AHLA Convener on the Opioid Crisis: Understanding the Complexities, Acknowledging the Challenges, and Exploring Possible Solutions

On September 25, 2018, AHLA hosted a convener session at American University's Washington College of Law in Washington, DC to address the national crisis of opioid-related harm. Twenty experts from around the country gathered for a day-long meeting to identify the most pressing issues and discuss possible solutions. The white paper featured below captures the major themes and recurring issues that convener participants, with their diverse experience, expertise, and perspectives, discussed and debated during the day-long session.A number of related resources that delve more deeply into many of the issues addressed at the convener session are included below organized by their relevance to a particular section of the white paper. This page also provides a collection of AHLA educational materials analyzing the policy and legal implications of the opioid crisis.  

Download The Opioid Crisis: Understanding the Complexities, Acknowledging the Challenges, and Exploring Possible Solutions White Paper

Convener Resources

I. Introduction

*No additional references.

II. An Overview of Legislative and Administrative Activity

• Jennifer M. Lohse and Brad Lerner, SUPPORT ACT: Highlights of the 2018 Opioid Legislation, AHLA Behavioral Health Task Force (Oct. 15, 2018).
• Corey S. Davis, The SUPPORT for Patients and Communities Act—What Will It Mean for the Opioid-Overdose Crisis? New. Eng. J. Med. (Jan. 3, 2019).
• J. Butler, W. Becker, and K. Humphreys, Big Data and the Opioid Crisis: Balancing Patient Privacy with Public Health, J.L. Med. & Ethics, 46(2), 440-453 (2018). 
• Kelly K. Dineen, Addressing Prescription Opioid Abuse Concerns in Context: Synchronizing Policy Solutions to Multiple Public Health Concerns, Law & Psychology Rev. (Aug. 10, 2016).
• L. Beletsky and Corey S. Davis, Today's fentanyl crisis: Prohibition's Iron Law, revisited, Int'l J. of Drug Policy, vol. 46, 156-159 (Aug. 2017).
• Alan D. Kaye, Sairam Atluri, Jaya Sanapati, Ramsin M. Benyamin, Joshua A. Hirsch, and Laxmaiah Manchikanti, Reframing the Prevention Strategies of the Opioid Crisis: Focusing on Prescription Opioids, Fentanyl, and Heroin Epidemic, Pain Physician, vol. 21(4) (2018).
• Theodore J. Cicero, Zachary A. Kasper, and Matthew S. Ellis, Increased use of heroin as an initiating opioid of abuse: Further considerations and policy implications, Addictive Behaviors, Vol. 87, 267-271 (2018).
• SUPPORT for Patients and Communities Act, Pub. L. No. 115-271 (2018).
• Comprehensive Addiction and Recovery Act, Pub. L. No. 114-198 (2016).
• 21st Century Cures Act (CURES Act), Pub. L. No. 114-255 (2016).
• House Appropriations Committee, Summary of FY 2019 Defense and Labor-HHS-Education Appropriations Minibus, Sep, 14, 2018.
• HHS, HHS Awards over $1 Billion to Combat the Opioid Crisis, Sept., 19 2018. 
• HHS, Telemedicine and Prescribing Buprenorphine for the Treatment of Opioid Use Disorder (Sept. 2018). 
• HHS OCR, How HIPAA Allows Doctors to Respond to the Opioid Crisis (Oct. 2018).  
• National Conference of State Legislatures, Prescribing Policies, States Confront Opioid Overdose Epidemic, (Oct. 31, 2018).  
• ARIZ. REV. STAT. § 32-3248
• N.C. GEN. STAT. § 90-106.  
• MICHIGAN DEPARTMENT OF LICENSING AND REGULATORY AFFAIRS (LARA) AND THE DEPARTMENT OF HEALTH AND HUMAN SERVICES (DHHS), MICHIGAN OPIOID LAWS, JANUARY 2019.

III. Overarching Barriers to Effective Solutions--Data Gaps, Social Stigma, Prescribing Practices, and the Impact of Payer Policies

A. Data Gaps

• CDC, Putting Data to Action in the Fight Against Opioids.
• CDC, Prescription Opioid Data.
• Corey S. Davis, Traci C. Green, Hector Hernandez-Delgado, and Amy Judd Lieberman, Status of U.S. Laws Mandating Timely Reporting of Nonfatal Overdose, Am. J. Pub. Health (Aug. 8, 2018) (*access to full article limited to AJPH subscribers).
• Catherine Martinez, Cracking the Code: Using Data to Combat the Opioid Crisis, J L Med. & Ethics, vol. 46(2), 454-471 (2018).  
• Ian Rockett, et al., Discerning suicide in drug intoxication deaths: Paucity and primacy of suicide notes and psychiatric history, PLoS ONE, 13(1) (Jan. 2018).

