The Problem:
The growing opioid crisis in Pennsylvania is one of the most prominent public health issues of the state. This increasingly dangerous issue has come afoot with many undesirable conditions. These conditions involve lifelong addiction, death, and less opportunities. In 2016 alone, there were 4,642 drug-related deaths. Of those deaths 85% of the drug overdoses involved opioids. (Analysis of Overdose Deaths in Pennsylvania, 2016, 2017) Many of these were also prescribed as well. Pennsylvania has seen an intense increase in drug related deaths within the past few years. Numbers for 2017 are still coming in and official reports haven’t been finished, but officials are estimating a large increase from 2016. While the United States as a whole is struggling with this public health issue, Pennsylvania is one of 8 states to have declared a disaster emergency for the opioid crisis. “It's the first time a disaster emergency has been declared for a public health crisis in the commonwealth. Usually, disaster emergencies are reserved for major weather events such as a hurricane or for a terrorist attack” (Lattanzio, 2018). The fact that the opioid crisis has been declared a disaster emergency is an indication of just how serious of a public issue it is.
There has also been an increase in fentanyl laced drugs which has played a large role in the increase of overdoses in 2016. Fentanyl in just small quantities is enough to kill a person and there has been a 130 percent change from 2015 to 2016 in drug-related overdoses. (Analysis of Overdose Deaths in Pennsylvania, 2016, 2017) This opioid crisis is a public health issue and a cause for social inequality in Pennsylvania because more people are dying from this than any other health crisis in Pennsylvania’s modern history. (Lattanzio, 2018) People are not receiving the help and support to overcome these addictions and many deaths are a result of this lack of proactivity. There is also stigma against drug users and a lack of sympathy. To combat that opinion, there are also supporters of the idea that addiction is a treatable disease or at least a manageable disease. It is compared to diabetes in the ways that it isn’t necessarily curable, but it can be maintained and watched closely. (Gallagher, 2017) Looking at it this way is another indication that there is a public inequality because it is in most cases seen as being treatable and instead a bad quality of the ones using.
The conditions and outcomes that result from this crisis are some of the worst with death being the most obvious. Those who succumb to this opioid crisis are also more likely to be addicted to drugs throughout their lives and it follows them around for life. (Heroin, 2018 Using these illicit drugs opens users to more health issues and concerns such as liver and kidney disease that will follow them throughout the rest of their lives. (Heroin, 2018) The main inequality here is that those suffering from addiction and ultimately succumbing to this crisis are not getting the help that they need. This has been compared to the HIV/AIDS epidemic in more than one way. “We are once again facing a public health crisis for which there is inadequate research, limited funding, and much public stigma” (Levine, 2018). The final outcome is lesser opportunities. Through this opioid epidemic if a user is charged with a felony they lose their voting rights as well as other job opportunities. Many jobs will not hire you if you have a felony or past drug use. There has been a focus on punishing those who commit drug related drugs instead of rehabilitation. This has been a result of the War on Drugs and its efforts against drug related crimes.
Discussion of Population:
This crisis can affect any age or racial group but is primarily seen with whites and is the number one cause of death in those under the age of 50. (Office of the Associate Director for Communications, 2015) People who suffer from addictions to opioids often lack the political power and ability to beat these addictions as well as improve their situations. Those who are lucky enough to have money may be able to afford to pay for treatment facilities that have the time and money for full treatment. However, this isn’t always the situation. Those who do drugs are followed by a stigma and are looked down upon. They are thought of as criminals, so their opinions are weighed very lightly in the grand scheme of things. With that said, in all reality, anyone can be addicted to drugs and other substances. Anyone is susceptible to addiction leading to drug use, but there has been an increase in rural counties vs urban counties. (Gallagher, 2017) Someone who is addicted to drugs or subjects themselves to drug use (no matter how often) puts themselves at risk and that is something that makes this public health issue unique in its population. Anyone can be addicted to drugs and anyone can die from a drug-related death. With the increase in fentanyl people have to be increasingly careful with the drugs that they buy. This puts them in a very vulnerable position because not only are they addicted and already exposed to the possibility of death, but now the drugs are being laced with fentanyl only further increasing the risk. Even though anyone can be addicted to opioids there are patterns of inequality between the lower class and upper class. Based on a National Survey on Drug Use and Health, heroin addiction is more common in people making less than $20,000 per year compared to those who make $50,000 or more and higher levels of education are also linked with lower rates of addiction” (Office of the Associate Director for Communications, 2015). This puts lower class opioid users vs those who are upper class in a unique position and limits their power and political clout.
