Dr Marcelina Jasmine Silva: Applying Lessons From COVID-19 to the Opioid Epidemic

Even before the coronavirus disease 2019 (COVID-19) pandemic, the struggle to curb the opioid epidemic in the United States has produced disappointing outcomes. Now that COVID-19 and the resulting social distancing requirements have allowed the opioid epidemic to flourish, authors in the July issue of The American Journal of Managed Care^® suggest an alternative approach that emphasizes building resiliency and investing in social support. Marcelina Jasmine Silva, DO, joined us to discuss the current approaches to opioid use and potential lessons to be learned from COVID-19.

Transcript

AJMC^®: Welcome to MJH Life Sciences News Network. Can you introduce yourself and tell us a bit about your work?

Marcelina Jasmine Silva: Yeah, thanks for having me. My name is Dr Marcelina Jasmine Silva, and I’m the creator and medical director of the FOOT Steps Program, and FOOT Steps stands for focus on opiate transitions. And it’s a program that helps patients with chronic pain transition away from classic opiate use. We’ve had great success, we’ve had a 90% success rate of helping patients transition away from classic opiates, and a 97% success rate at maintaining those results for up to 24 months of follow-up. So I feel pretty well qualified to talk about opiates and speak to the factors that aid in opiate cessation.

My program, FOOT Steps, was initially rooted in a workers compensation reimbursement model. And it was when I started looking at our outcomes and wanting to provide it for a broader range of patients that I started to investigate other types of managed care resources and fiscal models, and that’s when I came across the AJMC^® supplement “Deaths, Dollars, and Diverted Resources.” And that’s when it became apparent that the current way that the medical community has been treating the opioid epidemic is not only insufficient clinically, but also fiscally, it’s having some pretty poor outcomes. And I thought there’s a very strong case to be made, that on all accounts, we really need to change our tactics. And that’s when I became inspired to write this current article with my coauthor, Zak Kelly, and we wanted to overlay in some of the information that was presented in “Deaths, Dollars, and Diverted Resources” and also some of our own collected readings on industrial outcomes, public health outcomes, and the overall intersection of some really poor health results, to write this article entitled “The Escalation of the Opioid Epidemic Due to COVID-19 and Resulting Lessons About Treatment Alternatives.” I did most of this work before COVID came to the United States, but watching COVID act as an accelerant, kind of, on this flame of the opiate epidemic, I feel really illuminates a lot of issues and a lot of ways in which we can use this catalyst for bad change in order to make a better change in the future and treatment options.

AJMC^®: Going back to before COVID-19, what were some ongoing strategies to curb the opioid epidemic and what were the results?

Silva: The largest push towards a strategy came from the 2016 CDC guidelines for opiate prescribing. These were very thoughtful guidelines, and they were based on abundant published evidence. The main focus was on decreasing opiate exposure, and then also some suggestions for risk mitigation for patients who were already exposed chronically to opiate use. And a number of new practices came from those guidelines, which involved concerted efforts from the entire medical community. And again, the premise was to decrease or eliminate opiate exposure, and one of the ways we do that is by calculating opiates into what we call morphine equivalent doses, or MEDs. And there became a focus throughout physicians with patient care and prescribing practices to either decrease MEDs or eliminate opiates altogether. We saw pharmacists starting to question opiate prescribing, holding prescriptions even; managed care institutions denying coverage or modifying prescription coverage. And ERs and urgent cares revamping their protocols to deal with acute pain in ways that didn’t involve opiates at all. And so overall, we had this large-scale, coordinated effort to change opiate prescribing. Additionally, a lot of really thoughtful risk mitigation strategies were suggested, like frequent urine drug sampling, recommendations for naloxone prescribing. Simultaneously the DOJ bolstered their access to the prescription monitoring drug program, which is where clinicians can go and monitor controlled substance use and access for their patients to make sure that there’s not duplications happening.

It was impressive, and it was well organized, and it was a large-scale effort. But overall, despite all of that heroic work, really, the outcomes have been less impressive. So you know, those guidelines came out in 2016. Behavior change has been implemented since that time. But since that time, opioid-related deaths have continued to increase, and they’ve taken a real toll on US life expectancy. And in fact, the US life expectancy has been going down since 2014, and this is mainly attributed to unintentional injuries, which includes fatalities related to drug overdoses. And now there was a large headline that came out recently that said that in 2018, there was a plateau, finally, in life expectancy, actually a slight increase compared to 2017. But that reduction ended up being measurable in about a tenth of a year, which is around a month, and so it was sort of a small improvement and likely it was due to these really large-scale efforts that were implemented. But still, it’s a small improvement, and we’re still not back to the peak of American life expectancy, like we were back in 2014. And so we are still one of the lowest ranked countries in life expectancy and a large part of it is due to the opioid epidemic. So, on a public health front, we’re still not making the progress that we’d like to see; simultaneously, fiscal cost overall have continued to skyrocket despite all of these collective efforts. And so clearly, this approach of restricting opiate access is not the entire answer.

