Opioids overdoses now kill more Americans than car accidents or guns, with more than 350,000 Americans having succumbed to the painkillers since 2000.

“The opioid misuse and overdose crisis touches everyone in the United States,” Health and Human Services Secretary Alex Azar said in this recent report. “The effects of the opioid crisis are cumulative and costly for our society — an estimated $504 billion a year in 2015 — placing burdens on families, workplaces, the health care system, states, and communities.”

Now, new research led by Stanford shows that not only have opioid-related deaths jumped fourfold in the last 20 years, but that those most affected by the epidemic, and where they live, has also shifted dramatically. In fact, the District of Columbia has had the fastest rate of increase in mortality from opioids, more than tripling every year since 2013.

“Although opioid-related mortality has been stereotyped as a rural, low-income phenomenon concentrated among Appalachian or midwestern states, it has spread rapidly, particularly among the eastern states,” writes Mathew V. Kiang, ScD, a research fellow at the Center for Population Health Sciences at the Stanford University School of Medicine, in an original investigation published in JAMA Network Open.

The study found the highest rates of opioid-related deaths and more rapid increases in mortality were observed in eight states: Connecticut, Illinois, Indiana, Massachusetts, Maryland, Maine, New Hampshire and Ohio. Two states, Florida and Pennsylvania, had opioid-related mortality rates that were doubling every two years — and tripling in Washington, D.C.

Kiang and his co-authors, including Stanford Health Policy’s Sanjay Basu, MD, PhD,an assistant professor of medicine at Stanford Medicine, used data from the National Center for Health Statistics and corresponding population estimates from the U.S. Census. The other authors are Jarvis Chen, ScD, at the Harvard T.H. Chan School of Public Health, and Monica Alexander, PhD, in the Department of Sociology at the University of Toronto.

“It seems there has been a vast increase in synthetic opioid deaths in the eastern states and especially in the District of Columbia because illicit drugs are often tainted with fentanyl or other synthetic opioids,” Kiang said in an interview.  “People aren’t aware their drugs are laced and more potent than they expected — putting them at higher risk of overdose.”

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Synthetic opioid deaths now outnumber heroin deaths in these eastern states, which suggests fentanyl has spread to other illegal drugs and is no longer limited to heroin.

“The identification and characterization of opioid `hot spots’ — in terms of both high mortality rates and increasing trends in mortality — may allow for better-targeted policies that address the current state of the epidemic and the needs of the population,” the authors write.

The research suggests the opioid epidemic has evolved as three intertwined, but distinct waves, based on the types of opioids associated with mortality:

1. The first wave of opioid-related deaths was associated with prescription painkillers from the 1990s until about 2010.
2. From 2010 until the present, the second wave was associated with a large increase in heroin-related deaths.
3. And in the third and current wave, which began around 2013, the rapid increase is associated with illicitly manufactured synthetic opioids, such as tramadol and fentanyl.

“The evolution has also seen a wider range of populations being affected, with the spread of the epidemic from rural to urban areas and considerable increases in opioid-related mortality observed in the black population,” they write.

The Centers for Disease Control and Prevention reports that African-Americans experienced the largest increase in opioid overdose deaths among any racial group from 2016 to 2017, with a 26 percent surge.

“The identification and characterization of opioid ‘hot spots’ — in terms of both high mortality rates and increasing trends in mortality — may allow for better-targeted policies that address the current state of the epidemic and the needs of the population,” the researchers write.

States are trying to combat the epidemic by enacting policies, such as restricting the supply of prescription drugs and expanding treatment and access to the overdose-reversing drug naloxone.

“Treating opioid use as a disorder should be our top priority to curb the problem,” said Kiang. “Similarly, we have the ability that counteract the effects of an overdose — these life-saving drugs should be easily accessible and widely available.”

Science moves forward when scientists take risks.

“For example, one of the hottest new ideas in cancer treatment involves using patients’ own immune cells to treat their cancer,” writes Stanford Health Policy’s Jay Bhattacharya in this policy brief. “The researchers who worked on these ideas when they were novel risked failure, but still pursued them.” 

The National Institutes of Health plays an important role in addressing this fail-to-win strategy underlying scientific research, Bhattacharya said. With a $37 billion annual budget, the NIH is the world’s largest funder of biomedical research.

“As a public institution, it can be thought of as ‘patient capital,’ a funding source with a longtime horizon and an understanding that good ideas frequently lead down blind alleys,” Bhattacharya writes with his colleague, Mikko Packalen, a Stanford alumnus and associate professor of economics at the University of Waterloo in Ontario, Canada.

“By that standard, NIH ought to be putting money into novel ideas that cannot get funding from private sources,” they write.

But that doesn’t appear to be the case.

