On October 24th, 2018, nearly a year after declaring The Opioid Crisis a national emergency, flanked by lawmakers, president Trump signed into law the Support Patients and Communities Act “to provide for opioid use disorder prevention, recovery, and treatment, and for other purposes”. The sweeping bipartisan legislation, passed both chambers of congress by largest margin transcending partisan, racial, geographic divide, The Senate vote was 99-1; the House vote was 393-8. The 653-page bill combines multiple provisions intended to address numerous aspects of the crisis. The legislation represents an elevated federal response to the opioid epidemic, including increased financial support and some sound and sensible policy initiatives. Congress doesn't agree on much, but elected officials preparing for midterm elections recognize the urgency of the epidemic in their communities and regardless of their ideological position of the role of the federal government, agree that it's time for them to do more on opioids. Having followed many of the steps as the law travelled through the legislative process one cannot but be impressed, however the question is if the actual legislation will make a positive difference.
Provisions that address prevention, treatment, law enforcement elements, pain treatment, were introduced in its nearly two year long journey through the various subcommittees and committees in the house and the Senate and informed by the presidential commission. For greater detail of the provisions can read excellent reporting by Lev Facher at STAT and Abby Goodnough at the New York Times summarizing the major components of these bills. Here's a section-by-section summary of the Senate bill. Or the law itself at Congress.gov. The law’s overall uses the same approach to the many efforts over the past decade that have failed to stem the devastation of the epidemic. Although the current legislation has rightly been hailed for the bipartisan efforts on the opioid package, and highlights the potential for federal governmental action in an era of great polarization, it fails to recognize or acknowledge that major social pathology that contributes to addiction, the governmental corruption that sustains and amplifies it.
Given the track record of the government's involvement to date one must be cautious at best for this legislation having a net positive impact on the opioid epidemic. As has been scientifically shown, many of the policies undertaken by the federal and local governmental agencies have been suggestive of causing more deaths. Hundred of thousands of individuals suffering with chronic pain are subjected to governmental limitation on addressing their conditions. However the current moment with rare bipartisan support and efforts to tackle national problems can provide an opportunity to examine more ambitious approaches to better address the crisis. Elsewhere I have written about the opioid project as a way to reclaim the citizen role in the political process that provide a more expansive approach. This article will describe a number of “interventions” to address specific problems within the opioid crisis arc, review barriers to change and suggest actions.
In addition to the hundred of thousands of Americans who died from opioid related overdoses, in many ways the opioid epidemic has come to highlight and act as a symptoms for many underlying challenges faced by the body politic of the United States. In many ways the opioid crisis symbolic of the social and political pathology in the US if not is major symptom. Using the challenges of the opioid crisis as a symptom and the role of the political and social ecosystem in its emergence, devastating impact and potential treatment allows us to explore a deeper understanding and introduce potential solutions to the epidemic on multiple levels. We address a few challenges and discuss the potential to inform a broader discussion of the health care system. The possibility of leveraging the bipartisanism and the public focus into better understanding the challenges facing our society, nation and to consider strategies to enhance our institutions and address challenges facing our current and future citizens who will face a world challenged with increasing social divisions.
The general considerations are framed in a citizen oriented focus and suggest activity for reclaiming the citizen role in the political ecosystem. These topics are seen as part of a comprehensive approach that leverages the conceptualization of the opioid challenge as a complex ecosystem that requires a comprehensive approach to address the following:
Social Isolation and the opioid epidemic (Citizen alienation)
The social environment that contributes to addiction (Social Determinants)
The Role of Government
Enforcement of regulations (Federal, state and local)
Coordination of governmental efforts (Federal, State and Local)
The War on Drugs
The Pharmaceutical Company
The Medical Profession: The First/ Last Mile
Community coordination: (Align incentives)
The role of Insurance Companies
The role of the Media
Social Isolation and the Opioid Epidemic: Citizen Alienation
Sam Sam Quinones opening statement to the U.S. Senate Committee on Health, Education, Labor and Pensions - Jan 9, 2018 - Chairman Lamar Alexander; Sen. Patty Murray, ranking Democrat about the complex causes of the Opioid Epidemic.
