IN-DEPTH PERSPECTIVES ON COMBATING THE OPIOID EPIDEMIC

Transcription

1 Sponsored by IN-DEPTH PERSPECTIVES ON COMBATING THE OPIOID EPIDEMIC U.S. VIEWS AND EXPERT INSIGHTS FROM MEDICAL PRACTITIONERS, VETERANS AND THE GENERAL PUBLIC Written by 1

2 CONTENTS About the research Introduction An epidemic spiraling out of control A lot like everyone else How did this happen? Spotlight: veterans and the opioid crisis Approaches medical practitioners and Americans in general think are working Approaches to treatment communities want more of and examples of success Conclusion Contents

3 ABOUT THE RESEARCH The Economist Intelligence Unit (EIU) conducted two surveys, sponsored by Cigna, of 304 U.S. medical and addiction practitioners and 2,800 members of the American general public. Among the practitioners, 99% have treated patients taking opioids or suffering from opioid addiction and 70% have treated veterans. The members of the general public represent all 50 states; 40% have suffered from addiction themselves or have friends, family or co-workers who have done so and 21% are veterans. The surveys were conducted in June and July, The EIU also conducted in-depth interviews with 15 experts in various areas of addressing opioid addiction for this paper and its accompanying case studies. We would like to thank them all for their insights: Adam Bisaga, MD, a professor of psychiatry at Columbia University Medical Center Ben Bobrow, MD, a professor of Emergency Medicine at the University of Arizona College Of Medicine Eric D. Collins, MD, physician in chief at Silver Hill Hospital Joseph Helms, MD, founder and president of the Acus Foundation Allison Jaslow, executive director of the Iraq and Afghanistan Veterans of America Matt Feehery, CEO of Memorial Hermann Prevention & Recovery Center (PaRC) in Houston, Texas Ritz Koontz, opioid treatment psychologist in the Opioid Treatment Program (OTP) within the Substance Treatment and Recovery (STAR) clinic at the U.S. Department of Veterans Affairs (VA) Hospital in Oklahoma City Lisa McLaughlin, co-founder, co-ceo, Workit Health F. Gerald Moeller, MD, Division Chair for Addiction Psychiatry, director of the Institute for Drug and Alcohol Studies and director of Addiction Medicine and professor of Psychiatry, Pharmacology and Toxicology, and Neurology at VCU s Department of Psychiatry Stephen Rodgers, an RN in the Opioid Treatment Program (OTP) within the Substance Treatment and Recovery (STAR) clinic at the U.S. Department of Veterans Affairs (VA) Hospital in Oklahoma City Steven Schwab, executive director of the Elizabeth Dole Foundation Michael Stone, MD, president and founder of Recovery Homes of America, Inc., dba Cornerstone of Southern California Tammy Tucker, associate administrator at Memorial Regional Hospital and a licensed clinical psychologist Marvin Seppala, MD, chief medical officer at the Hazelden Betty Ford Foundation and adjunct professor of the Hazelden Graduate School of Addiction Studies Gabriel Wishik-Miller, MD, MPH, an internist at Boston Health Care for the Homeless Program This paper was developed for The Economist Intelligence Unit by Elaine Pofeldt and Josselyn Simpson. 3 About the Research

