The Supply and Demand of Opioids: Tackling the Demand Problem
Understanding and addressing the opioid crisis is a problem that presents many challenges. The supply and demand dynamics are multifaceted, and they require more than a simple approach. You can review a primer on opioid supply and demand here and a discussion on the supply side here.
Like the supply side of the opioid equation, the demand side has a legal and an illicit market. One can almost think of the opioid pathway as a road with a never ending line of cars entering the road. Some, like legitimate patients with acute injuries or surgery, get on the on-ramp out of necessity and immediately exit when it’s appropriate. Unfortunately, some of the patients have to stay on as chronic patients in need of treatment, and others become addicted or dependent. Some, however, get on this on-ramp in an illicit manner in that they are looking to experiment, feed their addiction after relapsing, or actually look for pain treatment because the medical community and even our government has failed them.
Regardless of the route, opioids serve a legitimate medical purpose; until science can discover pain relieving medications as effective as opioids, the medical demand will always be there. With incredibly addictive properties, illicit demand for opioids will remain a major problem in Tennessee and across the United States.
In this part of “The Supply and Demand of Opioids”, I’ll discuss the demand side of the equation including steps that we have taken at the state level and where we need to go from here.
Legal Demand for Opioids
Whether it is new patients having surgery, acute injuries with significant pain, patients with chronic pain, or patients undergoing rehab, there is a constant flow of demand for the legitimate use of opioids. With a seemingly never ending need, how do we go about decreasing the demand for opioids?
As providers, patients, and legislators, one of the first steps is recognizing that opioids aren’t the only method of treating pain. In fact, pain treatment often requires a multimodal treatment plan involving non-steroidal, anti-inflammatory medications, nerve blocks, neuromodulators, or pain pumps. Unfortunately, these alternative methods of pain treatment are frequently more expensive than an opioid pill and can be rejected by TennCare, insurance, the patient, or even the provider.
TennCare previously instituted a program entitled “Episodes of Care” in which the episode quarterback (usually a surgeon) was responsible for the entire cost of treating a patient. If their episodes cost more than their peers, then the quarterback would be responsible for paying a risk sharing payment back to TennCare. Since TennCare often pays less than Medicare and less than the cost to provide the service, providers were punished by the system for incorporating a multimodal treatment for pain that decreased opioid use, but increased the cost of service.
In 2018, I passed House Bill 2001 which became Public Chapter 843. The law creates an affirmative defense for providers related to a risk sharing payment if they use non-opioid modalities to treat pain as long as it is a routinely used modality. Now, providers can decrease the amount of opioids they use to treat patients with some assurance that they won’t be punished by the system.
While this law is one step in decreasing the legitimate demand for opioids, it sheds light on a problem within the health care system. Opioid pills are relatively cheap and a have an immediate effect. Alternate medications or other modalities aren’t seen as a first line treatment for pain, and, therefore, may get denied by insurers or not be prioritized by providers or patients. This mindset must change within the healthcare system if we are going to make progress.
Perhaps some of the most difficult patients to assess and treat are chronic pain patients and those with cancer pain. Each patient has unique needs, unique tolerance for pain, and have a subjective quality to their pain. Treating these patients through a cookie cutter method does a disservice to these patients and leads to needless suffering or patients turning to alcohol and illicit drugs. As I fought against this cookie cutter method to legislating medicine, most recently the Health and Human Services admitted their mistake with previous guidelines that were too strict.
By putting forth strict guidelines, doctors are placed in a position of either going against the guidelines and risking their license or adhering to the guidelines and undertreating their patients. Understanding the unique needs of patients and helping doctors and providers treat them appropriately and with other modalities is a must.
One such alternative modality is the use of cannabis based medicines for pain. Most people are aware of the chemicals THC and CBD within cannabis, but there are hundreds of other chemicals called cannabinoids, terpenes, and terpenoids. Cancer patients and chronic pain patients who go to the illicit market or who are able to get cannabis based treatments legally in their state will tell you they are able to decrease or eliminate their opioid usage for their pain. There is a growing body of empirical evidence to add to the anecdotal evidence that cannabis based treatments can help pain patients and also cut down on opioids.
