Opioid emergency declarations offer short-term benefit on a ‘slippery slope’

Michael Ashburn
Michael Ashburn

In 2016, more than 63,000 people overdosed and died; opioids caused approximately 66% of those deaths, according to research from the CDC.

“To put that in perspective, 58,220 American service members died during the entire Vietnam War, which lasted from 1955 to 1975,” Michael Ashburn, MD, MPH, MBA, director of Pain Medicine and Palliative Care at Penn Medicine, told Healio. “The highest annual death rate attributed to AIDS was 43,000 in 1995. We are in the middle of a public health crisis, and need to dedicate much more resources than we are currently dedicating.”

As drug overdoses – particularly opioid overdoses – continue to grow in frequency, public health officials called to implement emergency procedures to help fight the nationwide opioid crisis.

In response, President Donald J. Trump, in October 2017, officially declared the opioid addiction crisis a public health emergency.

However, six states – Alaska, Arizona, Florida, Maryland, Massachusetts and Virginia – had already declared opioid emergencies prior to the president’s proclamation. Recently, Pennsylvania became the seventh state to declare an emergency.

In 2016, there were 4,642 drug-related overdoses in Pennsylvania. Approximately 13 people died of a drug-related overdose each day and 85% of those deaths were attributed to opioids, according to data from the DEA.

“Addiction, unfortunately, carries with it significant stigma, which makes it more difficult to establish appropriate funding for research as well as clinical care, and stigma creates huge barriers to gaining access to quality care,” Ashburn said. “To a fair degree, the declaration increases awareness that opioid use disorder is a public health emergency that is leading to needless suffering by the individuals with this disease, as well as by their family and friends.”

How a statewide emergency works

A state declaration of an official emergency involves various specific details, including who can declare it and for how long the declaration lasts, according to Rebecca Haffajee, PhD, JD, MPH, an assistant professor in the Institute for Healthcare Policy and Innovation at the University of Michigan.

“The general idea is that they can leverage extraordinary powers that [states] normally couldn’t draw upon by going through normal, legal means,” Haffajee said. “They can access those powers and use them on a temporary basis with the idea that they need to leverage these powers to address imminent harm, but they will do so for a temporary time period and, they need to keep in mind individual liberties and not infringe on those as best as they can.”

Haffajee said most of the declarations have a 30- or 60-day duration unless they are renewed and to do so, an explicit action is typically required.

“They all vary in their specificity in what they aim to do,” she said. “Those that have some focus on medication-assisted treatment therapy are going to be the ones that are probably going to most effect physicians who are treating individuals with opioid use disorders.”

For example, Haffajee said that Pennsylvania’s declaration focuses somewhat on expanding medication-assisted therapy (MAT) by relaxing some rules regarding licensing and who can provide therapy.

Additionally, she said it appears that Pennsylvania waived the regulatory provision to permit dosing at satellite facilities, and waived annual licensing requirements for high-performing drug and alcohol treatment facilities.

Haffajee reported that it depends on what each state places in its declaration. Massachusetts, she said, infused $20 million for addiction treatment services in 2014 when it declared its emergency, but it’s unclear how those funds were spent.

“They can also go through the regulatory route like relaxing some of the red tape around these facilities so it’s just easier for them to not have to jump through a lot of hoops to provide this MAT, and who can provide the medications, but also the therapy and behavioral health counseling,” she said.

While most state declarations have not focused specifically on the initial prescribing of opioids, Haffajee said states are focusing on the issue on a separate front without declaring emergencies. Michigan, for example, is finalizing a mandate that would require prescribers to check a prescription-drug monitoring program prior to prescribing certain medications.

New York has passed laws stipulating that a physician cannot prescribe more than 7 days of a controlled substance for the treatment of acute pain, Lawrence S. Brown, MD, MPH, CEO of START Treatment and Recovery Centers and a clinical associate professor at Weill Cornell Medical College, said.

However, as he said, enforcement depends on how much funding the state provides for monitoring those things.

“You can have a regulation, but if you don’t have any teeth behind it and you don’t have any resources to monitor it, then you're going to be the horse behind the cart,” he said.

