POLICY BRIEF | FEBRUARY, 2019 The Opioid Crisis: Tragedy, Treatments and Trade-offs By Molly Schnell KEY TAKEAWAYS The United States has a drug problem. Overdose deaths have increased by more than 1,000 percent since 1980, with each n The United States is in the midst of the worst drug of the past 28 years surpassing the last. With over 70,000 fatal epidemic in its history. overdoses in 2017 alone — an average of 192 deaths per day — drugs now kill more people than HIV/AIDS at the height of n The crisis is tied to increases in the clinical use of the epidemic in 1995. Opioids — prescription pain killers like prescription opioids. OxyContin and Percocet, and illegal drugs including illicit fentanyl and heroin — are largely to blame. n Despite the rise of illicit opioids, prescription opioids The clinical use of prescription opioids in the United States quadrupled remain part of the problem. between 2000 and 2010, a rise that was accompanied by a nearly 300 percent increase in deaths involving these drugs (see Figure 1). While the exact n Policies aimed at reducing numbers vary across locations, the takeaway remains the same: On average, opioid prescribing involve areas that saw greater increases in opioid prescribing experienced greater trade-offs. increases in opioid-related mortality (Schnell and Currie, 2018). With deaths from prescription opioids hitting a new high in 2010, things got n Finding the right balance even worse. Fatal heroin overdoses — which had been largely stable across between limiting abuse and the past decade — began to rise. Tied to the 2010 reformulation of a popular managing pain is difficult, prescription opioid to make it more difficult to abuse (Alpert et al., 2018), fatal but necessary. heroin overdoses have since increased by more than 400 percent. And starting in 2013, deaths from synthetic opioids — including fentanyl — began to increase at unprecedented rates, accounting for 90 percent of the overall increase in drug-related mortality since 2012. While fentanyl is legally prescribed in the United States, evidence suggests that much of the fentanyl on the streets is illegally manufactured and comes from abroad. John A. and Cynthia Fry Gunn Building siepr.stanford.edu 366 Galvez Street, Stanford, CA 94305-6015 @siepr facebook.com/SIEPR/ 1 POLICY BRIEF | FEBRUARY, 2019 Figure 1: Opioid prescriptions and overdose deaths between 2000 and 2017 9 1000 Deaths per 100,000 6 MMEs per capita 500 3 0 0 2000 2004 2008 2012 2016 Overdose deaths involving: Commonly prescribed opioids Opioids prescribed in morphine milligram equivalents (MMEs) Other synthetic opioids (e.g., fentanyl) Heroin Sources: National Vital Statistics System (CDC) and ARCOS System (DEA). Prescription Opioids Are Still Part of numbers are not available for fentanyl, overdoses the Problem often occur accidentally when people take heroin or counterfeit prescription pills that contain fentanyl Does the rise of illicit opioids mean that prescription without their knowledge. opioids are no longer a problem? Unfortunately, the numbers suggest that such a conclusion would be overly As we look for solutions to the illicit opioid crisis, the path- optimistic. Non-medical use of prescription opioids way from legal to illegal opioid use cannot be ignored. remains the second most common type of federally illicit Furthermore, while opioid prescriptions peaked in 2012 drug use, second only to marijuana, and is over 12 times and have steadily declined since, the clinical use of opioids more common than heroin use (SAMHSA, 2018). And in the United States remains at three times the level while overdose deaths involving prescription opioids observed in 2000. According to the Centers for Disease leveled off in 2016, they remain at four-and-a-half times Control, nearly 60 opioid prescriptions per every 100 their level from 2000 and account for at least 40 percent Americans are still written annually, and medical providers of all opioid-related mortality. in 16 percent of U.S. counties continue to prescribe Despite the rise of illicit opioids, prescription opioid enough opioids for every resident to have a prescription. abuse and the associated risks are not going away. And not all of these prescriptions are used as intended: Results from the National Survey on Drug Use and Health Individuals who are dependent on prescription opioids demonstrate that over 75 percent of individuals who are also at far greater risk of turning to illicit opioids. misused a prescription