Surgeon General’s Perspectives A PROMISE FULFILLED— ADDRESSING THE NATION’S OPIOID CRISIS COLLECTIVELY Before I became Surgeon General and put on the uniform of the U.S. Public Health Service in 2014, I worked as a physician at a hospital in Boston. As I was leaving for my new job in Washington, D.C., I made one last stop at the hospital to say goodbye to the nurses. These were the women and men who had supported me during my training and who helped guide me to become the physician I am today. As we gathered around the nurse’s station one last time, they had a parting request: If you do just one thing as Surgeon General, please do something about substance use and addiction in America. Like so many health-care providers, we had treated numerous patients with substance use disorders over the years. I had met their families and come to understand the staggering impact substance use disorders and addiction have not only on patients, but also on the people who care about them. And since then, the problem has only grown. Today, more Americans die because of drug overdoses than because of car crashes, and most of these overdoses involve some form of opioid—either prescription opioids (e.g., oxycodone, hydrocodone, and morphine) or illicit opioids (e.g., heroin). Since 2000, overdose deaths from opioid drugs have more than quadrupled, translating to nearly one death every half hour.1 And, overdose deaths are just the tip of the opioid crisis. In a 2016 report, more than 10 million Americans reported nonmedical use of prescription opioids and 900,000 Americans reported use of heroin in the past year.1 People who have a prescription opioid use disorder are 40 times more likely than those without this disorder to use heroin,2 and these individuals are more likely to inject opioids, which substantially increases their risk of infection from human immunodeficiency virus and the hepatitis B and C viruses. As stark as these numbers are, it is easy to forget the people and families behind the statistics. The opioid crisis cuts across racial/ethnic groups, age, sex, geography, and socioeconomic status. In my travels as Surgeon General, I have sat with families, community leaders, health-care providers, and policy makers and heard about men and women who have lost their lives to this epidemic. Their stories have stayed with me.
Vivek H. Murthy, MD, MBA VADM, U.S. Public Health Service Surgeon General
The opioid epidemic is a shared problem that requires shared solutions. The good news is that more and more people are stepping up in government and communities to help. U.S. Department of Health and Human Services (HHS) Secretary Sylvia Burwell and President Barack Obama are leading the way on addressing the problem of opioid use disorder and doing everything possible to connect people to treatment. In March 2015, HHS launched the departmentwide Opioid Initiative aimed at reducing prescription opioid and heroin-related dependence, overdose, and death by focusing on improving prescribing practices, expanding the distribution of naloxone, and increasing access to medication-assisted treatment.3 To build on work already underway, the president’s fiscal year 2017 budget included a $1 billion investment to help ensure that every American who wants to get treatment for an opioid use disorder will get it.4 In addition, in March 2016, CDC issued new recommendations for prescribing opioid medications for chronic pain, excluding cancer, palliative, and end-of-life care. The CDC guidelines will help primary care providers ensure the safest and most effective treatment for their patients.5 The Office of the Surgeon General is doing its part as well. We are engaging physicians, dentists, nurses, physician assistants, and other health-care providers in helping to change how America thinks about substance
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use disorders and addiction—not as a moral failing, but as a chronic illness that must be treated with compassion, urgency, and skill. We are also working with health-care providers to improve opioid prescribing practices so that we treat pain effectively but reduce unnecessary prescriptions that may contribute to the opioid epidemic. My office will share actionable, evidence-based information on appropriate opioid prescribing practices, and we will connect health-care providers to education and training opportunities on the treatment of opioid use disorders and the availability of non-opioid pain treatment alternatives. We will also provide opportunities for prescribers to share challenges and success stories on reducing opioid use and deaths in their practices and