41. Prevention vs. Prescription: The Question About Opioids

Contagious Conversations  /  Episode 41. Prevention vs. Prescription: The Question About Opioids





Judy Monroe: Hello and welcome to Contagious Conversations. I'm Dr. Judy Monroe, president and CEO of the CDC Foundation and host of today's conversation. Every episode we hear from inspiring leaders and innovators who make the world healthier and safer for all of us. Contagious Conversations is brought to you by the CDC Foundation, an independent nonprofit that builds partnerships to help the Centers for Disease Control and Prevention save and improve more lives.

Joining me today is Dr. Chris Jones, director of the National Center for Injury Prevention and Control at the Centers for Disease Control and Prevention. Dr. Jones' Career in public health includes leadership and advisory roles at the Substance Abuse and Mental Health Services Administration, the U.S .Food and Drug Administration and the U.S. Department of Health and Human Services. He has authored more than 100 peer-reviewed publications on the topics of substance use, drug overdose, adverse childhood experiences and mental health. In this episode, we will discuss the challenges physicians face in treating people living with pain in light of the nationwide opioid overdose epidemic and the steps CDC has taken to address some of those challenges.

Welcome, Dr. Jones.

Dr. Chris Jones: Great. Thanks so much, Judy. Glad to be here to talk with you today.

Dr. Judy Monroe: Yeah. It's really wonderful to have you. So Chris, you are a captain in the U.S. Public Health Service and you serve as director of the National Center for Injury Prevention and Control at CDC. Can you tell us about your work and the role that you play at CDC?

Dr. Chris Jones: Sure. And I think, first I'll just say that the Injury Center has been around for 30 years. We just celebrated our 30th anniversary and people may know some of the topics we work on but may not be familiar with the center overall, and we have a broad mandate focusing on preventing all forms of violence, child abuse and neglect, adverse childhood experiences. But we also focus on a range of unintentional injury topics like drowning, motor vehicle transportation safety, traumatic brain injury, older adult falls, as well as suicide prevention and then the topic we're talking about today is really around substance use, overdose prevention, which also encompasses our work around pain and advancing pain care in the U.S.

And we really see ourselves as sort of that public health whole nationally to support state, local, tribal, territorial health departments, health systems, community organizations and other partners in the field who are doing that public health prevention work. That's what brings us to the table every day is recognizing that injuries and violence are the leading cause of death among young people and adults up to age 45, and that may be a shock for many people. It's not cancer or heart disease, but it is injury and violence that really impact younger populations. And those are the things that communities are struggling with and that's why we do what we do every day in the center.

Dr. Judy Monroe: So Chris, chronic pain is an issue that affects millions of Americans, but sadly we have an opioid overdose epidemic in this country. Talk to us about the impact of this epidemic.

Dr. Chris Jones: Yeah. I think this is a really important issue because in the Injury Center we're working to address both issues. I mean, the reality is that pain is one of the most common reasons that people present to their healthcare provider. And the latest data that we just put out from the CDC and NWR a couple of weeks ago shows that about one in five Americans struggle with chronic pain. So this is something that is ever present in homes across the country.

But at the same time, we have an overdose crisis that has been going on for two decades now, where the latest provisional data from CDC show about 108,000 overdose deaths in the 12 months ending November, 2022. So both of these issues are public health challenges–they are interrelated. But when we look at the overdose crisis now, we have seen that it has really evolved over time from one where prescription opioids were really the primary contributor to overdose to one where illicitly made fentanyl, fentanyl analogs–which are highly potent synthetic opioids, along with the resurgence of stimulants like cocaine and methamphetamine–are really what are driving deaths into communities. And that is separate from the pain issue.

But as we approach our work, we've really been trying to focus on the urgency that communities are facing to support harm reduction in overdose prevention efforts, connect people to life-saving care, like medications for opioid use disorder treatment or evidence-based substance use treatment for stimulant use disorders, while also putting out assistance and resources around appropriate management of pain. And that in particular, I think the highlight for us in the past year, it's been the release of the 2022 opioid prescribing guideline that came out last November, which again was I think an imported statement about how we can advance pain care at the same time also addressing the issues of overdose. They should not be in conflict. We can actually do those at the same time. And that's what we've been trying to do with our public health and clinical partners.

