Opioid Epidemic Solutions

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Takeaways and notes from research into possible solutions for the opioid epidemic.

Goal:

Massively reduce opioid overdoses

Most promising:

• Medication assisted treatments
• Harm reduction specifically focused on avoiding overdoses: avoid mixing, get naloxone, don’t use alone (look into — how much would this cost, would it work, are there other examples of harm reduction working in the US for other drugs, for these drugs, or in other countries where it worked?)
• More harm reduction: supervised injection, provision of MATs, syringe access
• HHS: better prescribing practice for long term. Short-term: naloxone access, and MAT access. Report has good specifics on proposed ways of doing so: https://aspe.hhs.gov/basic-report/opioid-abuse-us-and-hhs-actions-address-opioid-drug-related-overdoses-and-deaths

Notes:

• Important to curb the fastest growing issues. Some are low and will remain low. Others are growing rapidly.
• Media presents as a criminal issue though likely more productive if presented as a health issue: http://ps.psychiatryonline.org/doi/full/10.1176/appi.ps.201500065
• Media + public figures biased against effective treatment, “MAT”: http://www.salon.com/2013/12/22/the_new_york_times_is_dead_wrong_about_drug_addiction/ https://www.documentcloud.org/documents/3723472-Tom-Price-Letter-Re-MAT.html
• 1) Treated as a moral weakness/choice 2) Focus on opioid above other addictions 3) Stigma via language used 4) Crim justice system often prevents maintenance therapies: http://www.hcppainnetwork.org/file/opioid_disorder.pdf
• “Scared straight” doesn’t seem to work: http://pediatrics.aappublications.org/content/115/3/761?ck=nck&sso=1&sso_redirect_count=1&nfstatus=401&nftoken=00000000-0000-0000-0000-000000000000&nfstatusdescription=ERROR%3a+No+local+token, https://psychcentral.com/blog/archives/2010/11/26/scared-straight-not-really/
• Suboxone and other “MATs” are most effective remedy: http://www.pewtrusts.org/en/research-and-analysis/fact-sheets/2016/11/medication-assisted-treatment-improves-outcomes-for-patients-with-opioid-use-disorder
• Need more (affordable) treatment capacity? https://www.documentcloud.org/documents/3723472-Tom-Price-Letter-Re-MAT.html
• MAT seems to really help “Numerous studies have shown MAT to reduce overdose deaths—by 80 percent in France, 75 percent in Australia and 66 percent in Baltimore.” http://fair.org/home/stigma-over-solutions/
• “Common threads in stories of recovery without treatment include finding a new passion (whether in work, hobbies, religion or a person), moving from a less structured environment like college into a more constraining one like 9 to 5 employment, and realizing that heavy use stands in the way of achieving important life goals. People who recover without treatment also tend not to see themselves as addicts, according to the research in this area.” https://www.alternet.org/drugs/most-people-addiction-simply-grow-out-it-why-widely-denied
• Seems to be an overdose problem not an addiction problem https://www.alternet.org/drugs/most-people-addiction-simply-grow-out-it-why-widely-denied
• Addiction shouldn’t be framed as a disease, instead as a phenomenon driven by psychological and social factors: https://www.psychologytoday.com/blog/addiction-in-society/201703/the-solution-the-opioid-crisis
• Hillbilly elegy apparently shows that purpose and community are the cure
• Bad: increasingly potent heroin, also combining with fentanyl or sedatives https://www.nytimes.com/2016/07/28/us/naloxone-eases-pain-of-heroin-epidemic-but-not-without-consequences.html
• It’s an overdose problem but also an addiction problem. We can plug the problem with Narcan but also need treatment at the same time, I think? Don’t want tons of non-fatal overdoses either
• Lack of treatment for people without insurance? https://www.nytimes.com/2016/07/28/us/naloxone-eases-pain-of-heroin-epidemic-but-not-without-consequences.html
• People will recover over time, but probably ~10 years (and only if they don’t OD first) https://reason.com/archives/2014/02/01/the-government-wants-you-to-know-you-can/1
