From small-town boards to the White House, groups across America are seeking remedies to the issue of opioid addiction. Many of the potential solutions to the opioid crisis involve multiple levels and jurisdictions of government. Setting the focus to a more local perspective, with emphasis on policy and collaboration, this section will review some feasible potential solutions and strategies to combat the epidemic. Though focusing on local solutions means that it would be difficult to implement statewide policies or mobilize large volumes of resources, addressing the issue on the level of local government would allow for close interactions between policymakers and patients who are addicted and dealing firsthand with the crisis.
A study done by the National Academy of Sciences, Engineering, and Medicine presents four main intervention strategies to address the opioid epidemic: reducing supply, managing prescribing practices, reducing demand, and reducing harm. The first two, reducing supply and managing prescribing practices, are difficult to influence from a local government level due to a variety of structural barriers. The last two, reducing demand and harm, involve working closely with addicts and their families and require community teamwork, especially among branches of local government.
Reducing supply, the first of the intervention types, is difficult to implement with local policy. Town legislators, like county boards or local aldermen, can collaborate with local law enforcement to better allocate drug seizure efforts, but the most effective interventions at this level happen on a national scale. Organizations such as the Drug Enforcement Agency (DEA) typically deal with larger supply hubs that widely distribute illegal drugs, necessitating an increase in the scope of interventions. Thus, this type of direct action against illegal distribution would be difficult for local government alone. To address legal distribution, local governments have banded together to level class action lawsuits against pharmaceutical companies for false advertisement, like aggressive marketing and under-emphasis of the addictive potential of these medications. In Illinois, for example, five counties are currently involved in one of these lawsuits. The defendant companies in the case are Purdue Pharma, Abbot Laboratories, Teva Pharmaceuticals, Johnson & Johnson, Janssen Pharmaceuticals, and Endo Health Solutions, as well as three doctors in Kankakee County, Illinois.
Management of prescribing practices, the second policy intervention strategy, also proves difficult to address on a local level. Pain management, as a medical strategy, is largely decentralized and can vary between physicians. This is due to a variety of factors, primarily a lack of standard causes for chronic pain and thus a lack of standard treatment. Additionally, unlike in oncology or gynecology, there is no specific group of physicians specialized in treating chronic non-cancer-related pain. Specialty physicians are typically part of national professional organizations, such as the American College of Obstetricians and Gynecologists. For physicians treating chronic pain, however, the lack of professional networking and specialization creates further complications with standardizing pain management, since these national professional organizations are often the main source of medical treatment guides. Both of these factors, the nebulous nature of chronic pain and the decentralization of physicians treating it, make uniform medical practice difficult to define and enforce. Recently, large-scale organizations have published treatment guides and formed national physician coalitions dedicated to the treatment of chronic pain, but evidence on the efficacy of their curriculum is limited due to its novelty.
On a state level, medical boards are often the main regulators of prescribing practices. These boards manage the Prescription Drug Monitoring Programs (PDMP), statewide electronic databases that track opioid prescriptions from both sides, doctor and patient. All doctors with a license to prescribe “controlled substances” must register through the program in Illinois. The online database allows prescribers and dispensers to check patient prescription history and help prevent doctor-shopping, when patients visit multiple physicians or pharmacies to get access to drugs. In Illinois, only medical personnel have access to the information, with some indirect access allowed to law enforcement during an active investigation, but in other states, such as California, full access is granted to law enforcement. This brings up issues of privacy and the jeopardization of the doctor-patient relationship, as seen in cases such as Oregon PDMP v. US DEA. In this case, the DEA claimed that it ought to be able to access prescription records with a subpoena rather than a warrant, while the PDMP refused. A district judge ruled that, on the grounds of patient privacy, law enforcement must attain a warrant before accessing this information; the ninth circuit court later reversed the ruling on procedural grounds, leaving further legal discussion open. The discussion on the availability of this information to law enforcement has also been opened in New Jersey, where access to PDMP information is permitted by law enforcement upon attainment of a court order or a grand jury subpoena.
