On the 26th of August, for its part in driving Oklahoma’s spiralling opioid-epidemic, Johnson & Johnson was ordered to pay $572 million in a court-ruling against the pharma-conglomerate. The case follows similar trials against several major pharmaceutical-firms accused of aggressively marketing opioids as low-risk solutions whilst undermining their high potential for addiction, including Teva Pharmaceuticals and OxyContin-maker Purdue Pharma, which has offered up to $12 billion to settle more than 2, 000 lawsuits across 48 US states.
Monday’s landmark court-ruling has far reaching repercussions for opioid makers, distributors, and pharmacy chains nationwide.
The opioid epidemic, which refers to the rapid increase in the use of prescription (painkillers:hydrocodone, oxycodone) and non-prescription opioid drugs (heroin, fentanyl) in the U.S., has emerged as a national crisis. In 2017, opioids were responsible for 47600 drug overdoses deaths overall and the CDC estimates the economic-burden attributed to prescription opioid misuse alone is $78.5 billion per year.
To navigate the crisis, lawmakers must seek answers in data-driven policy addressing the root causes of addiction and opioid abuse.
i) Overdose death by opioid 2000-2016 illustrating the rise of synthetic opioids
ii) Comparison of lethal doses of heroin and the highly-lethal fentanyl.
A key driver to the opioid-crisis is poor access to addiction treatment, which is unevenly distributed based on provider-type and region. Medication-assisted treatment (MAT) including the use of opioid medications methadone and buprenorphine, has been shown to decrease overdose death rates by up to 50%.
However, MAT medications are prescribed in less than half of privately funded opioid treatment programs, and less than a quarter of publicly-funded ones. amfAR, an advocacy group, mapped the availability of facilities treating drug addiction.
Looking at 2016 federal data, they found just 41.2% of 12000+ US drug treatment centres offered one kind of medication for opioid addiction, and 2.7% offered all three. Some of the variations are geographical, with access to MAT medication lower in rural communities and the Midwest; this region recorded higher associated mortality-rates. In short, treatment is inaccessible enough that most patients who need it do not receive it, and available treatment rarely meets best standards.
amFAR map of opioid treatment centres by region and MAT medication availability shows wide disparities in health care coverage
Fixing the access problem will require a huge scale-up of funding to ensure high-quality addiction treatment and rehabilitation-infrastructure is built up across the country. Funds must be allocated to ensure multiple MAT treatment options are available alongside counselling even in less densely populated areas. In particular, money must be sustained for long time-periods (currently, Congress has allocated support funds via grants expiring after a year) for maximum effect.
Evidence for additional funding comes from McKinsey research, whose analysis has highlighted that aggregate investment in combating the opioid crisis (public and private spending) falls short of analogous investment in challenges of similar impact such as cancer research and developing electric vehicles (Figure 1).
Multiple Democratic primary candidates have voiced support for ambitious initiatives, most notably Senator Elizabeth Warren who has proposed a 2019 CARE act which would allocate $100 billion to combat the opioid crisis over 10 years. Her plans would be funded by a wealth tax of two cents per dollar on the super-wealthy (net worth exceeding $50 million) and direct federal funds towards policy and addiction-treatment programs with waivers to push facilities to offer the full range of MAT medications.
The problem remains, how can funding be scaled up to target the root causes of the opioid crisis nationwide amidst widespread disparities in treatment-access? The answer lies in data and technology.
Figure 1: (McKinsey & Company)
Data-driven policy innovation still needed
Scaling existing cutting-edge practice alone via increased funding may be insufficient to combat the opioid crisis.
This is represented by the fact that between 2014 and 2016, not a single state had a statistically significant decrease in the overdose death-rate. Secondly, the most effective treatment approaches utilising MAT medication plus counselling are highly resource-intensive and still retain a relatively high relapse rate.
To efficiently target healthcare interventions tackling the opioid crisis, policy-makers must embrace innovative solutions. A core area to address is an increased emphasis on data and advanced analytics solutions to identify at-risk individuals, prioritize scarce resources, and optimize the efficacy of each policy solution by comparing multiple approaches.
Figure 2 illustrates potential use-cases for analytics solutions. This includes predicting patient groups most likely to overdose based on demographic and contextual factors, and allocating rehabilitation medication on the basis of QALYs (quality-adjusted life years). Federal officials must enact a centralized database of opioid solutions and effectiveness and provide funding for localities to experiment with community-based interventions.
Moreover, non-traditional strategies must be tested to address the new challenge of synthetic opioids such as fentanyl into the US market, largely imported from unregulated markets in China and Mexico, which are responsible for tens of thousands of deaths annually.
This is particularly important when considering unintended consequences. Unchecked regulation could push prescription-opioid users towards cheaper illicit synthetic analogues with higher lethality. A broad and multi-tiered strategy must be considered encompassing new approaches such as supervised consumption sites to limit accidental overdose, as well as tighter monitoring of internet purchase of synthetic-opioids.
Figure 2: Advanced analytics use-case examples for the opioid crisis (McKinsey & Company)
Finally, data-driven process innovation must be achieved especially in regards to widely disparate opioid-prescription rates. For example, rates of new opioid prescription by orthopaedic surgeons for knee sprains can vary between 0-30% within a single state. Enhanced regulation on clinical core guidelines is critical to reducing maximum size and length of prescription-doses, whilst safeguarding opioid use for patients with genuine need.
The opioid crisis presents a multifaceted issue with severe consequences to individual Americans and communities alike. As Walter Bender, a deputy sheriff in Montgomery County, Ohio, put it, “Opioids reach every part of society: blue collar, white collar, everybody. It’s nonstop. It’s everyday.”
Improving access to gold-standard care and funding innovative data-driven solutions are critical to improve health outcomes nationwide.
Written by: Thomas Kurian
Sources and Wider Reading Resources
Time Magazine: https://time.com/opioid-addiction-epidemic-in-america
New York Times:
McKinsey and Company Insights:
The Guardian: https://www.theguardian.com/us-news/2019/jul/24/opioids-crisis-big-pharma-drugs-carnage
The Atlantic: https://www.theatlantic.com/ideas/archive/2019/08/what-america-got-wrong-about-opioid-crisis/595090/
Financial Times: https://www.ft.com/content/c4eddc22-cd86-11e9-99a4-b5ded7a7fe3
BBC News: https://www.bbc.co.uk/programmes/n3ct5f2x
Centre for Drug Control: https://www.cdc.gov/media/releases/2019/s0424-advises-misapplication-guideline-prescribing-opioids.html