communities. The Surgeon General’s opioids campaign involves a broad group of stakeholders, including health-care providers, policy makers, educators, law enforcement officers, and the larger community. Many communities around the country are hard at work, taking creative approaches to combat the opioid epidemic. Examples include the following: • The Partnership for a Drug-Free New Jersey (http://www.drugfreenj.org). This partnership organized the “Do No Harm” symposia to address New Jersey’s opioid epidemic. These symposia focused on educating health-care providers by demonstrating the link between overprescribing and opioid use disorders. Topics included appropriately prescribing controlled medications, the importance of safe and legal prescription drug disposal, and the value of participating in New Jersey’s prescription drug monitoring program (PDMP). Because of this educational effort, hundreds of physicians registered for the state PDMP via mobile registration. Most importantly, most of the 1,000 health-care providers who attended the symposia reported they would change the way they work with their patients. • Learn to Cope (http://www.learn2cope.org). This nonprofit peer-led support network was established in 2004 in Massachusetts. With 16 chapters throughout the state and nearly 7,000 online members, the group offers peer support to affected families on substance use, treatment, and recovery. Through a partnership with the state health department, Learn to Cope became the first parent network in the country to provide the overdose-reversal medication naloxone and training to family members at all Learn to Cope meetings. Today, almost one-third of the 160 Learn to Cope facilitators are trained and certified to provide Learn to Cope families with
overdose education and nasal naloxone kits at each chapter. • The Alexandria Treatment/Criminal Justice Initiative. This partnership between the Alexandria Community Services Board (ACSB) and the Alexandria Probation and Parole District provides a coordinated system of treatment services and supervision. As part of the collaboration, a member of the ACSB Substance Abuse Outpatient Program team is placed part-time at the probation office. There, probation officers screen for criminal risk and refer eligible clients to the ACSB team, which conducts a comprehensive assessment to determine if a substance use disorder exists. If one does exist, an appropriate level of treatment is determined and a referral to ACSB’s Substance Abuse Services Center is made. ACSB’s Substance Abuse Services Center offers medication-assisted treatment in the form of methadone or buprenorphine, along with cognitive behavioral therapy to treat individuals with an opioid use disorder. Thirty years ago, Surgeon General C. Everett Koop took on one of the most important public health crises in the history of our country when he sought to educate Americans about acquired immunodeficiency syndrome. Dr. Koop set a precedent: in this country, our medical and public health leaders have a moral obligation to tackle our toughest challenges head-on. In 2016, we are called on to do the same for the opioid crisis—not only for the nurses in Boston, but for the health of the nation. The author thanks Nazleen Bharmal, MD, PhD, MPP, Director of Science and Policy, and Sudeshna Mukherjee, PhD, MS, Health Policy Fellow, both of the Office of the Surgeon General, for their work in conceptualizing, drafting, and revising the manuscript.
REFERENCES 1. Rudd RA, Aleshire N, Zibbell JE, Gladden RM. Increases in drug and opioid overdose deaths—United States, 2000–2014. MMWR Morb Mortal Wkly Rep 2016;64(50):1378-82. 2. Jones CM, Logan J, Gladden RM, Bohm MK. Vital signs: demographic and substance use trends among heroin users—United States, 2002–2013. MMWR Morb Mortal Wkly Rep 2015;64(26):719-25. 3. Department of Health and Human Services (US), Office of the Assistant Secretary for Planning and Evaluation. Opioid abuse in the U.S. and HHS actions to address opioid drug-related overdoses and deaths. Washington: HHS; 2015. Also available from: https:// aspe.hhs.gov/pdf-report/opioid-abuse-us-and-hhs-actions-addressopioid-drug-related-overdoses-and-deaths [cited 2016 Apr 19]. 4. Fact sheet: President Obama proposes $1.1 billion in new funding to address the prescription opioid abuse and heroin use epidemic. 2016 Feb 2 [cited 2016 Mar 22]. Available from: https://www .whitehouse.gov/the-press-office/2016/02/02/president-obamaproposes-11-billion-new-funding-address-prescription 5. Dowell D, Haegerich TM, Chou R. CDC guideline for prescribing opioids for chronic pain—United States, 2016. JAMA 2016 (online).