The third intervention strategy, reducing demand, is deeply tied to community outreach and education, as well as treatment for existing opioid use disorders. In the larger, healthy population, drug prevention programs in local schools can improve perceptions and behaviors around substance abuse from a young age. Education and training for patients who are prescribed opioids have also been effective in improving compliance outcomes, including knowledge about proper use and disposal of medications. On the other side of addiction, treatment for opioid use disorders is an effective method to reduce demand and remove patients from the cycle of drug abuse. Two main medication-assisted treatment (MAT) plans exist: buprenorphine and methadone, both in combination with behavioral therapy. Methadone historically has been the most widely used MAT plan in the United States, but comes with significant barriers to treatment, such as geographic disparities and required daily methadone clinic visits. Furthermore, sources like the American Journal of Public Health (AJPH) indicate a lack of full public or private insurance coverage for these programs. Their estimates also show that 96 percent of states lack the treatment capacity to fully cover all methadone and buprenorphine patients. On top of this, the available resources for treatment operate at approximately 57 percent of their maximum capacity. Doctors, additionally, tend to under-prescribe such opioid recovery medications due to factors such as pharmacy restrictions, issues with clinician reimbursement practices, accessibility or availability of training to deliver such treatment, or stigma surrounding MAT. Thus, the issue is not just with the prescription of MAT for addiction on the physician side, but also with the allocation of state resources and the barriers between patients and possible treatment. Policy interventions in this sphere would involve re-allocation of more funding and research to MAT, advocacy of MAT prescription directed towards physicians, and reduction of treatment disparities and barriers. This could include integration of MAT into federally qualified health centers, local emergency departments, and even prisons. This aspect is hard to address from a local policy standpoint and would require state partnerships to achieve but could be a potential catalyst for networks across levels of government.
On a smaller scale, de-stigmatization of MAT, in addition to moving public perception away from the idea of “switching one addiction for another,” could be a feasible intervention strategy for local governments to adopt in order to increase recovery program utilization. Another local strategy involves forming a network of treatment resources to streamline the process of addiction recovery for patients. This involves everything from improving referral methods to addiction clinics to using court systems to help divert addicted individuals and start them on the journey to recovery. A particularly relevant example of an effective network is located in Lake County, Illinois. Their program, A Way Out, offers a full connection process to treatment hubs around the county, helping patients pay for treatment, waiving drug charges at the beginning of recovery, allowing access to the program both through emergency rooms and police departments, and offering immediate onboarding to the program. In addition to this, county drug courts are working to encourage convicts to seek treatment as part of their sentence. In counties across the United States, similar coalitions of local members of government, including Departments of Public Health, members of local law enforcement, and county boards, are devising their own similar initiatives. These organizations mobilize collaboration and use state grants to implement initiatives countering the epidemic.
The final intervention strategy, reducing harm, is interwoven with reducing demand. The primary difference lies in the focus on the adjacent harms of drug abuse, like infectious disease or the threat of overdose. Reducing harm in opioid abuse is highly stigmatized, with many believing that encouraging safer practices of use leads to encouraging use itself. Programs like safe injection sites, needle exchanges, or drug checking all fall victim to this type of bias. Safe injection sites provide users with a reliable area, with supplies, and medical providers on staff and available in case of an overdose. Needle exchanges allow users to dispose of their needles in a sanitary manner, preventing the spread of bloodborne pathogens. Drug checking allows users to get their substances tested for purity or spiking, since a common issue is not knowing the true purity or content of drugs. All of these measures have extensive backing evidence demonstrating their ability to prevent complications related to drug abuse without increasing drug abuse itself, but nevertheless face stigma.
One of the main harms of drug abuse, as mentioned, is the threat of overdose. The main method to reverse an overdose is immediate administration of naloxone (through injection or nasally). Locally, the sheriff’s office in DuPage recently participated in an initiative, the DuPage Narcan program, to train the majority of local law enforcement officers to carry and use naloxone in case they encounter an overdose. The effort depends on the collaboration of the Health Department, Coroner, Sheriff, State’s Attorney, Chiefs of Police, and their associated departments. The program has saved over five hundred lives since its inception in 2014, and almost 2,400 members of law enforcement have been trained to administer the inhalant form of naloxone.
Combining the four policy intervention methods involves a large investment of human capital across a variety of industries and professions. Local government can participate in and strongly influence this action, not just national policymaking bodies. The most effective intervention strategy will innovate to combine forces and streamline treatment of addiction, as well as prevent patients from becoming addicted in the future. Ultimately, building a team and creating an expansive network is critical to solving this crisis. The United States has begun to take steps towards a unified front against the opioid epidemic, an issue that I will explore in the next installment of this series.