Finding Consensus on Opioid Misuse is Critical to Overcoming It

The story behind the epidemic: 11.5 million Americans misuse prescription opioids.[i]

One of the reasons the opioid epidemic in the U.S. is so tragic is that for many who misuse prescription opioids, the misuse began because they were already experiencing severe, chronic pain.

With the best of intentions, they went to see their physicians for help. And their physicians responded by doing all they could to ease their patient’s pain. In many cases, that included prescribing a legal painkiller – that is, an opioid such as oxycodone or hydrocodone.

In most circumstances, opioids are generally safe when prescribed for a specific and brief period of time.[ii] And for many of those who take them, when their prescription ends, so, too, does their use of opioids.

But it’s not the entire story, because as of last year, it’s estimated that 11.5 million Americans misuse prescription pain relievers.[iii]

In fact, the National Institute on Drug Abuse (NIDA) notes that 21-29 percent of patients prescribed opioids for chronic pain eventually misuse them. In 2016, about 1.8 million of these users had a substance-use disorder involving misused prescription pain relievers. In 2015 alone, opioid misuse contributed to more than 33,000 deaths.[iv]

Veterans: Severely Affected

The misuse of opioids is particularly concerning in the veteran community. With higher rates of chronic pain and a 270 percent increase in opioid prescriptions over a 12-year period[v], veterans are especially vulnerable.

In fact, from 2010 to 2015 there was a 55 percent spike in opioid misuse in this population.[vi]

Veterans are 10 times more likely to misuse opioids than average Americans[vii] and two times as likely to die from accidental opioid overdoses than non-veterans.[viii]

By any definition, this is a tragedy of epic proportion. Our veterans deserve better.

The opioid epidemic can be especially calamitous for veterans because they often face multiple health challenges, including greater prevalence of pain, PTSD (post-traumatic stress disorder), depression and other health conditions, as well as challenges transitioning back to civilian life, which can greatly complicate issues of access and treatment.

Moving forward: Identifying gaps in perspective in order to narrow them.

As a critical player in the U.S. health care system, Cigna wanted to better understand what people generally – and veterans in particular – believe they need to overcome opioid misuse.

Cigna views veterans as an important part of our global team, and commits approximately 10 percent of our annual recruitment budget in the U.S. to recruit veterans and their spouses. Today, approximately 1,000 veterans work at Cigna, with approximately 20 percent of them still active in the Guard or Reserve.

We wanted to gain insight into how veterans perceive available treatment efforts – what works and what doesn’t – and how they feel these efforts could be more effective.

And we wanted the perspective of health care professionals, as well, not only on what works, but what they need to make those things work better.

With this in mind, we commissioned a study on these issues with The Economist Intelligence Unit (EIU). This work included two surveys involving more than 300 medical and addiction practitioners across the country, 99 percent of whom have treated patients taking opioids or suffering from opioid addiction, and 70 percent of whom have treated veterans; and 2,800 members of the general public, 40 percent of whom have suffered from addiction themselves or have friends, family or co-workers who have. Twenty-one percent of the general public are veterans, as well.

According to the EIU survey, medical practitioners (72%) and the general public (62%) agree that treating veterans with opioid addiction is more complex than treating other individuals with the same condition. Compounding this challenge, more than one out of three medical practitioners are not “very confident” they have the resources they need to treat veterans with opioid addiction in the first place.

The findings confirmed our belief that we do not have a moment to waste trying to address this crisis. Lives are at stake every day. People are suffering. Families are breaking down. Communities are coming apart.

We must find consensus on the best way to reduce opioid use and opioid misuse. We must find common ground so we can stand together and fight this battle together, with one common goal.

This study is a step in that direction. What we learned gave us important new insights into the opioid crisis, how it’s viewed across populations, and how society can continue to refine how to address it. Significantly, we identified gaps between what the general public and veterans believe is most effective in combatting the epidemic, as well as gaps between these groups and the medical community. Understanding and responding to these gaps are important because they may determine resource allocation and a host of other determinants that can impact who, how, when and where veterans and others are treated for opioid addiction.