4 INTRODUCTION Every day, 142 people in the U.S. die from overdoses of legal opioids, and deaths from legal and illegal opioid overdoses are growing exponentially. 1 More and more resources are being deployed against the crisis. However, there is considerable debate about how best to address the crisis, which is impacting Americans from every walk of life, including a disproportionate share of veterans, many of whom receive prescriptions for opioids following combat injuries. Those combat related prescriptions can lead to addictions. Approaches to prevent substance use disorders and to ensure that people with addictions can reclaim their lives and achieve a healthy and productive future have included behavioral therapy, alternative treatments for pain, detox and medication-assisted treatment (MAT). To uncover treatment options, policies and strategies that both medical practitioners and the American public think work best and want to see added or expanded in their communities, The Economist Intelligence Unit (EIU) embarked on a nationwide research program, sponsored by Cigna, in June and July, Although many areas of consensus emerged, there are some differences of opinion between practitioners and the public, highlighting areas where more communication between, and general education of, the two groups could help make a difference. One stark difference: while 70% of practitioners said opioid addiction is treatable, only 47% of Americans did, perhaps reflecting lack of familiarity with the options available. This paper describes the treatment approaches that were cited as most effective in the nationwide survey conducted by the EIU and puts them in context with interviews with medical and community leaders in the fight against opioid addiction. Eight complementary case studies (which can be found here) explore successful examples of the most often-cited treatment approaches in more depth. The goal of this research is to spark productive conversations about practical solutions among policymakers, practitioners, and all Americans to this national crisis Introduction

5 AN EPIDEMIC SPIRALING OUT OF CONTROL There is no doubt the opioid crisis in the U.S. is accelerating. 33,901 people died from opioid-related overdoses in 2015, a 2.8-fold increase from 2002, according to the U.S. Centers for Disease Control. 2 Among those deaths were 17,536 from prescription opioids. 3 Although the U.S. is the epicenter of the opioid crisis, opioid addiction is a global problem. The World Health Organization estimates that 69,000 people around the world die from opioid overdoses each year. 4 The epidemic is putting a strain on public and private resources. In the U.S., the total economic burden hit an estimated $78.5 billion in 2013, according to an analysis published in 2016 in the journal Medical Care. 5 Of that, about $28 billion was spent on healthcare and substance use disorder treatment in nonfatal cases; costs for lost productivity, including that of incarcerated people, hit an estimated $20 billion. 6 Fatal overdoses cost the economy $21.5 billion; that figure included costs related to lost productivity and healthcare for the people who died. 7 Another $7.7 billion went to criminal justice-related costs. The cost estimates also included losses to tax revenues due to opioid-related productivity losses. Given the scope of the crisis, it is not surprising that at least two-thirds of respondents in the EIU survey agreed that the opioid epidemic is out of control in the U.S. And that view holds across a wide range of Americans: Respondents to the survey included 304 medical and addiction practitioners 99% of whom have treated patients taking opioids or suffering from opioid addiction and 70% of whom have treated veterans. The survey also included 2,800 members of the public from all 50 states 40% of whom have suffered from addiction themselves or have friends, family or co-workers who have done so and 21% of whom are veterans. At least twothirds of respondents in the EIU survey agreed that the opioid epidemic is out of control in the U.S. 2 Overdose death rates. National Institute on Drug Abuse. January Available online at: The_Economic_Burden_of_Prescription_Opioid.2.aspx se.gov/related-topics/trends-statistics/overdose-death-rates 3 Overdose death rates. National Institute on Drug Abuse. January Available online at: The_Economic_Burden_of_Prescription_Opioid.2.aspx se.gov/related-topics/trends-statistics/overdose-death-rates Florence, Curtis S. PhD; Zhou, Chao PhD; Luo, Feijun PhD; Xu, Likang MD. The Economic Burden of Prescription Opioid Overdose, Abuse, and Dependence in the United States, (Medical Care: October Volume 54 - Issue 10 - p ). West Chester, PA. Available online at: 6 Florence, Curtis S. PhD; Zhou, Chao PhD; Luo, Feijun PhD; Xu, Likang MD. The Economic Burden of Prescription Opioid Overdose, Abuse, and Dependence in the United States, (Medical Care: October Volume 54 - Issue 10 - p ). West Chester, PA. Available online at: 7 Costs of U.S. Prescription Opioid Epidemic Estimated at $78.5 Billion. Wolters Kluwer. Sept 14, Available online at: 5 An Epidemic Spiraling Out of Control