Bhattacharya, a professor of medicine with a PhD in economics, and Packalen conducted a quantitative analysis to measure the extent to which NIH funds novel ideas. They looked at 24 million biomedical research articles in the MEDLINE database published between 1950 and 2017 with an American first author.

“An article was considered novel if the newest idea on which it was built upon was relatively recent in the sense that the idea had first appeared in any biomedical research paper at most a few years prior,” they said in the policy brief for the Stanford Institute for Economic Policy Research, where Bhattacharya is a senior fellow.

They found that from 2010 to 2016, the NIH disproportionately funded biomedical research based neither on the most recent ideas nor on the most longstanding ideas, but rather on those of intermediate vintage introduced into the literature between 1990 and 2005.

“Specifically, NIH funded research based on 10- to 25-year-old ideas at a 55 percent rate, compared with a 45 percent funding rate for more recent or older idea,” they write. “By contrast, from 1990 to 1999, NIH funded research based on new ideas at a higher rate than it funded research drawing on well-established ideas.

“This indicates that NIH has become less likely to support edge science over the past two decades,” the researchers concluded. “These results are disheartening and consistent with a growing body of scholarship that finds NIH review panels becoming more conservative and risk-averse.” 

Policy Reforms

The authors note the NIH recognizes the danger of underfunding high-risk ideas and has taken steps to counter “a creeping conservative bias” by increasing the number of training awards, paying bonuses to young researchers and developing methods for identifying high-risk ideas.

But more needs to be done, they said, recommending that the NIH:

1. Reform the review process and rethink how review panel members are selected;
2. Change the way it measures success to increase tolerance of failure;
3. Develop ways to directly measure the novelty of ideas;
4. Find additional ways to reward scientists working on novel ideas by taking steps to advance their careers.

“If the world’s foremost supporter of biomedical research has indeed become less open to edge science, as our analysis indicates, it bodes poorly for science.” 

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In this JAMA commentary, Stanford Health Policy's Victor Fuchs asks whether a single-payer system is an answer to the embattled U.S. health-care industry.

Fuchs, the Henry J. Kaiser, Jr., Professor of Economics and of Health Research and Policy, Emeritus, is also a senior fellow at the Freeman Spogli Institute for International Studies.

Considered one of the greatest thinkers on U.S. health-care policy and reform, Fuchs discusses three key problems for health care for Americans: the uninsured, poor health outcomes (relative to other high-income countries) and high cost. In discussing costs, he said, it will be critical to consider the form that a single-payer health-care system might take. 

"The recent challenges to the Affordable Care Act (ACA), which has increased the number of individuals with health insurance in the United States but has had little effect on cost, has revived the debate about a single-payer health care system. Whether a single-payer system is the answer or not depends on what question is being asked and what form single payer will take. Single payer can take many forms, and many questions can be asked. This Viewpoint considers 3 problems of US health care: the uninsured, poor health outcomes (relative to other high-income countries), and high cost. In discussing cost, it will be critical to consider the form that a single-payer health care system might take."

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Recently, at each of our hospitals, a woman gave birth to a baby with a severe heart defect. Twenty years ago, these babies may not have lived. Today, after complex surgery and specialist care, each will go to school, live a normal life. The medical miracles that saved these infants — and that could save the child of someone you love — were perfected with support from Medicaid. New medical technologies for children with debilitating (and often rare) conditions are almost universally discovered, tested, and improved at hospitals and clinics that have been largely funded over the past 50 years by the Medicaid program.

Unfortunately, the Senate’s version of the American Health Care Act contains more than $800 billion in cuts to the Medicaid program over the next 10 years — cuts that will likely have negative impact on healthcare for all US children.

All children — poor, rich, and middle class — depend on Medicaid. In the United States, more than 40 percent of children are insured by Medicaid, and in many states, Medicaid covers two out of three children. Without Medicaid, children in your child’s school will have decreased access to life-saving vaccinations, autism screening, and other preventive healthcare. When they get acutely ill, children who lose their Medicaid coverage will be more likely to come to school sick, or will become dependent on costly and unnecessary emergency room services. That increases the local tax burden and commercial-insurance premiums, and diverts emergency-care resources from the patients who need them most.

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The first time Devin cooked an opioid, it wasn’t to ease a back injury or chronic headaches. In an interview with NPR, he said he saw other people injecting, and it seemed like they were having a good time. He figured, why not?

He didn’t know his Indiana town of 4,500 people was in the midst of an HIV epidemic, so it never occurred to him to worry about sharing needles.

Over the past decade, the opioid epidemic in the United States has doubled the number of people injecting heroin, making the health risks associated with injection drug use a public health crisis.

During the same time period, the incidence of HIV has gone down, but as people like Devin share needles to inject drugs — particularly opioids — Stanford researchers are concerned that increased HIV transmission could be on the horizon.