Why is this Important?
This is an extremely important issue. This isn’t the same as many other social issues because this one actually deals with life or death. We need to make others’ lives a priority because everyone deserves the chance to live a healthy life. There is the stigma that those who do drugs are bad people, but I am a true believer that it is a disease and should be treated as one. I don’t think an opioid epidemic ever has a point in time that it shouldn’t be a priority. We need to get to the base of the issue instead of blaming those who “choose” to do drugs. Solving this problem will greatly benefit and impact Pennsylvania as well as the country as a whole. Solving this public health issue would have a lot of benefits. I believe that it would increase the happiness of those living in Pennsylvania as well as elongating the life span of many people. This should always be a priority in my mind. There are many cultural values associated to this issue. There is the stigma that goes along with drug use and addiction and instead of being treated as a sickness or disease it is treated as a wrong doing of the person. With that said, drug use shouldn’t be encouraged, but it should be addressed in a way that shows this person’s life is worth something.
Causal Mechanisms:
This public health issue in Pennsylvania can be seen through the mistreatment of those with addictions. The public health system has had a large role in this epidemic through the over prescription of opioid pain relievers that lead to the use of heroin and other street drugs. “The risk for overdose resides primarily among those harboring a medical diagnosis of an opioid use disorder. Prescription opioids remain a primary driver of opioid-related fatalities” (Madras, 2017). Researchers found a connection between those who are addicted to opioid painkillers and heroin. Those who use and are addicted to these prescribed painkillers are 40% more likely to be addicted to heroin. (Office of the Associate Director for Communications, 2015) In recent years, and currently being seen with the Wolf Administration, there have been stricter rules and regulations on doctors prescribing painkillers to their patients. Research has also shown that people will switch to heroin because it is less expensive and sometimes easier to get. This means the drugs that these people are getting are not regulated and therefore more dangerous as they may contain other chemicals or fentanyl. This unsafe “market” is a huge factor in the opioid crisis not just in Pennsylvania, but nationally as well. Another reason explored for the cause of this public health issue can be found on a chart from the 2016 DEA Drug Overdose Report specific to PA. It shows the progression of the natural history of Opioid Use Disorder. It shows that this is more than a weakness, but that it is also considered a disorder. It starts with people using to feel good, then it moves on to using to feel normal, and finally using to keep from getting sick. (PAMEDEA) It is just in more recent years that the general public has started to look at the Opioid Crisis in Pennsylvania as a possible health disorder and not just a bad decision made by those doing drugs. There is no one cause for this crisis, but the most significant causes are Opioid Use Disorder, over-prescription of drugs, and the stigma against drug users.
Overview of the Problem:
One of the most prominent public health issues in Pennsylvania is the growing opioid crisis and the effect it has on those involved. Using opioids can lead to many unfavorable conditions. Pennsylvania has seen an intense increase in drug related deaths within the past few years. (Lattanzio, 2018) This opioid crisis is a public health issue and a cause for social inequality in Pennsylvania because more people are dying from this than any other health crisis in Pennsylvania’s modern history. (Lattanzio, 2018) The drug world is a business that just keeps getting more customers. People are not receiving the help and support to overcome these addictions and many deaths are a result of this lack of proactivity.
The conditions and outcomes that result from this crisis are some of the worst with death being the most obvious. Those who succumb to this opioid crisis are also more likely to have been addicted to drugs throughout their lives. (Heroin 2018) Using these illicit drugs opens users to more health issues and concerns such as liver and kidney disease that will follow them throughout the rest of their lives. (Heroin, 2018) Ignoring death and the continuing use of opioids another outcome is lesser opportunities. Something that comes with this opioid epidemic is increased incarceration rates. Instead of helping with the true issues and offering cheap and affordable treatment they are often thrown into jail or criminalized. This essentially becomes a repeating cycle. Many jobs will not hire you if you have a felony or past drug use. This makes them even more disadvantaged because not only are they in bad health, but they are also being criminalized and essentially thrown to the side to try to drag themselves out of addiction.