• Longer term, will want more prevention strategies, patient education, insurance coverage for alternative pain solutions, more education via healthcare providers on non-opioid pain solutions: https://www2.deloitte.com/us/en/pages/life-sciences-and-health-care/articles/health-care-current-may31-2016.html
• Most people start w painkillers (though, not their own prescribed ones) https://www.vox.com/policy-and-politics/2017/8/9/16118526/opioid-epidemic-national-emergency
• Less pills means more heroin for current users. So would need to be combined with MATs, I believe: http://wwmt.com/news/local/hospitals-launch-prescription-guidelines-to-help-opioid-abuse
• In their sample most had their own prescription prior to abuse, though very biased group i.e. insured people https://www.ncbi.nlm.nih.gov/pubmed/25661018?dopt=Abstract
• Addiction is different than physical dependence http://www.nejm.org/doi/full/10.1056/NEJMra1507771#t=article
• Detox puts you at higher risk of overdose, can be still addicted but no longer tolerant http://www.nejm.org/doi/full/10.1056/NEJMra1507771#t=article
• Education to patients on dangers of sharing their meds seems important (and safe storage and disposal) http://www.nejm.org/doi/full/10.1056/NEJMra1507771#t=article
• Prescription drug monitoring programs? Doesn’t seem like it would be that effective? http://www.nejm.org/doi/full/10.1056/NEJMra1507771#t=article
• Require naloxone provided in conjunction w opioid prescription, with instructions for use? http://www.nejm.org/doi/full/10.1056/NEJMra1507771#t=article
• Naloxone can help https://www.ncbi.nlm.nih.gov/pubmed/26086633?dopt=Abstract
• ~4% of people addicted to pain pills transition to heroin http://www.nejm.org/doi/full/10.1056/NEJMra1507771#t=article
• Medication assisted therapy for people with opioid addiction http://www.nejm.org/doi/full/10.1056/NEJMra1507771#t=article
• Should separate everything into preventing new users and helping existing ones. Or stock and flow as Keith Humphreys says
• Long-term: “Increased Use of Science-Supported Prescribing and Management Practices” http://www.nejm.org/doi/full/10.1056/NEJMra1507771#t=article
• Friend or relative biggest culprit in general, doctor is the other big culprit. https://www.cdc.gov/drugoverdose/data/prescribing.html
• CDC: Improve prescribing, expand MAT, expand naloxone, promote prescription drug monitoring programs https://www.cdc.gov/drugoverdose/epidemic/index.html
• States via CDC: Similar to above. https://www.cdc.gov/drugoverdose/policy/index.html (Could rank all things by short & long-term impact)
• Heroin and fentanyl/other synthetic opioid deaths appear to be highest growth: https://www.cdc.gov/drugoverdose/data/index.html
• State by state death rate increases: https://www.cdc.gov/drugoverdose/data/statedeaths.html
• Prescribing rates appeared to peak around 2012. Though some areas still have extremely high prescription rates: https://www.cdc.gov/drugoverdose/maps/rxrate-maps.html
• Most new heroin users were Rx (their own or someone else’s / purchased) opioid users, but only 4% of opioid users become heroin users over 5 yr period https://aspe.hhs.gov/basic-report/opioid-abuse-us-and-hhs-actions-address-opioid-drug-related-overdoses-and-deaths
• Less Rx opioid supply doesn’t seem to be driver of overdoses https://aspe.hhs.gov/basic-report/opioid-abuse-us-and-hhs-actions-address-opioid-drug-related-overdoses-and-deaths What about reformulation?
• Does seem like better prescribing guidelines will reduce overdoses https://aspe.hhs.gov/basic-report/opioid-abuse-us-and-hhs-actions-address-opioid-drug-related-overdoses-and-deaths
• MAT is under-utilized https://aspe.hhs.gov/basic-report/opioid-abuse-us-and-hhs-actions-address-opioid-drug-related-overdoses-and-deaths
• Rx opioid deaths aren’t growing https://aspe.hhs.gov/basic-report/opioid-abuse-us-and-hhs-actions-address-opioid-drug-related-overdoses-and-deaths
• ! “38 percent of U.S. adults used opioid medication in 2015” https://www.pbs.org/newshour/health/opioid-misuse-starts-friend-family-members-prescription