This past year, I attempted to pass House Bill 573 which would have decriminalized the possession of 0.9 percent cannabis oil for patients with cancer pain. The oil is currently decriminalized for patients with seizure disorders. To me, it is unconscionable that as a state and as legislators, we would rather a patient leave Tennessee for treatment, suffer, or go to jail because they can find relief from cannabis oil that cannot get you high, but might actually decrease your opioids and decrease your opioid high. The bill was shot down in committee, but I will run it again in 2020.
Additionally, I introduced House Bill 919, which would have allowed Tennessee patients to possess non-smokable, non-recreational cannabis based medicines in Tennessee if they were participating in a clinical trial being performed in another state by the FDA, a hospital, medical school, or pharmacy school. If we are going to help develop alternatives to opioids for the treatment of pain and other diseases, allowing Tennesseans to participate in studies close to home is prudent, both scientifically and compassionately. Unfortunately, this legislation did not move in 2019, but I will continue to stand up for science, research, and patients, and plan on running this bill again.
Whether Tennessee is able to pass our own medical program utilizing and researching cannabis based medicines or changes are made regarding the legality of cannabis at the federal level is unknown. What is known is that the World Health Organization has acknowledged medical uses of cannabinoids and called for the decriminalization of the plant for medical and research purposes. I will continue to keep fighting for patients and against the fear and ignorance that hinders research and clinical uses that can decrease opioid use, abuse, and dependency.
Another population of patients with a unique demand for opioids are patients undergoing addiction treatment. They are often addicted to heroin, prescription opioids, or even fentanyl. As these patients often have a physical dependency, their opioid addiction treatment often involves substituting their opioid of choice with a longer acting and less potent opioid like methadone or substituting with an agonist-antagonist like buprenorphine. Buprenorphine is a mixed opioid in that it has both opioid like effects and opioid blocking effects. It can be in pill, patch, or sublingual strips.
Unfortunately, patients undergoing addiction have a greater than 90 percent relapse rate and both methadone and buprenorphine have a black market street value. Fortunately, new breakthrough delivery systems for buprenorphine have been developed, and it is available in both long acting injectable and implantable forms. One lasts a month while the other may last up to six months. In 2018, I passed House Bill 2002 which would allow for the use of these forms of buprenorphine in Tennessee. These long acting forms improve compliance and cannot be diverted to the streets by a patient.
Helping patients keep from getting on the opioid fast lane and ensuring that they exit as smoothly as possible should be the goals when addressing the legal demand side of the equation. But understanding that each patient has a different set of needs and circumstances is imperative.
Illicit Demand for Opioids
Dealing with illicit demand requires an understanding of what drives one to the black market. Why does one take that first step? Why does one keep going back? Is it peer pressure? Curiosity? Under treatment of pain? Addiction? Is someone looking for an escape? Realizing that there are various etiologies and recognizing that no single approach will prevent everyone from taking illicit opioids is paramount to addressing the problem.
If we can determine the primary motivations and identify appropriate interventions, then we can minimize those that take that first step. That is easier said than done, and while I don’t believe that we will prevent all from falling victim to addiction, we can help have an impact and make a difference. Education, support, and ensuring we connect people with the appropriate resources.
For patients, in order to minimize their risk of going to the illicit market we must ensure that they receive adequate education up front and appropriate treatment for their pain while, also, taking caution to not extend opioid treatments beyond what is necessary. This is a delicate balance and is often one of the more difficult situations in medicine to handle. Part of the TN Together legislation was to ensure that patients who received prescriptions for longer than three days received an informed consent. The law, also, provided a pathway for providers to have patient exemptions to the law if they required higher or longer doses of opioids. I argued for greater autonomy and flexibility in the law, as I was concerned that the law would push providers to adopting a too restrictive practice which would undertreat patients and push them to the illicit market. I had the bill amended to include a sunset provision so that it would require proof that the law was having positive effects in order for it to continue.
For addicted patients that are undergoing addiction treatment, it is as much about their support system as it is ensuring that they receive medication assisted therapy. The environment one is in and the availability of drugs and opioids to an individual play statistically significant roles in whether an individual will use drugs to begin with. While most envision an environment of run down neighborhoods and back alley drug deals, that isn’t always the case. For instance, anesthesiologists are the number one medical profession for opioid abuse and addiction. Stressful jobs and readily available opioids place anesthesiologists in a high risk environment.