6 AN EPIDEMIC SPIRALING OUT OF CONTROL The opinion that the epidemic is out of control is likely compounded by the fact that despite the fact that effective treatments are emerging many people with opioid use disorder are not getting treatment. 8 In 2015, nearly 80% of the more than 2 million Americans suffering from the disorder did not receive treatment. 9 Many Americans see a leadership gap in addressing the problem. Indeed, in our survey, the general public more often said no one in their community is leading efforts to address addiction than pointed to anyone who is doing so. One unusual feature of the opioid crisis is that for many, addictions may begin when patients received medical care; and indeed, among respondents to the EIU survey, 47% of practitioners said it usually develops after a necessary prescription for pain management. Other research shows that nearly half of opioid-related deaths involve a prescription opioid. 10 Veterans have been hit especially hard. Though the U.S. Department of Veterans Affairs (VA) has taken promising steps to reduce the prescribing of opioids to deal with veterans pain from injuries, from 2010 to 2015, the number of veterans with opioid addiction climbed to approximately 68,000, a 55% increase in that five-year period. 11 These veterans living with opioid addiction made up about 13 percent of all veterans being prescribed opioids; veterans are almost twice as likely to die from an overdose of opioid drugs as the civilian population. 12 Additionally, there was a 52.7% increase in outpatient veterans treated for substance use disorders from 1995 to Furthermore, the EIU survey found that nearly three-quarters of practitioners think that treating veterans who suffer from opioid addiction is more complex than treating other sufferers; they cite chronic pain and post-traumatic stress disorder as frequent influences on veterans addiction. 8 Department of Health and Human Services, Substance Abuse and Mental Health Services Administration. (2016). Medication-Assisted Treatment of Opioid Use Disorder Pocket Guide (HHS Publication No. SMA PG). Rockville, MD. Retrieved from 9 Department of Health and Human Services, Substance Abuse and Mental Health Services Administration. (2016). Medication-Assisted Treatment of Opioid Use Disorder Pocket Guide (HHS Publication No. SMA PG). Rockville, MD. Retrieved from 10 CDC. Wide-ranging online data for epidemiologic research (WONDER). Atlanta, GA: CDC, National Center for Health Statistics; Available at 11 VA. Healthcare Inspection - VA Patterns of Dispensing Take-Home Opioids and Monitoring Patients on Opioid. May 14, Available online at: 12 PBS. Veterans Face Greater Risks Amid Opioid Crisis. March 28, Available online at: An Epidemic Spiraling Out of Control

7 A LOT LIKE EVERYONE ELSE In the face of such a crisis, one important finding of the EIU survey is that practitioners and the general public more often describe people suffering with addiction as a lot like everyone else than any other description. Indeed, in our survey, the EIU survey found that 40% of the general public has experienced opioid addiction themselves or have family, friends or co-workers who have faced addiction. The risk of a substance use disorder, along with the consequences, and the processes for treatment and recovery vary by gender, race, ethnicity, sexual orientation, age, and other factors in complex ways beyond the scope of this paper. 14 The crisis crosses generational lines. According to data gathered by the Kaiser Family Foundation and based on federal statistics, for example, U.S. deaths involving natural, semi-synthetic and synthetic opioids in 2015 totaled: 3,165 for those 24 and under; 8,568 for those aged 25-34; 7,484 for those aged 35-44; 7,595 for those aged 45-54; and 6,277 for those aged 55 and older. 15 However, some groups within the population have been hit harder than others. Overdose rates are higher among non-hispanic whites and American Indian or Alaskan Natives, for example, than among non-hispanic blacks and Hispanics. 16 Geographically, the top five states in opioid-related overdose deaths per 100,000 of population in 2015 were: West Virginia (36), New Hampshire (31.3), Ohio (24.7), Massachusetts (23.3), and Kentucky (21). 17 Practitioners and the general public more often describe people suffering with addiction as a lot like everyone else. 1 4 Center for Substance Abuse Treatment. Substance Abuse Treatment: Addressing the Specific Needs of Women. Rockville (MD): Substance Abuse and Mental Health Services Administration (US); (Treatment Improvement Protocol (TIP) Series, No. 51.) Chapter 6: Substance Abuse Among Specific Population Groups and Settings. Available from: 15 Kaiser Family Foundation. Opioid Overdose Deaths by Age Group. Available online at: 16 CDC. Prescription Opioid Overdose Data. Atlanta, GA. August Available online at: 17 Kaiser Family Foundation. Opioid Overdose Death Rates and All Drug Overdose Death Rates per 100,000 Population (Age Adjusted). Available line at: death-rates/?currenttimeframe=0&sortmodel=%7b%22colid%22:%22location%22,%22sort%22:%22asc%22%7d 7 A Lot Like Everyone Else