B. Social Stigmas and Individual Biases

• William L. White, Long-Term Strategies to Reduce the Stigma Attached to Addiction, Treatment, and Recovery within the City of Philadelphia (With Particular Reference to Medication-Assisted Treatment/Recovery), Dep't of Behavioral Health and Intellectual Disability Servs. (DBHIDS). 
• Yngvild Olsen, Joshua M. Sharfstein, Confronting the Stigma of Opioid Use Disorder—and Its Treatment, JAMA, vol. 311(14), 1393–1394.
• Patrick W. Corrigan, Katherine Nieweglowski, Stigma and the public health agenda for the opioid crisis in America, Int'l J. of Drug Policy, vol. 59, 44-49 (Sept. 2018).
• Mario Brondani and Rana Alan, and Leeann Donnelly, Stigma of addiction and mental illness in healthcare: The case of patients' experiences in dental settings, PLOS ONE 12(5) (2017).
• S. Wakeman, G. Pham-Kanter, and K. Donelan, Attitudes, practices, and preparedness to care for patients with substance use disorder: Results from a survey of general internists, Substance Abuse 37(4):635-641 (2016).
• Scott M. Fishman, Daniel B. Carr, Beth Hogans, Martin Cheatle, Rollin M. Gallagher, Joanna Katzman, Sean Mackey, Rosemary Polomano, Adrian Popescu, James P. Rathmell, Richard W. Rosenquist, David Tauben, Laurel Beckett, Yueju Li, Jennifer M. Mongoven, and Heather M. Young, Scope and Nature of Pain and Analgesia-Related Content of the United States Medical Licensing Examination (USMLE), Pain Med. 19(3) 449-459 (Mar. 1, 2018).
• Michael Botticelli and Howard Koh, Changing the Language of Addiction, JAMA, 316(13):1361–1362 (Oct. 2016).
• A Goddu et al., Do Words Matter? Stigmatizing Language and the Transmission of Bias in the Medical Record, Gen. Internal Med. (2018). 
• Kathleen A. Crapazano, Rebecca Hammarlund, Bilal Ahmad, Natalie Hunsinger, and Rumneet Kullar, The association between perceived stigma and substance use disorder treatment outcomes: a review, Substance Abuse and Rehabilitation 10: 1–12 (2018).  
• Kelly K. Dineen, Opioid Prescribing in Stigmatized and Special Populations, in PRESCRIPTION DRUG DIVERSION AND PAIN: HISTORY, POLICY AND TREATMENT 190 (John F. Peppin, John J. Coleman, Kelly K. Dineen, and Adam J. Ruggles eds.) 2018. 

C. Attempts to Define "Inappropriate Prescribing" and the Impact of Current Prescribing Guidelines on the Provider Community

• Michael L. Barnett, Josh Gray, Anna Zink, and Anupam B. Jena, Coupling Policymaking with Evaluation—The Case of the Opioid Crisis, New. Eng. J. Med., 377:2306-2309 (Dec. 14, 2017). 

D. Reimbursement for Non-Opioid Pain Therapy

• CMS, Center for Consumer Information and Insurance Oversight, The Mental Health Parity and Addiction Equity Act (MHPAEA).
• Corey S. Davis, Amy Judd Lieberman, Hector Hernandez-Delgado, Carli Suba, Laws limiting the prescribing or dispensing of opioids for acute pain in the United States: A national systematic legal review, Drug and Alcohol Dependence vol. 194, 166-172 (Jan. 1, 2019).

IV. Potential Solutions

A. PDMP Data

• Corey S. Davis, Commentary on Pardo (2017) and Moyo et al. (2017) Much still unknown about prescription drug monitoring programs, Soc'y for the Study of Addiction vol 112, 1797–1798 (Sep. 10, 2017). 