The epidemic epidemic has been attributed to many of the social challenges facing Americans that lead to marginalization, alienation, despair and sense of hopelessness. It has often been stated and research appears to bear out that a major driver of the epidemic are societal changes, alienation and hopelessness experienced by many citizens. Political and economic forces associated with globalization, technological advances and social policy have contributed to citizen alienation, distrust and anger at the political system and our government.
Addiction in general and the opioid epidemic more recently has been attributed to many of the social challenges facing Americans and lead to marginalization, alienation, despair and sense of hopelessness. It has often been stated and research appears to bear out that a major driver of the epidemic are societal changes, alienation, helplessness and hopelessness experienced by many citizens. Rates of opioid abuse, addiction, and fatal overdose rise along with unemployment.
Collectively, these observations challenge us to expand our conceptualizations of the opioid crisis beyond the vector model.
A seminal National Academy of Sciences report provides this summary:
“Overprescribing (of opioid) was not the sole cause of the problem. While increased opioid prescribing for chronic pain has been a vector of the opioid epidemic, researchers agree that such structural factors as lack of economic opportunity, poor working conditions, and eroded social capital in depressed communities, accompanied by hopelessness and despair, are root causes of the misuse of opioids and other substances. “
As we are experiencing the impact of globalization and advances in digital technology, it is quite clear that other communities and more individuals will experience the despair of being as Yuval Harari says “useless” in a market economy. It is incumbent to find strategies to address this. The Opioid Epidemic in a canary in the coal mine.
What can be done to address the challenges of marginalization and alienation.
Geographical Reintegration of the various regions: Broadband digital integration
Institutional and political reform (Political reintegration-de-demioniational.)
Culture of respect.: Fly over country, address Immigration issue: Fair and honorable way to address it.
Many have recognized the need to address the dignity deficit that has continued to become larger and larger in the past few decades. The potential for the challenge of dignity as provided by meaningful work is being transformed.
The Role of GDP as a Measure of the Health of the Nation
A Really Good Thing Happening in America: A strategy for community problem-solving does an extraordinary job at restoring our social fabric.
“Building working relationships across a community is an intrinsically good thing. You do enough intrinsically good things and lives will be improved in ways you can never plan or predict. This is where our national renewal will come from.”
The recovery movement that provides meaning and community to individuals that have been marginalized and stigmatized. Efforts to address the stigma within institutions.
The Social Environment that Contributes to Addiction: Social Determinants
There is a growing recognition that health and wellness of the individual is impacted by social determinants* in addition to the more usual medical and physiological aspects of the person’s experience. The current healthcare system, excellent at addressing the medical concerns of most people, has not evolved a theoretical framework, organizational structure, incentives and process to address the social determinants that contribute to medical issues for individuals. While there are social and societal resources that are dedicated to addressing social needs for individuals and community, these are usually not well coordinated, difficult to access, and not assessed for the outcomes. Failure to effectively address the social determinants is assumed to contribute to preventable utilization of the medical system contributing to escalating cost. This failure is assumed to contribute to the cost of healthcare and misses an opportunity to target the needs of the whole person.
Of course this is not new, five decades ago, than Attorney General Robert Kennedy talked about what was really needed to ameliorate drug abuse…
“Now, more than at any other time in our history, the addict is a product of a society which has moved faster and further than it has allowed him to go, a society which in its complexity and its increasing material comfort has left him behind. In taking up the use of drugs the addict is merely exhibiting the outermost aspects of a deep-seated alienation from this society, of a combination of personal problems having both psychological and sociological aspects.”
“The fact that addiction is bound up with the hard core of the worst problems confronting us socially makes it discouraging at the outset to talk about solving’ it. Solving’ it really means solving poverty and broken homes, racial discrimination and inadequate education, slums and unemployment….”
A recent commentary that appeared in the American Journal of Public Health
“The accepted wisdom about the US overdose crisis singles out prescribing as the causative vector. Although drug supply is a key factor, we posit that the crisis is fundamentally fueled by economic and social upheaval, its etiology closely linked to the role of opioids as a refuge from physical and psychological trauma, concentrated disadvantage, isolation, and hopelessness.”
