The Problem Over the past two decades in the United States, the use of opioids—the group of drugs that includes heroin and prescription painkillers—has escalated dramatically, with enormous human and financial costs to individuals, families and communities. The Hazelden Betty Ford Foundation sees the devastating effects of opioid addiction every day. Our observations have been consistent with a wave of sobering statistics that reveal a public health crisis that the Centers for Disease Control and Prevention (CDC) calls the worst drug addiction epidemic in U.S. history. The CDC says deaths related to prescription painkillers have more than quadrupled. (Note: prescription pain reliever deaths are presumed to include those resulting from illegally made fentanyl, which in overdose reports is indistinguishable from pharmaceutical fentanyl. As a result, the CDC also compiles a separate set of numbers on prescription opioid deaths, but those figures are also imperfect because they exclude deaths resulting from prescribed fentanyl. We've chosen to report the larger number because it provides a more complete picture of all opioid deaths. (See the CDC's explanation.) Driven by the rise in opioid deaths, drug overdose has become the leading cause of accidental death in America, with 42,032 unintentional deaths in 2014 (115 per day). Car accidents, now a distant second, resulted in 33,736 deaths in 2014. Adding intentional deaths and those of undetermined intent, 47,055 people died of drug overdose in the United States in 2014. In fact, more people died from drug overdose in 2014 than in any other year on record. More than a half million lives have been lost to overdose since 2000. The most common drugs involved in prescription opioid overdose deaths are methadone, oxycodone and hydrocodone. Prescription drug addiction impacts nearly half of the public on a personal level. A 2016 Kaiser Family Foundation survey found that 44 percent of Americans personally know someone who has been addicted to prescription painkillers, with 26 percent saying the person they know is an acquaintance, 21 percent saying a close friend, 20 percent saying a family member, and 2 percent saying themselves. In 2011, Americans made more than 750,000 emergency department visits due to problems with prescription opioids (366,181—more than 1,000 a day), heroin (258,482) and unspecified opioids (138,130). Not surprisingly, opioid dependence is also on the rise. In 2015, the Hazelden Betty Ford Foundation treated 2,700 people for opioid addiction—about 23 percent of all patients, a 250 percent increase since 2001. The data across the entire healthcare system is even more striking. Analyzing figures compiled in 2014 by the Substance Abuse and Mental Health Services Administration (SAMHSA), the National Association of State Alcohol and Drug Abuse Directors reported that treatment systems nationwide had experienced a five-fold increase in admissions for prescription opioid use disorders since 2000. According to SAMHSA's National Survey on Drug Use and Health (NSDUH), in 2014, an estimated 1.9 million people had an opioid addiction related to prescription painkillers and an estimated 586,000 had an opioid addiction related to heroin use. A couple million more, while not addicted, also reported nonmedical use of prescription painkillers. Those numbers do not include the additional 2.5 million or more chronic pain patients who may have an opioid dependence but are excluded from the data because they are using opioids medically, or "as prescribed." These alarming increases in use, misuse, addiction and overdose deaths parallel, as one might suspect, a skyrocketing rate of opioid prescriptions and use. The CDC says the amount of prescription opioids sold nearly quadrupled in the U.S. from 1999 to 2010, despite no change in the amount of pain that Americans report. And the number of prescriptions filled by pharmacies nearly tripled between 1991 and 2013. In 2012, the CDC says 259 million opioid prescriptions were written, enough for every American adult to have a bottle of pills. And despite having only 4.6 percent of the world's population, the U.S. consumes 80 percent of the world's supply of painkillers. These troubling trends began to emerge in the late 1990s, after the U.S. Food and Drug Administration (FDA) approved OxyContin and allowed it to be promoted to family doctors for treatment of common aches and pains. Unfortunately, education campaigns funded by opioid manufacturers exaggerated the benefits and minimized the risks therefore causing state policymakers to loosen standards governing opioid prescribing. Then, in 2000, the Joint Commission on Accreditation of Healthcare Organizations implemented new pain management standards. Soon, more physicians and organizations began advocating for increased use of opioids to address what at the time was perceived to be a widespread problem of undertreated pain. When prescribed on a short-term basis to treat severe acute pain, opioids can be helpful indeed. In fact, they are one of the best medicines we have. But when these highly addictive medications are taken around-the-clock, for weeks, months and years to treat relatively common conditions, they may actually produce more harm than help. An increasing body of research suggests that for many chronic pain patients, opioids may be neither safe nor effective. Over time, patients often develop tolerance, leading them to