AJMC^®: Why do you think it’s insufficient to simply restrict access to opioid prescriptions?

Silva: Well, you know, the outcomes are just disappointing, frankly. We talked about the fact that restricting access hasn’t done much to move the needle in terms of poor US life expectancy. And in terms of financial and societal outcomes, we have evidence of decreasing opiate insurance coverage and decreasing prescribing practices occurring simultaneously with still increasing managed care costs for patients who use opiates. So for example, commercial insurance medical charges for patients with opiate dependency or abuse are 550% higher than patients who aren’t using opiates on an an annual per-patient charge. And that data encompasses things like comorbid conditions, other substance use, psychiatric/physical disorders, pain-related disorders, emergency room, and hospitalization visits to. And you know, most clinicians who are well acquainted with patients who are using opiates chronically, as soon as they’re cut off from their medication, the most common coping mechanism is to appear to the emergency room, which is inefficient, expensive, and it doesn’t really get anybody where they want to be. And so you can start to see that simply removing the cost of a prescription medication doesn’t remove all the costs that are associated with managed care around opiate use. And the reason that this happens overall is complex.

It’s, I believe, based on a theory of trauma and resulting lack of resiliency and lack of ability to heal. I didn’t discuss this theory explicitly in my article, but it’s implied. And this is a theory that I base my own clinical program and practice upon. And I think the dynamics of this theory has been illustrated by the negative effects of COVID-19. Basically, social distancing, while it’s been epidemiologically necessary, it’s cutting people off from any of the resources that enable them to be resilient. There’s an open discussion occurring currently, both in popular and clinical addiction literature, about the hazards that this current epidemiological climate is presenting for substance abuse triggering and relapse. I think overall, this dynamic is really best explained by a robust body of research that’s rooted in the effects of trauma, the foundation of which is the original, what we call the ACE studies or Adverse Childhood Experiences studies, which were studies that were founded by Dr Vincent Felitti and then were enlarged by a partnership with the CDC and Dr Robert Anda there, which basically has shown that there is a very strong association between trauma and health throughout life and chronic disease, and even things like chronic heart disease, cancer. Turns out that the more traumatic experiences you experienced, especially earlier in life, the more likely you are to have cancer. And so especially if you start to think about chronic conditions that have a behavioral health component, like chronic opiate use, or opiate misuse, or alcoholism or tobacco use, there’s a very strong association with a background in trauma.

And I’m not saying that everybody who uses opiates for chronic pain or everyone who has an opiate addiction—and those two things are not the same thing, but they’re both encompassed in the opiate epidemic—not all those people have had an abusive or traumatic childhood or traumatic past, but data shows that if you have a background of physical or emotional trauma, which is actually very common, then you’re much more likely to rely on opiates for chronic physical and/or emotional pain and simultaneously experience other health conditions that make a person feel nonresilient or otherwise physically or emotionally compromised and unable to heal. And as you start to think about the opiate epidemic in those terms, it obviously becomes much more complicated than simply refusing access or coverage for a prescription. That’s not going to solve the problem, and we need to start looking at our focus on identifying and treating the factors that make a person susceptible to chronic opiate use in the first place.

AJMC^®: How does the opioid epidemic inflict costs on both individuals and society?

Silva: Well, there are definitely some individual health costs, both immediate and long-term. Immediately, opiate use is associated with quite a bit of discomfort and uncomfortable side effects like constipation, dry mouth, brain fog, sleepiness, and of course, there’s the major side effect that we’re mostly worried about of overdose. Long-term, people have some insidious side effects that really, really decrease quality of life. Some major ones being immune compromised: opiates sort of sedate the immune system, for lack of a better term, which makes it harder for the immune system to identify certain viruses, certain illnesses, and even cancer cells. Long-term opiate use is associated with decreased sex hormones, and we see that markedly in a reduction of testosterone for men, so higher rates of osteoporosis and depression, fatigue, musculoskeletal strength loss. Also, people have a paradoxical reaction, sometimes, to long-term opiate use called hyperalgesia, where they will start to experience larger amounts of pain in areas where they don’t have an injury because of the chronic exposure to the opiates, which causes sort of a rewiring of the nervous system, which is just so counterproductive. So those are the individual costs. And the public health costs I think are reflected in our life expectancy decline. And then there’s the society costs that I think the benefit of time and our strategy so far have given us enough experience to look back now and start to see some of these society costs that really took a while to start to tally. In the workforce, we’re seeing that there’s some studies that have shown that patients with opiate dependence disorder in the setting of occupational spinal disorders are less likely to improve vocational and social function and have longer lengths of disability by 3-fold. These same patients are 2.5 times more likely to have surgery, they’re also more likely to engage in health care utilization with new providers, they’re more likely to be represented by an attorney. None of these things are necessarily the wrong thing to do in these clinical cases, but they’re all an inefficient use of time and money and they result in longer disability for the patient, which doesn't serve the patient well, either, and they’re expensive.

