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February 20, 2018

How 30 experts would spend $100B to combat the opioid epidemic

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    A survey by the New York Times' "The Upshot" finds experts on the opioid misuse epidemic generally believe that an effective response would fund four areas—treatment, harm reduction, supply-focused solutions, and demand-focused solutions—though experts are divided on the specific funding allocations.

    Your top resources for combatting the opioid epidemic in one place

    For the survey, "The Upshot" asked 30 experts—ranging from public health and policy experts to politicians and law enforcement officials—to outline how they would allocate $100 billion over five years to address the opioid misuse epidemic.

    Survey findings

    In aggregate, respondents said they would allocate:

    • 47% of funding to treatment, such as medication-assisted treatment and Medicaid coverage;
    • 27% of demand-focused solutions, such as efforts to reduce demand for opioids;
    • 15% of funding to harm reduction, which centers on the idea that efforts should be taken to reduce the risk of existing drug use; and
    • 11% to supply-focused solutions, such as prescription monitoring and law enforcement action.

    That said, "The Upshot" noted that the allocations were in aggregate, and that panelists disagreed about the best way to allocate funding—particularly when it came to funding treatment for opioid misuse versus funding efforts to "preven[t] addiction by reducing demand."

    1. Treatment

    Overall, more than 20 of the 30 panelists made treatment a top priority, "The Upshot" reports. Within the treatment category, the panel, on average, would put about:

    • $18 billion toward medication-assisted treatment;
    • $11 billion toward Medicaid, which is a significant source of funding for substance use disorder treatment, according to "The Upshot";
    • $7 billion toward treatment for prisoners;
    • $6 billion toward other research; and
    • $4 billion toward pre-trial diversion.

    Some of the panelists who made treatment a top priority include:

    • Rhode Island Gov. Gina Raimondo (D);
    • Andrew Kolodny, co-director of opioid policy research at Brandeis University; and
    • Tom Vilsack, former Agriculture Secretary and leader of former President Barack Obama's Rural Council.

    According to "The Upshot," strong evidence supports the use of medication-assisted treatment. Systematic reviews have found such efforts have reduced mortality by more than 50%.

    Regarding Medicaid, Jay Unick, a professor at the University of Maryland, said Medicaid expansion would be "the most important intervention for improving outcomes related to the opiate epidemic." He added, "All the other interventions discussed here only work if individuals have access to quality health care."

    And while all of the panelists supported funding treatment in jails and prisons, according to "The Upshot," nearly 90% of inmates with a substance use disorder do not receive any medical treatment. Experts say this increases the odds of relapse and overdose upon release.

    2. Curtailing demand

    Within the demand-focused category, the panel, on average, would put about:

    • 13% of the $100 billion toward community development;
    • 6% toward post-incarceration support;
    • 5% toward education; and
    • 3% toward pain research.

    Some of the panelists who made demand-focused solutions a top priority include:

    • Anna Lembke, the medical director of addiction medicine at Stanford University School of Medicine;
    • Helen Jones-Kelley, executive director of Montgomery County Alcohol, Drug Addiction and Mental Health Services in Ohio; and
    • Elizabeth Salisbury-Afshar, medical director of the Chicago Department of Public Health.

    According to "The Upshot," panelists who supported demand-focused solutions allocated the most funding toward community development initiatives, such as job training, family services, and child care. Lembke said, "Until we provide people with an alternative source of dopamine, in the form of family connections, meaningful work and a sense of purpose in their lives, the problem of addiction will continue to grow."

    Experts who emphasized demand in their budgets also allocated a substantial portion of their overall budgets to post-incarceration social programs aimed at facilitating social re-integration, "The Upshot" reports. At the same time, funding toward education efforts was limited, with about half of respondents overall giving less than a percentage point of their total budgets to that area. According to "The Upshot," experts are largely skeptical of the efficacy of various education initiatives—such as the DARE campaign, which research suggests was ineffective—although others pointed out that education initiatives could be more targeted, such as prescriber or clinician training.