Cora Bernard, a PhD student in Management Science and Engineering, led a study on prevention programs that could head off a resurgence of HIV and perhaps lessen the effects of the opioid crisis.

“There’s a real public health crisis associated with injecting,” said Bernard. “We think it’s important to understand what investments give highest value because HIV prevention programs, and especially programs that reduce the prevalence of injection drug use, can have outsized, positive impact on individuals, families and public safety.”

In July of 2016, Bernard and her co-authors published a different study examining pre-exposure prophylaxis (PrEP), a pill that reduces a person’s risk of infection when they come into contact with the HIV virus. They found that PrEP was effective, but expensive.

The new study examines alternatives that also reduce the risk of HIV infection but are more cost-effective. They created a model to determine how many quality-adjusted life years — a metric that incorporates both life expectancy and quality of life — a person could gain from four HIV prevention programs, and what those years would cost.

“The dynamics of HIV prevention and treatment are complex,” said Margaret Brandeau, PhD, the senior author of the study and a professor of Management Science and Engineering. “Our model allows us to evaluate the costs and effects of the interventions, singly and in combination, to determine what programs would be effective and cost-effective in preventing the spread of HIV among persons who inject drugs.”

Of the prevention programs simulated in the model, the authors found that opioid agonist therapy (OAT) was the most cost-effective. OAT replaces drugs like heroin with a prescription that provides similar effects under safer conditions.

Needle-syringe exchange programs (NSP) — in which people swap their dirty needles for clean ones — were the next most cost-effective option. This was followed by test-and-treat programs, which identify people with a high risk of contracting HIV, test them for the virus and treat them before the disease has much chance to spread — both within their own bodies and to others who are exposed.

The study estimated that PrEP can also successfully reduce HIV, but not in a cost-effective way. The authors write that the other three techniques could all cost less than $50,000 for each quality life year gained by individuals. PrEP would likely cost more than $600,000.

The prevention programs were most effective when used in combination. The authors project that combining OAT and NSP could avert up to 40,000 HIV infections over 20 years for people who inject drugs, not to mention preventing downstream sexual transmission of HIV to others.

According to Bernard, one of the benefits of OAT is that in addition to reducing the risk of HIV, it can also help people stop injecting drugs. The authors project that expanding OAT access could decrease the size of the injection population as much as 37 percent over 20 years.

“We started out thinking about this as an HIV problem, but we realized that the majority of health benefit actually comes from reducing injection drug use and improving quality of life for drug users,” said Bernard. “This is why we found OAT to be the highest-value investment.”

Bernard and her co-authors believe that employing techniques like OAT could help reduce the effects of the opioid crisis.

“Our study aims to help policy makers and clinicians understand how a variety of interventions can help improve health outcomes and prevent HIV,” said Douglas Owens, MD, an author of the study, a professor of medicine and an internist at the VA Palo Alto Health Care System. “We hope our analyses help show how to use limited resources efficiently to prevent the devastating consequences of substance use.”

As immigration policy ideas dance around Washington, children’s health rarely enters the discussion. According to Stanford pediatrician Fernando Mendoza, new policies could have a huge impact on the well-being of children with immigrant parents.
 
“If you make them fearful on a day-to-day basis that their parents are going to be taken away, it causes tremendous stress on children and families,” said Mendoza, a professor of pediatrics at the Lucile Packard Children’s Hospital.

Mendoza has gathered experts across Stanford University and throughout California and the United States to address these issues at the Child Health and Immigration Conference on May 25. The panelists will discuss potential impacts at the federal, state and local level and advise communities on how to navigate the effects on children.
 
“All immigrants are having their place in this country challenged,” said Mendoza. “Whether or not you have a parent who is undocumented, that is detrimental to the well-being of the children of all immigrants.”
 
According to a study at the Pew Research Center, one out of every eight children in California lives with an undocumented parent.
 
“Policies that would remove those parents would probably be the biggest social disruption that we’ve seen in this country,” said Mendoza. “We need to have experts discuss these things so that we can have clarity about what the effects of national immigration policies might be.”
 
Immigration experts Jeffrey Passel, a senior demographer at the Pew Research Center, and Bill Hing, a professor of law at the University of San Francisco, will kick off the conference by outlining immigrant family demographics and the legal system for enforcing immigration policy.
 
They will be followed by panels of experts from Stanford and other academic institutions, policy-makers, and leaders in local health and educational systems.
 
U.S. Rep. Zoe Lofgren (D-San Jose) will bring the on-the-ground Washington perspective with a short appearance via video. A former immigration attorney, she will discuss congressional movement on immigration policy.
 
Mendoza said, “We all value children. This conference is trying to create common ground around that American value.”
 
The conference will be held May 25 at Stanford University in Encina Hall’s Bechtel Conference Center from 8:30 a.m. to 5:15 p.m. To attend, please RSVP here.
 
