A look inside this public health nightmare and actuarial challengeFebruary 2018 Web Exclusive
In 2015, the newest studies of mortality1 produced by the Society of Actuaries (SOA) noted that there was a change in the steady increase in life expectancy. Not all populations were experiencing continuing improvements; in fact, some groups are showing a real increase in mortality at younger ages. Additional studies2 of subsections of the population found that much of the change was due to increases in accidental poisoning, and this grouping includes overdose. While this may have been an eye opener for many actuaries, the reality of the opioid epidemic has been evident to the people on the forefront—first responders, families, health providers, law enforcement and certainly to the public health community.
The Opioid Epidemic is a Public Health Issue
The Public Health Association provides the following definition3 on its website: “Public health promotes and protects the health of people and the communities where they live, learn, work and play.”
Consider the many ways in which the opioid epidemic involves the “health of people and the communities where they live, learn, work and play.”
The most immediate impact to the public at large has been the shock of deaths due to overdose. Death betimes is a loss to all. Very little needs to be added to emphasize the urgency of the current state of affairs beyond a careful look at the statistics. Consider Figure 1. There clearly is an increase in deaths due to drug overdose over last few years, with opioids being the largest contributor.
Figure 1: Drugs Involved in U.S. Overdose Deaths, 2000–2016
The Reach of the Opioid Epidemic Is Comprehensive
In 2012, Substance Abuse and Mental Health Services Administration (SAMHSA), the Centers for Disease Control and Prevention (CDC), National Institute on Drug Abuse (NIDA) and other government sources all reported at length that there were 259 million prescriptions written for opioids and an estimated 20 million people had a substance use disorder (SUD). More than 50,0004 died of overdose in 2015.
Substance use has never been associated with class or income, and it takes its victims wherever it finds them. Now it reaches into the white middle class in rural counties and urban populations of color. Suburban newspapers are full of stories of deaths, busts and family woe. It is the whole of our society that has problems with the fruit of the poppy.
Health issues for the addicted range from ailments that are a direct result of drug use, such as injuries or the terrible toll on body systems from drug use, to the problems that arise out of neglect, such as advanced dental disease or severe skin infections. Some of the increase in suicide rates noted in demographic reports also is an offshoot of the struggle with addiction. Those far into the addiction cycle may not be able to consider wellness issues such as their diet or heart health. They may not be able to manage chronic disease such as diabetes or kidney disease. In addition, there is often the presence of other substances, such as alcohol or tobacco, which can contribute to an overall health burden made worse by addiction.
The cost of the opioid epidemic to communities is another issue that makes this of interest to the public at large. It can be hard for employers in some particularly hard-hit areas to find skilled employees who can pass drug tests. Communities must deal with law enforcement burdens beyond normal expectations, including administering Narcan to counteract opioid overdoses. Illicit drug dealing and use is not a peaceable activity; violence and turmoil are byproducts of the opioid epidemic. Smaller communities are swamped with bodies awaiting autopsies. Hospitals and clinics are stressed by steady streams of the injured or overdosed. Community resources, both paid and volunteer, intended to make a community more livable, are diverted to coping with incarceration, diversion and rehabilitation.
Families Suffer When a Member Loses Control to Substances
SUD tears families apart, bringing grief to survivors. Children grow up in chaos making them more prone to health issues later in life, if not becoming substance users themselves. According to the Adverse Childhood Experiences5,6 (ACE) study, the rougher your childhood—due to exposure to family discord, physical or psychological abuse, or having a family member who has substance use issues—the higher your risk for later health problems.
As ACE scores7 increase, so do the risks of disease and social and emotional problems. With even a moderate ACE score, things start getting serious. The likelihood of developing chronic pulmonary lung disease increases by 390 percent; the likelihood of developing hepatitis increases by 240 percent; the likelihood of developing depression increases by 460 percent; and the likelihood of developing suicide increases by 1,220 percent. As shown the “Findings” sidebar8,9 (taken from the CDC-Kaiser Ace Study), there is lengthy list of attendant health issues reaching well into adulthood.
Major Findings on ACEs
Adverse Childhood Experiences (ACEs) are common. Almost two-thirds of study participants reported at least one ACE, and more than one in five reported three or more ACEs.
The ACE score, a total sum of the different categories of ACEs reported by participants, is used to assess cumulative childhood stress. Study findings10 repeatedly reveal a graded dose-response relationship between ACEs and negative health and well-being outcomes across the life course.