• Long-term, better anxiety/depression treatments needed, as people with anxiety more likely to misuse opioids http://www.sciencedirect.com/science/article/pii/S0163834317300270
• Long-term: implementation of better pain strategies, e.g. HHS National Pain Strategy report https://iprcc.nih.gov/sites/default/files/HHSNational_Pain_Strategy_508C.pdf
• Seems like opioids shouldn’t be prescribed for chronic pain? >3 weeks used for ‘chronic’ in one study. https://www.pbs.org/newshour/health/opioid-misuse-starts-friend-family-members-prescription
• HHS report was from 2015. That seems bad because it doesn’t seem like they’ve been effective in making it happen?
• Evidence based dosing and best practice guidelines and PDMP had very weak impact in Washington https://www.drugabuse.gov/about-nida/legislative-activities/testimony-to-congress/2016/what-science-tells-us-about-opioid-abuse-addiction 27% over 4 yrs (compare that against growth of heroin deaths in last few years.)
• “There is some concern that the increase in heroin-related overdoses may be an unintended consequence of reducing the availability of prescription opioids.25,26” https://www.drugabuse.gov/about-nida/legislative-activities/testimony-to-congress/2016/what-science-tells-us-about-opioid-abuse-addiction
• “eighty percent of new heroin users started by abusing prescription opioids. However, there are many more prescription opioid users than heroin users, and, overall, heroin use is rare among individuals who misuse prescription opioids.” https://www.drugabuse.gov/about-nida/legislative-activities/testimony-to-congress/2016/what-science-tells-us-about-opioid-abuse-addiction
• Seems important to make MATs cheaper and easier to obtain than heroin
• Make sure that court ordered drug treatment for opioids allows MATs, and long term, not short-term detox https://www.drugabuse.gov/about-nida/legislative-activities/testimony-to-congress/2016/what-science-tells-us-about-opioid-abuse-addiction
• Drug treatment programs for prisoners seems important, unclear on the magnitude of impact https://www.drugabuse.gov/about-nida/legislative-activities/testimony-to-congress/2016/what-science-tells-us-about-opioid-abuse-addiction
• Just because you want to go to rehab doesn’t mean there’ll be a bed http://www.observer-reporter.com/20170903/recovery_town_washingtonx2019s_opioid_epidemic
• 12 step programs don’t seem to be very helpful (https://www.ncbi.nlm.nih.gov/pubmed/16856072, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2746426/, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4285560/), but 80% of residential treatment centers are based on it? http://www.slate.com/articles/health_and_science/medical_examiner/2016/11/we_do_not_use_an_evidence_backed_method_for_treating_heroin_addiction.html
• MATs help. Going to a “low threshold model” for prescription like Baltimore seems like it would help http://www.slate.com/articles/health_and_science/medical_examiner/2016/11/we_do_not_use_an_evidence_backed_method_for_treating_heroin_addiction.html
• Resources for faith leaders and community leaders to help https://www.hhs.gov/about/agencies/iea/partnerships/opioid-toolkit/index.html
• FDA is considering whether they are looking enough at abuse possibility in drug review process https://blogs.fda.gov/fdavoice/index.php/2017/05/fda-commissioner-asks-staff-for-more-forceful-steps-to-stem-the-opioid-crisis/
• Seems opioids can be used with low rates of issue https://blogs.scientificamerican.com/mind-guest-blog/opioid-addiction-is-a-huge-problem-but-pain-prescriptions-are-not-the-cause/
• ~33% of scripts are abused, ~5% of prescribed opioid users doctor shop http://archive.castlighthealth.com/typ/the-opioid-crisis/
• Very high rates of childhood trauma in heroin addicts http://onlinelibrary.wiley.com/doi/10.1111/j.1360-0443.2012.04001.x/full
• Lifetime PTSD diagnoses of 50% in heroin users http://onlinelibrary.wiley.com/doi/10.1111/j.1360-0443.2012.04001.x/full
• Depression and dysthymia, and anxiety disorders, have life-time prevalence of 33%-50% in heroin users http://onlinelibrary.wiley.com/doi/10.1111/j.1360-0443.2012.04001.x/full
