In landmark report, public health leaders outline steps for urgent action on opioids

A group of experts, led by researchers at the Johns Hopkins Bloomberg School of Public Health in collaboration with the Clinton Foundation, today issued a new report with comprehensive recommendations aimed at stemming the opioid epidemic, a spiraling crisis that kills on average 90 people a day in the United States and shows few signs of reversing. This report, "The Opioid Epidemic: From Evidence to Impact," maps out a blueprint for national action on the epidemic and details dozens of concrete, evidence-based steps for everyone working to fight the opioid crisis in America – from the health care, advocacy, nonprofit, government, academic, and business sectors.

The recommendations were developed by the Bloomberg School and the Clinton Health Matters Initiative with input from a diverse group of stakeholders, including leaders in clinical care and pain treatment, pharmacy benefit managers, health policy and insurance, injury prevention and law enforcement, among others. The report and its recommendations are among topics that will be discussed at an opioid summit taking place Monday, Oct. 30, at the Bloomberg School and co-sponsored by the Clinton Foundation's Health Matters Initiative.

The report was prepared by researchers at the Bloomberg School's Center for Drug Safety and Effectiveness and its Center for Injury Research and Policy, in collaboration with the Clinton Health Matters Initiative of the Clinton Foundation. The report includes an introduction by President Bill Clinton, founder and board chair of the Clinton Foundation.

"Unlike with many diseases, we have the science and the experience to end the opioid epidemic," President Clinton writes in his introduction. "This report contains specific recommendations for how to most effectively combat the epidemic – from allowing physicians to more effectively treat those suffering from addiction; to expanding coverage and accessibility of opioid overdose reversal drugs like Naloxone; to changing the way that health care professionals, employers, and advocates talk about addiction to reduce stigma."

In 2016, more than 64,000 people died from drug overdoses in the United States, the most of any year on record and a 19 percent increase from 2015, according to initial estimates by the Centers for Disease Control and Prevention. More than half of these were opioid-related, with especially large increases in deaths from heroin and illicit fentanyl.

"The nature of the epidemic has changed enormously during the past few years, and our report provides a timely synthesis of the current state of the field," says G. Caleb Alexander, MD, co-director of the Center for Drug Safety and Effectiveness at the Bloomberg School and one of the report's editors. "The opioid epidemic is a highly complex issue with an enormous human toll. But ultimately, the crisis can be stemmed with approaches that have been shown to be effective."

The report includes 10 priority recommendations upon which to build a comprehensive solution.

• Optimize Prescription Drug Monitoring Programs (PDMPs): PDMP utilization is associated with decreased opioid prescribing and adverse events, yet many states do not mandate PDMP registration and use.
• Work with Medical Boards to Enact Policies Reflecting the CDC Opioid Prescribing Guideline: The Guideline, issued in 2016, remains the gold standard for a comprehensive, evidence-based approach to prescribing opioids for chronic non-cancer pain in primary care, yet many organizations have not yet incorporated the Guideline into practice.
• Support Evaluation Research of Pharmacy Benefit Managers (PBMs) and Pharmacy Interventions: PBMs and pharmacies are engaged in many interventions to reduce opioid overuse and improve pain care, yet all too often these are not rigorously evaluated, leading to important knowledge gaps regarding what works.
• Secure Funding to Assess Effectiveness of Innovative Packaging and Designs: Data on the effectiveness of packaging interventions is limited. Evaluations of the available engineering innovations and those under development are needed to inform practice.
• Provide Clear and Consistent Guidance on Opioid Disposal and Expand "Take Back" Programs: There are enormous volumes of unused opioids in homes throughout the United States that are too often diverted for nonmedical use. Safe disposal options for prescription opioids are needed.
• Invest in Surveillance of Misuse and Use Disorders Including Information about Supply Sources: Surveillance of opioid use, misuse, and opioid-use disorders is critical for the improvement of primary, secondary, and tertiary prevention efforts.
• Allocate Federal Funding to Build Treatment Capacity in Communities of Greatest Need: Some communities are harder hit than others and cannot begin to meet the demand for treatment. They need urgent funding.
• Partner with Product Developers to Design Easier to Use and Less Costly Naloxone Formulations: Having multiple products that are easy for non-medical personnel to use would increase uptake and reduce costs. Price is consistently raised as a concern, and recent reports indicate that the cost of the drug is increasing dramatically.
• Establish and Evaluate Supervised Consumption Spaces: Medically supervised consumption of heroin in supervised consumption spaces may help prevent overdoses and can encourage users to get treatment.
• Avoid Stigmatizing Language and Include Messages Communicating Effectiveness of Treatment and Acknowledgement of Structural Barriers to Care: Promoting language that does not stigmatize those with opioid use disorders can increase support for effective treatment of this condition.

Prescription opioids serve a vital role in the treatment of cancer pain and pain at the end of life. A major challenge is to balance benefits with the potential harms of opioid medications, given the high potential for addiction, diversion, and overdose. Another challenge is that those already addicted need access to effective treatment without fear of stigmatization.

"The opioid situation is certainly dire, but we are seeing progress in some areas," says Shannon Frattaroli, PhD, associate director for outreach at the Johns Hopkins Center for Injury Research and Policy at the Bloomberg School and one of the report's editors. "Communities across the U.S. are organizing prevention efforts such as increased naloxone distribution that reverse an overdose, and drug 'take back' programs that reduce the supply of unused medications that are being unsafely stored in patients' homes. Taken together, these and other efforts suggest we can intervene in both the supply and demand of these drugs in communities and turn the crisis around."

At the same time, downstream effects of the epidemic are becoming more visible and include strains to the foster care system, HIV and hepatitis outbreaks related to intravenous drug use, and most starkly, a declining U.S. life expectancy.

"Our hope is to get this report into as many hands as possible—lawmakers, health care providers, first responders, employers, policymakers, journalists, faith-based leaders, community organizers and activists—so they can see what works and what still needs to be done," says Andrea Gielen, ScD, director of the Center for Injury Research and Policy and one of the report's editors. "We want people to consider what we've identified in the report: Policies, programs, products, and approaches that work, and advance the recommendations that fit their communities' needs."