require higher and higher doses, which ultimately can lead to quality-of-life issues and functional decline, not to mention addiction. According to the CDC, 25 percent of people prescribed opioids for long term, non-cancer pain struggle with addiction. And in some cases, opioids can even make pain worse, a phenomenon called hyperalgesia. Many people associate prescription painkillers with older adults, and that certainly is a significant population affected by the current crisis. But overdose rates have been highest among people aged 25-54. Youth are also at risk of opioid addiction, especially with the increased availability in medicine cabinets. Young brains are particularly vulnerable because they aren't fully developed until the mid-20s. Teens may think the drugs are safe because a doctor prescribed them, unaware that painkillers can be as life-threatening as heroin. In the 2012 National Survey of American Attitudes on Substance Abuse, 34 percent of teenagers reported they could get prescription drugs within a day. The National Institute on Drug Abuse (NIDA) says 70% of 12th graders who used prescription opioids non-medically in 2011 reported obtaining the drugs from a friend or relative. Friends and family are the number 1 source of opioids for non-medical users in most age groups. The good news is the 2015 Monitoring the Future survey shows that teen drug use has declined in recent years. Nevertheless, the numbers add up. According to the NSDUH, 467,000 adolescents were current nonmedical opioid users in 2014, and 168,000 had a prescription opioid addiction. In addition, 28,000 adolescents used heroin in the past year, and 18,000 had a heroin addiction. While most prescription opioid users do not go on to use heroin, those who are addicted to prescription opioids are 40 times more likely to become addicted to heroin. And multiple studies now indicate that almost 80 percent of new heroin users did previously use prescription opioids. That is consistent with what we hear anecdotally from our young patients who have an opioid addiction. They often report a relatively swift path from medicine bottle to heroin needle. As prescription supplies dry up and doctor-shopping options run out, heroin becomes the cheaper and more available alternative. A 2014 survey of people in treatment for opioid addiction validated our experience, with 94 percent of respondents saying "they used heroin because prescription opioids were far more expensive and harder to obtain." Notably, heroin use has more than doubled in the past decade among adults aged 18-25, and heroin overdose death rates increased 26 percent from 2013 to 2014 and have tripled since 2010. Opioid problems are affecting every area of the country, devastating an entire generation in some communities like the New York City borough of Staten Island, where someone died of an opioid overdose every five days, on average, in 2014. States like West Virginia, New Mexico, New Hampshire, Kentucky and Ohio have been hit particularly hard. Opioid overdoses are now contributing to reduced life expectancy for entire segments of our population. For example, a study published in November 2015 found that white Americans, ages 45-54, have suffered a startling rise in death rate since 1999. The sharp reversal of progress toward longer lives is most attributable to a surge in overdoses from prescription opioids and heroin, liver disease and other problems that stem from alcohol use, and suicides. In January 2016, the New York Times published an investigative report revealing rising death rates among young white adults, ages 25-34, making them the first generation since the Vietnam War to experience higher death rates in early adulthood than their previous generation. At the center of this problem is overprescribing. Doctors didn't start overprescribing opioids out of malicious intent but, rather out of a desire to treat pain more compassionately. The number 1 reason people visit a physician is pain. As mentioned, doctors were mistakenly informed beginning in the 1990s that treating pain with opioids was safe. Physician visits are shorter. Non-prescription related health support services for pain patients have been fragmented and underutilized. Pressure to make decisions and provide quick solutions add to the doctor's dilemma. Often it is easier for a physician to write a prescription to maintain the 'status quo' than to ask the difficult question, "Should I change how I am treating this patient?" We have a culture that seeks opioid medication for pain relief, perhaps a natural outgrowth of pleasure seeking within a significant percentage of patients who take opioids for pain. In the absence of more holistic self-care approaches, it makes sense that some patients are at significant risk for the development of addiction in our culture which promotes 'quick-fixes', instant gratification and escapism. We have learned that recovery from pain conditions, and recovery from pain and addiction, require far more than taking pills. Some progress has been made to confront this crisis. Because of new policies to rapidly expand access to the overdose reversal agent "naloxone," thousands of people are surviving overdoses and getting another chance to recover from their opioid addiction or dependence and reclaim their lives. A robust national conversation has also led to more doctors and patients becoming aware of the serious risks associated with opioid