• Antisocial personality disorder in 33%+ of heroin users vs 4% of general population, and borderline personality disorder in heroin users at a rate of ~65% vs 2% in general population (!) http://onlinelibrary.wiley.com/doi/10.1111/j.1360-0443.2012.04001.x/full
• Classic psychedelics and MDMA may help with BPD and ASPD? https://www.maps.org/news-letters/v05n3/05303psy.html https://www.reddit.com/r/BPD/search?q=lsd&restrict_sr=on&sort=relevance&t=all
• Much higher rates of childhood abuse and neglect including sexual abuse in heroin users http://onlinelibrary.wiley.com/doi/10.1111/j.1360-0443.2012.04001.x/full
• To a large degree heroin use is a self-medication issue https://blogs.scientificamerican.com/mind-guest-blog/opioid-addiction-is-a-huge-problem-but-pain-prescriptions-are-not-the-cause/
• Info on stigma https://www.end-opioid-epidemic.org/removing-stigma/
• Naloxone and PDMP use is increasing https://www.ama-assn.org/sites/default/files/media-browser/public/physicians/patient-care/opioid-task-force-progress-report.pdf
• Really hard to reduce trafficking of drugs https://www.vox.com/policy-and-politics/2017/4/19/15326286/trump-wall-opioid-epidemic
• MATs seemed to reduce opioid dependence from 100% to <10% over 3 yrs https://www.drugabuse.gov/news-events/nida-notes/2015/11/long-term-follow-up-medication-assisted-treatment-addiction-to-pain-relievers-yields-cause-optimism
• Good report to the President on what the President can do to help. Includes a few things that probably don’t matter / help much, but solid overall https://www.whitehouse.gov/sites/whitehouse.gov/files/ondcp/commission-interim-report.pdf
• Good info on what’s been happening in terms of progress on solutions https://obamawhitehouse.archives.gov/the-press-office/2016/02/02/president-obama-proposes-11-billion-new-funding-address-prescription
• Important to address underlying issues soon, otherwise issues will probably manifest in other areas https://www.vox.com/science-and-health/2017/8/1/15746780/opioid-epidemic-end
• Iceland’s social movement around activities seems really good https://www.vox.com/science-and-health/2017/8/1/15746780/opioid-epidemic-end
• BC apparently has economic safety net, rx heroin, universal health care, but still has opioid issue https://www.vox.com/science-and-health/2017/8/1/15746780/opioid-epidemic-end
• Implies that reducing stigma should help us more effectively roll out solutions https://www.vox.com/science-and-health/2017/8/1/15746780/opioid-epidemic-end
• Tens of billions each year needed in spending? https://www.vox.com/science-and-health/2017/8/3/16079772/opioid-epidemic-drug-overdoses
• States are responding with “new war on drugs” https://www.vox.com/policy-and-politics/2017/9/5/16135848/drug-war-opioid-epidemic
• Abuse resistant oxycontin formulation ignited the heroin epidemic https://www3.nd.edu/~elieber/research/ELP.pdf https://www.reddit.com/r/Drugs/comments/6t2zcf/august_2010_a_new_formulation_of_oxycontin_was/
• Anxiety, benzo use, and alcohol abuse increase likelihood of opioid addiction relapse https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3922612/
• Shy behavior and childhood aggression predict drug use, though there’s nuance, make sure to read the article. Also I think this just looks at drug use, and not drug abuse. Looking at just drug abuse would be much better. https://archives.drugabuse.gov/NIDA_Notes/NNVol10N1/Earlychild.html (through what mediating factor?)
• Sniffing/snorting opioids, and increasing frequency of use, and starting Rx opioids at younger age predict more likelihood of heroin use https://www.drugabuse.gov/news-events/latest-science/factors-predicting-transition-prescription-opioids-to-heroin
• Not many strong takeaways for me. Probably is important or at least very helpful if all young people can be part of some healthy community that they get significant exposure to http://dera.ioe.ac.uk/6903/1/rdsolr0507.pdf
• Keto may help? I could see it helping via reducing chronic pain. https://www.reddit.com/r/keto/comments/77k7ot/keto_saved_my_life_and_i_no_longer_need_opiods/ I could also see low sugar diets helping by reducing metabolic issues that lead to other problems, see Robert Lustig’s book (hacking of american mind).

