Addressing a national crisis: 10 things to know about the presidential opioid commission's recommendations

The President's Commission on Combatting Drug Addiction and the Opioid Crisis issued its final report Nov. 1, detailing more than 50 recommendations on how the federal government can help address what many politicians and addiction experts have called the worst drug crisis in the nation's history.

Provisional data released by the CDC in September suggests more than 64,000 people died of drug overdoses in 2016, which surpasses the 58,200 Americans who died in the Vietnam War. The 2016 overdose death total marks a 21 percent increase from the year prior and was primarily driven by opioid-related overdoses, which were attributable to about 75 percent of all drug overdose deaths in 2016.

President Donald Trump established the opioid commission via an executive order in March to develop actionable recommendations to address the crisis.

Here are 10 things to know about the recommendations.

On federal funding

1. The panel's recommendations listed in the final report included addressing the mechanisms behind the disbursement of federal funds to address the crisis, expanding addiction treatment and prevention services, increasing the availability of the opioid overdose antidote naloxone and supporting research into improving pain management and addiction services.

2. The commission acknowledged a dearth of funding as the primary obstacle to achieving some of these recommendations. The group urged Congress to act upon President Trump's declaration of a public health emergencyin October and allocate sufficient funds to implement the recommendations.

3. While the commission did not outline a specific dollar amount needed to achieve its recommendations, the group did make specific recommendations regarding how money should be distributed among states to address the crisis. The commission said currently fragmented federal funds for addiction and prevention services should be streamlined into block grants — a move supported by every governor in the nation. This change would allow states to file a single application for funds rather than several to multiple agencies. Additionally, the commission argued the Office of National Drug Control Policy should develop and coordinate a system to track all federally funded opioid initiatives.

"If we are to invest in combating this epidemic, we must invest in only those programs     that achieve quantifiable goals and metrics," wrote the commission. "We are operating blindly today; ONDCP must establish a system of tracking and accountability."

On preventing opioid addiction

4. The commission's recommendations to prevent opioid addiction address elements of education, prescribing guidelines, prescription drug monitoring and law enforcement. With regards to education, the report argued for the Department of Education to collaborate with states to screen at-risk youth for possible opioid addiction or misuse. The commission also suggested the Trump Administration launch a national media campaign to address the dangers of opioid use and the stigma of drug addiction.

5. In the report, the commission suggested HHS develop and coordinate the implementation of care standards for opioid prescribing to supplement the CDC's guidelines. Additionally, the commission recommended CMS remove all questions on pain management from patient satisfaction surveys to eliminate physician incentive to prescribe opioids at a patient's request to boost reimbursement-linked survey scores.

6. In the report, the commission highlights opioid prescriptions for post-surgical pain as being one of the key contributing factors to the crisis. This issue has been exacerbated by CMS reimbursement policies that create incentives for prescribing opioids instead of nonopioid, multimodal pain medication. The commission called for the implementation of more equitable reimbursement rules for nonopioid pain medication for postsurgical pain. Under current federal policies, reimbursement for drugs administered to reduce postsurgical pain are bundled under an all-inclusive payment for surgical supplies. This policy results in Medicare distributing a fixed reimbursement fee to hospitals whether the surgeon administered a nonopioid medication or not, increasing hospital expenses.

"The Commission recommends CMS review and modify rate-setting policies that discourage the use of nonopioid treatments for pain, such as certain bundled payments that make alternative treatment options cost prohibitive for hospitals and doctors, particularly those options for treating immediate postsurgical pain," wrote the commission.

7. With regards to law enforcement, the commission called for establishing drug courts in all federal judicial districts to help individuals with opioid addiction avoid jail time in favor of addiction treatment. The group also recommended enhancing federal penalties for the trafficking of fentanyl and fentanyl analogues. Additionally, the commission recommended establishing a national outreach plan for first-responder safety with regards to exposure to extremely potent synthetic opioids, which can induce overdose via inadvertent inhalation or contact with the skin.

On opioid addiction and overdose treatment

8. The commission recommended CMS, HHS, the Department of Veteran's Affairs and the Substance Abuse and Mental Health Services Administration implement quality initiatives to ensure healthcare providers adequately screen patients for substance use disorders.

9. The commission also advocated for increasing first-responder access to naloxone and expanding the availability of medication-assisted treatment for addiction. Additionally, the group called for expanded access to other addiction treatment services such as recovery coaches. The commission said the federal government should "partner with appropriate hospital and recovery organizations to expand the use of recovery coaches, especially in hard-hit areas."

On research and development

10. The opioid commission recommended multiple federal agencies, including the CDC and the National Institutes of Health, review current research programs and establish goals for research into pain management and addiction treatment. To support such research initiatives, the commission recommended the federal government provide resources to multiple branches of the NIH, including the National Institute on Drug Abuse.

"NIDA should continue research in concert with the pharmaceutical industry to develop and test innovative medications for [substance use disorders] and [opioid use disorders], including long-acting injectables, more potent opioid antagonists to reverse overdose, drugs used for detoxification and opioid vaccines," wrote the commission.

What role will healthcare play in solving the crisis?

The opioid epidemic is a deeply complex public health issue and bringing it to a close will require substantial efforts from multiple industries and sectors of government. The role of hospitals and health systems will undoubtedly have a crucial part to play in solving the crisis as multiple healthcare industry stakeholders, whether knowingly or not, helped facilitate its onset, according to the commission.

When considering the commission's recommendations, it's reasonable to assume changes with regards to reimbursement for opioid and nonopioid pain medication are on the horizon. One place hospital leaders can look to head off opioid addiction before it has a chance to take hold is in the operating room.

Recent research conducted by the QuintilesIMS Institute and sponsored by Pacira Pharmaceuticals, Inc., identified postsurgical opioid trends that suggest the operating room has become an unintentional gateway for the opioid epidemic.

For the report — dubbed "The United States for Non-Dependence" — researchers analyzed prescriptions for 2,075 surgical patients treated at 600 private hospitals. The report found nearly all postsurgical patients received opioids despite the availability of nonopioid pain medication. Those given prescriptions received an average of 85 pills each. Additionally, researchers found one in ten patients exposed to opioids in the surgical setting were still on these medications three to six months after surgery and nearly one in ten patients exposed to postsurgical opioids went on to long-term use of these medications.

Some hospitals have already reported significant success on this front. Richmond, Va.-based Bon Secours St. Mary's Hospital achieved an 80 percent reduction in postoperative opioid use among laparoscopic colorectal surgical patients after implementing a new surgical recovery program, which included the use of nonopioid pain medications, according to an October report from the Richmond Times-Dispatch.

In its introduction, the presidential report offers a summary of the nation's first opioid crisis, which occurred in the mid- to late-19th century and was associated with Civil War veterans and medications such as morphine, codeine and heroin. The commission described the solution to that crisis as involving physicians, pharmacists and medical education, among other entities. This solution model, according to the commission, provides historical precedent for a resolution to the nation's current crisis.

"[T]his crisis can be fought with effective medical education, voluntary or involuntary changes in prescribing practices, and a strong regulatory and enforcement environment," wrote the commission.

More articles on opioids: 
Seizure drug accelerates post-surgical opioid cessation, study finds 
CareFirst BCBS restricts opioid prescriptions, unveils $1.5M in grants to combat epidemic 
5 things to know about Kellyanne Conway's role as head of 'opioids cabinet'

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