The Opioid Overdose Crisis

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16. Reductions in Opioid Prescribing for People with Severe Pain

"According to the Medical Expenditure Panel Survey, the annual share of US adults who were prescribed opioids decreased from 12.9 percent in 2014 to 10.3 percent in 2016, and the decrease was concentrated among adults with shorter-term rather than longer-term prescriptions. The decrease was also larger for adults who reported moderate or more severe pain (from 32.8 percent to 25.5 percent) than for those who reported lessthan-moderate pain (from 8.0 percent to 6.6 percent). In the same period opioids were prescribed to 3.75 million fewer adults reporting moderate or more severe pain and 2.20 million fewer adults reporting less-thanmoderate pain. Because the decline in prescribing primarily involved adults who reported moderate or more severe pain, these trends raise questions about whether efforts to decrease opioid prescribing have successfully focused on adults who report less severe pain."

Mark Olfson, Shuai Wang, Melanie M. Wall, and Carlos Blanco. Trends In Opioid Prescribing And Self-Reported Pain Among US Adults. Health Affairs 2020 39:1, 146-154.
https://www.healthaffairs.org/...

17. Estimated Economic Impact of Illegal Opioid Use and Opioid-Related Overdose Deaths

The White House Council of Economic Advisers [CEA] released its analysis of the economic costs of illegal opioid use, related overdoses, and overdose mortality in November 2017. It reported a dramatically higher estimate than previous analyses, largely due to a change in methodology. Previous analyses had used a person's estimated lifetime earnings to place a dollar value on that person's life. According to the CEA, "We diverge from the previous literature by quantifying the costs of opioid-related overdose deaths based on economic valuations of fatality risk reduction, the “value of a statistical life” (VSL)."

The CEA noted that "According to a recent white paper prepared by the U.S. Environmental Protection Agency’s (EPA) Office of Policy for review by the EPA’s Science Advisory Board (U.S. EPA 2016), the EPA’s current guidance calls for using a VSL estimate of $10.1 million (in 2015 dollars), updated from earlier estimates based on inflation, income growth, and assumed income elasticities. Guidance from the U.S. Department of Health and Human Services (HHS) suggests using the range of estimates from Robinson and Hammitt (2016) referenced earlier, ranging from a low of $4.4 million to a high of $14.3 million with a central value of $9.4 million (in 2015 dollars). The central estimates used by these three agencies, DOT, EPA, and HHS, range from a low of $9.4 million (HHS) to a high of $10.1 million (EPA) (in 2015 dollars)."

In addition, the CEA assumed that the number of opioid-related overdoses in the US in 2015 was significantly under-reported. According to its report, "However, recent research has found that opioids are underreported on death certificates. Ruhm (2017) estimates that in 2014, opioid-involved overdose deaths were 24 percent higher than officially reported.4 We apply this adjustment to the 2015 data, resulting in an estimated 41,033 overdose deaths involving opioids. We apply this adjustment uniformly over the age distribution of fatalities."

The combination of that assumption with the methodology change resulted in a dramatically higher cost estimate than previous research had shows. According to the CEA, "CEA’s preferred cost estimate of $504.0 billion far exceeds estimates published elsewhere. Table 3 shows the cost estimates from several past studies of the cost of the opioid crisis, along with the ratio of the CEA estimate to each study’s estimate in 2015 dollars. Compared to the recent Florence et al. (2016) study—which estimated the cost of prescription opioid abuse in 2013—CEA’s preferred estimate is more than six times higher, reported in the table’s last column as the ratio of $504.0 billion to $79.9 billion, which is Florence et al.’s estimate adjusted to 2015 dollars. Even CEA’s low total cost estimate of $293.9 billion is 3.7 times higher than Florence et al.’s estimate."

In contrast, the CEA noted that "Among the most recent (and largest) estimates was that produced by Florence et al. (2016), who estimated that prescription opioid overdose, abuse, and dependence in the United States in 2013 cost $78.5 billion. The authors found that 73 percent of this cost was attributed to nonfatal consequences, including healthcare spending, criminal justice costs and lost productivity due to addiction and incarceration. The remaining 27 percent was attributed to fatality costs consisting almost entirely of lost potential earnings." According to the CDC, there were 25,840 deaths in 2013 related to an opioid overdose.

According to the CEA, "We also present cost estimates under three alternative VSL assumptions without age-adjustment: low ($5.4 million), middle ($9.6 million), and high ($13.4 million), values suggested by the U.S. DOT and similar to those used by HHS. For example, our low fatality cost estimate of $221.6 billion is the product of the adjusted number of fatalities, 41,033, and the VSL assumption of $5.4 million. Our fatality cost estimates thus range from a low of $221.6 billion to a high of $549.8 billion."

"The Underestimated Cost of the Opioid Crisis," Council of Economic Advisers, Executive Office of the President of the United States, November 2017.
https://www.whitehouse.gov/sit...
Warner M, Trinidad JP, Bastian BA, et al. Drugs most frequently involved in drug overdose deaths: United States, 2010–2014. National vital statistics reports; vol 65 no 10. Hyattsville, MD: National Center for Health Statistics. 2016. Table B, p. 64.
https://www.cdc.gov/nchs/data/...
https://www.cdc.gov/nchs/produ...