The authors point out that
“The social determinants lens lays bare the urgency of integrating clinical care with efforts to improve patients’ structural environment. Training health care providers in “structural competency” is promising, as we scale up partnerships that begin to address upstream structural factors such as economic opportunity, social cohesion, racial disadvantage, and life satisfaction. These do not typically figure into the mandate of health care but are fundamental to public health.”
In 1961 Congress established the Office of Economic Adjustment within The U.S. Department of Defense to help local communities adapt to DoD program changes, expansions and cutbacks, as well as incompatibilities between military operations and local development. The program has been successful in helping avoid the devastation of loss associated with base closing, major social force in many communities. FEMA, has played a critical role in helping individuals and communities recover from devastation of natural disasters. Leveraging the experience and the manifestation of social contract driven federal- state, public private programs that assist individuals and communities adjust to severe disruption can play an important role for communities to regain their social capital. Most importantly, consider social strategies to engage more citizens and provide a container for reclaiming citizen meaning to counter the alienation and distrust.
Community Action Agencies (CAA) are local private and public non-profit organizations that carry out the Community Action Program (CAP), which was founded by the 1964 Economic Opportunity Act to fight poverty by empowering the poor as part of the War on Poverty.
Potential interventions may include incorporating lessons learned from the American experience of base closing to a more informed conversation and exploration of policy options for Universal Health Care and Universal Basic Income.
Government as a Stakeholder
The federal government and the Legislative branch in particular have embraced the opioid epidemic and have regardless of political ideology and view of the role of government, tried to address its toll. For a review of the federal government's role check here… The following aspects of the congress's involvement highlight the pathology of the political system and opportunity to change.
Coordination of governmental efforts
In 1971 President Nixon, responding to the growing drug addiction challenges confronting the US in the Vietnam Era, called upon congress to mobilize to fight against the problem and set out what has become the “War on drugs”. At the time Mr. Nixon states that,
“The magnitude and the severity of the present threat will no longer permit this piecemeal and bureaucratically-dispersed effort at drug control. If we cannot destroy the drug menace America, then it will surely in time destroy us. I am not prepared to accept this alternative.”
45 years later, the opioid epidemic continues to have a devastating impact on many individuals and communities throughout the United States.
Distrust of Government
Among the many challenges confronting the democracy in the United States is the growing distrust of government as well as other civil institutions. There is a growing distrust of the political structure and many have questioned the value of democracy. For example, repeated polls show that only a small minority of the citizenry holds the congress in positive esteem and many believe that the “system is rigged” against them. An increasingly negative political discourse complicated with disinformation and emotion fueled narrative leads to more citizen to get disengaged from the political system,
Some of the causes for the growing distrust are the failure of various governmental agencies to carry out their responsibility in preventing the opioid epidemic, providing “a treatment plan and considering primary prevention approaches.
That Democrats and Republicans were able to agree on a number of effective policies, and shepherd them through the complex legislative landscape is understandable given the nature and devastation of the crisis and the political advocacy of the a growing community of individuals touched by it. Of course similar legislation was passed with great majorities and signed into law by president Obama in 2016 and did little to change the reality of the epidemic.
In opening statement to a senate judiciary committee to Evaluate The Propriety And Adequacy Of The Oxycontin Criminal Settlement the Hon. Patrick J. Leahy, A U.S. Senator From The State Of Vermont stated,
“I look forward to discussing today with the witnesses how best to prevent this type of dangerous corporate decision-making from ever occurring again. Americans should not have their lives reduced to a mere factor in an actuarial table. While the makers of OxyContin have been prosecuted, have pled guilty, and are paying a multi-million dollar fine, no one from the company is going to jail. Frankly, I felt in my days as a prosecutor and I am sure others, like Senator Specter, who had the privilege of serving as prosecutors know that nothing focuses the mind as much as thinking you are going to be behind bars. Fines can sometimes become simply a cost of doing business. When you sit behind bars, you think far more about whether you did the right thing.”
