Heller is home to expertise on the opioid crisis

The United States' opioid epidemic has permeated the public conversation, from news reports to the presidential campaign trail. The crisis' causes and  potential solutions it are the focus of many researchers at Heller, which is home to both the National Prescription Drug Monitoring Program Center of Excellence and the Institute for Behavioral Health (IBH).

National media coverage 

Senior scientist Andrew Kolodny is a national figure in substance abuse disorder and treatment. He regularly comments on the prescription opioid and heroin epidemic on major media outlets in print, television and radio. Below are a few highlights:

• October 25, 2015 Interviewed on C-SPAN Washington Journal "Dr. Andrew Kolodny on Combating Drug Abuse."
• January 16, 2016 Interviewed in the New York Times "Drug Overdoses Propel Rise in Mortality Rates of Young Whites."
• January 21, 2016 Interviewed on the Diane Rehm Show "New Efforts To Address America’s Growing Addiction Crisis."
• February 5, 2016 Self-authored op-ed in the Boston Globe "FDA must revisit OxyContin decision" to permit oxycontin prescriptions for children. 
• February 8, 2016Interviewed in USA Today on Super Bowl ad that normalizes dangerous long-term opioid prescribing
• February 10, 2016 Interviewed in the Daily Beast "Addicted to Heroin? Trump Says Blame the Mexicans."
• February 12, 2016 Interviewed in the Washington Post "Cruz, Trump want to secure the border to keep out heroin. But will it work?"
• February 17, 2016 Self-authored op-ed in the New York Times' Room for Debate "Crooked Doctors Are Not Fueling the Opioid Epidemic."
• February 22, 2016 Interviewed in Consumer Reports "Avoid Withdrawal Symptoms From Prescription Painkillers."
• February 23, 2016 Interviewed in PBS Frontline "The Options and Obstacles to Treating Heroin Addiction."
  
• March 15, 2016 Interviewed in the Los Angeles Times "Opioids are bad medicine for chronic pain, say new federal guidelines"
• March 15, 2016 Interviewed in the Washington Post "CDC warns doctors about the dangers of prescribing opioid painkillers"
• March 16, 2016 Interviewed in USA Today "Doctors told to avoid prescribing opiates for chronic pain"
• March 17, 2016 Interviewed on the Diane Rehm Show "The CDC’s New Guidelines On Prescribing Opioid Painkillers."
• March 29, 2016 Interviewed in Forbes "The FDA's Support For Abuse-Deterrent Opioids May Not Be Enough"
• April 7, 2016 Interviewed on Fox5 New York "Evolution of the Opioid Epidemic"
• April 27, 2016 Interviewed in The Wrap "Prince and the Opioid Epidemic: ‘These Are Essentially Heroin Pills,’ Expert Says"
• May 6, 2016 Interviewed in Consumer Reports "Prince's Death and the Addiction Risk of Opioids"
• May 6, 2016 Interviewed in the Sydney Morning Herald "America is in the grip of an unprecedented epidemic of drug addiction"
• May 18, 2016 Interviewed in the New York Times "Actions by Congress on Opioids Haven’t Included Limiting Them"
• May 19, 2016 Interviewed in Q13Fox "Health insurance companies step up to fight the opioid epidemic"
• May 21, 2016 interviewed in the New York Times "Children of Heroin Crisis Find Refuge in Grandparents’ Arms"

Closer to home: A Q&A with behavioral health researchers on Massachusetts' bill to combat opioid addiction

Here in Massachusetts, the House of Representatives unanimously passed a bill to combat the state's growing opioid addiction problem. The House legislation offers significant differences from another opioid bill previously put forth by Governor Charlie Baker. Heller Communications talked with IBH Director Constance Horgan and Sharon Reif, IBH deputy director, about the bills and the significant public health issue they try to address.

There are several key differences between the bills that Massachusetts House lawmakers passed and the governor's version. One is that the governor's version would let patients be committed involuntarily to drug treatment facilities for up to 72 hours if they're considered an immediate danger, while the House bill does not include this provision. What's your take on coerced treatment?