Dr. Judy Monroe: The number of drug overdose deaths has actually quintupled since 1999. I mean, it's staggering. It really is. So this has got to create challenges for physicians. So talk to us about the challenges the physicians are facing when they're trying to treat people living with pain with opioids in the face of this overdose epidemic.

Dr. Chris Jones: Yeah. Well, one of the things that we really tried to highlight in the 2022 guideline is that opioids do have a role to play in pain care. Oftentimes, that's where there is a pretty severe acute pain injury, or in some cases for certain types of chronic pain, opioids may play a role. But what we tried to highlight in the guideline is that there are actually other evidence-based strategies, whether there are other medications like ibuprofen, nonsteroidal anti-inflammatory drugs, certainly antidepressants, other medications that have been approved for migraine treatment that in many cases can be more effective than opioids. And then we also underscored that non-pharmacological treatments–exercise, physical therapy, acupuncture, other non-pharmacological interventions or non-medication treatments–also have good evidence for both acute pain as well as subacute and chronic pain. And really, those non-pharmacological treatments have the best long-term evidence for many different types of pain above opioids or other medications, and certainly have fewer harms.

I think the challenge for physicians in clinical practice today is that oftentimes those other medications or those other treatments aren't covered by insurance companies. People haven't been trained. There may not be providers to do physical therapy or acupuncture in communities, and it creates a challenge for patients as well as clinicians to navigate those systems and the barriers that exist in the systems.

We also are working against, I think, a momentum where the belief has been that we shouldn't use opioids at all. What we really tried to strike with the new guideline was the balance that pain is highly variable. Patients will respond to treatments in different ways, and we really have to have flexibility built in. In some cases, opioids alone–or opioids with other treatments–might be the absolute right thing for a patient. And we want to be able to have clinicians feel comfortable in managing the use of opioids.

And that's what the guideline does. It really walks through that initial decision process of, are opioids the right thing? What else should I be considering for the type of pain the patient has and the circumstances that's going on? If you decide opioids are right, how do you do it? How do I prescribe it? What dose do I use? How long? How should I monitor patients? And then as patients transition on to longer term use of opioids, how does the benefit risk calculation change? What do I need to be doing and how do I need to be engaging with the patient to make sure that their goals are being met, that if something else happens to their underlying health conditions or other medications are added, we're taking steps to mitigate any risk for overdose or the development of an opioid use disorder?

So it really is just sort of the practical tips that clinicians can use to find that balance that patients who are living with pain deserve evidence-based compassion and empathetic care. In some cases, opioids are going to be a part of that care and should be a part of that care. But when they are, we want it to be done thoughtfully and with shared decision making with the patient about what this looks like in the long run. If we make the decision to use opioids, what's our plan for discontinuing if opioids are not benefiting the patient as well?

Dr. Judy Monroe: Yeah, no, that's really excellent. I do remember back in 2016 when the CDC released the set of opioid guidelines that really inspire laws restricting doctors and pharmacy practices. So now with the 2022 [guidelines], and what you've just described, finding that balance, how would you say the overall response has been from physicians and pharmacists to the 2022 guidelines?

Dr. Chris Jones: Yeah, I think overall the response has been generally positive and fairly welcoming of the guidelines. And we undertook a very intentional process for how we updated and replaced the guideline in 2022, which is really a multi-year process of engaging with outside experts, many opportunities for public comment to get feedback, external peer review, working with partners across the federal government to get their feedback. And I think three things that I would raise were most important from that feedback. One is that words matter. How we structure the recommendations, what words we use, how we frame the guideline and what it is and what it is not is all very important, because misapplication happened in 2016 because you could so easily just pull out little bits and pieces of the guideline that were taken out of context and applied as sort of a one size fits all approach. So we heard that words matter.

We heard that shared decision making needs to be a part of it. It's foundational that really patients have an important role in their own health in advocating for their own health and decisions about what medications and treatments they should receive, and that should be done in concert with physicians.

And then the third area was, again, recognizing that we really should be leaning in on general principles rather than very specific thresholds. Some of the biggest challenges with 2016 and misapplication came where we had specific recommendations around dose, morphine milligram equivalents or duration, the number of days that somebody should be prescribed. And again, it made it all too easy to have this one size fits all approach. And so I think the feedback that we've received since the guideline was released was really supportive of that move to say, here are practical considerations, flexibility is built in, let's lean in with general principles.