Knowing these risk factors in the general population and that relapse rates in patients undergoing addiction treatment is over 90 percent, it is imperative that patients have a supportive environment. Unfortunately, opioid addiction treatment is a long-term problem and inpatient treatment is expensive and often short term. Addressing this issue can play a pivotal role in the opioid crisis. Earlier this year, Tennessee received 25 million in federal funding to help combat the opioid crisis. It is projected that around 18 million will go towards treatment and recovery.
We have an understanding of what drives demand from patients, but what compels an opioid naive person that is not a patient to take that step to illicit opioids? According to an article in Anesthesia & Analgesia, previous or current substance abuse or use, environment, psychosocial factors and disorders, and younger age increase ones risk factors.
While many subscribe to the gateway theory of substance abuse progression, it is not necessarily one drug causing the step to the next drug like opioids. It is that once a person with psychosocial risk factors who has already interacted with the black market for one drug now has entered an environment where they have access to stronger or different drugs. If this is the case, then it isn’t necessarily the physical effects of the first drug that leads one to opioids like heroin, but the environment, psychosocial factors and opportunity that play significant roles and where our attention need to be allocated.
One of those areas includes a phenomenon known as Adverse Childhood Experiences or ACEs. We know that our brains do not completely develop until around age 25. The prefrontal cortex which influences our higher level thinking including determining consequences of our actions is one of the last areas to fully develop. That is why we often see younger individuals making more impulsive or reckless decisions and it is a factor that increases their risk of drug use. When you take an immature brain and add in adverse experiences like trauma, death in the family, poor home environment, abuse or neglect, or family addiction, that child is at greater risk for addictive behaviors like opioid abuse.
The Tennessee Department of Children’s Services has started an initiative called Building Strong Brains/ TN ACEs which is touted as a “major statewide effort to establish Tennessee as a national model for how a state can promote culture change in early childhood based on a philosophy that preventing and mitigating adverse childhood experiences, and their impact, is the most promising approach to helping Tennessee children lead productive, healthy lives and ensure the future prosperity of the state.” By raising public awareness about ACEs, impacting policy, and supporting state and local projects, they are working to decrease the negative impact of ACEs on the long term health of children including addiction and substance use disorders.
Of note is the emphasis on state and local projects where they look to address “ACEs and toxic stress in children”. In the past, programs like D.A.R.E. (Drug and Alcohol Resistance Education) were utilized at state and local levels, but proved to be counterproductive and increased the likelihood of drug use. Newer programs like “Keepin’ it Real” and Operation Prevention, a program from the DEA and Discovery Education, are other programs that have been used in schools. The former has not been shown to be effective and the latter has not been out long enough to have proven results.
However, if one is to move forward with a state or local program to decrease one’s risk of opioid abuse, research from the Recovery Research Institute, which is a non-profit research institute of Massachusetts General Hospital and an affiliate of Harvard Medical School, seems to support the goals of the Building Strong Brains initiative and addressing ACEs and toxic stress. In their research, they concluded that evidence based prevention interventions that focused on life skills training and a strengthening families program were cost effective approaches to preventing opioid misuse.
They found that it cost “about $613 to prevent one student from misusing opioids before 12th grade”. When one looks at the cost to society and taxpayers for failed prevention, an ounce of prevention on the front end can save a pound of misery for our families, communities, and our state.
The opioid crisis is a complicated and devastating problem with an intricate dynamic between supply and demand. Unfortunately, many addicts must reach rock bottom before they finally admit there is a problem. Though we have made some progress, if effectiveness is measured in decreased deaths associated with opioid misuse, Tennessee has been trending in the wrong direction because we have suffered our deadliest year to date. Perhaps we have reached our own rock bottom.
Taking responsibility and understanding the issues that guide our citizens on the path to destruction is a necessary first step to recovery. Tennessee is in such a position with our ongoing drug and opioid crisis. In times like these, we realize that we have reached uncharted territory. It’s going to take a concerted effort by all of us to focus on our patients, our families, and our children. We must work together to mitigate risk factors associated with opioids and other illicit drugs, but also create comprehensive solutions that better address this issue so we can finally end the cycle of addiction in Tennessee and improve the well-being of those impacted by this deadly scourge.