We often talk about coerced treatment in the context of the criminal justice system, where someone on probation, for instance, must go to substance use treatment or go to jail. In this context coerced treatment is often as successful as “voluntary” treatment. However, treatment for opiate addiction is a long-term endeavor, frequently involving medications such as buprenorphine or methadone that require the person to be motivated and engaged. The involuntary 72 hour hold proposed in the governor’s bill would allow the patient to be educated about treatment options and be removed from the environment, but is not treatment itself. And the involuntary nature may backfire, making people who are already reluctant to enter treatment more so.

Another difference between the two bills is that the governor's bill would limit opiate prescriptions to a three-day supply, while the house bill would limit opiate prescriptions to a seven-day supply. It would also include a requirement that overdose victims who would need to be evaluated by a mental health professional within 24 hours. What impact does prescription length have, and where do you come down on the mandatory evaluation?

The longer seven-day supply will give doctors more flexibility to treat pain, which is a legitimate concern for many people. The shorter limit on prescriptions can be a great barrier to treatment for people with pain, who already have absorbed many restrictions on their ability to receive needed treatments, as determined by the doctor managing their care. We applaud efforts to provide more training and guidance for physicians around responsible opioid prescribing, and other approaches to increasing appropriate prescribing. For instance, the Centers for Disease Control and Preventions has released draft opioid prescribing guidelines to ensure that doctors adopt best practices.

An evaluation within 24 hours is an excellent idea. An overdose, accident or other traumatic event can be “teachable moments” where the consequences of addiction are highlighted. We often treat the person but do not address the underlying cause, thus the call for evaluations. We must be careful however, that there is an adequate treatment system to support referrals to treatment (or other services that are needed) stemming from this evaluation. And that we have a sufficient and adequately trained mental health and addiction workforce available to ERs to address this need.

As you point out, recognizing and determining the need for treatment is important, but we need to make sure the treatment system has the capacity to meet what could be a large increase in the number of patients. How significant is this challenge, and how can the system meet it?

In many cases the first step is detoxification, which is limited by the number of “beds” or treatment slots. It is essential, however, to provide continuity of treatment post-detox, thus capacity of the system in terms of adequate supply of services is also an issue at that point.  Access to buprenorphine is limited by the number of physicians authorized to prescribe. These barriers can be overcome by some innovative approaches. For instance, is full detoxification needed if someone will be starting buprenorphine? If not, shorter stays in detox may speed up access to and engagement in treatment, and allow more people to move through the process. We need to keep working on the “no wrong door” approach to bringing people into treatment. 

The House version of the bill was passed unanimously, so clearly there is a public interest in addressing this issue. Outside of what’s outlined in the proposed bills, what do you see as the next important steps for lawmakers and the medical community to take?

These bills reflect long-needed action to address the opioid addiction crisis. They are a positive step and are one part of a comprehensive view of the opioid crisis. Such a comprehensive vision should include aspects of prevention, treatment and recovery, prescribing practices and criminal justice reform. 

For example, we often hear about a shortage of doctors who are willing to prescribe buprenorphine, for a variety of reasons. An expanded focus on training to prescribe buprenorphine would be valuable. The DPH has just promulgated regulations to license large outpatient practices that prescribe buprenorphine, to ensure the quality of treatment. The problem of stigma associated with drug addiction and its treatment is another issue that has a tremendous negative impact on successful outcomes. To address stigma about treating addiction, education about the effectiveness of evidence-based treatments for addiction is needed. The Department of Public Health is conducting a public awareness campaign to reduce stigma for addiction. Other systems are also key components to address the opioid crisis, such as criminal justice, education, and social services.  Our Brandeis/Harvard NIDA Center to Improve System Performance for Substance Use Disorder Treatment brings this essential system focus to improve treatment overall and promote evidence-based practices to ensure quality of care for people with addictions.