The public health system has had a large role in this epidemic through the over-prescription of opioid pain relievers that lead to the use of heroin and other street drugs. In recent years, and currently being seen with the Wolf Administration, there have been stricter rules and regulations on doctors prescribing painkillers to their patients. Research has also shown that people will switch to heroin because it is less expensive and sometimes easier to get. This means the drugs that these people are getting are not regulated and therefore more dangerous as they may contain other chemicals or fentanyl. (Office of the Associate Director for Communications, 2015) On top of that, those who do struggle with addiction cannot afford to get the help as it is actually quite pricey. Whether they are buying Narcan or getting treatment, it just isn’t cheap. Studies have shown that even with their prescription people just aren’t picking them up. Price of the copay plays a huge role in that. “According to research from the drug manufacturer, nearly 35 percent of Aetna members prescribed Narcan between January to June 2017 did not pick up their prescription” (Aetna, 2017). When it comes down to it, the opioid crisis is a social inequality because the people who are victims are rarely offered the help they need and are often criminalized because of it. It is just in more recent years that the general public has started to look at the Opioid Crisis in Pennsylvania as a possible health disorder and not just a bad decision made by those doing drugs. There is no one cause for this crisis, but the most significant causes are Opioid Use Disorder and not getting the proper help, over-prescription of drugs, and the stigma against drug users.
Explanation of Solutions:
The first solution I found in my research was a policy that Aetna has actually began to put in place. This would be an administrative policy that would look at many of the issues with the opioid crisis that have been addressed earlier. They want to focus on making Narcan more accessible to those who may need it. It is their goal to help prevent overdoses. Another goal of theirs is to limit the prescription given to patients after surgery in hopes of lowering their chances of addiction. “Aetna will be the first national payer to waive copays for Narcan for its fully-insured commercial members – a move that will increase access and remove possible financial barriers to the lifesaving drug” (Aetna, 2017) Their main goal in all of this is to help those with addictions live long enough to be able to get the help they need. “In addition, Aetna will limit the quantity of opioids prescribed for acute pain and post-surgery to a seven-day supply for its commercial pharmacy members. Both changes will be effective Jan. 1, 2018” (Aetna, 2017). They also address the issue with over-prescribing and ways that they want to limit it through their policy. Although this does not solve the whole issue it does address things such as over-prescription and life-saving drugs. Some states have also started implementing 7-day limits in hopes of lowering the amount of people who get addicted off of prescription pills. This of course could be very effective for the parts that it addresses. The Narcan waiver is beneficial simply because it is life-saving. Looking at the cost of this is very difficult to find because their plan is so multi-faceted. However, they have assigned a specific unit known as the Special Investigations Unit to look at waste, fraud and other abuse. This will save and recover more than $200 million each year. (Aetna, 2017)
Another solution that was suggested was through a proposal to prosecute those who overdose if they refuse treatment. Currently Pennsylvania provides protection against people who overdose from being prosecuted. However, many do not believe that is doing enough. (Roper, 2017). “House Bill 1501 proposes that anyone who survives a drug overdose will be forced to get help for their addiction or face prosecution” (Roper, 2017). This would obviously come as a governmental policy and would essentially punish those who overdose. Their main idea behind this is to hold those involved accountable for their actions, while hoping they choose treatment over prosecution. This addresses the idea that prevention is very important. However, looking into its effectiveness I can see this angering a lot of people. It is a common belief that people who don’t want to be helped don’t take well to being forced to do so. It also places blame on them and adds to the stigma they may already face. This may also not be the most cost effective because it’s sad to say, but many might not choose to get the help which could result in fines and maybe even jail time. It could also result in people choosing treatment just to get out of the charges and not being 100% dedicated. This could cause a cycle of repeating addiction abuse. This repetition is the type of “abuse” the system receives from “repeat offenders”. It is only cycling people in and therefore is very costly because unless the government is providing treatment (which is also costly) then it is expected that users will have to pay. If they cannot afford to do so they have no choice but jail time which is also an expense to the government.