That hearing took place Tuesday, July 31, 2007, months before the financial crisis of 2007–2008 that inflicted overwhelming misery to millions of Americans and for which no executive of the financial institutions went to jail. The settlements that the senators were evaluating were The criminal charge involves a matter where there was a plea to a felony offense, including an intent to mislead. “According to the DEA, in just 2000 and 2001, there were 146 deaths (nationally) in which OxyContin was determined to be the direct ``cause of'' or ``a contributing factor to'' the deaths and an additional 318 deaths that were ``most likely'' caused by OxyContin.” (Last year according to CDC there were 62,000).
August 28th, 2001, two weeks before one of the worst attacks on the US homeland a congressional hearing was held to explore Oxycontin: Its Use and Abuse.
Making congress more democratic and transparent (Tools for decision making)
During the process leading to the passage of the currently legislation, Senator Susan Collins of Maine, questioned he individuals in charge of administering the , Comprehensive Addiction and Recovery Act 2016 as to why although congress appropriated the finances for addressing the crisis nearly half of the funds had not been spent. The current legislation may suffer a similar fate without more robust congressional oversight and transparent outcome indicators. Of course one must be particularly mindful of unintended negative outcomes.
Enforcement of government regulations
DEA’s Diversion Control Program is tasked by congress to oversee the supply of chain of controlled substances. Recent media reports and congressional testimony by Robert W. Patterson, Acting Administrator, U.S. Drug Enforcement Administration (Video) , demonstrate the colossal failure of this agency to carry out its role with in the opioid ecosystem. Washington Post and 60 minutes described an agency that while more and more Americans were getting addicted and overdosed, pill mills proliferated, increase in written opioid prescription was on the side lines . This is particularly problematic as the agency was supported by hundred of millions of dollars charged to physician, pharmacies, etc. And has had hundred of millions of dollars in settlements.
“The mission of the DEA’s Diversion Control Program is to prevent, detect, and investigate the redirection from legitimate channels of controlled pharmaceuticals (such as narcotics, stimulants, and depressants) and certain listed chemicals (such as ephedrine). Federal law requires the DEA to recover “the full costs of operating the various aspects” of its Diversion Control Program through the fees charged to DEA registrants, such as manufacturers, distributors, dispensers (including physicians), importers, and exporters of controlled substances and listed chemicals.”
It is not surprising that in a recent article Leo Beletsky and Jeremiah Goulka suggested the need for overhauling the agency, or even getting rid of it entirely. At an age when digital technology allows tracking manufacturing from seed to sale, it is inconceivable that the DEA needs to special funding to track the journey of opioids and other controlled substances through the medical pipelines from manufacturing to use by patients. Additionally, the congressional responsibility for oversight through yearly reporting accounting for the activities of the agency and justifying the fees paid by the medical community need to be enforced with transparent process that engages the various stakeholders and the public.
The criminalization of opioid use
The "War on Drug" initiated to rid society of drugs has been increasingly recognized as a failure. Not only has Opioid (and other drugs) have continued to be available to the millions of individuals who choose/ or are addicted to them, but the societal devastation inflicted by the various levels of government has been disastrous for many nations and communities. The consequences of policies and actions associated with the drug wars have been noted to have exacerbated the negative consequences. This is not surprising, the use of governmental power to criminalize and develop a state opratus to punish individuals who are involved in drug experience with little oversight is familiar.
When the Founders rebelled against British tyranny, they grounded their cause in a belief in the natural rights of the individual and the Enlightenment ideas of progress through reason. Understanding the dangers of an excessive concentration of political power, they divided and limited the reach of that power through a federal structure with the states, the separation of powers among the three branches, and the guarantees of personal freedom in the Constitution itself and in the Bill of Rights.
The cost of the drug war
The drug war has diverted important funds to achieve increasingly harmful results. Rather than spending societal resources on social programs that promote individual and community well being, the drug war has left in its wake traumatized individuals and devastated impoverished communities.
Milton Friedman, in response to the “war on drug” was able to anticipate the current state of our crisis. Heeding to his caution may serve us well.
