were trending in the wrong direction even before the COVID-19 pandemic. In the 12 months prior to May 2020, the CDC reported more than 81,000 overdose deaths in the U.S. — the most ever recorded. Overall life expectancy dropped in the first half of 2020, according to CDC data. While COVID was a factor, so was the rise in drug overdose deaths.

A Monetary and Human Toll

In addition to the tens of thousands of lives lost each year due to opioids, the crisis carries a heavy financial cost. A 2013 analysis places the economic burden of prescription opioid overdose, abuse and dependence at an estimated $78.5 billion, factoring in the larger societal impacts. While a relatively small portion of this amount ($2.8 billion) is estimated to be spent on treatment, the National Institute on Drug Abuse suggests the cost of treating prescription opioid use disorders is markedly higher than that of other chronic diseases, including diabetes and kidney disease.

These costs are generally reflective of a historical model in which individuals are treated for opioid use disorder after they’ve become addicted. In order to change the trajectory, broader emphasis must be placed on preventing addiction and mitigating the risk factors of opioid misuse. Specifically, this means identifying the medical, socioeconomic, behavioral and environmental factors that predispose people to opioid addiction and making targeted interventions — ideally, before addiction occurs.

Same Barriers, Different Disease

While COVID-19 brought renewed urgency to the opioid crisis, it also provided many lessons to be applied in addressing risk factors and barriers to treatment.

For instance, during the pandemic, modalities like telehealth provided a lifeline for patients who could not access in-person care. However, it became clear that not everyone has the technology and broadband capacity to connect with providers, care teams and support systems via the required audio-visual media. In a Stat News article, Stephen Taylor, a Birmingham, Alabama-based psychiatrist and addiction specialist, told the publication that, in order to get a Wi-Fi signal, “we have people who sit in a McDonald’s parking lot so they can do Zoom meetings.”

Accounts such as these underscore the need for expanded broadband access in low-income, rural and otherwise underserved communities — populations disproportionately impacted by COVID-19 and particularly vulnerable to chronic disease, including opioid addiction. In the meantime, however, extending pandemic rules to enable treatment by phone is one way to overcome a potential barrier to treatment and support for opioid-dependent individuals.

Starting from Behind; Getting Ahead

The COVID-19 pandemic added fuel to an uncontrolled fire. Although earlier referenced statistics showed a minor dip in recent years, the broader chart shows a dangerously unsustainable trajectory that will only continue to have devastating implications for our healthcare system and society at large. New research draws a worrisome link between COVID-19 and opioid addiction, as doctors may be more likely to prescribe opioids to those who experience lingering symptoms of the disease — approximately 10% of COVID survivors.

It is also important to understand that as prescription control processes tighten, more individuals are turning to illicit sources of opioids. This makes identifying high-risk individuals and offering accessible treatment even more important.

It’s time we take what we know — the known risk factors for opioid addiction and lessons learned during the pandemic — to get ahead of the problem at the individual and population levels.

Through cross-sector research, we can better understand the factors contributing to opioid addiction and identify effective treatment methods. Gainwell’s HMS, in collaboration with the Digital Health Cooperative Research Centre and Stanford University, is nearing the end of an  opioid research initiative, for which HMS supplied a massive, deidentified database of more than 2 million patients.

Using predictive analytics and modeling techniques, we can identify individuals at a high or rising risk of opioid misuse based on medical, social and behavioral factors. With this information, we can develop care plans and behavioral science-backed engagement methods that are effective in preventing addiction as well as poor outcomes associated with opioid misuse. Proactively identifying high-risk individuals gives healthcare providers critical information that will influence their patient education and prescribing behaviors.

Deploying personalized, multi-modal outreach, we can engage high-risk individuals with personalized messages and interventions that take into account their medical needs along with socioeconomic stressors affecting their ability to access treatment or support services.  An example is increasing pre-operative education about opioid use to high opioid risk individuals about to undergo surgical procedures. Increased education may facilitate patients having conversations with their providers about the need for and appropriate use of post-procedure opioid prescriptions.

Increased funding and federal actions to strengthen our public health infrastructure and expand the availability and accessibility of treatment are vital to the effort.

By combining all of the above and treating the whole person — incorporating medical, behavioral and social determinants of health into care coordination and management — we can steer away from the broad-based approach of decades past in favor of personalized, evidence-based care that saves lives and costs.

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Getting Ahead of the Opioid Crisis: Lessons Learned From COVID-19
Getting Ahead of the Opioid Crisis: Lessons Learned From COVID-19

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