Impact on health care

There are four things that impact and drive how physicians and health care providers operate, according to Brown. Regulations, reimbursements, risk management and reinforcement all play a pivotal role in influencing how a health care provider offers care to patients, he said. Unless a state declaration of emergency aligns with any one of those ‘four Rs,’ it may have little impact on physician practice.

Additionally, Brown said if a physician was not involved in addiction medicine treatment prior to a statewide declaration, then a declaration would likely not motivate the physician to become more engaged.

“And, that’s really important,” he said. “Because, addiction medicine as a specialty is still in its embryonic stage. The way to get doctors involved with a specialty is there tends to be some exposure during the path of training and education.”

Brown further explained: “The impact is not likely to be immediate. If anything, it may mean down the road” there is more exposure in medical training. He said that for his colleagues who do not specialize in addiction medicine, the state declarations may have a negative effect.

This may be due to the stigma associated with addiction, which may cause some physicians to treat patients under the suspicion that the patient may have a substance use disorder.

“The way someone appears in a doctor’s office may very well affect the way that doctor approaches that patient,” he said. “If there is even the slightest sense that the patient may have a substance use disorder, it is possible that the doctor may no longer engage in that patient’s care. My concern is that, having these declarations is necessary, but not sufficient to really change the trajectory of being able to have prevention, treatment and then also to engage in policies to help to reduce the likelihood of us continuing to be in this pandemic.”

Haffajee partially agreed in that the declarations are a potential tool that can be beneficial, but that they are not going to be a panacea and much more needs to be done.

“We could see more declarations and they could be potentially beneficial, but longer term, I think we’re going to need be thinking about how we control these supply networks [and] change the culture of prescribing – which we’re doing a lot of,” she said. “But those things are going to take a lot longer.”

Appropriate use of powers

Traditionally, state and federal emergencies have been dedicated for infectious diseases, natural disasters and acute harms that suddenly present a public health threat, according to Haffajee. The question, she said, is can the severities of a public health epidemic be addressed over a short timeframe and can lives be saved in the interim?

“The question has been, ‘Is the opioid epidemic an appropriate area in which to be using these powers?’” she said. Emergency declarations typically are not used for non-communicable diseases or injury threats in the past.

“So, this is a new legal area that we’re wading into,” she said.

Haffajee said there is a concern about creating a “slippery slope.” Some experts wonder if declaring an opioid emergency would then lead to declaring public health emergencies for things including obesity, which, per Haffajee, are longer term prospects and aren’t as easy to address in the short timeframe of an emergency declaration.

“It is appropriate to declare opioid emergencies, but it’s important to differentiate those acute harms from the long-term harms and to focus and target the public health emergency actions toward those acute harms,” she said.

Haffajee highlighted the growing number of overdose-related deaths, as well as the growing number of children entering foster care due to losing parents or guardians to an overdose and the shortage of medication-assisted treatment facilities in rural areas as reasons for declaring an emergency.

Moreover, Haffajee noted that another potential trigger for declaring an emergency is the spread of disease such as HIV and hepatitis C because of individuals sharing needles for injecting heroin.

“We can triage death,” she said. “We can provide people with naloxone, which is what a number of states have done with these public health emergency powers (pretty much all except one have had a strong naloxone component), ... increase the money, the training and standing orders for pharmacists so that they can provide naloxone without a prescription to individuals. These are acute harms, and there are immediate things we could do that could reverse those harms.” — by Ryan McDonald

References:

https://www.asam.org/docs/default-source/advocacy/opioid-addiction-disease-facts-figures.pdf

https://www.cdc.gov/nchs/data/databriefs/db294.pdf

https://www.dea.gov/docs/DEA-PHL-DIR-034-17%20Analysis%20of%20Overdose%20Deaths%20in%20Pennsylvania%202016.pdf

Haffajee R, et al. N Engl J Med. 2014;doi:10.1056/NEJMp1406167.

Disclosures: Ashburn, Brown and Haffajee report no relevant financial disclosures.