The State Level
The Opioid Epidemic and the current efforts to address its many aspects are an excellent case study of federalism. The nature of the addiction problem its universal presence throughout the nation and the need for local solutions, highlights the importance of a coordinated effort that transcends regional. Ethnic, religious, class, racial, ideological categories. States in general and more specifically counties and cities are at the forefront of the epidemic, working hand in hand with federal employees with in a complex ecosystem. The new bill will further highlight the importance of federalism as a framework for problem solving.
Any exploration of the state’s role, would benefit from an understanding the various roles of the governors, AG, boards, legislators. For example what was the role of state attorney generals in maintaining the epidemic?
An important case study, as state driven litigation of the Pharma industry ‘s role and responsibility for the epidemic proceeds, can be the The Tobacco Master Settlement Agreement — Strategic Lessons for Addressing Public Health Problems. What happened to the payments made by the pharmaceutical companies (Purdue, etc) in 2006?
The role of the State Attorney General
State AGs are responsible for protecting the public and can intervene individually or collectively by means of lawsuits or negotiation when public health is threatened. AG-led efforts are particularly important when other officials and government entities at the local, state, and federal levels are disinclined to pursue action or when laws and regulations that protect health are rescinded. AGs may be viewed as the “actors of last resort” when an industry with substantial legislative influence is harming the public. The tobacco settlement is a key example of one such effort; the MSA was successfully negotiated after federal legislative efforts collapsed. AGs can use and have used a range of state laws to protect health — most important, consumer-protection laws, but also public-nuisance, antitrust, and conspiracy laws, tort liability, state statutes equivalent to the federal Racketeer Influenced and Corrupt Organization Act, and financial and securities-fraud statutes.
Currently, 41 AGs are suing or are poised to sue companies that manufacture, distribute, and sell opioids, relying mostly on public-nuisance claims.2 More than 400 complaints have been filed in multiple jurisdictions, and confidential settlement talks are under way in the U.S. District Court for the Northern District of Ohio. The AGs claim that the companies violated state and federal laws by making false claims about opioids’ addictiveness and safe dosing levels, diverting drugs and failing to monitor or report excessive deliveries to individual distributors and retailers, and allowing fraudulent prescriptions to be filled. The consumer-fraud, public-nuisance, and other charges include those against manufacturers for their collective efforts to mislead the public and health care providers into believing that opioids were generally not addictive and were formulated to be addiction-proof; that there was no ceiling on dosing levels; and that signs of addiction were probably “pseudoaddiction,” a fictitious condition invented by the vice president of Purdue Pharma’s policy office.3
The 1998 Master Settlement Agreement (MSA) between the tobacco industry and 46 state attorneys general (AGs), five U.S. territories, and Washington, D.C., remains the largest legal settlement ever executed in the United States. The MSA achieved important public health objectives, including substantially reduced smoking rates and lives saved.1 Given its success, the agreement has enormous promise as a model for similar litigation or settlements that could hold industries accountable when they knowingly deceive and injure consumers with their products.
The Medical Profession and the Healthcare Ecosystem: The First/ Last Mile
Existing medical system stakeholders are reluctant to expand the framework for patient care to include a biopsychosocial- spiritual framework and incorporate that understanding into clinical care. More specifically, most health care systems lack the infrastructure, communication among stakeholders and incentives to develop comprehensive, systematic screening-and-referral protocols and relationships with the array of community service providers that would be required to address their patients’ health-related social needs.
The medical care ecosystem, for which the US spends about 20% of GDP, plays an important part in the “creation” and the maintenance of the opioid crisis. In order to mobilize the clinicians and other health related stakeholders we need to establish a frictionless system that is driven by agreed upon guidelines. That would include a ways to visualize the ecosystem and the players within it. Providing transparency for individuals and communities about the available resources and outcomes.
The Treatment (Recovery) community
Pain and Its Management
Pain is an ever present human condition. The medical profession has a moral imperative to alleviate the suffering associated with pain. For various reasons over, under and inappropriate prescribing of opioids for pain conditions is common. Recently, responding to regulatory and criminal justice activity, the medical community has been going through a profound change in the “Culture of Prescribing”. New guidelines for physicians in primary care have further eroded clinician's treatment choice. Financial incentives, insurance guidelines, laws and policies impact the ability of individuals to get the non opioid based pain relief.