Gap One: Risk factors

Veterans often return to civilian life with underlying health conditions that not only can make everyday life more challenging, but the risk of opioid addiction greater later on. While both the veteran population and the general public agree on the top three risk factors for misuse, perhaps from greater firsthand knowledge and experience, higher shares of veterans point to prescription drugs, chronic pain and over-prescribing as the top three risks than does the general public.[ix]

Of note: When it comes to over-prescribing as a significant risk factor that may lead to opioid misuse, 43 percent of all medical practitioners (and 48 percent of medical specialists[x]) believe it is, while only 37 percent of addiction specialists do. Despite this belief, 58 percent of practitioners say that in the moment, they mostly or completely focus more on treating a patient’s current condition than the potential for opioid misuse later on.

Bottom line: These risk factors may not stand alone. Chronic pain can lead to the use of a prescription drugs that, in turn, could lead to over-prescribing if a practitioner is not thinking ahead about the potential for misuse. Veterans themselves and the general public do not see eye to eye on what contributes to opioid misuse among veterans, however, which could impact limited resource allocation and use of evidence-based treatment options.

Gap Two: Treatment

Because individuals with opioid addictions are different, no one treatment approach works best for everyone. A cookie-cutter approach won’t work. But in an era of limited resources, and with an epidemic that continues to grow and devastate more communities, finding consensus across medical practitioners and the general public about what treatment options will be most effective for more people will be increasingly important moving forward.

Before we can find consensus, however, we need to know what practitioners and the public think does work, doesn’t work and what they believe is already available in their communities.

There are disconnects in some of the data, with, for instance, 38 percent of practitioners believing outpatient treatment is a key component of an effective addiction program, while only 21 percent of the general public believing that. On the flipside, 40 percent of the general public puts its faith in inpatient treatment, while only 32 percent of practitioners do.

Practitioners also believe more strongly than the general public in the effectiveness of medication-based treatment (65% v. 44%), behavioral therapy (56% v. 37%) and peer counseling (50% v. 37%). Interestingly, practitioners perceive these efforts to be available in their communities more than does the general public.[xi]

Of note: Only 55 percent of veterans and 47 percent of the general public believe opioid addiction is treatable , even though, according to NIDA, it is.[xiii] This suggests that both populations are less optimistic about overcoming addiction than medical practitioners, 70 percent of whom believe it is treatable.[xiv] A gap like this can have important reverberations, since those who need treatment most may not seek it out if they do not believe it will be effective.

Bottom line: The gaps illustrated here are significant – and not only because they’re wide. The differences in what these groups think is effective can impact the services practitioners offer, while the lack of awareness about what is actually available in their communities can impact the services those who misuse opioids seek out. Until what treatments are thought best and what treatments are known to be available can better sync up, the results for those who offer services and those who need them may not be in sync either.

Gap Three: Complications

Just as veterans’ underlying health conditions, such as chronic pain and PTSD, can pose a risk for opioid misuse, so, too, can they complicate its treatment later on. For example, we know that veterans are 40 percent more likely to experience severe pain than non-veterans.[xv] Medical specialists and addiction specialists are on the frontlines of treatment, so their perspective on these underlying conditions are important considerations. It will impact the kind of treatments they emphasize, educate themselves on, seek to expand and recommend to patients.

Of note: More than half of veterans (53%) want more clinics or therapists devoted to addressing opioid addiction in Department of Veterans Affairs (VA) health facilities.[xvi] Pain management (and mismanagement) often leads to opioid prescription and, in turn, misuse later on.

Bottom line: While almost half of both medical specialists and addiction specialists agree that chronic pain is a risk factor for misuse among veterans, their perspectives vary greatly when it comes to other risk factors. More than half (55%) of addiction specialists believe that PTSD, a mental health condition, poses risk for veterans, while fewer than a third (32%) of medical specialists believe PTSD is a risk factor. This gap alone can significantly impact the type of treatment recommended to veterans and complicates coming to consensus on what is the most effective mix of treatment approaches.[xvii]

Gap Four: Success

Having a wide array of resources available, as well as past experience treating veterans generally, impacts how successful those who treat veterans with opioid addictions feel they will be. Medical specialists and addiction specialists know there is no silver bullet, no one thing that will, on its own, be sufficient. But knowing that doesn’t in every case make treatment easier if these specialists don’t have the resources and experience they need to be as effective as they know they need to be.