The final suggestion for a possible solution I am going to address is Medication and Counseling Treatment. It can also be called Medication-Assisted Therapy and there are multiple approaches to how it is implemented. “A common misconception associated with MAT is that it substitutes one drug for another. Instead, these medications relieve the withdrawal symptoms and psychological cravings that cause chemical imbalances in the body. MAT programs provide a safe and controlled level of medication to overcome the use of an abused opioid” (Walsh, 2015). This typically means substituting heroin and other short acting drugs with other medications. These medications have a way of tricking the brain into thinking it is getting the opioid and therefore people are not experiencing the withdrawal symptoms that they normally would. This is essentially to make it easier for addicts to stop heroin and still be able to do it without going through withdrawal. For many people withdrawal is too much to handle and a reason as to why they continue with their addiction to opioids. There are governmental regulations and policies set in place for this already, but there have been suggestions of making policy that would require these clinics to follow stricter guidelines. Looking into the effectiveness it isn’t a perfect solution, but it is a step into helping those with opioid addictions and hopefully a good one. It can be quite expensive depending on the clinic and the physicians there. The cost of medication-assisted treatment varies depending on the medication being used. Generally, MAT is expensive (approximately $500 per month including physician visits)” (Rudy Hatfield, 2017). There have been efforts to make it more affordable and close the treatment gap that exists, but as of now it has not been “fixed” yet.
Recommended Policy:
Of the three policies I have found, the policy that I would suggest would be the first suggestion. I think Aetna is making a very good effort at trying to help the Opioid Crisis. They are looking at more than just one issue that may play a role in the opioid crisis. They are addressing the relationship between prescription drugs and opioid/heroin overdoses. It is their goal to still provide these prescription opioids when needed but within reason. Aetna is also enacting this policy to make it easier to save addicts who may overdose. This is showing addicts that their lives are still important. There is this feeling in our society that drug users don’t deserve to live and that they choose to do drugs. Sympathy just doesn’t exist like it should. Aetna takes a different approach. By making Narcan easier to obtain they are making it easier to save lives at the same time. I think that the second solution of giving them a choice between jail and treatment will not actually go over well. People don’t like to have their hands forced and it doesn’t seem as if it will actually help the opioid crisis. It instead looks like it will create a cycle of going in and out of jail or treatment. As for the third solution. I really like this solution, but it is quite expensive and does not seem like something that can be implemented as fast as Aetna. With that in mind Aetna does have plans to help medication-assisted treatment flourish. I think Aetna’s solution is the most multi-faceted and addresses more than on element of the opioid epidemic.
Counter Arguments:
One argument is that Aetna’s policy doesn’t stop the opioid crisis with Narcan. The argument is that Narcan acts as a crutch to an addiction. This means that people who overdose will use Narcan, but it won’t change the fact that these people will still be addicted and are very likely to overdose again. (Narcan: Compass to Healing or Crutch in Addiction? 2018) I agree that Narcan is not the magical solution to the opioid epidemic, but in my mind how can you help people through their addictions if they’re dead. The focus, in my mind, should be keeping these people alive so that they can at some point hopefully get the help that they need. Knowing people who have been administered Narcan and have come back and beat their addiction is the reason I believe Aetna is right in making Narcan more accessible. People have an idealized vision of what Narcan does. It doesn’t just bring you back without consequence. Most people don’t simply use heroin because they know they have Narcan. In fact, for most people being given Narcan is not a great experience.
Another argument towards this policy is that prescriptions should not be limited to 7 days because some people suffer from really bad chronic pain. My response to that is that not all patients receive only a 7 days’ supply. That is simply the standard. There are cases that are different and are thus placed outside of the standard. My counter argument for this, however, is I myself have been over-prescribed. I received a full pill bottle of oxycodone for pain and a subsequent surgery. As a 16-year-old I was given a pretty strong opioid before I even had the surgery and basically told to take it whenever I wanted to or felt like I should. There is no reason that I should have been given the quantity that I was given so casually. While there are very many illnesses and other such issues that warrant longer usage times, there should still be a standard so that we are holding our physicians accountable. Such strong drugs should not be given out so freely.
