Public health leaders urge far-reaching reforms to curb prescription opioid epidemic

The report calls for changes to the way medical students and physicians are trained, prescriptions are dispensed and monitored, first responders are equipped to treat overdoses, and those with addiction are identified and treated. The report grew out of discussions that began last year at a town hall co-hosted by the Bloomberg School and the Clinton Health Matters Initiative, an initiative of the Clinton Foundation. The recommendations were developed by professionals from medicine, pharmacy, injury prevention and law. Patient representatives, insurers and drug manufacturers also participated in developing the recommendations.

The call to action comes at a time of heightened awareness about the prescription opioid epidemic. More than 16,000 people died in the U.S. from overdoses related to opioid pain relievers in 2013, four times the number who died in 1999, according to the U.S. Centers for Disease Control and Prevention (CDC). Prescription opioid sales have increased 300 per cent since 1999. The CDC estimates that two million Americans were dependent on opioid medications in 2013.

"What's important about these recommendations is that they cover the entire supply chain, from training doctors to working with pharmacies and the pharmaceuticals themselves, as well as reducing demand by mobilizing communities and treating people addicted to opioids," says Andrea Gielen, ScD, ScM director of the Johns Hopkins Center for Injury Research and Policy at the Bloomberg School and one of the report's signatories. "Not only are the recommendations comprehensive, they were developed with input from a wide range of stakeholders, and wherever possible draw from evidence-based research."

Carefully used, opioids provide important pain relief for many patients with acute or post-surgical pain. Up until the late 1990s, prescription opioids were prescribed primarily to cancer patients. They became more widely used as new products were developed and aggressively promoted for wider use. In addition, their addictive potential was substantially underestimated. Another complicating factor is so-called diversion-use by friends and family rather than those actually prescribed the painkillers. According to the CDC, in 2012, health care providers wrote 259 million prescriptions for opioid pain relievers, enough to supply every adult in the U.S. a four-week, round-the-clock supply.

The report, titled "The Prescription Opioid Epidemic: An Evidence-Based Approach," breaks its recommendations into seven categories:

• Prescribing Guidelines • Prescription Drug Monitoring Programs (PDMPs) • Pharmacy Benefit Managers (PBMs) and Pharmacies • Engineering Strategies (i.e., packaging) • Overdose Education and Naloxone Distribution Programs • Addiction Treatment • Community-Based Prevention Strategies

"This is a complex epidemic with no simple solutions," says G. Caleb Alexander, MD, MS, co-director of the Johns Hopkins Center for Drug Safety and Effectiveness at the Bloomberg School and another of the report's signatories. "We tried to identify as many windows as possible, and to tie together as much research as available, to inform these recommendations which together we believe provide the best chance of turning this steamship around."

The report calls for stricter oversight of clinical prescribing and more comprehensive training of medical students, who presently receive very little instruction on the subject. The signatories also recommend expanding the role of pharmacies and Pharmacy Benefits Managers, both of which stand between the prescribers and the patients who receive the medication. For example, increased use of electronic prescribing to identify high-risk patients and prescribers, along with expanded availability of drug take-back programs, would give pharmacies a greater role in reducing opioid misuse and abuse.

The authors also call for mandatory use of Prescription Drug Monitoring Programs (PDMPs), state databases that include controlled substance prescriptions from in-state pharmacies. Every state but Missouri has a version of a PDMP, as do Washington, D.C., and Guam. At present, PDMPs are voluntary in many states and actual use varies -- many prescribing providers are not aware of them -- and their design varies from state to state. In addition to making PDMPs mandatory, the report recommends making them more accessible to law enforcement when warranted.

The report calls for expanding the availability of naloxone, which can reverse the effects of an overdose if administered promptly.

Among the recommendations to address addiction, working group members call for providing funding for treatment programs to communities with high rates of addiction and educating prescribers and pharmacists on ways to prevent addiction.

Among the report's other recommendations: develop more secure and tamper-resistant packaging through design contests and other approaches and, as noted above, expand "take back" programs that allow patients to return unused medication to pharmacies to reduce chances that the pills might be taken by potential abusers.

The report is available at: http://www.jhsph.edu/research/centers-and-institutes/center-for-drug-safety-and-effectiveness/opioid-epidemic-town-hall-2015/2015-prescription-opioid-epidemic-report.pdf