8 A LOT LIKE EVERYONE ELSE On a gender basis, overdose rates are highest among men, but the gap between men and women is closing. 18 In 2015, 11,420 U.S. women died from overdoses of natural, semi-synthetic and synthetic opioids, up from 7,770 in In comparison, 21,671 men died from the same causes in 2015, up from 13, People with chronic pain have also been hard hit, as the EIU survey highlighted, and this is one key reason that veterans are so often affected by opioid misuse. The VA has reported that approximately 60% of returning military personnel who had been deployed in the Middle East and 50% of veterans from prior deployments suffered from chronic pain. 21 That compares to 30% of the general public who suffer from chronic pain. 22 Veterans have more complex injuries than the average civilian, notes Allison Jaslow, executive director of the Iraq and Afghanistan Veterans of America (IAVA), who served two tours of duty in Iraq as an Army captain. We have to embrace the fact that if we jump too soon to prescribe an opioid, we could be treating something before addressing the underlying issues. Programs within the VA system discussed in the companion case studies illustrate some approaches being used (see the case studies here). 18 CDC. Prescription Opioid Overdose Data. Atlanta, GA. August Available online at: drugoverdose/data/overdose.html 19 Kaiser Family Foundation. Opioid Overdose Deaths by Gender. Available online at: 22:%22Location%22,%22sort%22:%22asc%22%7D 20 Kaiser Family Foundation. Opioid Overdose Deaths by Gender. Available online at: 2:%22Location%22,%22sort%22:%22asc%22%7D 21 See Statement of Dr. Carolyn Clancy, M.D., Interim Under Secretary for Health, before the Committee on Veterans Affairs, U.S. Senate, March 26, See Statement of Dr. Carolyn Clancy, M.D., Interim Under Secretary for Health, before the Committee on Veterans Affairs, U.S. Senate, March 26, A Lot Like Everyone Else