A recent report by the IHI, Addressing the Opioid Crisis in the United States several reasons for the failure of the current approach to address the Opioid Epidemic:
From education of health care students to tools to address challenges in daily practice. How do hospitals provide care to their community. The Joint and other accrediting agencies.
Lack of awareness among patients and consumers of the danger of prescription opioids. In our research, both expert interviews and informal conversations highlighted the lack of awareness about the danger of opioids. We were surprised to learn how many individuals did not realize that commonly prescribed medications, such as Percocet or OxyContin, are opioids just as heroin is an opioid.
Failure to spread promising practices.
There are many encouraging examples in the campaign against the opioid crisis, primarily at the regional, state, local levels. However, these promising practices are often not adopted elsewhere, or even spread from small test sites to the larger geographic area. In other domains, IHI has engaged in a number of large-scale initiatives focused on spread and scale-up of better practices, and we believe our work has application to the opioid crisis.
Lack of effective implementation of promising practices.
The lack of progress is not, in general, due to a lack of knowledge. Johns Hopkins Bloomberg School of Public Health recently published a comprehensive guide to evidence-based practices and recommendations for actions to address the opioid epidemic at different points in the system. While the guide is useful for understanding potential strategies, it is insufficient to lead to systemic changes. Many efforts have resulted in publication of strategies or guidelines, but without support for execution of those strategies. We need to go a step further and move these guidelines and recommendations into implementation.
To successfully implement interventions, community-wide improvement efforts must engage those members of the community intended to be helped by the interventions. Initiatives must look beyond public health and health care to stakeholders such as law enforcement, community-based organizations that are not primarily focused on health, faith-based organizations, schools, and individuals and families directly affected by opioid abuse. Engagement and understanding of the local context is particularly important, due to the significant geographic variation in the opioid epidemic (see below).
What can be done?
The Health care Insurance Industry
Insurance companies plan an important role in the primary prevention , treatment availability and access and secondary prevention of opioid related challenges. For example, lack of available comprehensive pain treatment options, lead to increased use of Opioids. Making access and approval to treatment of Opioid Use Disorder, limits the utilization of the potentially effective treatments. Although health care parity for medical care of behavioral, addiction and physical problems is the law of the land, individuals seeking treatment for addiction related challenges often confront bias and roadblocks to minimize the potential for successful management of their condition.
The Media Industry: Examining the role of the media in the Pain Opioid Epidemic Ecosystem
We are also living through a precarious time in journalism. The click-bait strategy, while clearly destined to fail as online ad revenues continue to go to Facebook and Google, remains the default mode embedded into the habits of a generation of digital journalists who have been conditioned to work without the resources to report at length. Instead, they repackage received wisdom as fact, to drive narratives that generate engagement through online contention, and profit off the cycles of polarization they feed. The rewards for stirring up outrage on the basis of deliberately malfeasant or merely incompetent misreading are too great for even many otherwise intelligent commenters to resist. It has polluted the discourse and deranged the minds of a great many otherwise-intelligent people.
Media outlets coverage of the opioid epidemic illustrate the challenges and opportunities for the media in reporting and covering complex social issues. As the shapers of public opinion, the media plays a crucial role within the pain opioid ecosystem. Their role however is diminished by the changing nature of the business models reshaping the media landscape. This is particularly unfortunate given the impact the epidemic is having on so many levels of American society.
The opioid epidemic presents an opportunity to test a way to be more relevant to major social challenge and test a journalistic approach that is consistent with your vision and challenges confronting all of media.
The New York Times and other media outlets coverage of the Opioid Epidemic illustrate that challenges and opportunities for the media in reporting and covering complex social issues.
The ultimate question is how to reclaim public reason and what is the media’s responsibility for promoting the “public welfare”.
In many ways, the recent legislation is one of numerous efforts at all levels of government, non for profit and community groups have been the result of advocacy and mobilization of citizens to address the challenge of the opioid epidemic.