pain medications. We were especially happy to support the new voluntary opioid prescription "guidelines" issued by the CDC in 2016. We believe they strike a common-sense balance that will help address overprescribing without stigmatizing pain. We were also happy to support enhanced warning labels on opioids, which the FDA announced in 2016. Much more needs to be done. This is a crisis that demands our continued attention and commitment. Together, We Can. In pursuit of our mission to be a force of healing and hope for individuals, families and communities affected by addiction, the Hazelden Betty Ford Foundation has mobilized its entire organization to comprehensively confront the national opioid epidemic, and to make our leading practices and learnings available in ways that can be used in communities and care organizations anywhere. In addition to the Institute for Recovery Advocacy's public education and policy efforts, our clinical teams have developed the field's most innovative approach to treating opioid addiction. Hazelden Publishing is leading the way in bringing our knowledge, experience and solutions to individual communities, as well as to other professionals and healthcare providers. Joining Together the Best Evidenced-based Practices to Establish a New Clinical Care Model: the Comprehensive Opioid Response with Twelve Steps (COR-12™) In 2012, prior to the Hazelden and Betty Ford Center merger, Hazelden launched a new treatment protocol designed to address the grim reality that more people were becoming addicted to opiates and dying from overdose. Of particular concern was the risk that patients whose tolerance decreased during abstinence could relapse and easily overdose just by taking the same doses they used to take. The new protocol - Comprehensive Opioid Response with Twelve Steps or COR-12 - embraced the latest and best research that indicated certain medications could be used to improve recovery outcomes for people with opioid addiction, and integrated those treatments into our world-class Twelve Step Facilitation model to form the foundation of a unique new approach. The Hazelden Betty Ford Foundation's COR-12 team consists of medical, clinical and research professionals whose collective goal is to improve the lives of those suffering from opioid addiction. Our program encompasses the whole spectrum of recovery—from pre-recovery, to recovery initiation, to ongoing and lifelong recovery support services. The COR-12 treatment path includes group therapy and lectures that focus on opioid addiction as well as two extended medication assistance options - 1) use of buprenorphine/naloxone (Suboxone®) or 2) use of extended release naltrexone (Vivitrol®)—offered and provided under closely supervised care. Patients can also choose to participate in COR-12 without medication assistance. "We use medications to engage our opioid dependent patients long enough to allow them to complete treatment and become established in solid Twelve Step recovery," said Chief Medical Officer Marvin Seppala, M.D. "Our goal will always be to discontinue the medications as our patients become established in long-term recovery." Joining Forces with Communities to Confront the Opioid Epidemic The impact of the opioid epidemic is felt in families, law enforcement, health care, schools and virtually every segment of society. Hazelden Publishing's Solution and Training team has joined forces with communities throughout the United States to hold Community Mobilization Events focused on the dangers of heroin and prescription painkiller misuse. By partnering with community leaders in health care, treatment and law enforcement—along with community coalition groups—thousands of individuals are more aware of the dangers of heroin and prescription painkiller misuse, as well as the hope of recovery from addiction. One-Day Community-Wide Mobilization Training Events help community leaders: Understand the history and current impact of heroin and prescription painkiller use in their community Identify resources for opioid use prevention, intervention and referrals to treatment Develop a community-based action plan for addressing the opioid epidemic Joining Forces with Organizations to Ensure Effective, Evidence-based Treatment is Available to Everyone Hazelden Publishing's Solution and Training team has supported other healthcare and treatment organizations in the execution of a five-point plan designed to comprehensively address the opioid epidemic in their communities. This approach addresses the prevention of opioid misuse in communities along with effective treatment and support for lifelong recovery. Mobilize communities with Heroin and Prescription Painkiller Community Mobilization events Plan by hosting or attending a three-day Clinical Leadership Training event Assess the current state of readiness with an Onsite Readiness Assessment Train clinical staff on implementation of the COR-12 model within current treatment delivery systems Support leadership and frontline staff through Professional Learning Communities The same COR-12 model of care that has been implemented at Hazelden Betty Ford clinics has now been helping others in states like Kentucky, which has been hit hard by the opioid epidemic. As partnerships are developed with other organizations throughout the nation, access to effective treatment for all transforms from hope to reality. Joining Forces with Professionals to Deliver