9 HOW DID THIS HAPPEN? There are myriad medical, legal and economic reasons that opioids are at the core of a crisis affecting so much of the country. One clear factor, however, is that opioids have long been considered the most effective treatment for pain and, beginning in the mid-1990s, physicians felt more pressure to prescribe opioids in hospital settings to relieve pain since patient satisfaction survey questions about pain relief were tied to Medicare reimbursements, says Matt Feehery, CEO of Memorial Hermann Prevention & Recovery Center (PaRC) in Houston, Texas. However, a focus on relieving pain with medication can lead patients into a vicious cycle. Indeed, half of the medical practitioners the EIU surveyed and 37% of the American public said that people in chronic pain are the community that suffers most from opioid addiction. Perhaps more telling, the survey also found that 43% of practitioners cited overprescribing as a cause of addiction but also found that, when treating patients, 58% focused more on treating the current condition rather than the potential for opioid misuse. In other words, practitioners are aware of the potential for misuse but don t always focus on it in the moment of prescribing. One reason may well be modern medical training. In 1996, the American Pain Society (APS) introduced the concept pain as the 5th vital sign, emphasizing that pain assessment is just as important as monitoring the standard four vital signs (body temperature, pulse rate, respiration rate and blood pressure) and that clinicians need to take action when patients report pain. 23 Medical schools embraced this outlook and have taught it to physicians for the past 20 years. Another factor was the Affordable Care Act and the reimbursement restructuring that came along with it, which favored providers who scored favorably on criteria including patients surveys on how well their pain was controlled. 24 Although it has now become clear to many medical professionals that this approach needs to be adjusted to take the opioid crisis into account, 25 many physicians still receive little training in either proper pain management or addiction. 26 Practitioners are aware of the potential for misuse but don t always focus on it in the moment of prescribing. 43% Practitioners cited overprescribing as a cause of addiction 58% Focused more on treating the current condition rather than the potential for opioid misuse Data from a survey conducted by The Economist Intelligence Unit American Pain Society, Pain as the 5th vital sign. Available online at: 24 Gregory, Sean. How Obamacare is Fueling America s Opioid Epidemic. Available online at: 25 Kliff, Sarah. The Opioid Crisis has Changed How Doctors Think about Pain. Vox. June 5, Available online at 26 Nora D. Volkow, M.D., and A. Thomas McLellan, Ph.D. Opioid Abuse in Chronic Pain Misconceptions and Mitigation Strategies. N Engl J Med 2016; 374: March 31, Available online at: nejm.org/doi/full/ /nejmra #t=article 9 How Did This Happen?

10 SPOTLIGHT: VETERANS AND THE OPIOID CRISIS Not only do majorities of both practitioners and the general public say in our survey that treating veterans who suffer from opioid addiction is more complex than treating other sufferers, but more than a third of practitioners say they aren t very confident they have the right resources and training to treat veterans living with opioid addiction. The survey findings from veterans themselves offered useful insights into how to best to address both veterans pain and addiction. Veterans were, as one might expect, more focused than other Americans on chronic pain, the need to treat it and the interplay of those factors with addiction. Fortunately, many veterans have an idea of the approaches that would particularly help them. For example, veterans more often cited encouraging the medical community to prescribe less addictive painkillers as an effective way to reduce the supply of opioids to the general public than Americans in general (32% vs 26%), perhaps recognizing that painkillers are necessary for many. It s about developing a treatment plan unique to them, treating injuries that are not on the surface, and making sure that most options are available to avoid opioids, says Allison Jaslow, executive director of Iraq and Afghanistan Veterans of America. MOST EFFECTIVE TREATMENT Two of the top three responses to how respondents characterize addiction; the other top choice is is treatable Usually develops after a necessary prescription for pain management Usually develops among people who often suffer pain such as veterans or athletes 53% 47% 40% 35% Percentages of veterans (green) and Americans in general (orange) citing each as a way to characterize opioid addiction Data from a survey conducted by The Economist Intelligence Unit Spotlight: Veterans and the Opioid Crisis

11 SPOTLIGHT: VETERANS AND THE OPIOID CRISIS Veterans also more often than the general public wanted to expand access to medical treatment with traditional and alternative practices in their community (38% compared with 31%), the survey found, as well as expanded access to veteran-specific resources on pain management. In addition to veterans, their caregivers can also be a valuable source of input on needed resources, notes Steven Schwab, executive director of the Elizabeth Dole Foundation, which runs programs to support and empower military caregivers. What we hear from caregivers is they want to be trained on how to recognize the signs of addiction and what the options are available to them are, whether they seek inpatient care, medicationassisted treatment or counseling, says Mr. Schwab. They also need to understand how the system works both the VA and private insurance services. One key to addressing the opioid crisis fully will undoubtedly be to include both veterans and their caregivers in the national conversation. Says Mr. Schwab, What we need to do is ensure that veterans and their caregivers have a voice and community to leverage as they address these addiction issues. 11 Spotlight: Veterans and the Opioid Crisis