I think there's still some concerns about other agencies like DEA or insurance payers, PBMs–how will they interpret or implement or use the guideline to advance pain care and avoid misapplication? But I think on the front end, we tried to structurally design the guideline to avoid this application, but our work is not done. We continue to engage with professional societies and payers and other agencies to get feedback to understand what resources might be needed to clarify intent of the guideline, what it is and what it isn't. I was actually at the Federation of State Medical Boards meeting last week, and I've presented on the guideline. I've done the same with the natural conferencing, state legislators, pharmacy boards, other regulators to share this new resource, the latest science, but also that human story of the challenges that patients and providers face when trying to strike that balance on using opioids for treatment of pain.

Dr. Judy Monroe: You just gave a wonderful example of building what it takes to build good guidelines and all the input from so many different stakeholders, so thank you for that work. It's really tremendous. CDC also does a lot of work at the community level. You mentioned this at the top of the podcast, but can you give us some more examples around about the work that CDC is doing around the country to combat the opioid epidemic at that community level?

Dr. Chris Jones: Yeah, so we have sort of multiple mechanisms in which we're engaging with communities to do substance use and overdose prevention work. A large part of that work happens through our Overdose Data to Action program, which is a four-year cooperative agreement that funds 66 jurisdictions, 47 states, D.C., two territories in 16 large cities, counties. That work is coming to an end, and a new five-year cooperative agreement is getting ready to get started, which will fund states as well as local jurisdictions. So that's our biggest investment into state and local public health. And part of that work is really trying to support innovation at the local level. Some of this is really thinking about just the urgency of the situation. How do we help health departments be that connector in communities to address spikes in overdoses? So one example is in West Virginia where they used our funding to organize quick response teams, the actually 29 quick response teams, which are made up of first responders, law enforcement, substance use counselors, peer specialists that deploy out to the community when overdoses are happening and then can be that connector to ongoing treatment.

We often see that somebody has a touchpoint with a health system or an EMS and acutely address our situation. We get them stabilized and we send them on their way, which doesn't do anything for the underlying challenges or addiction or substance use that's happening. And so these quick response teams are really intentionally developed to be that connector to address the acute issue of the overdose, but also to say again, the work is not done, right? We need to figure out, what are the needs of this patient to save their life and get them on a path to recovery? We've also seen rising concerns around youth substance use and use mental health and the intersection of mental health and substance use during the COVID-19 pandemic. And we're particularly concerned about young people and using substances because the illicit drug supply is so lethal and so potent, and there is this massive proliferation of counterfeit pills that look like commonly misused prescription drugs, but are in fact highly potent fentanyl tablets.

And so you think about a young person who might be experiencing some mental health challenges or just engaging in typical adolescent health risk behavior, initiating substance use, or trying something that somebody gave them, they have no tolerance for opioids, so they're at very high risk for overdose. And we've seen a large increase in overdose among young people in recent years. So some of the work in the use space, Louisiana through our funding expanded its teen crisis text line to reach youth at risk for exposure to opioid misuse and to connect them into services recognizing that young people are using texts more so than say 1-800-NUMBERS to get help. And we also have our Drug-Free Communities program, which supports youth substance use prevention in over 700 communities across the country. That's an effort that is between the White House Office of National Drug Control Policy and CDC.

And these coalitions are really bringing together multiple sectors of the community to say–at an individual, at a family relationship, at a policy, and community level–how do we work together to change the context in communities so that youth are not initiating substance use or that we can invest as early as possible for those who are? And that's a program that we sort of took over from SAMSA a couple of years ago, but has been a great way for us to really have touchpoints with communities across the country and highlight those innovations that are happening that then we can put into our bigger funding announcements for stadium local jurisdictions as well.

Dr. Judy Monroe: We'll be right back with Dr. Chris Jones.

Opioid addiction has touched millions of lives in the United States. Physicians across the country face daily challenges in caring for the health and wellbeing of chronic pain patients, while also carefully restricting the overuse of these powerful drugs. To learn more about CDC's updated opioid guidelines and to access opioid tools and resources, visit cdc.gov/opioids.

And now back to our conversation with Dr. Chris Jones.