Evidence-based Solutions As the world leader in publishing evidence-based treatment materials, Hazelden Publishing has been focused on delivering materials that help communities prevent opioid addiction and overdose deaths along with resources to help organizations effectively treat opioid addiction, with a focus on lifelong recovery. The Publishing team travels the nation, listening to the challenges and success of others, and responding with tools that help make a difference. Joining Forces with Primary Healthcare The Hazelden Betty Ford Foundation Professionals in Residence (PIR) programs in Minnesota and California offer doctors and other health care professionals the opportunity to learn how to recognize and assess substance use disorders, including opioid addiction. These programs allow professionals to visit our facilities and participate in the treatment experience for one week while they are learning. The experiential model facilitates an in-depth, personal and unique learning experience that tends to "stick with" participants. Our PIR staff also helps us host special events. For example, we have hosted multiple conferences on Addiction Medicine for the Primary Care Provider, at which much of the discussion revolved around opioids. Such events demonstrate how our PIR programs can help us address the nation's opioid crisis. Another leverage point for us in the fight against opioid overprescribing is our Summer Institute for Medical Students (SIMS). The SIMS program, like our PIR programs, gives students the opportunity to be part of the addiction treatment experience for one week. The main difference is that it targets medical students rather than those already working in the profession. Instead of sitting in a classroom, the students learn by integrating into the daily life of either patients or family program participants at the Betty Ford Center. The idea is to help our nation's future doctors understand the recovery process by letting them see it happen. In the effort to educate doctors about the risks of overprescribing opioids and how to recognize and treat opioid addiction, the SIMS program can serve as a powerful model and resource. In Minnesota and Oregon, we also now have a specialty treatment track for health care professionals who become addicted to opioids and other drugs themselves. We help them recover from their addiction, salvage their careers and eventually re-enter the workforce as advocates for addiction prevention and recovery. Recovering health care professionals, whether they publicly disclose their recovery status or not, can be valuable allies in our effort to promote more cautious opioid prescribing practices, as well as other related priorities. Joining Together Treatments for Substance Use Disorder and Pain At the Betty Ford Center in Rancho Mirage, Calif., we now offer a unique Pain Management Program where patients can initiate their recovery from a substance use disorder while simultaneously addressing their chronic pain problems. People who use opioids, alcohol and other drugs to cope with chronic pain develop a state of chronic stress. We help them relearn how to focus and how to de-stress. When the mind is relaxed—and this is key to our treatment—it will go to a place of healing. Rather than dealing with the physical cause of pain, our pain management program is based on reshaping how the brain reacts to pain, utilizing non-opioid interventions. Our Public Policy Priorities As the nation's largest nonprofit provider of addiction prevention, treatment and recovery services, the Hazelden Betty Ford Foundation has an important responsibility, and is uniquely qualified, to comment on public policy opportunities that could help reduce the enormous impact of opioid misuse and addiction, which we see every day across our 16 locations in the United States. As such, we are pursuing the following advocacy priorities. 1) EDUCATE & PREVENT Training for dentists, doctors and pharmacists. We support the aggressive expansion of education and training for health care providers about the dangers of overprescribing opioids, screening for and recognizing the signs of addiction to alcohol and other drugs, appropriately intervening when addiction is suspected and referring to specialty care when needed. This is especially relevant in the area of opioids, where education is desperately needed on the dangers of overprescribing and alternatives for addressing pain. Public education. We support national education and prevention campaigns that target youth and their parents, older adults and the general population to dispel myths, provide facts and resources, and reduce stigma. One idea we support is educational literature for consumers, provided with their opioid prescriptions. Another might be to add a "penny a pill" or similar surtax to opioids, with the proceeds to fund public education campaigns. Promotion of non-medication pain management therapies. We encourage public and private organizations to follow the lead of groups like Minnesota's Veterans Administration in embracing healthy approaches to pain management that do not rely so heavily on pain medications. We also urge state medical boards to include diverse pain management guidelines in their policies. A survey we commissioned in October 2014 supports this priority, finding that 80 percent of respondents are willing to reduce or eliminate their current chronic pain medications and try alternatives