The conference is sponsored by Stanford’s Division of General Pediatrics; the Center for Policy, Outcomes and Prevention; and the Lucile Packard Foundation for Children’s Health.
 


MEDIA CONTACTS:

Fernando Mendoza, General Pediatrics: (650) 725-8314, fmendoza@stanford.edu

Nicole Feldman, Stanford Health Policy: (650) 725-3389, nicoletf@stanford.edu

Stanford Health Policy’s Douglas K. Owens has been appointed vice chair of the U.S. Preventive Services Task Force, an independent, volunteer panel of national experts in prevention and evidence-based medicine.

Owens, the Henry J. Kaiser, Jr. Professor at Stanford University is a general internist at the VA Palo Alto Health Care System, and a professor of medicine, health research and policy, and management science and engineering at Stanford.

He is the director of the Center for Health Policy in the Freeman Spogli Institute for International Studies, where he is also a senior fellow, and the Center for Primary Care and Outcomes Research in the Department of Medicine and School of Medicine, and Associate Director of the Center for Innovation to Implementation at the VA Palo Alto Health Care System.

“Through his stellar work, Dr. Owens enables Stanford Medicine to advance its mission to precisely predict and prevent disease,” said Lloyd Minor, MD, dean of the Stanford School of Medicine. “As our country faces an increasingly diverse, aging patient population and rising health care costs, I am thrilled that Dr. Owens will contribute his perspective and expertise to this national task force.”

Owens served a previous four-year term on the independent, volunteer panel of national experts in prevention and evidence-based medicine. He will serve for two years as vice chair and then a year as chair. Members come from health-related fields ranging from internal medicine, family medicine, pediatrics, behavioral health, obstetrics/gynecology, and nursing.

The task force issues preventive care guidelines based on detailed assessment of the evidence about preventive interventions and is supported by the Agency for Healthcare Research and Quality within the U.S. Department of Health and Human Services.

“It’s humbling because the task force guidelines impact virtually every primary care patient in the United States,” said Owens, who is also past president of the Society for Medical Decision Making. “Having an unbiased, independent assessment of the benefits and harms of preventive services is very important for primary care clinicians and patients.”

The task force works to improve American’s health by making evidence-based recommendations about clinical preventive services such as screenings, counseling services and preventive medications. Its members have tackled everything from whether to screen for certain cancers, which medications should be taken to prevent diseases and reduce blood pressure and high cholesterol, and screening for infectious diseases, including HIV, HCV, TB, syphilis and other sexually transmitted diseases.

“We are honored to welcome Dr. Owens back to the task force in a leadership role,” said task force chair David C. Grossman, MD, MPH, a senior investigator and medical director for population health strategy at the Group Health Research Institute.

“His experience in guideline development, both with the task force and partner organizations, and his work in evidence-based medicine and clinical decision-making are valuable additions to our leadership team,” Grossman said.

The task force, for example, just released its draft guideline on prostate cancer screening. And some of the medical topics under development are screening for cervical and BRCA-related cancer, as well as pre-exposure prophylaxis for HIV infection.

Owens said that it was critical that the task force remains unbiased and independent. The 16 volunteer members who are nationally recognized experts in prevention, evidence-based medicine and primary care, carefully evaluate the science behind preventive interventions.

“The task force has very rigorous methods for assessing evidence, and we are fortunate to have state-of-the-art evidence reviews provided by AHRQ funded Evidence-Based Practice Centers,” he said.

Each year, the task force makes a report to Congress that identifies critical evidence gaps in research related to clinical prevention services and recommends priority areas that deserve further explanation. All their reports and recommendations are made public on the task force website and leave room for public comment.

The Journal of General Internal Medicine (JGIM) has appointed Stanford Health Policy’s Steve Asch as an editor-in-chief.

JGIM is the highest rated journal for primary care research in the world. It publishes research on health services, implementation science, medical education and the humanities in addition to primary care.

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“Steve is widely known as an outstanding writer and editor, and as having very broad methodological expertise,” said Douglas Owens, director of the Center for Health Policy/Primary Care and Outcomes Research. “He's a terrific choice to lead JGIM.”

Asch’s work focuses on quality improvement, and he has lead several national projects to develop tools that measure quality of care for veterans, Medicare users and the public. An avid mentor, Asch has trained dozens of physician fellows in health services research at Stanford and the VA system.

“We’re going to try to get research out there where it can make a difference in the world,” said Asch.

The editor team plans to focus more on best practices and implementation science. By combining the efforts of many researchers, they hope to ensure that doctors get the best answers to the big questions in health care.

“I think it’s going to be fun,” said Asch.

He looks forward to mentoring researchers to submit articles to journals like JGIM.

“Primary care is important,” said Asch. “As the health-care system transforms, it will play an increasingly important role, and the journal is very much in the lead in trying to publish new ways of organizing primary care.”