An Evidence-Based Road Map to Navigating the Opioid Epidemic

Prescription drug monitoring programs are often overseen by state departments of health or boards of pharmacy, and can be used to identify potential abuse/diversion of controlled substances, obtain data on a given patient’s controlled substance history, and detect problematic prescribing/dispensing practices. Additional interventions include the regulation of pain management clinics to reduce a significant source of prescription opioids often used for diversion or nonmedical use. Screening, brief intervention, and referral to treatment is a “public health approach…that incorporates universal screening, detection of risky or hazardous substance use, early intervention, and referral to treatment for individuals identified with substance use disorder within a single, evidence-based model.”

Tertiary prevention “focuses on decreasing the complications of a disease through treatment and other support.” This includes referring patients to medication-assisted treatment involving pharmacotherapies such as methadone, buprenorphine, and naltrexone, often in combination with psychosocial interventions. No single treatment approach is effective for all individuals with opioid use disorder; therefore, approaches and settings need to be individualized.

Neonatal abstinence syndrome can be addressed by treating the mother and the infant, as well as preventing a second pregnancy.

A pregnant woman who has addiction should receive medication-assisted treatment, as well as nonpharmacologic interventions after childbirth.

Drug courts have been shown to facilitate the integration of evidence-based addiction treatment into the criminal justice system, as drug abuse, criminal activity, and involvement with the criminal justice system are often intertwined. Approximately half of incarcerated inmates meet diagnostic criteria for drug abuse or dependence, but only a minority receive treatment. Drug courts are typically operated by a multidisciplinary team and target criminal defendants and offenders, juvenile offenders, and parents with pending child welfare cases.

Finally, the review authors recommend training the public on using naloxone. Although some concerns have been raised that the presence of naloxone may be regarded as a “safety net,” the drug has been found to be effective in saving countless lives.

Education of Healthcare Professionals

On a policy level, there have been attempts to restrict the supply of opioids. “Constraining the supply of prescription opioids, which is a current strategy for attempting to curb the opioid epidemic, means that a number of people who are dependent on opioids have moved into a situation where they’re looking for the same type of physical effect that their prescribed opioids had,” noted Dr Pack. These individuals often “move either to diverted opioids that were prescribed to someone else or, in some cases, to heroin or fentanyl, and this is part of what has been driving the second and third waves of the opioid epidemic.” To counter this phenomenon, healthcare professionals must be “vigilant about identifying patients who are physically dependent [on opioids] and are moving into OUD, and are becoming impaired in ways that are really impacting their lives,” he advised. “We need to move these patients to medical assistance quickly, and do that at a better and larger scale, ideally alongside a primary care provider who can also then modify the extent to which the patient’s other medications are also affecting their lives.” To achieve this goal, prescribers should become familiar with facilities that offer these medical treatments and refer patients. Prescribers should also become familiar with professionals, such as caseworkers, who might facilitate the practicalities of receiving treatment, such as financial or logistical access. “Recognize that some patients might feel stigmatized about the fact that they need this type of treatment and providers should approach the subject nonjudgmentally,” recommended Dr Pack. “Healthcare professionals need to talk to each other about their respective patients; for example, a pharmacist might see that a doctor prescribed 2 medications that interact negatively and may advise the patient to talk to the physician, but the pharmacist may not necessarily pick up the phone to talk to the physician.”

A Message of Hope

The risk factors and key drivers of nonmedical use of prescription opioids and for OUD are “amenable to change,” the review authors noted. “The most important thing to remember is that people do get better,” emphasized Dr Pack. “It may be a complicated situation for the patient, but I have a lot of people around me on a daily basis who have dealt with their own [OUD] problems and are living great lives, both on and off medically assisted treatment. It is imperative that physicians and clinicians in the whole orbit of patient care, including nurse practitioners, physician assistants, and pharmacists, take a long view on the patient and know that even very desperate cases can wind up as success stories.”

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1. Mathis SM, Hagemeier N, Hagaman A, Dreyzehner J, Pack RP. A dissemination and implementation science approach to the epidemic of opioid use disorder in the United States. Curr HIV/AIDS Rep. 2018;15(5):359-370.

2. The White House. The Opioid Crisis. Accessed December 18, 2018.

3. Buchanich JM, Balmert LC, Burke DS. Exponential growth of the USA overdose epidemic. bioRxiv. 2017;134403.

4. US Department of Health and Human Services (HHS). What is the U.S. Opioid Epidemic? Updated January 22, 2019. Accessed December 18, 2018.4.