Look further into:

• 21st Century Cures Act: https://en.wikipedia.org/wiki/21st_Century_Cures_Act#Opioid_epidemic
• Comprehensive Addiction and Recovery Act of 2016: https://en.wikipedia.org/wiki/Comprehensive_Addiction_and_Recovery_Act http://www.drugpolicy.org/press-release/2016/07/congress-passes-landmark-opioid-bill-comprehensive-addiction-and-recovery-act
• Has marijuana legalization cut into cartel’s profits and caused them to push more heroin? Doubtful, don’t think that fits into how supply/demand works, unless they cut cost to acquire more users?
• Look into impact of decrim abroad on opioid usage rates. Compare countries with/without good treatment programs in addition
• Predict how growth rates will change over time / what the upper-limit is if any. Look for other countries or addiction crises from the past for models
• How much would decreasing supply decrease initiation rates? My guess is it’s pretty inelastic, but I’m not sure. Look at this over time. Why did rates increase over time? Was it due to increased supply? And is that through increased availability or decreased prices or both?
• If people had pure heroin always the same strength, how many overdoses would there be?
• Addiction rates are lower when people start later after the brain is more developed? Look into this. https://www.centeronaddiction.org/addiction-prevention/teenage-addiction https://www.centeronaddiction.org/addiction-prevention/adult-addiction
• What % of the opioid overdose people started abusing some substance before the age of 18? May need to find and interview people who are “on the path” to overdose :/
• Social support/belonging/lack of community/ similar solutions?
• If most people grow out of addictions, is this true for opioid/high overdose addiction specifically, assuming they don’t die? Look into Maia Szalavitz’s work, or email her, or her books
• Not overdoses? “they’re not overdoses, see above” https://www.psychologytoday.com/blog/addiction-in-society/201703/the-solution-the-opioid-crisis I think referring to it’s about mixing drugs?
• Why aren’t there no overdoses already, given narcan/naloxone availability laws? What prevents that from solving the issue?
• What are the things that are changing over time? e.g. % of new initiates over time - split via source, e.g. if they’d been an abuser of another drug already or not, or just via doctor, percent of users that are dying, etc. what are the fast growing factors fucking things up?
• Talk to someone like: “Oliver Bradeen, a substance use disorder liaison for the Police Department in Portland, Me., who responds to most emergency overdose calls.” Maybe nurses, treatment clinic people, etc
• What percent of people overdosing have health insurance?
• ADAPT Pharma seems to own Narcan nasal spray. Work with them to fund things that provide increased access?
• People to talk with: http://ourohiorenewal.com/advisory-board/?
• Unclear what they are actually planning on doing, but probably worth talking with people running it: http://ourohiorenewal.com/
• What’s the chance people will overdose assuming their addiction lasts for 10 years? https://reason.com/archives/2014/02/01/the-government-wants-you-to-know-you-can/1
• Hm. Read it more later. Not sure that I agree. https://dupress.deloitte.com/dup-us-en/industry/public-sector/fighting-opioid-crisis-heroin-abuse-ecosystem-approach.html?id=us:2el:3dc:dup3406:awa:dup:dcpromo#endnote-2
• Keith Humphreys may be good person to talk to.
• Look into state of emergency, whether it’s likely to make things substantially worse, and if it could be influenced to avoid that, or if it could influenced to make things better https://www.vox.com/policy-and-politics/2017/8/9/16118526/opioid-epidemic-national-emergency
• What does average overdose victim look like? What % had their own script first, at time of death, etc, etc
• Why did heroin and synthethic opioid death rates inflect for the worse in 2010? https://www.drugabuse.gov/related-topics/trends-statistics/overdose-death-rates https://www.cdc.gov/nchs/products/databriefs/db190.htm Was this when OxyContin formulation changed? If so, does that explain most of the inflection or just a small part?
• Which studies? No citation provided. “Studies have shown that the most effective treatments for opioid use disorders are those that include a set of comprehensive medical, social, psychological and rehabilitation services that address all the needs of the individual.” https://aspe.hhs.gov/basic-report/opioid-abuse-us-and-hhs-actions-address-opioid-drug-related-overdoses-and-deaths