B. Educating Early, Changing Mindsets, and Understanding Opioid use Disorder as a Medical Condition

• Corey S. Davis and Derek Carr, Physician continuing education to reduce opioid misuse, abuse, and overdose: Many opportunities, few requirements, Drug and Alcohol Dependence, vol. 163, 100-107 (June 1, 2016).
• P.G. O'Connor, J.G. Nyquist, and A.T. McLellan, Integrating Addiction Medicine Into Graduate Medical Education in Primary Care: The Time Has Come, Annals Internal Med., 154(1):56-59 (Jan. 2011). 
• S. Polydorou, E.W. Gunderson, and F.R. Levin, Training physicians to treat substance use disorders, Current Psychiatry Rep., vol. 10, 399-404 (Oct. 2008).
• APA, Opioid Use Disorder: Diagnostic Criteria. 
• Patrick Corrigan, Lessons learned from unintended consequences about erasing the stigma of mental illness, World Psychiatry, vol. 15(1) (2016).

C. Prescribing Practices

• Corey S. Davis, Amy Judd Lieberman, Hector Hernandez-Delgado, Carli Suba, Laws limiting the prescribing or dispensing of opioids for acute pain in the United States: A national systematic legal review, Drug and Alcohol Dependence vol. 194, 166-172 (Jan. 1, 2019). 
• Kelly K. Dineen, Defining Misprescribing to Inform Prescription Opioid Policy, Hastings Ctr. Rep., vol. 48, 5-6 (2018).
• Lynn Webster, Pain and Suicide: The Other Side of the Opioid Story, Pain Med., vol. 15, 345 (2014). 
• Marilyn Serafini, The Physicians Quandary with Opioids: Pain v. Addiction, New Eng. J. Med. Catalyst (Apr. 2018). 
• Maria A. Oquendo and Nora D. Volkow, Suicide: A Silent Contributor to Opioid Overdose Deaths, New Eng. J. Med. (2018). 
• Martin Cheatle, Managing a Patient in Pain with a History of Substance Use Disorder, in PRESCRIPTION DRUG DIVERSION AND PAIN: HISTORY, POLICY AND TREATMENT (John F. Peppin, John J. Coleman, Kelly K. Dineen, and Adam J. Ruggles eds. 2018).
• S.K. DeCaria and V. Patel, Relationship of Chronic Pain and Suicide, in CHALLENGING CASES AND COMPLICATION MANAGEMENT IN PAIN MEDICINE (Anitescu M., Benzon H., Wallace M. eds. 2018). 
• Walter Eisner, Dr. Tom Graham Killed After Denying Opioid Prescription, This Week Orthopedics (Aug. 3, 2017). 
• Amy S.B. Bohnert and Mark A. Ilgen, Understanding Links among Opioid Use, Overdose, and Suicide, New Eng. J. Med. (2019).  

D. Overdose Reporting: Toxicology Data

*No additional references

V. Increasing Access to Opioid Use Disorder Treatment

• SAMHSA, Medication Assisted Treatment.
• SAMHSA, Buprenorphine Waiver Management. 
• SAMHSA, Qualify for Nurse Practitioners (NPs) and Physician Assistants (PAs) Waiver.
• Laura Amato, Silvia Minozzi, Marina Davoli, Simona Vecci, Psychosocial combined with agonist maintenance treatments versus agonist maintenance treatments alone for treatment of opioid dependence, Cochrane Library (Oct. 2011).
• APA, Opioid Use Disorder: Diagnostic Criteria.

VI. Reducing Opioid-related Harms

A. Naloxone--Accessibility and Cost

• Alice Bell, Alex S. Bennett, T. Stephen Jones, Maya Doe-Simkins, and Leslie D. Williams, Amount of naloxone used to reverse opioid overdoses outside of medical practice in a city with increasing illicitly manufactured fentanyl in illicit drug supply, Substance Abuse (June 2018). 

B. Overdose Prevention Sites or Safe Injection

• Chloé Potier, Vincent Laprévote, Françoise Dubois-Arbere, Olivier Cottencin, and Benjamin Rolland, Supervised injection services: What has been demonstrated? A systematic literature review, Drug and Alcohol Dependence, vol. 145, 48-68 (Dec. 2014).
• Colleen L.Barry, Susan G. Sherman, Elizabeth Stone, Alene Kennedy-Hendricks, Jeff Niederdeppe, Sarah Linden, and Emma E. McGinty, Arguments supporting and opposing legalization of safe consumption sites in the U.S., Int'l J. of Drug Policy, vol. 63, 18-22 (Jan. 2019). 
• Jennifer Ng, Does evidence support supervised injection sites?, Canadian Fam. Physician, vol. 63 (Nov. 2017). 
• Michaela Winberg, This state rep threatens to freeze Philly's funding if an overdose prevention site opens, BillyPenn (Sept. 12, 2018).
• Michaela Winberg, Do safe-injection sites offer proven benefits to those facing addiction? BillyPenn (Apr. 5, 2018).