instead. We are especially grateful for the new opioid prescribing guidelines recently issued by the Centers for Disease Control and Prevention (CDC). Limits on medications. We support legislation like that recently signed into law in Massachusetts that forbids doctors from writing opioid prescriptions for more than a seven-day supply. Lawmakers in Vermont and Maine are considering similar laws, which would go a long way toward reducing excess supply in medicine cabinets and limiting the expectation on length of use. A ban on direct marketing of opioids. The Food and Drug Administration (FDA) should forbid the makers of opioids from marketing them to doctors and the public. Responsible medication approvals and labeling. We urge the U.S. Food and Drug Administration (FDA) to refrain from approving new high dosage opioid painkillers, especially those easily crushed and therefore more prone to misuse and diversion, unless they are clearly safer than existing products. We encourage medication labels that appropriately limit approved uses. In addition, we encourage a strong FDA warning on all opioid labels. Such warnings would help ensure that patients are aware of the dangers and the availability of alternatives. These are deadly drugs that in essence represent "heroin in the medicine cabinet." We believe natural painkillers like "kratom" should be investigated for possible inclusion on the DEA's controlled drug schedule. Kratom, derived from a plant, has properties of amphetamine and opioids and is marketed as a "natural painkiller." It doesn't show up on drug screens, which means people with opioid use disorders can use it without being detected. Those selling it are doing so publicly without consequences, as it remains legal in spite of its addictive qualities. In 2014 the FDA banned the import of kratom under its authority to keep out substances strongly suspected to be harmful. The Drug Enforcement Administration (DEA) has also listed kratom as a "drug of concern" but not a controlled substance. Indiana, Tennessee, Vermont and Wyoming have banned it on their own, and the Army has forbidden its use by soldiers. 2) MONITOR Effective Prescription Drug Monitoring Programs (PDMP). We support establishing a national PDMP and mandating its use by all prescribers. PDMPs help prescribers see what prescriptions their patients may be getting from other prescribers, identifying problematic drug-seeking early on. State-level PDMPs are often voluntary, and the information is usually not shared across state lines. Short of a national system, we encourage more efforts to strengthen state PDMPs, including mandated utilization, appropriate funding and coordination of PDMPs across state lines. Utilization is especially key, since studies show that in states where it is not mandatory, the PDMP is used only a third of the time. Grants to state substance abuse agencies, including the Substance Abuse Prevention and Treatment Block Grant, could require coordination across state lines and mandatory PDMP utilization, for example. The addition of naloxone revivals as an item tracked by PDMPs. We also think prescribers need to know if their patients have ever had to be revived from an overdose. A recent study in the Annals of Internal Medicine found that too many folks who are revived are then prescribed opioids again. Effective law enforcement. We support strong sentences for criminal overprescribing of opioids as well as enterprising diversion schemes intended to supply the illegal drug market. 3) DISPOSE Disposal of unused, unneeded medications. We support the U.S. Drug Enforcement Administration's regulations governing the safe and secure disposal of prescription medications at authorized collection locations. We also support the DEA's National Prescription Drug Take-Back Day and urge communities to vigorously promote their authorized collection locations with other community-wide Prescription Drug Take-Back Days. Such efforts facilitate continued public education about the dangers of keeping excess medications in the home or workplace. 4) REVIVE Availability of overdose "rescue drugs." We encourage expanded access to the opioid antidote "naloxone," and we support "Good Samaritan" laws which encourage people to call 911 for help when they witness an overdose without fear of being arrested themselves for drug possession or being under the influence. States such as New York have trained thousands of first responders and lay individuals to recognize and respond to opioid overdoses using naloxone, and many have companion "Good Samaritan" laws. We encourage similar policy nationwide. Immediate intervention for people revived from an opioid overdose. We believe health care providers should adopt a "standard of care," or recommended protocol, for helping people after they have been revived from an opioid overdose with naloxone. Such a standard or protocol would help ensure that overdose survivors are thoroughly evaluated, educated and referred to addiction treatment and/or community-based support resources. Too often today, people revived are sent home without further care. They are at extreme risk to "use" and possibly overdose again. 