This white paper is a summary of a 2018 AMSUS Executive Advisory Board (EAB) forum. EAB members are thought leadership industry partners creating a think tank for the federal health sector, a platform for federal-civilian networking and communications, and a partnership to share the future of federal healthcare.
Opioid addiction and overdose have been rising at such alarming rates that opioid overdoses now account for more deaths per year than deaths from breast cancer. More than 42,000 people in 2016 alone died of opioid overdose, up from more than 33,000 in 2015. More men die of opioid overdose than do women, but the gap is closing. Most of the fatal overdoses are from illicit drugs, particularly fentanyl, a powerful drug that often is used as an additive to street drugs. But 40 percent of the fatal overdoses involved prescription opioids.
In an effort to search for solutions to this national problem, AMSUS, The Society of Federal Health Professionals hosted a panel of experts to discuss how informatics can be applied to help address the opioid crisis. It was one topic in a series of forums hosted by AMSUS to help shape changes in federal health care.
Moderated by Fred Cecere, MD, Executive Director and Vice President of the Think, Lead, Innovate Foundation, panelists were:
Andrew Gettinger, MD
Chief Clinical Officer & Executive Director of the Office of Clinical Quality and Safety
Office of the National Coordinator, US Department of Health & Human Services
Inna Belfer, MD, PhD
Office of Research on Women’s Health
National Institutes of Health
Bonnie Sakallaris, PhD, RN
Think, Lead, Innovate Foundation
Ahmed Calvo, MD
Think, Lead, Innovate Foundation
Vice President of Defense Department Programs
Sam Shekar, MD
Chief Medical Officer
Northrop Grumman Technology Services
Comments weren’t restricted to the formal members of the panel, however. Members of the audience, which included physicians and nurses, representatives from pharmaceutical companies and information technology companies, defense health program subject matter experts, and others, also contributed to the discussion. They, too, shared their views on how information may be shared faster, easier and more broadly in a coordinated fashion to curb the national opioid epidemic. Their comments, along with those of the formal panel, are included in this summary.
The conversation was far-reaching; it ventured beyond health informatics, and into socio-economic and law enforcement issues. Understanding the supply chain of opioids is important, but so is getting a handle on the reasons for demand. The larger solution involves stakeholders throughout the community, including providers and healthcare systems, drug makers, technology developers, law enforcement agencies, and social services.
Building such a system has its hurdles, such as patient privacy laws, long-standing requirements for lengthy clinical trials for proven therapies, and not overburdening the provider workflow, to name a few.
A solution not only has implications for responding to and thwarting today’s health crisis, but also tomorrow’s.
It may result in physicians who are better educated on pain management, patients whose options include complementary and integrative treatments and access to mental health care, communities with strong education systems and economies, and methods in place to share that information.
The Office of the National Coordinator (ONC) for Health Information Technology in the Department of Health and Human Services is guiding public and private stakeholders in developing a “Trusted Exchange Framework and Common Agreement” to share information between different health information networks.
Some see hope in blockchain technology, a decentralized, digital ledger best known for its use in financial transactions. It has potential to share data from different systems and different types of data, such as law enforcement and health care. The Office of the National Coordinator for Health Information Technology (ONC) technology experts are beginning to look at blockchain technology to determine if it is a candidate for sharing health information. There is some concern that blockchain may lack the speed necessary to provide the response time required for some health information exchange.
Lessons may be learned from others’ experience. Finland, for example, is integrating its nationwide electronic health record system with social services, police and other systems, and is finding ways to overcome challenges of doing so. The concept is “person” centered, not patient-centered, so the view is a broader one.
There are efforts under way in both the public and private sectors to curb the opioid crisis.
Since its launch in 2013, the Department of Veterans Affairs Opioid Safety Initiative, for example, has led to a reduction in the dosage and number of patients receiving opioid drugs. The Army’s Interdisciplinary Pain Management Clinics offer conventional and integrative approaches. Information gathered there may help predict how an individual will respond to treatments.
Academic research institutions are using computers to help patients manage their pain. At the University of Pittsburgh, for example, researchers developed an online tool for children who have sickle cell anemia. The tool helped the patients characterize their pain as either chronic, acute or in crisis, and identify when it occurs, so that the proper treatment approaches can be applied. If pain can be predicted, it allows for interventions without opioids. Now another university is using that same information to develop an algorithm that can be used to assess and manage pain for patients who may not be able to clearly express how they are feeling.
Healthcare plans and pharmacy benefit managers are limiting the amount of opioids that can be dispensed at any one time. Pharmacists who exceed that limit without permission aren’t paid for the extra pills.
A large prescription drug benefit management company can search for any drug and see on a map of its nationwide network where the prescription is being dispensed or denied. Sharing that information with providers can help drive more thoughtful clinical decisions. Patients who are given opioid prescriptions receive letters mailed to their homes to educate them on the drug and a disposal bag for leftover pills to render them inactive.
Mandatory use of Prescription Drug Monitoring Programs also can help reduce overprescribing of opioids and in some places have already demonstrated success.
Virtually every state has launched a Prescription Drug Monitoring Program (PMP) to track prescribing or dispensing of controlled substances. How each PMP operates varies by state, including who consults the database, who reports information to the database, and the timeframe in which they enter the information. Some states require physicians and pharmacists to report information to the database or consult the database before prescribing or dispensing. Other states only require the prescriber to check the database, and 17 states don’t require checking at all. Some states require information be entered the same day, while others allow as much as 30 days.
In states where prescribers were required to use the PMP, there was a 9 to 10 percent reduction in the number of opioid prescriptions given to Medicaid users.