• Find out more about this “HHS has also prioritized the development of an evaluation strategy to identify the most effective strategies and inform future policymaking that will have the greatest public health impact.” Try and get in contact w people involved? Share my notes w them and get their notes? https://aspe.hhs.gov/basic-report/opioid-abuse-us-and-hhs-actions-address-opioid-drug-related-overdoses-and-deaths
• Does shutting down pill mills help? https://www.drugabuse.gov/about-nida/legislative-activities/testimony-to-congress/2016/what-science-tells-us-about-opioid-abuse-addiction See info from Maia Szalavitz I think she tweeted about shutting pill mills down being bad, look into that
• Probably important to make mandated treatment from drug courts effective, and insure that it doesn’t hurt https://www.drugabuse.gov/about-nida/legislative-activities/testimony-to-congress/2016/what-science-tells-us-about-opioid-abuse-addiction
• Do abuse deterrent opioids encourage people to use heroin and indirectly kill more people? NIDA recommends research into them so this seems important to know. https://www.drugabuse.gov/about-nida/legislative-activities/testimony-to-congress/2016/what-science-tells-us-about-opioid-abuse-addiction
• Did Washington programs make their heroin deaths rise less proportionally to other states when controlled with some kind of baseline? (Evidence based dosing and best practice guidelines and PDMP had very weak impact in Washington https://www.drugabuse.gov/about-nida/legislative-activities/testimony-to-congress/2016/what-science-tells-us-about-opioid-abuse-addiction 27% over 4 yrs (compare that against growth of heroin deaths in last few years.))
• What are the outlier states? Ones that should be high but are low, or opposite
• What are rates of opioid users trying heroin in other countries? In US, ~0.4% https://www.drugabuse.gov/about-nida/legislative-activities/testimony-to-congress/2016/what-science-tells-us-about-opioid-abuse-addiction. Is it even possible to reduce this rate?
• What are the barriers for naloxone? What prevents all overdoses from being stopped by naloxone? In best case or good scenario, how many overdoses could be stopped by naloxone (and don’t forget, if one person has 5 overdoses but only 4 stopped, then naloxone didn’t help in the end except for those where it buys enough time to get treatment which seems extremely unlikely.) Look into rates of overdose over time on average for opioid users.
• Info government organizations have seems great. How’s their progress? Are they following their recommendations or doing less effective things? What’s preventing them from being effective?
• Where do strong incentives from people/groups/companies with resources/power work against the most important solutions? http://www.fox9.com/news/facing-the-opioid-epidemic-doctors-struggle-to-find-solutions
• Do most users want help? Seems so http://www.newsweek.com/how-cure-americas-opioid-epidemic-630346. I should sketch out how the whole interaction will play out with the new solutions — i.e. who else they require action from, then that will reveal other assumptions that are important to check. e.g. if more naloxone, does EMS have the bandwidth to administer? Can it be successfully done through friends of users/users themselves?
• Does supply matter at all? Where does it matter — e.g. Rx drug vs heroin, pill mills, etc? Figure out which things people talk about, and also which things matter, and if it’s worth putting effort to get the people/journalists/politicians/tv people talking about it talking about the correct things i.e. talking about solutions w same ratio as potential effectiveness (prob not). http://www.newsweek.com/how-cure-americas-opioid-epidemic-630346
• How can treatment access be provided to everyone? How will success rates be if that’s the case? What is success defined as — no drug abuse? Happy healthy life? No opioid addiction? How many people will want to use treatment? How many will be able to access given their own personal circumstances?
• Contact/talk with these two authors? http://www.newsweek.com/how-cure-americas-opioid-epidemic-630346
• Is it worth putting lots of effort into “don’t use drug” stuff? I think not based on data I recall seeing, but verify that.
• Go through everything and assign magnitude in terms of how impactful it can be. Too much stuff to focus on need to identify the top few most impactful.
• Doctors can’t easily prescribe Suboxone? Fix? http://labblog.uofmhealth.org/rounds/what-will-it-take-to-overcome-opioid-epidemic