5) TREAT Accessible evidence-based treatment for opioid use disorder. Longer-term care. Research, as well as the experience of our Comprehensive Opioid Response with Twelve Steps (COR-12) program for treating opioid addiction, shows that engaging patients longer improves their chances for sustained recovery. While we believe the level of care (i.e. residential, intensive outpatient, etc.) is best determined by clinicians using American Society of Addiction Medicine (ASAM) criteria, we support an emphasis on longer-term care. Enforce insurance "parity" to guarantee that insurance companies are not arbitrarily discontinuing coverage for treatment at a certain time. Our organization was at the forefront in supporting the 2008 parity law. We still see "fail-first" violations, though, whereby patients are forced to fail at lower levels of care before receiving the appropriate level of care. The parity provisions also are inconsistently adhered to by insurance companies, something our staff contends with daily. We firmly believe that insurers and other payers should be required to disclose their medical management criteria and how they employ them. Safe, responsible use of medication to assist addiction treatment when appropriate. We support the use of certain medications if used adjunctively with therapy and recovery support to minimize risks and maximize the benefits of treatment. Our COR-12 program is a model. To that end, we believe primary care doctors who prescribe medications for opioid addiction need to also "prescribe" therapy, regular drug screens and recovery support resources as well. Current regulations make these suggestions, but do not require anything. At minimum, we'd like to see weekly drug screens and at least one hour of counseling a week required for patients receiving medications for opioid addiction. In addition, we encourage doctors to consider naltrexone or its extended-release version—Vivitrol—as a viable alternative to Suboxone in some cases, and to consider both of those options as the safest alternatives. To ensure thorough consultations are possible between primary care doctors and their patients with opioid addiction, we also urge that existing limits be maintained on the number of patients to whom a doctor can prescribe Suboxone; at the same time, we would like to see more doctors certified to prescribe the medication. Abstinence as long-term goal. We know from years of experience that abstinence is a realistic goal for people with opioid addiction, and we urge all professional caregivers to pursue that goal. Criminal justice reform. We strongly support the expansion of Drug Courts and similar correction alternatives that are more rehabilitative than punitive and that have proven to reduce crime, save money, ensure compliance and restore families. We also believe legislative efforts like The Second Chance Act can help those who were convicted of drug offenses get back on their feet through treatment, re-entry programs and employment training. We further support efforts to reform draconian mandatory sentencing laws, restore the voting rights of recovering drug offenders and provide them with more and better sober housing options. 6) SUPPORT Expanded infrastructure for community-based recovery. Addiction is a chronic illness, and we need to think of recovery from addiction as we do cancer remission - something that needs close attention and support for up to five years. That doesn't mean we need five-year-long treatment programs, but rather support mechanisms that help connect recovering people so they can support one another in the community context and be a magnet for others in their community who might seek recovery as well. While recovery often begins with treatment, it is sustained in the community, and people with addiction benefit substantially from long-term recovery engagement. We support grants and targeted efforts to establish recovery community organizations; expand and improve recovery housing; and promote collegiate recovery programs and recovery high schools. Loan forgiveness for licensed addiction counselors who practice in high need areas. There is a huge need for addiction counselors right now, with a projected 31 percent employment growth rate by 2022 for these jobs. In fact, more than 21,000 new counselors will be needed to fill the need, according to the Bureau of Labor and Statistics. We can encourage prospective counselors to go into the field, and fill a need in the country, by offering targeted loan forgiveness for those who commit to practicing in certain high need areas, for a specified period of time, similar to what's been implemented for doctors in rural areas, for example. Telehealth and other remote supports. We urge federal and state legislation that would make it more feasible for organizations like ours to provide care remotely using telehealth technologies. The greatest challenges are obtaining provider licenses across multiple state lines and accessing insurance reimbursements for care delivered in this manner. This is relevant because patients on medication assistance for opioid addiction require continuing care services that support their long-term journey to abstinence, and it is difficult to engage them long term without doing so remotely. Telehealth technologies also could help bring therapy resources to locations where primary care doctors are able to prescribe Suboxone but unequipped to provide addiction counseling. That is a clear need expressed by participants at our Addiction Medicine for the Primary Care Provider Conferences. American Indians, military veterans, and residents of rural areas, for example, would benefit greatly from increased access to care.