opioid in 2017 got their most recent Among those who started using heroin between 2002 supply directly or indirectly from a medical provider. and 2011, nearly 80 percent reported previously using prescription opioids non-medically, whereas only Despite meaningful reductions to the supply of 1 percent of users initiating prescription opioid misuse prescription opioids, legally prescribed opioids remain reported prior heroin use (SAMHSA, 2013). While similar part of the problem. John A. and Cynthia Fry Gunn Building siepr.stanford.edu 366 Galvez Street, Stanford, CA 94305-6015 @siepr facebook.com/SIEPR/ 2 POLICY BRIEF | FEBRUARY, 2019 Notably, there remains no agreed-upon level of (Buchmueller and Carey, 2018). These reductions are appropriate prescribing. While some of the differences accompanied by reductions in prescription opioid- across specialties and locations indisputably reflect related deaths: On average, states that mandated differences in pain profiles, prescribing differences PDMP use experienced a 9 percent reduction in fatal exist even among physicians in the same specialty who prescription opioid overdoses (Meinhofer, 2018). practice in the exact same clinic (Schnell and Currie, Recent work further demonstrates that opioid 2018). And these differences can have consequences. prescribing decreases by 10 percent when a physician is Researchers have found that long-term opioid use was notified of a patient’s overdose, suggesting that feedback 1.3 times more likely among patients who happened to on patient outcomes can shift prescribing behaviors see providers who were more likely to prescribe opioids (Doctor et al., 2018). This is in contrast to earlier work (Barnett et al., 2017). While it remains unclear whether finding that simply informing potential overprescribers high-intensity prescribing reflects overprescribing or low- that their prescribing practices are highly unlike those intensity prescribing reflects an undertreatment of pain, of their peers does not change subsequent prescribing the prevalence of “doctor shopping” — a practice in which (Sacarny et al., 2016). patients search over providers to access prescriptions — As pressure continues to grow for policymakers to solve indicates that patients know that there is variation in the growing drug crisis, states are increasingly turning prescribing and are willing to take advantage of it. toward more heavy-handed policies to alter prescribing. Since 2016, nearly half of states have passed legislation limiting opioid prescribing, placing statutory caps on Adjusting Opioid Prescribing Practices allowable number of days supplied and/or daily dosage in So what can be done? certain clinical circumstances. While it remains to be seen whether this wave of new legislation will be more effective We’ve seen a range of policies aimed at changing than previous quantitative prescription limits, which were prescribing during the past decade. Many of them are shown to have no impact on measures of opioid abuse based on the premise that providing practitioners with (Meara et al., 2016), these policies are certain to limit more information — either about their patients or their clinical autonomy and threaten the ability of practitioners own prescribing practices — could be useful in guiding to address the needs of individual patients. appropriate prescribing. One such policy is the implementation of prescription drug monitoring programs (PDMPs) — electronic databases that Opioid Policy Involves Trade-offs track prescriptions for controlled substances. While nearly So what should be done? all states have PDMPs in operation, states differ in their requirements for when, if ever, providers are required to Efforts to reduce unnecessary prescribing may be required check the database before prescribing. to prevent future addiction, but such policies are not without trade-offs. While quantitative prescribing limits Studies demonstrate that “must access” PDMPs are have been decried for regulatory overreach, even light- successful in shifting prescribing practices, while touch policies to reduce opioid prescribing have costs. voluntary PDMPs have no effects. Notably, mandatory PDMP use has been shown to reduce opioid prescribing Recent evidence suggests that mandated PDMP use, by 9 percent (Meinhofer, 2018) and indicators of opioid while reducing prescription opioid abuse as intended, abuse — such as obtaining a prescription from five or leads to increases in overdoses involving illicit drugs