• “Rates of injuries and deaths from these products have increased in lockstep with the volume of opioids in circulation.” Is this true? Find this data. http://www.wbur.org/hereandnow/2017/04/18/opioid-epidemic-solutions And is it this that explains the rise, or something else?
• To what extent is education needed / a problem?
• Would it be better if shorter cycles were enforced, with people needing to go back to the doctor or at least pharmacy more often to get refills, vs longer fills? Should reduce amount of opioids people end up with “left over.”
• What leads to people giving away to friends? What is their mindset? Is it that it’s harm-free? Would the national state of emergency on opioids be enough to deter people from giving opioids to family and friends, or do we need more? How impactful is preventing the spread through family and friends?
• Are there any easy things to improve the effectiveness of the most effective things — which seem likely to be naloxone, and MATs? e.g. maybe people giving MATs don’t check for double prescription of opioids? http://www.wbur.org/hereandnow/2017/04/18/opioid-epidemic-solutions (cmd-f: buprenorphine)
• What makes naloxone expensive? How much is it? Does price vary by purchaser — if so, how much? What can we do to make it cheaper? Is it important to make it cheaper?
• Does Narcan access prevent overdoses? Maybe not in the long run? Is it just a case of long-run probability, like how people keep gambling until they run out of $ (see also https://medium.com/incerto/the-logic-of-risk-taking-107bf41029d3)? https://www.wired.com/2016/07/end-opioid-epidemic-need-way-od-treatments/
• How can we collaborate with churches/religious organizations, like “Pennsylvania Adult and Teen Challenge,” to help people? http://www.observer-reporter.com/20170903/recovering_addict_speaks_candidly_about_drugs_rehab_stigma
• Where would criminal justice stuff help? e.g. would eliminating mandatory minimums help? Are people at greater risk after incarceration? What’s the best outcome for someone addicted to interfaces w criminal justice system for drug related offense only, and separately for other offense e.g. violent crime? What’s the current outcome? Are people being sent to rehab or jail? Is the rehab they are sent to effective? How do prosecutors/people who decide sentences/punishments feel?
• Would there be benefit of decriminalizing? How much would this help? How could this hurt? (All drugs, or just opioids)
• What’s the status/need for more safe injection sites, rehab+treatment programs?
• Why does the harm reduction focus help vs criminalization? Is it a cause or correlation?
• To what extent are large employers and large health insurance companies incentivized allies? Do most of these people have insurance? Are they costing the insurers or large employers lots of money? If so, what are those groups doing? What could they do? What would they do?
• When does changing supply reduce use? Does it by impacting price and availability? Can we reduce availability? Though people get through their friends — are new prescribing practices already fixing that, or do we need to do more?
• Can we change culture of 12 step programs so they all include effective treatments like MATs? https://www.vox.com/science-and-health/2017/7/20/15937896/medication-assisted-treatment-methadone-buprenorphine-naltrexone
• Need to increase prescription limits for doctors / ways to get MATs to people who need them https://www.vox.com/science-and-health/2017/7/20/15937896/medication-assisted-treatment-methadone-buprenorphine-naltrexone
• Most people with substance abuse disorders don’t get treatment, due to lack of access to care, non-affordable care, fear of shame/discrimination, not wanting to get treatment / not feeling they have a problem https://addiction.surgeongeneral.gov/executive-summary
• How to prevent new war on drugs or aspects of new war on drugs that would lead to bad outcomes? https://www.vox.com/policy-and-politics/2017/9/5/16135848/drug-war-opioid-epidemic
• Abuse resistant oxycontin formulation ignited the heroin epidemic. How to prevent/reverse/avoid this worsening in the future? I can imagine laws being passed that mandate more abuse resistant formulations. Will that make it worse? How to avoid that happening? https://www3.nd.edu/~elieber/research/ELP.pdf https://www.reddit.com/r/Drugs/comments/6t2zcf/august_2010_a_new_formulation_of_oxycontin_was/
• Are people who have overdoses or die typically those with prescriptions? What is the typical overdose candidate like? How does that compare with non-medical users who don’t overdose? (Is this an important question? I think it might not be important.)