New York is an excellent example of how PMPs can curb prescription opioids. The Interstate System for Tracking Over-Prescribing (I-STOP) mandates use by physicians and pharmacists, and has reduced doctor-shopping for opioids by 98 percent. I-STOP is interoperable with 25 states and Washington, D.C., giving prescribers access to about 150 million patient records on controlled substances. In New York’s program, physicians must prescribe electronically and first check the PMP before prescribing controlled drugs. Pharmacists must report filling prescriptions for controlled substances to the PMP in real time.
Another source of community data can come from emergency departments. Information about the types of visits is known in 24 to 48 hours and can serve as early warning signs of widespread opioid abuse, the presence of a particularly deadly drug on the street, and prescriber practices.
At the National Institutes of Health, researchers have been working for the last five years on new initiatives for pain management and, separately, also for reducing opioid use disorders. Improved pain management includes a chronic pain data registry to identify interventions that may be more effective for managing chronic pain. It also includes prescriber education.
Research is ongoing in precision and individualized pain management medicine. Multiple efforts are under way to develop algorithms based on personal qualities and history to calculate the likelihood of opioid abuse. In the next three years, researchers may be able to identify “signatures” that predict opioid abuse.
One of the newest initiatives from the National Institutes of Health was announced April 4. It’s called HEAL, which stands for Helping to End Addiction Long-term. HEAL has two main objectives:
prevent addiction through enhanced ways to manage pain and improve treatments for opioid misuse and addiction.
Participants at the AMSUS meeting expressed concern that physicians need more education on opioid doses, the length of time a patient should take the drug, proper follow-up after writing the prescriptions, and alternate therapies to opioids. They said that in particular, primary care doctors staffing emergency departments could benefit from more training, as could dentists.
Improving treatment protocols can be achieved in teaching hospitals. Hospitals train all health care practitioners and can help train providers to better manage pain without reaching first for high-dose opioids. This can be achieved through peer-to-peer learning and machine learning.
In one academic institution, the section chief of general surgery challenged the defaults in the Electronic Health Record system, saying the default dose for pain medication was too high. By lowering the default dose, they dramatically reduced the amount of narcotics used by patients following surgery, without increasing their pain level scores. The same approach can be used to include evaluation and consultations for complementary treatments.
Complementary and integrative treatments can be used to help treat pain, but availability of such treatments depends in part on insurance coverage. In the Military Health System, for example, people who use the military hospitals and clinics may have access to alternative pain therapies, such as acupuncture or chiropractic care. But military dependents and retirees who receive their care through TRICARE’s civilian market aren’t afforded the same opportunities.
Naturopathy, complementary and alternative medicine is specifically excluded from TRICARE’s purchased care—an exclusion that may be outdated.
Beyond that specific exclusion is the requirement that any covered treatment must meet rigid definitions of safety and efficacy through randomized, controlled trials, technical assessments and analysis of data across multiple studies, and consensus of professional opinion.
Rehabilitative care, and complementary and alternative medicine are areas that lend themselves well to pragmatic, real-world and multimodal research approaches. There are records documenting treatments and what happened to the patients, even de-identified patients. There is an opportunity to use large batches of metadata to help understand the outcomes of different kinds of treatments.
Data taken from medical encounters can be used to help drive faster research findings. Adaptive clinical trials cost less, are based on real world experience and allow treatments to develop quicker. But they require rigorous math.
Opportunities exist not only for information technology experts, but also for device makers. Smart pills, those equipped with chips to track ingestion, can monitor adherence and overuse. This technology could also be used to identify the drug’s origin to track counterfeit or foreign-made drugs, for example.
While much focus has been on opioid overdose deaths, those numbers tell only part of the story. Every three minutes, for example, a woman goes to the emergency room for misusing or abusing prescription painkillers, according to the National Institutes of Health.
Women shoulder a large burden of the opioid crisis. They suffer more from painful conditions than do men; are more likely to be prescribed opioids; receive higher doses, and stay on the drugs longer. Because of sex differences in metabolism, absorption and elimination, women become dependent on opioids more quickly than men. Some 66 percent of caregivers are women and their care-giving responsibilities can impede access to rehabilitative treatment.
Understanding what drives the demand for opioids is important. Physical pain is one reason for demand. But turning to drugs to help cope with emotional pain is another. Sometimes there are clues to indicate what communities can be vulnerable to opioid abuse. Thriving communities rely on multiple factors, primarily: good health and nutrition, economic empowerment through employment opportunities, strong education systems, and sharing critical bits of information related to all of these factors. When these crucial systems are lacking, the sense of community is lost, and people living there may experience overwhelming feelings of hopelessness and helplessness. As a result, they may be vulnerable to opioid abuse and other problems. This scenario has played out in many of the areas of the country hit hardest by the opioid epidemic.
Data from health, education, and employment systems can help identify vulnerable communities. Preventive measures can be deployed to avert widespread drug addiction problems or to respond to existing problems with treatment options.
Opioid addiction isn’t the country’s first drug epidemic. In the past there have been large demands for cocaine and crack cocaine, for example. To battle any such crisis, officials must address what is driving the demand for these and future drugs. To better understand the demand requires a 360-degree view of the person taking the drugs. It includes knowing the person’s health status, but also their education, socio-economic situation, spirituality, and lifestyle.
Deborah Funk is a freelance writer and president of DF Communications.
For questions regarding the AMSUS Executive Advisory Board, contact Stacie McArdle.
For questions or comments regarding this EAB Forum, contact Fred Cecere.