Certainly a lot of collaboration is needed, both for, as you've mentioned, in developing the guidelines and addressing the opioid epidemic. And then I've also heard you talking about this great challenge striking the right balance with opioids in the medical field. Either of those topics you want to say more about anything that you haven't addressed?

Dr. Chris Jones: Yeah, I mean, I think for me, the collaboration piece is so important. I mean, I go out across the country and talk to health officers and health systems and other policy makers and leaders, and I think oftentimes on issues that are just so urgent, like overdose or rising suicide or rising violence, people often want, what's the one thing I can do? What's a solution here? And these are complex issues. They have complex group drivers, and there's no single agency or entity that has all of the levers to solve this. And I think what we have historically seen is that people have tried sort of one agency solutions and it just hasn't worked. And to me, collaboration is just absolutely the key. And as we look at the changing dynamics of overdose, we see that the demographics are shifting, that communities of color have been particularly impacted over the last couple of years.

And those thought leaders in those communities often have not been at the table when we've thought about shared solutions. And so the collaboration piece is so important to say, ‘Who's not at our table that needs to be here as we're talking about this?’ And it gets to criminal justice, education, health, substance use and mental health services, harm reduction organizations, people with lived experience, people in recovery, faith-based leaders, community organizations. A broad tent is needed. But I do think that public health can be that convener and coordinator. It's what we've done. It's what public health does. But that essence of collaboration to me is really key because the issues are quite complex. They're not inevitable; they are preventable, but they do require that people work together, that they have a shared understanding of the data, what's driving the challenges, where are we missing opportunities, and then what are the levers and how do we pull the levers together to make an impact?

Dr. Judy Monroe: You've really painted the picture for us of how important collaboration is, and especially those missing voices at the table. If we don't have everybody involved, you're not going to get to all the solutions or have the granular information to really understand the root of the problem.

So, I do like to end on a positive note with a look to the future. So what do you see as our greatest opportunity to address the opioid overdose epidemic?

Dr. Chris Jones: I think for me, I mean it does get back to collaboration and that there is a shared commitment and recognition that this is an issue that is not on the margins of society. Everybody knows somebody who has been touched by this issue. And I think we've seen over the last several years in particular, embracing people who have walked that path, people with lived experience, people in recovery. I'm a person in long-term recovery. I got into recovery my first year of pharmacy school. I celebrated 21 years last year in recovery. And I think having that perspective in communities for people who have been down that road but have found a way out and found a different path to me in embracing those communities as part of the solution is something that gives me tremendous hope, because there is just a hard-earned insight from those individuals that is just so critical as policymakers and others think about, what do we need to do to address this?

But there is also so much stigma, and that is a roadblock from a policy program practice perspective. It's a roadblock for people saying, ‘I need help and getting connected to help.’ And I think the part of the hope for me and the opportunity is to embrace those voices, embrace the millions of people who are in recovery as a part of the solution. And that is, I think, increasingly a key part of our work, and what we're asking health departments to do as well, is to engage and bring in that lived experience. And to me, that unlocks so much innovation, so many new pathways for connections and solutions. I've been working on this issue for a long time. And to see that numbers continue to go up year after year, it is heavy. It's a very weighty thing. And to know that underneath those numbers are families, communities, that are being torn apart, that are losing loved ones. It's a lot, day-to-day to continue to do this work.

But you see that hope and that transformation that happens for people in recovery that can help change how communities think about these issues and how they focus on these issues. And to me, that's the opportunity. No matter how high the numbers go, we can't stop. We have to keep working towards solutions and innovation and collaboration. And to me, there is momentum there. There is positive momentum and a commitment to find solutions and implement solutions. So that is what keeps me going. And certainly I know for our staff here in the center who are dedicated to this work, it's that idea that we have a roadmap here. We have solutions that can be brought to bear. We just have to work together to put them into practice now.

Dr. Judy Monroe: Very well said. And obviously a very complex problem, complex issue, as you've stated. I will tell you, it gives me hope knowing that you're there with your knowledge and your passion and your team behind you working collaboratively. So thank you so much for joining podcast today and for sharing all the information about this critically important topic.

Dr. Chris Jones: Yeah. Thanks, Judy. Really appreciate the opportunity and appreciate your partnership and the Foundation's partnership with us.

Dr. Judy Monroe: Thank you.

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