Stakeholder Analysis and Feasibility:
One of the most obvious stakeholders in the Opioid Crisis are government officials and other political figures. They really have the power and presence to bring forward the issue and make it known as to what is going on. They have the ability to address thousands of people and rally them behind their viewpoints. Although not every candidate and political figure may see the opioid epidemic in the same way I believe that they have a duty and a responsibility to the people. With the swift increases in drug overdoses political figures have the opportunity to make drug rehabilitation and treatment options a priority in their civil service. They are able to bring the issue to the forefront and make it a talked about issue. Speaking on such a prominent issue and making it one of their own can bring a lot of attention to their campaigning and ultimately can benefit their careers. This can be seen in the War on Drugs. Although it did not have the outcome many would have liked it really helped to define Reagan’s presidency and it brought a lot of attention to drug use (the wrong kind of course). With this type of publicity and attention I believe it makes political figures very large stakeholders in the issue of the opioid crisis. It is just how much they choose to use their power and political clout to address the issue. Officials like Governor Wolf have made it a forefront in the minds of their constituents by declaring disaster emergencies and placing restrictions and other such things on prescription drugs.
Another key stakeholder in helping to combat the opioid epidemic is treatment centers and other forms of treatment. These facilities play a huge role in rehabilitating those and actually helping the core issues that accompany the addiction to painkillers and other illicit drugs. They have a lot of resources and backing from all over. They have dedicated doctors and therapists that are willing to get to the base of the issue instead of solely focusing on a cold turkey detox. This is beneficial in ending the opioid crisis because it looks at more than just the superficial level of overdoses which is people choose to do drugs and that’s why they overdose. These different types of treatment options, some better than others, are solely focused on getting the “patient” better and helping them cope in a world without drug use. although we need to keep in mind that many of these places do make a profit and rely on money. This idea of drug treatment being for profit is a whole other issue itself, but that doesn’t take away from all the good they do and can do.
Another key player in the opioid crisis which may very well hinder the progress in fighting the crisis is the pharmaceutical companies and doctors prescribing medication. Although medication is prescribed for very legitimate reasons there is significant research showing that prescriptions are given out more freely than they should be. On top of that prescriptions and other medical treatments are treated more like a business and less of a lifesaving tool. It is very easy to get your hands onto prescriptions and other such things if your insurance covers it. It is so expensive and so you can As I have already addressed prescription drugs can very much lead to more illicit drug use. Those in charge of prescribing and handing out these prescriptions have really dropped the ball and it has been less regulated in the past 2 decades. If this continues to go on and doctors are able to prescribe so easily it will only further perpetuate the opioid crisis in the long run.
Another obvious stakeholder in this crisis are drug dealers and manufactures themselves. They obviously hinder the positive progression of the opioid crisis. This is their business and they make good money. They market off drugs way cheaper than prescription drugs. “ In fact, over the past few decades, the price of heroin in the US has dramatically dropped- to the point that it’s not only cheaper than opioid painkillers sold in the black market, but frequently even candy bars” (Levine, 2018). This makes it very easy for them to get their product sold. With that said, their products are usually not “controlled” and stronger opioids than prescribed. Because drugs like heroin are so cheap they are often the go to in place of prescription drugs. So, there are many cases where someone may need a prescription opioid for a certain amount of time, but once they run out of refills or can no longer afford them they move on to “street” opioids. Drug dealers make their prices “reasonable” to draw in these types of people. Once again, these drugs are not controlled and therefore are much more dangerous than any prescription drug. However, they are also highly addictive, so it is hard to stop using once you have started. This puts those buying drugs in a very difficult place and those selling at a very advantageous place. They can ultimately control the market on opioid drugs and because not all drug dealers are honest people they can alter the drugs without the buyer ever knowing unless they overdose or have other adverse effects. Once again, drug dealers and those who manufacture illegal drugs have a lot of power and stake in the opioid crisis because they are what keep it running.
Elevator Pitch:
The group that I will be addressing is insurance companies and other health providers. The growing opioid crisis in Pennsylvania is an issue that has resulted in too many deaths. In the United States as a whole the numbers lost to drug overdoses has surpassed those that passed in the peak years of the AIDS/HIV epidemic. We need to prevent more people from dying and you are the perfect start for this. Follow Aetna’s footsteps by putting policies in place that hold hospitals and other pharmaceutical providers accountable. By providing Narcan and making care and treatment more available we are showing how much we care for those who are just stuck in a bad place and need help. We could be responsible for saving thousands of lives and providing support for people who may have never had it in the past. That is why I think as health providers and insurance companies you should help in the efforts to make things such as to Narcan and medication-assisted treatment easier to obtain for those who truly need it. With that said, you should also push the need for stricter prescription drug policies so that we can avoid unnecessary prescriptions that only contribute to the growing opioid crisis.