12 APPROACHES MEDICAL PRACTITIONERS AND AMERICANS IN GENERAL THINK ARE WORKING Preventing opioid addiction is the best way to reduce the harm and costs associated with it. Preventive efforts include public education and encouragement of physicians to use alternative methods for treating pain, such as acupuncture and non-opioid painkillers. However, for the millions of people already struggling with opioid use disorders, treatment with evidencebased solutions is the next best option to prevention. Sixty-five percent of practitioners the EIU surveyed said medication-assisted treatment (MAT) is the most effective approach. And MAT, which combines behavioral therapy and medications to treat substance use disorders, has been widely found to be effective in peerreviewed medical journals. The U.S. Department of Health and Human Services has identified five key strategies 27 to address the opioid crisis: 1. Improving access to treatment and recovery services including the full range of MAT; 2. Promoting targeted availability and distribution of overdose-reversing drugs (such as Naloxone); 3. Strengthening understanding of the epidemic through better public health and data and reporting; 4. Providing support for cutting-edge research on pain and addiction; and 5. Advancing better practices for pain management. MOST EFFECTIVE TREATMENT Encouraging medication-assisted treatment Behavioral therapy Peer counseling Alternative therapies (such as acupuncture or meditation) 15% 44% 56% 37% 50% 37% 29% 65% Top four treatments or responses most effective in helping individuals with addiction stop using opioids permanently cited by practitioners (blue) and Americans in general (orange) Data from a survey conducted by The Economist Intelligence Unit SAMHSA. New Report shows that Opioid Misuse Increases among Older Adults. Rockville, MD. July 26, Available online at: 12 Approaches Medical Practitioners and Americans in General Think are Working

13 APPROACHES MEDICAL PRACTITIONERS AND AMERICANS IN GENERAL THINK ARE WORKING It is heartening that the EIU survey shows that many practitioners and the general public share these views on the whole. Only 7% of the general public, for example, cites forcing people to go cold turkey as an effective approach to treatment, while 44% cite encouraging MAT. Putting someone in the hospital, detoxing them and sending them out to Narcotics Anonymous (NA) meetings is dangerous, says psychiatrist Adam Bisaga, MD, a professor of psychiatry at Columbia University Medical Center. It increases your risk of dying. Detox should only be used if you are going to start medication to prevent relapse. However, there are some notable differences in emphasis between the approaches to treatment cited as most effective by the two groups of respondents, which may reflect practitioners professional familiarity with current medical research on opioid addiction an area that may be new to families suddenly encountering the opioid crisis firsthand. Indeed, the EIU survey found that more Americans have turned to the internet for information about addiction than any other single source while practitioners put the internet far down the list of sources they think provide the best information to the general public, behind their own doctors, peer counseling meetings, other medical professionals, social workers and experts available through the workplace. ELEMENTS OF THE MOST EFFECTIVE TREATMENT PROGRAMS Enrollment in a community based program offering support in many areas of life Psychiatric counseling for individual with addiction and family Peer counseling 57% 30% 50% 33% 44% 31% Elements to include in a treatment program to make it effective, as cited by practitioners (blue) and Americans in general (orange) Data from a survey conducted by The Economist Intelligence Unit 2017 Outpatient treatment 21% 38% Inpatient treatment 32% 40% 13 Approaches Medical Practitioners and Americans in General Think are Working