    3. Harm reduction

    Within the harm-reduction category, the panel, on average, would put about:

    • $4 billion toward the opioid overdose reversal drug naloxone;
    • $3 billion toward syringe exchanges;
    • $3 billion toward surveillance;
    • $2 billion toward HIV/hepatitis treatment;
    • $2 billion toward supervised consumption spaces; and
    • $1 billion toward drug checking services, which allow people to test drugs for presence of contaminants or fentanyl.

    Some of the panelists who listed harm reduction as a top priority included:

    • Keith Humphreys, Esther Ting Memorial Professor at Stanford;
    • Brandon Marshall, associate professor of epidemiology at Brown University School of Public Health; and
    • Michael R. Brumage, director of the West Virginia Office of Drug Control Policy and assistant dean for Public Health Practice and Service at W.V.U. School of Public Health.

    According to "The Upshot," some individual harm reduction strategies received widespread support, with most of the panelists, for instance, giving at least 1% of their overall budgets toward boosting distribution of naloxone. As Alexander put it, "Naloxone is safe, effective, and it saves lives."

    Meanwhile, other options, such as supervised consumption, garnered less support.  Within the United States, there has been some interest in starting safe consumption spaces—though the sites are currently banned under federal law. The country does have at least one unsanctioned site in use, and certain cities are considering legally sanctioned ones.

    4. Supply

    Within the supply-focused solutions category, the panel, on average, would put about:

    • $4 billion toward prescription monitoring;
    • $3 billion toward interdiction;
    • $3 billion toward local police; and
    • $2 billion toward reducing diversion.

    Panelists who made supply-focused solutions a top priority include:

    • Tom Frieden, former CDC director;
    • J. Scott Thomson, chief of police in Camden County, New Jersey, and president of the Police Executive Research Forum; and
    • Stephanie Patton, prevention coordinator in Stoughton, Massachusetts.

    While public health experts are often skeptical of law enforcement efforts, several panelists allocated a small amount for interdiction, largely because of the appearance of illicit fentanyl, according to "The Upshot." Jon Zibbell, a public health scientist at RTI International, said, "No one in the public health community would say that we should let China keep sending fentanyl to the United States."

    Meanwhile, no panelists allocated funding for building a border wall along the United States' border with Mexico—a project the White House requested $18 billion for in its fiscal year 2019 budget proposal. According to Vox, the administration said, "Building the wall is critical to impeding and denying the flow of illicit drugs into our country." However, Thomson said, "For any parent [who] has experienced the unimaginable pain of burying a child [who] has overdosed, a wall would not have prevented your tragedy." He added, "The No. 1 entry point for fentanyl into this country is J.F.K. Airport via U.S. Mail, postmarked from China."

    Separately, Humphreys said, "Too many people in the public health community see police as the enemy, when they should see them as valuable partners in responding to the opioid epidemic."

    Funding can't propel all necessary change, experts say

    Despite the focus on funding allocation, several panelists pointed out that the some of the most important efforts to fight the opioid misuse epidemic must come from cultural changes, such as reducing the stigma around substance use disorders and changing how we think about pain.

    The panel also suggested several federal law updates that would help address the epidemic. Such changes include:

    • Increasing substance use disorder training for physicians;
    • Pharmaceutical industry reforms; and
    • Removing federal restrictions on buprenorphine prescribing (Katz, "The Upshot," New York Times, 2/14; Lopez, Vox, 2/14).

    Learn more: How to combat the opioid epidemic

    Opioid misuse and abuse is one of the most pressing public health issues in the U.S., and hospitals and health systems are on the front lines. Currently, most health systems focus their opioid management efforts on select medical specialties.

    This report outlines three imperatives to guide hospitals and health systems in their efforts to reduce the impact of inappropriate opioid prescribing and misuse.

    Get the Report

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