Michael Ashburn
Michael Ashburn

In 2016, more than 63,000 people overdosed and died; opioids caused approximately 66% of those deaths, according to research from the CDC.

“To put that in perspective, 58,220 American service members died during the entire Vietnam War, which lasted from 1955 to 1975,” Michael Ashburn, MD, MPH, MBA, director of Pain Medicine and Palliative Care at Penn Medicine, told Healio. “The highest annual death rate attributed to AIDS was 43,000 in 1995. We are in the middle of a public health crisis, and need to dedicate much more resources than we are currently dedicating.”

As drug overdoses – particularly opioid overdoses – continue to grow in frequency, public health officials called to implement emergency procedures to help fight the nationwide opioid crisis.

In response, President Donald J. Trump, in October 2017, officially declared the opioid addiction crisis a public health emergency.

However, six states – Alaska, Arizona, Florida, Maryland, Massachusetts and Virginia – had already declared opioid emergencies prior to the president’s proclamation. Recently, Pennsylvania became the seventh state to declare an emergency.

In 2016, there were 4,642 drug-related overdoses in Pennsylvania. Approximately 13 people died of a drug-related overdose each day and 85% of those deaths were attributed to opioids, according to data from the DEA.

“Addiction, unfortunately, carries with it significant stigma, which makes it more difficult to establish appropriate funding for research as well as clinical care, and stigma creates huge barriers to gaining access to quality care,” Ashburn said. “To a fair degree, the declaration increases awareness that opioid use disorder is a public health emergency that is leading to needless suffering by the individuals with this disease, as well as by their family and friends.”

How a statewide emergency works

A state declaration of an official emergency involves various specific details, including who can declare it and for how long the declaration lasts, according to Rebecca Haffajee, PhD, JD, MPH, an assistant professor in the Institute for Healthcare Policy and Innovation at the University of Michigan.

“The general idea is that they can leverage extraordinary powers that [states] normally couldn’t draw upon by going through normal, legal means,” Haffajee said. “They can access those powers and use them on a temporary basis with the idea that they need to leverage these powers to address imminent harm, but they will do so for a temporary time period and, they need to keep in mind individual liberties and not infringe on those as best as they can.”

PAGE BREAK

Haffajee said most of the declarations have a 30- or 60-day duration unless they are renewed and to do so, an explicit action is typically required.

“They all vary in their specificity in what they aim to do,” she said. “Those that have some focus on medication-assisted treatment therapy are going to be the ones that are probably going to most effect physicians who are treating individuals with opioid use disorders.”

For example, Haffajee said that Pennsylvania’s declaration focuses somewhat on expanding medication-assisted therapy (MAT) by relaxing some rules regarding licensing and who can provide therapy.

Additionally, she said it appears that Pennsylvania waived the regulatory provision to permit dosing at satellite facilities, and waived annual licensing requirements for high-performing drug and alcohol treatment facilities.

Haffajee reported that it depends on what each state places in its declaration. Massachusetts, she said, infused $20 million for addiction treatment services in 2014 when it declared its emergency, but it’s unclear how those funds were spent.

“They can also go through the regulatory route like relaxing some of the red tape around these facilities so it’s just easier for them to not have to jump through a lot of hoops to provide this MAT, and who can provide the medications, but also the therapy and behavioral health counseling,” she said.

While most state declarations have not focused specifically on the initial prescribing of opioids, Haffajee said states are focusing on the issue on a separate front without declaring emergencies. Michigan, for example, is finalizing a mandate that would require prescribers to check a prescription-drug monitoring program prior to prescribing certain medications.

New York has passed laws stipulating that a physician cannot prescribe more than 7 days of a controlled substance for the treatment of acute pain, Lawrence S. Brown, MD, MPH, CEO of START Treatment and Recovery Centers and a clinical associate professor at Weill Cornell Medical College, said.

However, as he said, enforcement depends on how much funding the state provides for monitoring those things.

“You can have a regulation, but if you don’t have any teeth behind it and you don’t have any resources to monitor it, then you're going to be the horse behind the cart,” he said.

