Strategy to battle opioid epidemic encourages multilevel approach

Years of coordinated efforts will be required to contain and reverse the harmful societal effects of the country's ongoing prescription and illicit opioid epidemic, according to a new report from the National Academies of Sciences, Engineering and Medicine (NASEM). The report, requested by the U.S. Food and Drug Administration (FDA) and published July 13, said it is possible to stem the still-escalating epidemic without eliminating access to opioids for patients who suffer from pain and whose providers prescribe the drugs responsibly.

The 18-person committee that authored the report recommended actions the FDA, other federal agencies, state and local governments, and health-related organizations should take—including promoting more judicious prescribing of opioids, expanding access to treatment for opioid-use disorder, preventing more overdose deaths, weighing societal impacts in opioid-related regulatory decisions, and investing in research to better understand the nature of pain and develop nonaddictive alternatives.

The committee was composed of experts involved in different aspects of pain management and opioid-use disorders. Among them was Jose A. Moron-Concepcion, associate professor of anesthesiology at Washington University School of Medicine in St. Louis. He studies the emotional component of pain and opioid receptors that modulate the sensory component of pain and the negative emotions associated with it. He discussed some of the key points addressed in the new report:

What is the status of the ongoing epidemic?

We were asked to characterize the epidemic and recommend actions the FDA and other organizations should take to respond. Overall, we found that the opioid epidemic is getting worse. Each day, 90 individuals in the United States die from an overdose that involves an opioid. Trends indicate that premature deaths associated with the use of opioids are likely to climb and that opioid overdose and other opioid-related harms will dramatically reduce the quality of life for many people in years to come.

What, in general terms, is recommended in the new report?

These are the key elements highlighted in the report:

• Changing the culture of prescribing, partially through enhancing education for physicians and the general public.
• Investing in treatment for the millions of individuals with opioid-use disorder and removing impediments to those treatments. Also, improving health-care provider education for opioid-use disorder.
• Preventing overdose deaths, including access to naloxone (also known by its brand name Narcan) and safer injection equipment.
• Weighing societal impacts, not just an individual's, regarding opioids, such as incorporating public health considerations into the FDA's current framework for making regulatory decisions regarding opioids.
• Investing in basic research, particularly to better understand the nature of pain and the neurobiology of the intersection between pain and opioid-use disorders. In addition, increasing the investment in developing nonaddictive alternatives to opioids for pain management.

Opioids are still known to be effective drugs for pain. How does the report balance the needs of patients who need pain treatment with reducing the availability of opioids?

When examining what actions to take, we also wanted to get the balance right and ensure that whatever measures we recommend to the FDA would still leave room for responsible prescribing and reasonable access for patients and physicians. As mentioned above, this also includes changing the culture of prescribing, which will necessitate improvements in education for the medical community, including establishing pain-education materials and curriculum for health-care providers. For the general public, we recommend evaluating the impact of patient and public education about opioids in an attempt to promote safe and effective pain management. The epidemic took nearly two decades to develop, and it will take many years to control, contain and reverse. Therefore, years of a sustained and coordinate effort will be required.

You and your colleague Adrianne Wilson-Poe, instructor in anesthesiology, recently published a review article about this problem, an update on where things stand regarding the chronic pain and opioid epidemics. Does this new report help to address some of the issues raised in your article?

Yes. As we also reported in our review article, we found that despite a decrease in the number of opioids being prescribed, many people who otherwise would have been using prescription opioids have transitioned to heroin, with a threefold increase in heroin-involved deaths from 2010 to 2014. Based on this, a change in prescribing and in patient behavior is crucial.

Importantly, our review also highlighted the need for a major investment in basic research to further elucidate the neurobiology of pain and opioid-use disorders. As mentioned above, the new report recommends a significant increase in funding to improve understanding of the neurobiology of pain, to support the discovery of innovative treatments and to improve understanding of the intersection between pain and opioid-use disorders.