When you start also tallying up the astounding data that came out of the AJMC^® supplement, “Deaths, Dollars, and Diverted Resources,” about Medicaid, you know, estimations of Medicaid costs back in 2013 were billions to individual states, because almost a third of all patients who have a substance use disorder are covered by Medicaid, and that’s before even life expectancy started to decline. So you can only assume that those costs have skyrocketed, skyrocketed since that time, loss of billions of sales tax revenue, income tax revenue, opportunity costs from inefficient opiate use, and spending in criminal justice systems and foster care systems and educational systems. And then the fact that as the age of the population of opiate users increases and the amount of what we attribute to permanent disability increases, our Medicare population increases. So all of these costs, these billions upon billions of dollars, are being spread to all of us through these public and private health care systems as well.

AJMC^®: Going back to the present, how has the COVID-19 pandemic complicated our efforts to reduce opioid use?

Silva: Yeah, the current epidemiological climate and resulting necessary social distancing has really eroded resiliency for patients. It’s increased psychological, physical, and financial stressors; increased emotional and social isolation; decreased opportunities for physical activity; and access to medical uncomplimentary care. It also decreased as a clinician my ability to always be able to perform urine drug screening if I’m performing a telemedicine visit, and some of the other risk assessment tools that really benefit from face to face interactions, decreasing access to psychosocial support. Overall, this whole environment just allows the opioid epidemic to flourish.

AJMC^®: Are there any lessons that we can learn from the COVID-19 pandemic and apply to the opioid epidemic?

Silva: I think so. And I think this is the good news of this whole situation, you know, in many ways COVID is offering this big wrong way, do not enter sign. Whereas before, maybe the treatment approach has been a little unclear and we’ve been, you know, applying our best efforts. And I liken it to us being on a road trip all together, starting off in Texas, maybe we want to head to California. But if we keep seeing all of the highway signs pointing us to New York, we’re going the wrong direction. And I think that as we start to look at the clinical and financial outcomes of the way that we’ve been going in the opioid epidemic, and especially the way in which our outcomes have accelerated during COVID-19, we’re looking at our treatment approach has so far been not entirely the correct direction. So the way that I see it, if COVID has created certain factors that have been an accelerant, let’s focus on the opposite of those factors. You know, where we have isolation, let’s focus on community building, and that can be virtual. I certainly think that there are ways to be epidemiologically safe. And we’ll also continue to build peer support and group treatment models, which are financially supported and sustainable.

If we have limited access to resources currently, then let’s provide more access and easier resources to access, especially medication assisted therapy, buprenorphine type of therapies. I have this ridiculous scenario that I come across frequently, where I’ll be asking for buprenorphine for a patient who has been using opiates for a long period of time and if it’s not on formulary, the response I get back from an insurance company is, “Well, have you tried fentanyl yet?” and that’s very counterproductive, as you can imagine.

If we have higher amounts of emotional strain currently, then let’s add easier, better access, more abundant access to behavioral health services, group mental health services, support groups. With physical constraints, the health community can be very helpful and helping patients figure out how to add safe physical activity that’s sustainable at home, even if it’s only in their own bedroom. So, you know, overall, if you look at all these things that I’ve just suggested, I can just hear little voices, I think for many people, they look expensive. But when we look back at what we’ve been doing so far, it’s financially unsustainable and we need to do something different. So I’m arguing that a moderate investment in a bolus of health care resources early on with abundant access as an intervention early on can be much more financially viable than the piecemeal approach that we’ve been taking the last several years.

AJMC^®: How do you think opioid treatment approaches will look different after COVID-19?

Silva: I’m hoping that this painful time will be a clear catalyst for change for the better. I’m hoping that we’ll see some change and improvement in options for treatment strategy and corresponding reimbursement for innovation. I think we’re seeing the power of peer support and community and connectivity and a well-rounded approach to patient care, and I’m hoping that we can invest in that from seeing the benefits. And I think it’s a time to embrace innovation to try to really outsmart these long standing health opponents like the opioid epidemic. We need to be science-based; we need to be long-sighted. And if the model we were using before wasn’t working, we’ve already kind of had to change it and adapt to COVID-19. Let’s keep that change moving and make it something that sustainable and that can work in our favor. We need to really use these innovations, use what we’ve learned, and address the factors that cause people to rely on opiates in the first place and make that type of treatment readily abundant, available.

AJMC^®: That’s the end of my questions. Was there anything else you wanted to add?

Silva: I just really want to thank you for allowing me the opportunity to participate in this conversation about managed care around opiate use. I think that for many clinicians, we can get so overwhelmed and engrossed in patient care, we can sometimes feel separate from the people who make decisions about financing and access for treatment opportunities. And I think that role specialization is really important because health care is a huge, huge field that requires multiple different types of specialists, but cross communication is so very important as well, and sometimes it’s hard to know how to jump into the conversation, so thanks for giving me the opportunity.

AJMC^®: Great. Thanks for joining us.