18. Restrictions On Opioid Prescribing Are Negatively Impacting People With Cancer And Other Serious Illnesses

"A growing number of restrictions on opioid prescribing are already impacting these patient populations."

According to a survey conducted for the American Cancer Society Cancer Action Network and the Patient Quality of Life Coalition:

Patients answering yes to "Has your doctor indicated his or her treatment options for your pain were limited by laws, guidelines, or your insurance coverage?"
Patients Being Treated For Cancer: 48%
Patients Being Treated For Chronic Pain: 40%
Patients Being Treated For Other Serious Illnesses: 56%

Patients answering yes to "Has your insurance company or pharmacy required you to only have opioid prescriptions from one doctor?"
Patients Being Treated For Cancer: 36%
Patients Being Treated For Chronic Pain: 25%
Patients Being Treated For Other Serious Illnesses: 26%

Patients answering yes to "Has your doctor refused to give you a prescription for an opioid plan medication?"
Patients Being Treated For Cancer: 35%
Patients Being Treated For Chronic Pain: 25%
Patients Being Treated For Other Serious Illnesses: 36%

Patients answering yes to "Has the pharmacist give you only part of your opioid prescription (for example: for 7 days instead of 30 days the prescription was written), and told you to call your doctor for a new prescription if you need more?"
Patients Being Treated For Cancer: 31%
Patients Being Treated For Chronic Pain: 18%
Patients Being Treated For Other Serious Illnesses: 21%

Patients answering yes to "Have you been unable to get your opioid prescription pain medication because the pharmacist or pharmacy sent you home without your prescription because they had to contact your doctor before filling the prescription?"
Patients Being Treated For Cancer: 26%
Patients Being Treated For Chronic Pain: 30%
Patients Being Treated For Other Serious Illnesses: 22%

Patients answering yes to "Has the pharmacist given you only part of your opioid prescription (for example: for 7 days instead of 30 days the prescription had been written), and told you to come back if you need more?"
Patients Being Treated For Cancer: 25%
Patients Being Treated For Chronic Pain: 26%
Patients Being Treated For Other Serious Illnesses: 26%

Patients answering yes to "Has your doctor or pharmacist told you that you have been flagged in their system as a potential opioid abuser?"
Patients Being Treated For Cancer: 21%
Patients Being Treated For Chronic Pain: 14%
Patients Being Treated For Other Serious Illnesses: 11%

American Cancer Society Cancer Action Network, Patient Quality of Life Coalition, and Public Opinion Strategies. Key Findings Summary: Opioid Access Research Project. June 2018.
https://www.acscan.org/release...
https://www.acscan.org/sites/d...

19. Reasons Why Many in the US Receive Inadequate Treatment for Pain

"Currently, large numbers of Americans receive inadequate pain prevention, assessment, and treatment, in part because of financial incentives that work against the provision of the best, most individualized care; unrealistic patient expectations; and a lack of valid and objective pain assessment measures. Clinicians’ role in chronic pain care is often a matter of guiding, coaching, and assist­ing patients with day-to-day self-management, but many health professionals lack training in how to perform this support role, and there is little reimbursement for their doing so. Primary care is often the first stop for patients with pain, but primary care is organized in ways that rarely allow clinicians time to perform comprehensive patient assessments. Sometimes patients turn to, or are referred to, pain specialists or pain clinics, although both of these are few in number. Unfortunately, patients often are not told, or do not understand, that their journey to find the best combination of treatments for them may be long and full of uncertainty."

Institute of Medicine, "Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education, and Research" (Washington, DC: National Academy of Sciences, 2011), p. 8.
http://www.nap.edu/openbook.ph...

20. Prevalence Of Illegal Use of Prescription Drugs In The US

"In 2016, an estimated 6.2 million Americans aged 12 or older misused psychotherapeutic drugs at least once in the past month, which represent 2.3 percent of the population aged 12 or older (Figures 18 and 19). Of the four categories of prescription drugs that are presented in this report, prescription pain relievers were the most commonly misused by people aged 12 or older. The 6.2 million people aged 12 or older who misused prescription psychotherapeutic drugs in the past month included 3.3 million who misused prescription pain relievers in that period. Approximately 2.0 million people aged 12 or older misused prescription tranquilizers in the past month. An estimated 1.7 million people aged 12 or older misused prescription stimulants, and 497,000 (0.5 million) misused prescription sedatives in the past month.

"An estimated 389,000 adolescents aged 12 to 17 misused psychotherapeutic drugs at least once in the past month, which rounds to the estimate of 0.4 million adolescents shown in Figure 19. Stated another way, about 1 in 60 adolescents (1.6 percent) were current misusers of psychotherapeutic drugs. An estimated 1.6 million young adults aged 18 to 25 were current misusers of psychotherapeutic drugs, which corresponds to 4.6 percent of young adults. There were 4.2 million adults aged 26 or older who were current misusers of psychotherapeutic drugs, or 2.0 percent of adults in this age group."

Substance Abuse and Mental Health Services Administration. (2017). Key substance use and mental health indicators in the United States: Results from the 2016 National Survey on Drug Use and Health (HHS Publication No. SMA 17-5044, NSDUH Series H-52). Rockville, MD: Center for Behavioral Health Statistics and Quality, Substance Abuse and Mental Health Services Administration. Retrieved from https://www.samhsa.gov/data/
https://www.samhsa.gov/data/si...
https://www.samhsa.gov/data/si...

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