As the number of ACEs increases so does the risk for the following:
- Alcoholism and alcohol abuse
- Chronic obstructive pulmonary disease
- Fetal death
- Health-related quality of life
- Illicit drug use
- Ischemic heart disease
- Liver disease
- Poor work performance
- Financial stress
- Risk for intimate partner violence
- Multiple sexual partners
- Sexually transmitted diseases
- Suicide attempts
- Unintended pregnancies
- Early initiation of smoking
- Early initiation of sexual activity
- Adolescent pregnancy
- Risk for sexual violence
- Poor academic achievement
This list is not exhaustive. For more outcomes see selected journal publications.
Dose-response describes the change in an outcome (e.g., alcoholism) associated with differing levels of exposure (or doses) to a stressor (e.g. ACEs). A graded dose-response means that as the dose of the stressor increases the intensity of the outcome also increases.
People with SUD often alienate themselves from their families. Aging parents lose the comfort and support of their SUD-affected children. This is a public health issue because we know that isolation from a community or family is as great a health hazard as many chronic diseases. The risk of two of the most common causes of death, heart disease and stroke, is elevated by 30 percent11,12 in people who are defined as isolated.
The financial consequences for families caught up in the opioid crisis are both immediate and long term. Not only do families suffer from day-to-day challenges of theft, loss of employment and diversion of assets as they deal with SUD-afflicted family members who will do anything to support a habit, even if it harms those they love, it becomes difficult to plan for retirement or to save for occasional health expenses, much less plan for the long-term care or disability costs they are likely to face in the future.
Opioid Abuse Affects Core Public Health Areas
The general public often thinks of public health only in relation to communicable diseases, and in this sense the opioid epidemic is a traditional public health challenge. Opioid abuse is associated with transmissible diseases such as HIV/AIDS, hepatitis, sexually transmitted infections (STIs) and tuberculosis (TB).
According to the CDC, more than 2 million cases13 of STIs, including chlamydia, gonorrhea and syphilis, were reported in 2016. The one year increase in cases of gonorrhea was 18.5 percent, while syphilis increased by 17.6 percent (congenital syphilis alone increased by 27.6 percent). This increase has been largely driven by the closure of health clinics, but STIs and risk-taking behavior, such as unprotected sex, and the lack of routine medical care associated with SUD, go hand in hand. Successful treatment of many of these diseases, as well as other infections often found in people who chronically use substances, depends on the completion of a course of treatment requiring strict compliance. Incomplete or abandoned courses of treatment contribute to the rise of drug-resistant pathogens.
Everyone Will Need to Help Out
Another reason the opioid epidemic is a classic public health problem is that the remedy is beyond the control of anyone—or even a broad collection of stakeholders.
Suppose the task list is something like this:
- Finding and fixing the addict in the short term.
- Choking off the supply.
- Preventing new addictions.
- Cleaning up the collateral damage.
- Creating a community where the choice to use is not appealing.
Then it is possible to see that all participants must contribute, no one entity can do it all, and that a solution implemented unilaterally by one actor may cause problems for another. An example of this is a sudden lack of access to prescription medications or an increase in their cost could drive people to use illicit, cheaper and dangerous alternatives. Or aggressive incarceration tactics could mean that more people will not be able to find work due to criminal records, making it harder to find a path out of addiction.
The U.S. Department of Health and Human Services (HHS) has designated a considerable amount of money toward this fight. In September 2017, HHS announced it would be awarding $28.6 million in grants to combat the epidemic.
The expanded funding is part of HHS’ five-point strategy to fight the opioid epidemic by:
- Improving access to prevention, treatment and recovery services, including the full range of medication-assisted treatments.
- Targeting availability and distribution of overdose-reversing drugs.
- Strengthening our understanding of the crisis through better public health data and reporting.
- Providing support for cutting-edge research on pain and addiction.
- Advancing better practices for pain management.
But this really is a public health initiative, so it must go beyond government to find solutions, and it requires a coordinated approach.
Providers are looking closely at best practices to make sure opioids are prescribed at the right time and place. The National Academy of Medicine issued a call to action in “First, Do No Harm,”14 stating: “For the nation’s clinicians, the burdens are heavy and multifaceted, contending as they must with the immediate consequences of the crisis for their patients, their colleagues and their own families, as well as with the reality that a share of the responsibility for the problem’s source lies with themselves.” This is a poignant acknowledgement that we all have some responsibility.
