How psychology impacts the fight against the opioid epidemic
When I was in graduate school in the late 1980s, working in a preclinical lab specializing on opiate receptor pharmacology, the consensus was that pain patients did not become addicted to opiates.
Vivek Murthy, the current Surgeon General of the United States, recently expressed similar sentiments as he reflected on the events that led to the current opioid epidemic. Murthy, according to Politico, said "I came across a training booklet for nurses and doctors from the early 1990s, and one paragraph in particular struck out to me. 'If your patient is concerned about developing an addiction to opioids, you can safely tell them that addiction to opioids is exceedingly unusual in individuals who suffer pain,' it said. I'm haunted by just one line "he stated "During my training, I recall being taught it and having to relearn it. And I'm sure there are many clinicians who were taught the same thing and still practice with the best of intentions based on it."
From the patient's perspective, the all-too-familiar scenario plays out as follows: a patient is given a large dose of opioid medication for pain and becomes addicted to it. When the prescription runs out, the addicted patient seeks for an illicit source of prescription opioids — or, worse, switches to a less expensive alternative: heroin. And the unfortunate headline-grabbing effect has been a growing rate of overdose deaths, whether as a result of the switch to heroin or just self-medication with too much of a prescription formulation. As a user develops pharmacologic tolerance to the drug, the mode of administration becomes more crucial — the faster the drug reaches the brain, the better it feels — and a frequent transition is from oral to intranasal to intravenous injection. Through shared injection paraphernalia, the last step has resulted in a surge of collateral damage, including huge increases in HIV and Hepatitis C infection.
In stark contrast to a long-standing congressional ban on federal funding of needle exchange programs based on ideological grounds, a mini-epidemic of HIV infection in Scott County, Indiana led to the emergency implementation of a science-based intervention — needle exchange — to stem the epidemic, in a sobering realization that science must inform policy. As an aside, when the National Institutes of Health (NIH) switched its HIV/AIDS research emphasis away from behavioral and social science research, APA and allies exploited that example to excellent use (PDF, 107KB).
Congress is paying attention.
The only good news in all of this is that a long-overdue national conversation on drug use, misuse, abuse, and addiction is now happening. In policy circles, the ripple effect has transformed into a tsunami. Over fifty proposals focused on some part of the opioid issue were under discussion on Capitol Hill at one point this spring. The administration is also keeping a careful eye on things. President Barack Obama's 2017 budget proposed $1.1 billion in new funding to promote a variety of opioid prevention and treatment programs.
On the legislative front, the Comprehensive Addiction and Recovery Act (S 523 CARA) (PDF, 364KB), which was enacted on March 10, 2016, has been the main vehicle in the Senate. Sens. Rob Portman (R-Ohio) and Sheldon Whitehouse (D-R.I.) first presented the bill in 2013, and it has since been championed by a broad coalition. Several psychologists — Redonna Chandler, National Institute on Drug Abuse (NIDA) on criminal justice; Kathleen Carroll, Yale University, on veterans; and Thomas McLellan, Treatment Research Institute, on the science of addiction — spoke at Addiction Policy Forum briefings on Capitol Hill to drum up support for the bill.
While the Senate had hoped that the House would act on CARA directly, the opioid crisis has become a political football. Members of Congress in tight election races, or in some of the epidemic's hardest-hit areas, must be perceived to be taking action. The House passed a bundle of fifteen legislation as an amendment to S 523 on May 13, and the House and Senate proposals will now be merged to resolve the differences. Furthermore, on May 17, the House Appropriations Subcommittee that funds the Department of Justice approved a budget of $103 million to address the opioid epidemic, as recommended by the House. Because paying CARA and passing CARA are two independent legislative procedures, disagreements about how to fund CARA programs may linger long after the law has been successfully conferenced and delivered to the president for signature.
APA, through its Science Government Relations division, began to raise the alarm as early as 2006, despite news reports that the disease had just recently reached crisis proportions. That year, on behalf of the Friends of NIDA organization, the office hosted a congressional briefing titled "Prescription Drug Abuse: An Emerging Public Health Threat." In 2013, the American Psychological Association held a conference on "Preventing Prescription Drug Abuse: Applying Science to Solve a Community Epidemic," and in 2015, it held a conference on "Heroin Addiction and Overdose: What Can We Do to Address This Growing Problem?" In January 2016, APA was called to speak before the Bipartisan Heroin Task Force, and Jessica Peirce (Johns Hopkins University) was brought in to share her experiences directing a 400-patient opioid treatment program as part of the National Institute on Drug Abuse's Clinical Trials Network.
HHS is taking action.
The American Psychological Association has chosen one strategy to raising awareness about NIDA-funded research, but much of the policy and political action has been taking place across other departments of the Department of Health and Human Services (HHS). The opioid pandemic has prompted debate over if, when, and to whom opioids should be prescribed. Sen. Joe Manchin, D-W.Va., issued a blistering letter condemning the Food and Drug Administration (FDA) for rewriting its pediatric guidelines to approve OxyContin for the treatment of long-term chronic pain in children aged 11 to 16, describing the action as "a horrifying example of the disconnect between the FDA approval process and the realities the deadly epidemic of prescription drug abuse is having on our communities."
The FDA had long been chastised for failing to communicate adequately about the dangers of opiates, so in March 2016, it imposed new labeling regulations, including boxed warnings about opiate misuse, abuse, addiction, overdose, and death. Importantly, psychologists have been involved in the FDA's decision-making process. In June 2015, APA Fellow Roxane Cohen Silver served as head of the FDA's Risk Communication Advisory Committee, which met to discuss communication problems around the use of medication assisted treatment in pregnant women (PDF, 6.5MB).
The role of physicians in supporting an indirect path from appropriate use of opioids in the management of pain to their inappropriate use leading to dependence, as stated by the Surgeon General, has focused attention on physician training and practice. However, as the debate moved from the FDA to the Centers for Disease Control and Prevention (CDC), advocates for palliative care who were concerned about inadequate pain treatment at the end of life found themselves in constant conflict with advocates concerned about over-prescribing and opioid dependence at any stage. With the introduction of a draft version of a Guideline for Prescribing Opioids for Chronic Pain in 2015, controversy emerged between these parties. The majority of the criticism directed at the CDC was focused on the lack of evidence supporting the guideline on opioid usage.