Closing this gap would be a win-win for both those who treat opioid addiction and those they treat.

Of note: The top three resources that medical specialists and addiction specialists say would help make them feel more confident treating veterans with opioid addictions are additional medical support staff with experience treating veterans, new evidence-based guidelines from the Federal government or medical societies and more experience treating veterans more generally.[xix]

Bottom line: Though more than half of medical specialists and two-thirds of addiction specialists say they are at least somewhat confident they can treat veterans who misuse opioids – and that sounds pretty good – a third of medical specialists and a fifth of addiction specialists do not feel confident. It may be a much smaller percentage, but it is not insignificant, especially when lives are at stake. This suggests the continued need for additional resources and education among those treating veterans to ensure that the veterans themselves have the best chance to fight their addiction.

Conclusion

Like the 70 percent of practitioners who believe opioid addiction is treatable, Cigna is optimistic that this is a challenge we as a country can overcome – by working together. The intelligence we gained from the EIU study is important because it points out where there are gaps to be narrowed, and how we may begin to address them. It will help us come together and know how best to work toward our common goal. Given the survey results, we know it will be important to engage the vast Cigna medical network to better understand their needs in treating veterans, and in supporting them with tools and training resources.

In 2016, Cigna committed to reducing its customers’ opioid use by 25 percent by 2019. To help in this fight, we asked medical practices in our Collaborative Care network across the country to join us by signing a pledge to reduce opioid prescribing. As of April 2017, 170 medical groups representing nearly 164,000 doctors had signed the pledge and we’ve reached a 12 percent reduction, almost half way to our goal.

Cigna is reaching out to veterans. In July 2017, the Cigna Foundation made a three-year grant to Iraq and Afghanistan Veterans of America (IAVA) of $300,000 to help expand its Rapid Response Referral Program, a community effort to help veterans meet their life goals through connections to educational, medical and legal resources and benefits.

And, we’re adding veteran resources. In fall 2017, Cigna will expand staff and training in order to open up a Veteran Support Line operated by Cigna Behavioral Health to veterans who need counseling, whether they’re Cigna customers or not.

We’re on our way to success. However, we still have a long way to go. We are excited about the future and our ability to succeed in this critical endeavor. Those who are impacted by opioid misuse – the general public, veterans, families, communities – are our friends, our neighbors, our colleagues and, most importantly, our fellow citizens.

We won’t – we can’t – let them down.

Footnotes

[i]https://www.behavioral.net/article/prescription-drug-abuse/most-substance-use-numbers-hold-steady-national-survey
[ii]https://www.drugabuse.gov/drugs-abuse/opioids
[iii]https://www.drugabuse.gov/drugs-abuse/opioids/opioid-crisis
[iv]https://www.drugabuse.gov/drugs-abuse/opioids/opioid-crisis
[v]http://www.pbs.org/wgbh/frontline/article/veterans-face-greater-risks-amid-opioid-crisis/
[vi]http://www.pbs.org/wgbh/frontline/article/veterans-face-greater-risks-amid-opioid-crisis/
[vii]https://www.psychologytoday.com/blog/invisible-wounds/201701/va-says-68000-vets-addicted-opioid-painkillers
[viii]http://www.pbs.org/wgbh/frontline/article/veterans-face-greater-risks-amid-opioid-crisis/
[ix]Economist Intelligence Unit Survey. July 2017. Question 10.
[x]For the purposes of this report, medical specialists are defined as specialists in orthopedics, emergency medicine, pain management or psychiatry.
[xi]Economist Intelligence Unit Survey. July 2017. Question 7-9.
[xii]Economist Intelligence Unit Survey. July 2017. Question 4.
[xiii]https://www.drugabuse.gov/publications/drugfacts/treatment-approaches-drug-addiction
[xiv]Economist Intelligence Unit Survey. July 2017. Question 3.
[xv]https://nccih.nih.gov/news/press/veterans_pain
[xvi]Economist Intelligence Unit Survey. July 2017. Question 21.
[xvii]Economist Intelligence Unit Survey. July 2017. Question 10.
[xviii]Economist Intelligence Unit Survey. July 2017. Question 13.
[xix]Economist Intelligence Unit Survey. July 2017. Question 12.