PAF: Opioid Epidemic

egastfriend

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Thanks for a great report! Now I'm not an economist, nor a smart not-economist, so I'm unable to provide any valuable insight to the subject itself.

It is really refreshing read something this object level from EA. Reading the full report gave me a lot of facts about the world that I can make use of.

Staying 6 levels of meta above something is only productive for so long, and while being on a low level isn't particularly sexy, it's important.

I realize that while writing this I'm falling prey to the exact failur I'm trying to criticize. I'm not actually debating the issues I found with your spotlight on Opioid Use Disorder in Teenagers, I'm making a meta-comment that is hard to refute.

It makes me super happy to see someone doing the tough legwork, instead of writing objections to meta objections of meta reviews of opioid abuse interventions, like I currently am.

thank you for making me less ignorant about opioid abuse!

tomaskavka

Hi,
I dont have much time right now, but at first sight - I think some parts of this blog are wrong.
You write that these interventions are recommended for pain treatment:

- Chiropractic manipulation for chronic back pain
- Acupuncture for chronic back pain

But probably they are not.

For manipulation there is some high quality evidence of "thats nothing special" (Rubinstein, S.M., et al., 2011. Spinal manipulative therapy for chronic low-back pain: an update of a Cochrane review. Spine, 36(13), pp.E825-E846. and Gross, A. et al., 2015. Manipulation and mobilisation for neck pain contrasted against an inactive control or another active treatment. Cochrane Database of Systematic Reviews, (9).Vancouver).

No doubt there is evidence for "some effect", but its important to aknowledge what is control group recieving and also in what time-frame are the outcomes measured. Immediate effect for pain - probably. Long-term effect for pain, disability and quality of life? Doesnt seem so...
Most experts (from what I know) in this field share view, that mobilisation/manipulation can be used as adjunct (Lin, Ivan, et al. "What does best practice care for musculoskeletal pain look like? Eleven consistent recommendations from high-quality clinical practice guidelines: systematic review." Br J Sports Med (2019): bjsports-2018. APA), but not as stand-alone treatment. It should be used just to help chronic pain patients to be more active (because of possible short-term pain relief). Some are against completely since it can lead to dependence, passive coping, lower self-efficacy etc. - all this can have negative effect on chronic pain and adaptive coping.

For acupuncture it is also tricky. Some people are saying that only studies from "biased" researchers (but who is not?) show some effect and if the studies are methodologicaly good, the results are not good et all (Derry, C. J., et al. "Systematic review of systematic reviews of acupuncture published 1996–2005." Clinical Medicine 6.4 (2006): 381-386. and Ernst, E., Lee, M. S., & Choi, T. Y. (2011). Acupuncture: does it alleviate pain and are there serious risks? A review of reviews. PAIN®, 152(4), 755-764.). Again, the effect doesnt seem to be clinicaly relevant.

I understand and support effort to manage opioid-crisis, but the recomendations should be really precise - there are serious risks, if they are not. Please consult it with some physiotherapist/medical doctor/psychotherapist, who is experienced in treating chronic pain and also scientifically educated - its really complicated topic and the research is really biased.

If EA is interested in this topic, Id like to help somehow...

egastfriend

Sorry I am just seeing this comment now, 4 years after you posted it!
In the full version of the report ( http://www.harvardea.org/s/Final-Presentation-PAF-LJAF-Report-on-Opioid-Epidemic-clean.pdf ), we point out that the evidence for these interventions is shoddy.
However, even if they are only providing placebo effect, they can still have a great positive value in substituting for opioids as a treatment for chronic pain. Opioids also don't work, but they cause much more damage than chiropractic or acupuncture could ever do.

Liam_Donovan

Did the report consider increasing access to medical marijuana as an alternative to opioids? If so, what was the finding? (I didn't see any mention while skimming it) My impression was that many leaders in communities affected by opioid abuse see access to medical marijuana as the most effective intervention. One (not particularly good) example

egastfriend

Medical marijuana fell outside the scope of our consulting project, but I think the evidence is weak for medical marijuana as a promising intervention: "When researchers extended their analysis through 2013, they found that the association between having any medical marijuana law and lower rates of opioid deaths completely disappeared. Moreover, the association between states with medical marijuana dispensaries and opioid mortality fell substantially as well." https://www.rand.org/news/press/2018/02/06.html

It's definitely an interesting/intriguing idea, but it also carries risks of increasing some of the harms associated with marijuana use. Curious to see more evidence come out about it.

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tomaskavka

Hi,
I dont have much time right now, but at first sight - I think some parts of this blog are wrong.
You write that these interventions are recommended for pain treatment:

- Chiropractic manipulation for chronic back pain
- Acupuncture for chronic back pain

But probably they are not.

If EA is interested in this topic, Id like to help somehow...

Summary of Recommendations

In this report, we evaluated interventions to combat the growing opioid epidemic in the United States. We developed a methodology for evaluating interventions based on 3 key criteria: evidence, cost-effectiveness, and scalability. We also created a scoring rubric to simplify our conclusions on the strength of the interventions in each of these 3 areas. We looked at interventions in 5 broad problem areas: pain treatment, opioid supply, addiction treatment, access/referral to treatment, and harm reduction. There are many more interventions and problem areas that deserve consideration but fell outside the scope of our project (e.g. criminal justice, drug policy). Our research was based on expert interviews, reading reports and studies, and our own Fermi estimations when data was unavailable. In particular, we relied heavily on Phillips 2017 and Tick 2017 for assessments of the quality of evidence, and on the Washington State Institute for Public Policy for cost-effectiveness estimates. The scope of this report is to evaluate a set of interventions for addressing the opioid epidemic, but does not consider particular organizations implementing these interventions, or the best ways that philanthropy could promote these interventions.

Our recommendations are:

Invest more effort in continuing this line of high-level, strategic philanthropy resource to better determine where resources can be best allocated for the crisis.

Develop a formal model of the opioid ecosystem
Fund the Washington Institute for Public Policy to publish more detailed cost-benefit analyses
Deepen and broaden the intervention search beyond what this report has started

Pain Treatment: Recommended Interventions

Chiropractic manipulation for chronic back pain
Acupuncture for chronic back pain
Exercise therapy for chronic back pain

Opioid Supply: Recommended Interventions

Opioids safe prescribing training during medical school

Addiction Treatment: Recommended Interventions

Computerized CBT
Contingency Management

Access/Referral to Treatment: Recommended Interventions

Inpatient Addiction Consult Teams
ER post-overdose referral to care
Level-of-Care Treatment Matching

Harm Reduction: Recommended Interventions

Drug Checking

Prevention/Education: Recommended Interventions

Preventure

The full report is available here. Please contact [email protected] if you would like more detailed information contained in our research spreadsheet.