Law enforcement and public safety personnel are carrying Narcan, and they are also following up with families and patients in a more supportive way. The criminal justice system is using things like drug courts to try to resolve issues in a more focused and solution-oriented fashion. Parties are engaging cooperatively with other members of their communities to build collaborative solutions.
Schools, as they always have and will continue to do, are watching out for children who may be in jeopardy. But now they are doing it with a little more understanding and urgency. Some innovations include after school activity programs like dance or separate schools for students in recovery. One community has a program that connects the police department to the school so relevant teachers are informed if police have interacted with a family during the night. This means a child might need food, or clean clothes or a safe place, and the school knows to “handle with care.”
Payers are monitoring use patterns to find patients or providers whose prescribing patterns indicate potential issues. They are then following up to find out if the concern is warranted. Many are requiring treatment plans or restricting amounts dispensed before approving payment for some pharmaceuticals.
Peer groups, church groups and community organizations are providing support for recovery or support as people with SUD and their families try to get back on track. These include everything from shelters to job training, and even gardening.
What about our role as actuaries? We can help find ways to quantify the costs of this epidemic now. This includes the costs of addressing the immediate issues and the costs for future lingering issues we can see arising from all of the direct and indirect consequences of widespread opioid use. Actuaries examining the characteristics of the epidemic and proposed solutions can see the areas that would benefit from our risk management insight. Because even if no one else ever ingests another opioid, there would still be current and future costs to bear. The risk profile of the most affected populations has been changed forever.
- 1. Society of Actuaries. 2017. “U.S. Population Mortality Rates 2000–2005.” July. ↩
- 2. Holman, R. Jerome. 2017. “U.S. Population Mortality Rate Study: Variation by Age Group, Cause of Death and Region From 2000–2015.” Society of Actuaries. May. ↩
- 3. American Public Health Association. “What is Public Health?” ↩
- 4. Rudd, Rose A., Puja Seth, Felicita David, and Lawrence Scholl. 2016. “Increases in Drug and Opioid-involved Overdose Deaths—United States, 2010–2015.” Morbidity and Mortality Weekly Report 65 (50–51): 1445–1452. ↩
- 5. National Center for Injury Prevention, and Control and Division of Violence Prevention. 2016. “Adverse Childhood Experiences (ACEs).” Violence Prevention. Center for Disease Control and Prevention. April 1. ↩
- 6. Felitti, Vincent J., Robert F. Anda, Dale Nordenberg, David F. Williamson, Alison M. Spitz, Valerie Edwards, Mary P. Koss, and James S Marks. 1998. “Relationship of Childhood Abuse and Household Dysfunction to Many of the Leading Causes of Death in Adults. The Adverse Childhood Experiences (ACE) Study.” American Journal of Preventive Medicine 14 (4): 245–258. ↩
- 7. “The Adverse Childhood Experience Study: A Springboard to Hope.” ↩
- 8. Centers for Disease Control and Prevention. 2018. “National Center for Health Statistics.” February 13. ↩
- 9. Centers for Disease Control and Prevention, National Center for Injury Prevention and Control, and Division of Violence Prevention. 2016. “About the CDC-Kaiser Study.” Violence Prevention. June 14. ↩
- 10. Supra note 9. ↩
- 11. Valtorta, Nicole K., Mona Kanaan, Simon Gilbody, Sara Ronzi, and Barbara Hanratty. 2016. “Loneliness and Social Isolation as Risk Factors for Coronary Heart Disease and Stroke: Systematic Review and Meta-analysis of Longitudinal Observational Studies.” Heart 102 (13): 1009–1016. ↩
- 12. Holt-Lunstad, Julianne, Timothy B. Smith, Mark Baker, Tyler Harris, and David Stephenson. 2015. “Loneliness and Social Isolation as Risk Factors for Mortality: A Meta-analytic Review.” Perspectives on Psychological Science 10 (2): 227–237. ↩
- 13. Centers for Disease Control and Prevention. 2017. “2016 Sexually Transmitted Diseases Surveillance.” September 26. ↩
- 14. National Academy of Medicine. 2017. First, Do No Harm: Marshaling Clinician Leadership to Counter the Opioid Epidemic. Washington, DC: National Academy of Medicine. ↩