The Opioid Crisis: An interview with Mandy K. Cohen, MD, MPH, Secretary of the N.C. Department of Health and Human Services

What is the opioid crisis and how did we get here?

The opioid crisis is a devastating and complex issue. We arrived here on a path paved with good intentions. Twenty years ago, clinicians were encouraged to treat pain more aggressively, sometimes without proper safety guidelines or training. Similarly, patients were incorrectly counseled that pain could be easily controlled by opioids without any long-term side effects. We now know that these practices - along with a series of other complex factors - led us to where we stand today.

How bad is the opioid crisis in North Carolina?

Since 1999, over 13,000 North Carolinians have died from an opioid overdose. And the number of deaths have increased year-over-year. In 2016, an estimated 1,360 North Carolinians died from an unintentional overdose. This is 25 percent more than in 2015 and a greater than ten-fold increase since 1999. This harrowing statistic doesn’t even account for the more than 13,000 opioid overdose reversals using naloxone by our EMS and first responders.

What are the effects on our state?

Besides the tragic loss of life and the heavy toll of addiction felt by countless individuals, the opioid crisis is also affecting our families and kids. In the last five years, North Carolina has seen a 25 percent increase in the number of children in foster care. In addition, we are seeing more pregnant women fighting opioid addiction. North Carolina has seen a nearly 900 percent increase in hospitalizations associated with drug withdrawal in newborns over the last ten years.

How has this epidemic changed over time?

People have progressed from prescription opioids to heroin and fentanyl. Since 2010, we’ve seen an over 800 percent increase in deaths from heroin and these statistics will only get worse as the use of more deadly fentanyl is expected to increase. More than half of all opioid overdose deaths now involve these illicit drugs.

Is the opioid crisis worse in North Carolina than other states?

It is worse here in North Carolina because many people struggling with mental health and substance use disorders do not have health insurance and therefore treatment. A major step North Carolina could take to turn the tide on the opioid crisis is to access the additional federal dollars to provide insurance coverage to working folks in North Carolina.  This would allow our state to receive nearly $4 billion in federal dollars to increase access to insurance coverage for over 500,000 folks in our state.

What can we do to turn the tide on the opioid crisis?

There has been good work done all over the state to combat the opioid crisis. Over the last 10 years, North Carolina has:

• launched a Prescription Drug Monitoring Program to address prescription drug abuse, addiction and diversion;
• introduced Operation Medicine Drop, which has since become the largest drug take-back program in the U.S.;
• passed the Good Samaritan/ Naloxone Access Law, allowing our EMS, law enforcement and other first responders to distribute and carry naloxone reversing thousands of overdoes; and
• issued a Statewide Standing Order for naloxone, allowing any person at risk of experiencing an opiate-related overdose or a family member or friend of someone at risk, to get naloxone from a pharmacy without a prescription.

This year, Governor Roy Cooper also signed the bipartisan STOP Act, which limits doctors to prescribing no more than five days of opioids for acute pain — such as a broken bone — and requires providers to utilize the state’s Controlled Substance Reporting System to monitor prescriptions.

I am encouraged by the great work that has been done across the state by our partners and am very proud of their work to turn the tide on the opioid epidemic. But despite all this hard work, the crisis is getting worse.

That’s why in June, we launched North Carolina’s Opioid Action Plan. The intent of the Plan is to catalogue specific, tangible, achievable steps that will have the greatest impact on reducing the burden of death from the opioid epidemic and the partners in North Carolina that are engaging in this work. Our goal is to change the trajectory of opioid deaths and reduce opioid overdose deaths by 20 percent by 2021.

To date, we have made great progress on this plan—including purchasing nearly 40,000 units of lifesaving naloxone and making changes to our Medicaid program to allow people to start on suboxone, a medication-assisted treatment, immediately without prior authorization. We are also using federal and state grant dollars and allocations to get more people with an opioid-use disorder into treatment. While we have made great progress, we know that until we get more people access to health insurance and therefore get them access to long-term treatment and recovery services, we will not fully turn the tide on this crisis.

Tell us about North Carolina’s Opioid Action Plan.

We know the necessary steps to turn the tide on this crisis. That is why we released North Carolina’s Opioid Action Plan, a coordinated plan to get partners and stakeholders around the state centered on one goal — to reduce opioid overdose deaths by 20 percent over the next five years. Under this plan, North Carolina will: (1) create a coordinated infrastructure, (2) reduce oversupply of prescription opioids, (3) reduce diversion of prescription drugs and flow of illicit drugs, (4) increase community awareness and prevention, (5) make naloxone widely available and link overdose survivors to care, (6) expand treatment and recovery-oriented systems of care, and (7) measure our impact and revise strategies based on results.

How can DHHS turn the tide on the opioid crisis through the Medicaid program?

As part of the overall North Carolina’s Opioid Action Plan, we recognize the important role health care payers can play in addressing the opioid epidemic and improving health outcomes through benefit design, member services and pharmacy policies. DHHS has been proactive and has made policy changes to promote safe opioid prescribing, non-opioid pain management, and access to naloxone for patients covered by Medicaid and Health Choice and will continue to consider other policy changes to improve health outcomes. For example, the Medicaid program removed the prior authorization requirement for suboxone, a medication-assisted treatment option, which allows Medicaid patients to start treatment immediately.

In addition to our work within Medicaid and Health Choice, we will convene a Payer’s Council to bring together public and private payers with a goal of identifying, aligning and implementing policies that:

• Support providers in the judicious prescribing of opioids;
• Promote safer and more comprehensive alternatives to pain management;
• Improve access to naloxone, substance use disorder treatment and recovery supports; and
• Engage and empower patients in the management of their health.