Public Health Reports / May–June 2016 / Volume 131
Letter to the Editor NIS VS. IMMUNIZATION REGISTRY MMR RATES FOR COUNTIES IN OREGON The article by Smith et al. in the September/October 2015 issue of Public Health Reports (PHR) used the National Immunization Survey (NIS) to provide information on measles immunization among young children and adolescents with finer detail than previously reported.1 One of the long-term goals of immunization surveillance is to identify local areas of lower rates by geography or demography; in their article, Smith et al. used NIS data to produce measles immunization rates for 210 U.S. counties selected by NIS sample size. Another approach to identifying pockets of need is to use state immunization registries or immunization information systems (IISs). IISs are population-based repositories of state and local immunization records. I recently described in PHR a methodological foundation for using IIS data to calculate teen populations and immunization rates.2 IISs such as the Oregon ALERT IIS offer the potential for finding county-level or smaller pockets of need. Although there is a need to compare IIS data across states and to validate local IIS estimates, it is important to account for structural and population differences across IISs. Matching IIS data with NIS local estimates is one method by which local estimates can be validated. Among the 210 U.S. counties for which Smith et al. produced NIS measles immunization estimates, five
were in Oregon. For these five Oregon counties, it is possible to compare local (county) estimates between the IIS and NIS using data on measles, mumps, rubella (MMR) vaccine coverage (Table). In this comparison, county IIS rates for two doses of the MMR vaccine were also included for context, because two doses of MMR vaccine are recommended. The NIS-Teen adolescent rates and the Oregon ALERT IIS rates for $1 dose of MMR vaccine are undistinguishable, given 95% confidence intervals. Comparing the two categories produced a Cohen’s w of 0.007, indicating that differences are small. This concordance suggests that further work in integrating NIS and IIS surveillance is warranted. In an ideal immunization surveillance system, the NIS could provide a basis for state-to-state comparisons and selected smallarea validation against state IIS-determined rates, while local areas could be examined by using state IIS data. Steve G. Robison Oregon Health Authority, Immunization Program, Portland, OR REFERENCES 1. Smith PJ, Marcuse EK, Seward JF, Zhao Z, Orenstein WA. Children and adolescents unvaccinated against measles: geographic clustering, parents’ beliefs, and missed opportunities. Public Health Rep 2015;130:485-504. 2. Robison SG. Addressing immunization registry population inflation in adolescent immunization rates. Public Health Rep 2015;130:161-6.
Table. Measles immunization rate estimates for 13- to 17-year-olds in the NIS-Teen and Oregon ALERT IIS, selected Oregon counties, 2010–2014 Oregon ALERT IIS 2014b
NIS Teen 2010–2013a Oregon county
$1 dose MMR Percent (95% CI)
Multnomah Washington Clackamas Marion Lane
96.2 95.5 96.2 94.6 94.8
(94.4, (93.3, (94.5, (91.9, (92.5,
$1 dose MMR Percent (95% CI)
98.0) 97.7) 97.9) 97.3) 97.1)
97.2 95.9 95.0 95.3 96.4
(97.0, (95.7, (94.7, (95.0, (96.1,
97.4) 96.1) 95.3) 95.6) 96.7)
$2 doses MMR Percent (95% CI) 93.4 91.2 90.4 89.3 91.2
(93.2, (90.9, (90.0, (88.9, (90.8,
93.6) 91.5) 90.8) 89.7) 91.6)
a Smith PJ, Marcuse EK, Seward JF, Zhao Z, Orenstein WA. Children and adolescents unvaccinated against measles: geographic clustering, parents’ beliefs, and missed opportunities. Public Health Rep 2015;130:485-504.
Source: Oregon Health Authority. Oregon adolescent immunization rates [cited 2015 Dec 4]. Available from: https://public.health.oregon.gov /preventionwellness/vaccinesimmunization/pages/researchteen.aspx
b
NIS 5 National Immunization Survey IIS 5 immunization information system MMR 5 measles, mumps, rubella CI 5 confidence interval
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Vivek H. Murthy, MD, MBA VADM, U.S. Public Health Service Surgeon General
The opioid epidemic is a shared problem that requires shared solutions. The good news is that more and more people are stepping up in government and communities to help. U.S. Department of Health and Human Services (HHS) Secretary Sylvia Burwell and President Barack Obama are leading the way on addressing the problem of opioid use disorder and doing everything possible to connect people to treatment. In March 2015, HHS launched the departmentwide Opioid Initiative aimed at reducing prescription opioid and heroin-related dependence, overdose, and death by focusing on improving prescribing practices, expanding the distribution of naloxone, and increasing access to medication-assisted treatment.3 To build on work already underway, the president’s fiscal year 2017 budget included a $1 billion investment to help ensure that every American who wants to get treatment for an opioid use disorder will get it.4 In addition, in March 2016, CDC issued new recommendations for prescribing opioid medications for chronic pain, excluding cancer, palliative, and end-of-life care. The CDC guidelines will help primary care providers ensure the safest and most effective treatment for their patients.5 The Office of the Surgeon General is doing its part as well. We are engaging physicians, dentists, nurses, physician assistants, and other health-care providers in helping to change how America thinks about substance
Public Health Reports / May–June 2016 / Volume 131