14 APPROACHES MEDICAL PRACTITIONERS AND AMERICANS IN GENERAL THINK ARE WORKING I think there s a very general lack of awareness among families about what the treatment options are, says Steven Schwab, executive director of the Elizabeth Dole Foundation, which runs programs to support and empower military caregivers including the Hidden Heroes Campaign, which raises awareness of the issues facing military caregivers and their families. I don t think there is enough awareness out there about MAT or counseling programs that can be done with a mix of inpatient or outpatient facilities. That s probably why you re seeing a discrepancy between practitioners and the general public. Fatigue in dealing with the challenges of opioid addiction may also be a factor in why, for instance, members of the general public may be less inclined than practitioners to gravitate to community-based programs, such as peer counseling and programs offering support in all areas of life, than an inpatient program where the patient receives treatment outside of the home environment, says Mr. Schwab. When they are dealing with a loved one who is facing the dramatic circumstances of opioid abuse, I think that family feels held prisoner and is desperate, says Mr. Schwab. They think they need to get that loved one into an inpatient treatment program. That s just what comes to their mind. They don t know how to deal with it at home. MISALIGNMENT BETWEEN ACCESSIBILITY AND EFFECTIVENESS Peer counseling Outpatient treatment First responders who carry Naloxone Inpatient treatment 18%* 18% 29% 16% 27% 19%* 38% 44%* The most accessible options to address opioid addiction in their community, as cited by practitioners (blue) and Americans in general (orange) *Top three choices as part of an effective treatment program Data from a survey conducted by The Economist Intelligence Unit 2017 Enrollment in a community-based program Psychiatric counseling for individual with addiction and family 12% 10% 21% 27%* 14 Approaches Medical Practitioners and Americans in General Think are Working

15 APPROACHES TO TREATMENT COMMUNITIES WANT MORE OF AND EXAMPLES OF SUCCESS Strong majorities of both general respondents and practitioners say in our survey that resources in their communities for helping those with opioid addiction and their families and caregivers are at best somewhat adequate today, and there is some mismatch between the approaches to treatment seen as widely available and those seen as most effective. As one might expect, the options for addressing the opioid epidemic that respondents to the EIU survey want to see expanded in their communities do include more of the approaches they most often cite as effective. Such programs include: In Massachusetts: Boston Healthcare for the Homeless Program runs a communitybased program where people with opioid addiction can drop in (or be brought in by others) for observation if they are worried about being over-sedated. It has saved an estimated 1,200 emergency room visits per year (read the case study on this program here). In Florida: Memorial Healthcare System in Hollywood, Fla., has used federal funds to create a program in which peer counselors in the emergency room of Memorial Regional Hospital encourage patients with opioid addiction to try MAT. The program, launched in June 2017, will also incorporate emergency responders, to visit the homes of patients immediately following treatment with peer counselors to help with medication adherence (read the case study on this program here). In Oklahoma: The Star outpatient program at the VA hospital in Oklahoma City, in a state that ranks 15th in the country for deaths from prescription opioids, combines MAT with psychosocial approaches and connects veterans to the VA s classes on managing post-traumatic stress disorder (PTSD) and pain, so opioid regimens on their own are not these veterans only option (read the case study on this program here) Source of state ranking on deaths: 15 Approaches to Treatment Communities Want More Of and Examples of Success