more prescribers or pharmacies — by up to 15 percent (Meinhofer, 2018). And reformulating OxyContin to make John A. and Cynthia Fry Gunn Building siepr.stanford.edu 366 Galvez Street, Stanford, CA 94305-6015 @siepr facebook.com/SIEPR/ 3 POLICY BRIEF | FEBRUARY, 2019 it more difficult to abuse — a strategy encouraged by the Meara, E., J.R. Horwitz, W. Powell, L. McClelland, W. Zhou, A.J. O’Malley, FDA — has been tied to the subsequent rise in heroin use and N. Morden. (2016) “State Legal Restrictions and Prescription-Opioid Use Among Disabled Adults.” New England Journal of Medicine, 375: 44-53. (Alpert et al., 2018). When the legal supply of prescription opioids is disrupted, some users may substitute to other, Meinhofer, A. (2018) “Prescription Drug Monitoring Programs: The Role potentially more dangerous, drugs. of Asymmetric Information on Drug Availability and Abuse.” American Journal of Health Economics, 4(4): 504-526. Further, prescription opioids are legitimate medical Sacarny, A., D. Yokum, A. Finkelstein, and S. Agrawal. (2016) “Medicare products used to treat pain. Efforts to reduce prescribing Letters to Curb Overprescribing of Controlled Substances Had No therefore have the potential to make it more difficult for Detectable Effect on Providers.” Health Affairs, 35(3): 471-479. patients — even those who will use opioids appropriately Schnell, M., and J. Currie. (2018) “Addressing the Opioid Epidemic: — to access effective pain relief. Opioid policy is plagued Is There a Role for Physician Education?” American Journal of Health by a fundamental trade-off between maintaining access Economics, 4(3): 383-410. to compassionate pain management and limiting Substance Abuse and Mental Health Services Administration. (2013) prescription opioids available for misuse. “Association of Nonmedical Pain Reliever Use and Initiation of Heroin Use in the United States.” CBHSQ Data Review. Rockville, MD: Substance Any single policy is unlikely to be sufficient to address the Abuse and Mental Health Services Administration. current crisis. Policies aimed at reducing prescriptions should be paired with broad access to treatment for Substance Abuse and Mental Health Services Administration. (2018) “Key Substance Use and Mental Health Indicators in the United States: Results those with problematic opioid use. And policies must from the 2017 National Survey on Drug Use and Health.” HHS Publication, be designed so as to not prevent providers from using Number SMA 18-5068, NSDUH Series H-53. Rockville, MD: Substance opioids as a tool to help manage their patients’ pain. Abuse and Mental Health Services Administration. As new policies are designed and implemented to battle the opioid crisis, policymakers must work closely with practitioners, patients, and researchers to identify — and Molly Schnell is a postdoctoral promptly mitigate — any unintended consequences. research fellow at SIEPR and will Finding the right balance between limiting abuse and be joining Northwestern managing pain is difficult, but necessary. University as an assistant professor of economics in July 2019. Much of her research examines the provision References of pharmaceuticals in markets across the United Alpert, A., D. Powell, and R.L. Pacula. (2018) “Supple-Side Drug Policy in the States with a particular focus on markets for Presence of Substitutes: Evidence from the Introduction of Abuse-Deterrent opioid analgesics. Opioids.” American Economic Journal: Economic Policy, 10(4): 1-35. Barnett, M.L., A.R. Olenski, and A.B. Jena. (2017) “Opioid-Prescribing Patterns of Emergency Physicians and Risk of Long-Term Use.” New England Journal of Medicine, 376: 663-673. The Stanford Institute for Economic Policy Buchmueller, T.C., and C. Carey. (2018) “The Effect of Prescription Drug Research (SIEPR) catalyzes and promotes evidence- Monitoring Programs on Opioid Utilization in Medicare.” American based knowledge about pressing economic Economic Journal: Economic Policy, 10(1): 77-112. issues, leading to better-informed policy solutions Doctor, J.N., A. Nguyen, R. Lev, J. Lucas, T. Knight, H. Zhao, and M. for generations to come. We are a nonpartisan Menchine. (2018) “Opioid Prescribing Decreases After Learning of a research institute, and SIEPR Policy Briefs reflect Patient’s Fatal Overdose.” Science, 361(6402): 588-590. the views and ideas of the author only. John A. and Cynthia Fry Gunn Building siepr.stanford.edu 366 Galvez Street, Stanford, CA 94305-6015 @siepr facebook.com/SIEPR/ 4