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388 Surgeon General’s Perspectives
use disorders and addiction—not as a moral failing, but as a chronic illness that must be treated with compassion, urgency, and skill. We are also working with health-care providers to improve opioid prescribing practices so that we treat pain effectively but reduce unnecessary prescriptions that may contribute to the opioid epidemic. My office will share actionable, evidence-based information on appropriate opioid prescribing practices, and we will connect health-care providers to education and training opportunities on the treatment of opioid use disorders and the availability of non-opioid pain treatment alternatives. We will also provide opportunities for prescribers to share challenges and success stories on reducing opioid use and deaths in their practices and communities. The Surgeon General’s opioids campaign involves a broad group of stakeholders, including health-care providers, policy makers, educators, law enforcement officers, and the larger community. Many communities around the country are hard at work, taking creative approaches to combat the opioid epidemic. Examples include the following: • The Partnership for a Drug-Free New Jersey (http://www.drugfreenj.org). This partnership organized the “Do No Harm” symposia to address New Jersey’s opioid epidemic. These symposia focused on educating health-care providers by demonstrating the link between overprescribing and opioid use disorders. Topics included appropriately prescribing controlled medications, the importance of safe and legal prescription drug disposal, and the value of participating in New Jersey’s prescription drug monitoring program (PDMP). Because of this educational effort, hundreds of physicians registered for the state PDMP via mobile registration. Most importantly, most of the 1,000 health-care providers who attended the symposia reported they would change the way they work with their patients. • Learn to Cope (http://www.learn2cope.org). This nonprofit peer-led support network was established in 2004 in Massachusetts. With 16 chapters throughout the state and nearly 7,000 online members, the group offers peer support to affected families on substance use, treatment, and recovery. Through a partnership with the state health department, Learn to Cope became the first parent network in the country to provide the overdose-reversal medication naloxone and training to family members at all Learn to Cope meetings. Today, almost one-third of the 160 Learn to Cope facilitators are trained and certified to provide Learn to Cope families with
overdose education and nasal naloxone kits at each chapter. • The Alexandria Treatment/Criminal Justice Initiative. This partnership between the Alexandria Community Services Board (ACSB) and the Alexandria Probation and Parole District provides a coordinated system of treatment services and supervision. As part of the collaboration, a member of the ACSB Substance Abuse Outpatient Program team is placed part-time at the probation office. There, probation officers screen for criminal risk and refer eligible clients to the ACSB team, which conducts a comprehensive assessment to determine if a substance use disorder exists. If one does exist, an appropriate level of treatment is determined and a referral to ACSB’s Substance Abuse Services Center is made. ACSB’s Substance Abuse Services Center offers medication-assisted treatment in the form of methadone or buprenorphine, along with cognitive behavioral therapy to treat individuals with an opioid use disorder. Thirty years ago, Surgeon General C. Everett Koop took on one of the most important public health crises in the history of our country when he sought to educate Americans about acquired immunodeficiency syndrome. Dr. Koop set a precedent: in this country, our medical and public health leaders have a moral obligation to tackle our toughest challenges head-on. In 2016, we are called on to do the same for the opioid crisis—not only for the nurses in Boston, but for the health of the nation. The author thanks Nazleen Bharmal, MD, PhD, MPP, Director of Science and Policy, and Sudeshna Mukherjee, PhD, MS, Health Policy Fellow, both of the Office of the Surgeon General, for their work in conceptualizing, drafting, and revising the manuscript.
REFERENCES 1. Rudd RA, Aleshire N, Zibbell JE, Gladden RM. Increases in drug and opioid overdose deaths—United States, 2000–2014. MMWR Morb Mortal Wkly Rep 2016;64(50):1378-82. 2. Jones CM, Logan J, Gladden RM, Bohm MK. Vital signs: demographic and substance use trends among heroin users—United States, 2002–2013. MMWR Morb Mortal Wkly Rep 2015;64(26):719-25. 3. Department of Health and Human Services (US), Office of the Assistant Secretary for Planning and Evaluation. Opioid abuse in the U.S. and HHS actions to address opioid drug-related overdoses and deaths. Washington: HHS; 2015. Also available from: https:// aspe.hhs.gov/pdf-report/opioid-abuse-us-and-hhs-actions-addressopioid-drug-related-overdoses-and-deaths [cited 2016 Apr 19]. 4. Fact sheet: President Obama proposes $1.1 billion in new funding to address the prescription opioid abuse and heroin use epidemic. 2016 Feb 2 [cited 2016 Mar 22]. Available from: https://www .whitehouse.gov/the-press-office/2016/02/02/president-obamaproposes-11-billion-new-funding-address-prescription 5. Dowell D, Haegerich TM, Chou R. CDC guideline for prescribing opioids for chronic pain—United States, 2016. JAMA 2016 (online).