“$920 million to support cooperative agreements with States to expand access to medication-assisted treatment for opioid use disorders. States will receive funds based on the severity of the epidemic and on the strength of their strategy to respond to it. States can use these funds to expand treatment capacity and make services more affordable.“

https://obamawhitehouse.archives.gov/the-press-office/2016/02/02/president-obama-proposes-11-billion-new-funding-address-prescription

Who is this $$ going to?

$10s of billions needed each year? That’s a shit load of spend. https://www.vox.com/science-and-health/2017/8/3/16079772/opioid-epidemic-drug-overdoses

Dig into how they’ll roll out these things, what they’ll fund, etc?

Longer term:

• Social inequality
• Belonging, community
• Purpose
• Better treatments for chronic pain
• Better regulations around prescribing opioids/drugs?
• Labor migration + safety net/social support for people who are migrating to areas (though watch out for brain drain side effect https://www.nytimes.com/2017/03/16/opinion/why-im-moving-home.html leaving desolate towns)
• Better solutions to or less childhood trauma, chronic stress, mental illness, unemployment
• More family dinners (prob correlation not causation)? https://www.centeronaddiction.org/addiction-research/reports/importance-of-family-dinners-2012

Not that helpful / not worth prioritizing in the short-term:

• Better pain management stuff, access to physical therapy
• Better practices for prescriptions from doctors

Links and resources we went through:

• Excellent: http://fair.org/home/stigma-over-solutions/
• Decent for some ideas. One particularly detailed comment: https://news.ycombinator.com/item?id=14985084
• Ok, but not impactful: http://thehill.com/blogs/pundits-blog/healthcare/331972-the-simple-solution-to-fight-the-opioid-epidemic
• Solid: https://www.psychologytoday.com/blog/addiction-in-society/201703/the-solution-the-opioid-crisis
• Eh mostly marketing, very biased: https://www2.deloitte.com/us/en/pages/public-sector/solutions/solving-the-countrys-opioid-crisis.html
• Interesting: https://www.vox.com/policy-and-politics/2017/8/9/16118526/opioid-epidemic-national-emergency
• Decent: http://wwmt.com/news/local/hospitals-launch-prescription-guidelines-to-help-opioid-abuse
• Very solid: http://www.nejm.org/doi/full/10.1056/NEJMra1507771#t=article
• Excellent: https://aspe.hhs.gov/basic-report/opioid-abuse-us-and-hhs-actions-address-opioid-drug-related-overdoses-and-deaths If you just read one thing, probably this. They clearly did the research.
• Very useful: https://www.cdc.gov/drugoverdose/data/prescribing.html
• Excellent: https://www.drugabuse.gov/about-nida/legislative-activities/testimony-to-congress/2016/what-science-tells-us-about-opioid-abuse-addiction
• Not very useful: http://www.fox9.com/news/facing-the-opioid-epidemic-doctors-struggle-to-find-solutions
• Not very useful: https://www.ems1.com/opioids/articles/282264048-The-solution-to-the-opioid-epidemic-requires-unconventional-thinking/
• Not additive: http://time.com/collection-post/4521562/2016-election-opioid-epidemic/
• Ok: https://addiction.surgeongeneral.gov/executive-summary/report/health-care-systems-and-substance-use-disorders
• Great resources and overview: https://www.hhs.gov/opioids/index.html
• Excellent, exec summary of HHS report: https://aspe.hhs.gov/system/files/pdf/122101/es_OpioidInitiative_0.pdf
• Excellent: http://onlinelibrary.wiley.com/doi/10.1111/j.1360-0443.2012.04001.x/full (Sort of a summary: https://blogs.scientificamerican.com/mind-guest-blog/opioid-addiction-is-a-huge-problem-but-pain-prescriptions-are-not-the-cause/)
• Seems unlikely to be additive: https://www.ncbi.nlm.nih.gov/pubmed/25871819?dopt=Abstract
• Good: https://www.end-opioid-epidemic.org/ (Particularly the task force overview)
• Doesn’t seem very good. Focuses on enforcement, doesn’t mention narcan/naloxone https://obamawhitehouse.archives.gov/sites/default/files/ondcp/policy-and-research/rx_abuse_plan.pdf
• Decent: https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/1918924
• Excellent: https://www.vox.com/science-and-health/2017/8/1/15746780/opioid-epidemic-end
• Good: https://www.drugabuse.gov/drugs-abuse/opioids/opioid-crisis
• Very good overview: https://www.nytimes.com/interactive/2017/08/03/upshot/opioid-drug-overdose-epidemic.html
• Didn’t read, but has a bunch of data: http://www.painphysicianjournal.com/current/pdf?article=MTcwNA==&journal=68
• Excellent, see executive summary: http://www.cityofithaca.org/DocumentCenter/View/4224