Impact on health care

There are four things that impact and drive how physicians and health care providers operate, according to Brown. Regulations, reimbursements, risk management and reinforcement all play a pivotal role in influencing how a health care provider offers care to patients, he said. Unless a state declaration of emergency aligns with any one of those ‘four Rs,’ it may have little impact on physician practice.

PAGE BREAK

Additionally, Brown said if a physician was not involved in addiction medicine treatment prior to a statewide declaration, then a declaration would likely not motivate the physician to become more engaged.

“And, that’s really important,” he said. “Because, addiction medicine as a specialty is still in its embryonic stage. The way to get doctors involved with a specialty is there tends to be some exposure during the path of training and education.”

Brown further explained: “The impact is not likely to be immediate. If anything, it may mean down the road” there is more exposure in medical training. He said that for his colleagues who do not specialize in addiction medicine, the state declarations may have a negative effect.

This may be due to the stigma associated with addiction, which may cause some physicians to treat patients under the suspicion that the patient may have a substance use disorder.

“The way someone appears in a doctor’s office may very well affect the way that doctor approaches that patient,” he said. “If there is even the slightest sense that the patient may have a substance use disorder, it is possible that the doctor may no longer engage in that patient’s care. My concern is that, having these declarations is necessary, but not sufficient to really change the trajectory of being able to have prevention, treatment and then also to engage in policies to help to reduce the likelihood of us continuing to be in this pandemic.”

Haffajee partially agreed in that the declarations are a potential tool that can be beneficial, but that they are not going to be a panacea and much more needs to be done.

“We could see more declarations and they could be potentially beneficial, but longer term, I think we’re going to need be thinking about how we control these supply networks [and] change the culture of prescribing – which we’re doing a lot of,” she said. “But those things are going to take a lot longer.”

Appropriate use of powers

Traditionally, state and federal emergencies have been dedicated for infectious diseases, natural disasters and acute harms that suddenly present a public health threat, according to Haffajee. The question, she said, is can the severities of a public health epidemic be addressed over a short timeframe and can lives be saved in the interim?

“The question has been, ‘Is the opioid epidemic an appropriate area in which to be using these powers?’” she said. Emergency declarations typically are not used for non-communicable diseases or injury threats in the past.

“So, this is a new legal area that we’re wading into,” she said.

Haffajee said there is a concern about creating a “slippery slope.” Some experts wonder if declaring an opioid emergency would then lead to declaring public health emergencies for things including obesity, which, per Haffajee, are longer term prospects and aren’t as easy to address in the short timeframe of an emergency declaration.

“It is appropriate to declare opioid emergencies, but it’s important to differentiate those acute harms from the long-term harms and to focus and target the public health emergency actions toward those acute harms,” she said.

Haffajee highlighted the growing number of overdose-related deaths, as well as the growing number of children entering foster care due to losing parents or guardians to an overdose and the shortage of medication-assisted treatment facilities in rural areas as reasons for declaring an emergency.

Moreover, Haffajee noted that another potential trigger for declaring an emergency is the spread of disease such as HIV and hepatitis C because of individuals sharing needles for injecting heroin.

“We can triage death,” she said. “We can provide people with naloxone, which is what a number of states have done with these public health emergency powers (pretty much all except one have had a strong naloxone component), ... increase the money, the training and standing orders for pharmacists so that they can provide naloxone without a prescription to individuals. These are acute harms, and there are immediate things we could do that could reverse those harms.” — by Ryan McDonald

References:

https://www.asam.org/docs/default-source/advocacy/opioid-addiction-disease-facts-figures.pdf

https://www.cdc.gov/nchs/data/databriefs/db294.pdf

https://www.dea.gov/docs/DEA-PHL-DIR-034-17%20Analysis%20of%20Overdose%20Deaths%20in%20Pennsylvania%202016.pdf

Haffajee R, et al. N Engl J Med. 2014;doi:10.1056/NEJMp1406167.

Disclosures: Ashburn, Brown and Haffajee report no relevant financial disclosures.