Public Health Reports / May–June 2016 / Volume 131
Letter to the Editor NIS VS. IMMUNIZATION REGISTRY MMR RATES FOR COUNTIES IN OREGON The article by Smith et al. in the September/October 2015 issue of Public Health Reports (PHR) used the National Immunization Survey (NIS) to provide information on measles immunization among young children and adolescents with finer detail than previously reported.1 One of the long-term goals of immunization surveillance is to identify local areas of lower rates by geography or demography; in their article, Smith et al. used NIS data to produce measles immunization rates for 210 U.S. counties selected by NIS sample size. Another approach to identifying pockets of need is to use state immunization registries or immunization information systems (IISs). IISs are population-based repositories of state and local immunization records. I recently described in PHR a methodological foundation for using IIS data to calculate teen populations and immunization rates.2 IISs such as the Oregon ALERT IIS offer the potential for finding county-level or smaller pockets of need. Although there is a need to compare IIS data across states and to validate local IIS estimates, it is important to account for structural and population differences across IISs. Matching IIS data with NIS local estimates is one method by which local estimates can be validated. Among the 210 U.S. counties for which Smith et al. produced NIS measles immunization estimates, five
were in Oregon. For these five Oregon counties, it is possible to compare local (county) estimates between the IIS and NIS using data on measles, mumps, rubella (MMR) vaccine coverage (Table). In this comparison, county IIS rates for two doses of the MMR vaccine were also included for context, because two doses of MMR vaccine are recommended. The NIS-Teen adolescent rates and the Oregon ALERT IIS rates for $1 dose of MMR vaccine are undistinguishable, given 95% confidence intervals. Comparing the two categories produced a Cohen’s w of 0.007, indicating that differences are small. This concordance suggests that further work in integrating NIS and IIS surveillance is warranted. In an ideal immunization surveillance system, the NIS could provide a basis for state-to-state comparisons and selected smallarea validation against state IIS-determined rates, while local areas could be examined by using state IIS data. Steve G. Robison Oregon Health Authority, Immunization Program, Portland, OR REFERENCES 1. Smith PJ, Marcuse EK, Seward JF, Zhao Z, Orenstein WA. Children and adolescents unvaccinated against measles: geographic clustering, parents’ beliefs, and missed opportunities. Public Health Rep 2015;130:485-504. 2. Robison SG. Addressing immunization registry population inflation in adolescent immunization rates. Public Health Rep 2015;130:161-6.
Table. Measles immunization rate estimates for 13- to 17-year-olds in the NIS-Teen and Oregon ALERT IIS, selected Oregon counties, 2010–2014 Oregon ALERT IIS 2014b
NIS Teen 2010–2013a Oregon county
$1 dose MMR Percent (95% CI)
Multnomah Washington Clackamas Marion Lane
96.2 95.5 96.2 94.6 94.8
(94.4, (93.3, (94.5, (91.9, (92.5,
$1 dose MMR Percent (95% CI)
98.0) 97.7) 97.9) 97.3) 97.1)
97.2 95.9 95.0 95.3 96.4
(97.0, (95.7, (94.7, (95.0, (96.1,
97.4) 96.1) 95.3) 95.6) 96.7)
$2 doses MMR Percent (95% CI) 93.4 91.2 90.4 89.3 91.2
(93.2, (90.9, (90.0, (88.9, (90.8,
93.6) 91.5) 90.8) 89.7) 91.6)
a Smith PJ, Marcuse EK, Seward JF, Zhao Z, Orenstein WA. Children and adolescents unvaccinated against measles: geographic clustering, parents’ beliefs, and missed opportunities. Public Health Rep 2015;130:485-504.
Source: Oregon Health Authority. Oregon adolescent immunization rates [cited 2015 Dec 4]. Available from: https://public.health.oregon.gov /preventionwellness/vaccinesimmunization/pages/researchteen.aspx
b
NIS 5 National Immunization Survey IIS 5 immunization information system MMR 5 measles, mumps, rubella CI 5 confidence interval
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