16 APPROACHES TO TREATMENT COMMUNITIES WANT MORE OF AND EXAMPLES OF SUCCESS Many programs are making innovative use of digital technology, as well. Among them are an online community for veterans caregivers run by the Elizabeth Dole Foundation that enables thousands of caregivers to participate in conversations moderated by paid caregivers; a private sector digital program in Michigan founded by people recovering from their own addictions called Workit Health that includes peer coaching and an on-demand van that rapidly meets people in person in the community who seek help with their addiction; and an online community run by a professor of Emergency Medicine at the University of Arizona College of Medicine called The Pain Project, which helps people self-manage pain through a shift in mindset and behavior, with doctors using telemedicine, to teach patients how to do this. Whether a program relies heavily on technology or not, ultimately, many successful programs offer tools for human connection among people who are living with addiction, practitioners, peers and other key stakeholders. What we have found families really, really desire is an online community of support others they can relate to who can lend their personal advice and expertise, says Mr. Schwab. It s notable that respondents to the EIU survey who have themselves struggled with addiction most often cited medical treatment with traditional practices alone (43% of people who have struggled vs. 13% of other respondents) as a resource they would like to see more available and less often cited options preferred by most other groups such as psychiatric treatment for the person with addiction and his or her family (21% vs. 34%). This desire may reflect in part a shortage of beds in traditional medical inpatient programs in many communities. While peer communities like ours are super important for getting someone to admit there is an issue and find support, I think there is a huge void for inpatient programs, says Mr. Schwab. SEEKING MORE OF WHAT S EFFECTIVE Options practitioners want most in their community Enrollment a community based program offering 50% support in many areas of life* Psychiatric counseling for individual with 47% addiction and family* Options Americans in general want most in their community Psychiatric counseling for individual with addiction and family* Medical treatment with traditional and alternative practices* 34% 31% Outpatient treatment 37% Inpatient treatment 26% Medical treatment with traditional and alternative practices 31% *Top two choices as part of an effective treatment program Data from a survey conducted by The Economist Intelligence Unit 2017 Enrollment in a community based program offering support in many areas of life 24 Oklahoma Department of Mental Health and Substance Abuse Services. Fact Sheet on Prescription Drug Abuse, Misuse and Consequences Among Oklahoma. Available online at: documents/pr%20rxabuse-factsheet.pdf 22% 16 Approaches to Treatment Communities Want More Of and Examples of Success

17 CONCLUSION Given the toll the opioid epidemic is taking on the U.S., socially and economically, finding the most effective approaches to prevention and treatment is crucial. It s also time critical, given that major government agencies are in the process of distributing national resources for instance, the Department of Health and Human Service s Substance Abuse and Mental Health Services Administration (SAMHSA) is responsible for disbursing nearly $1 billion to relevant programs over the next two years under the 21st Century Cures Act, particularly in states hardest hit by overdoses. 29 Creative solutions are rapidly emerging from many sectors. Finding ways to improve communication among the public, practitioners, non-profit and academic experts, people with substance use disorders and caregivers seems likely to be the best way to find practical, cost-effective and scalable solutions that the public will embrace and to prioritize resources. The notable mismatches between practitioners and other Americans views on how best to address the opioid crisis such as the finding that Americans in general value communitybased options less than practitioners do indicate that better communication between the groups and mutual support could yield more cohesive efforts to combat and prevent opioid addiction. Education of both the public and providers about the best preventive methods and the most effective evidence-based treatments is a critical step. Practitioners have an opportunity to do more to encourage their peers to focus on the potential for addiction when treating patients and since many see overprescribing as a cause of opioid addiction, they have impetus to do so to prevent addiction from becoming even more of a crisis. Beyond the general population, survey respondents agree that treating veterans suffering from opioid addiction is particularly complex. Given that a third of practitioners don t feel confident in treating them, finding ways to share the knowledge of practitioners with experience treating veterans and increasing training and hiring of those practitioners would likely help as well. Finally, continuing to develop reliable outcomes data for the many nascent programs around the country that have not yet been able to prove how effective they may be is another step that will improve the quality of the debate on where to allocate resources to help the most people. It will be important for programs to continue sharing data on their outcomes and communicating about their results in order to enable other programs to replicate or draw inspiration from other successful programs. It will be important for programs to continue sharing data on their outcomes and communicating about their results in order to enable other programs to replicate or draw inspiration from other successful programs. 29 Williams, Arthur Robin; Nunes, Edward and Olfson, Mark. To Battle The Opioid Overdose Epidemic, Deploy The Cascade Of Care Model. Health Affairs Blog. March 13, Available online at: org/blog/2017/03/13/to-battle-the-opioid-overdose-epidemic-deploy-the-cascade-of-care-model/ 17 Conclusion

18 All Cigna products and services are provided exclusively by or through operating subsidiaries of Cigna Corporation, including Cigna Health and Life Insurance Company or their affiliates. The Cigna name, logo, and other Cigna marks are owned by Cigna Intellectual Property, Inc. 18