As both state and national governments look to combat the opioid epidemic, Duke has joined a group of universities investigating how to reduce rampant opioid usage.

Led by RTI International, a non-profit organization based in the Research Triangle Park, the $9 million study will be conducted in collaboration with the Mid-South Clinical Data Research Network, which is centered at the Vanderbilt University Medical Center and includes the Duke University Health System and the University of North Carolina at Chapel Hill. The study will test two different approaches with patients on chronic opioid therapy to try and find potential alternatives to long-term opioid usage.

Nearly one in three Americans suffer from chronic non-cancer pain. North Carolina and Tennessee are among the states with the highest concentration of opioid use in the country.

“I’m very excited about this study. It’s a really interesting combination of a way to reduce opioid over-prescription that doesn’t only put a limit on what doctors can do,” said Nicole Schramm-Sapyta, assistant professor of the practice in Duke Institute for Brain Sciences. “Many patients have long-term pain, and many are just on long-term opiate treatment, but patients all develop tolerance, and it’s unproductive.”

Schramm-Sapyta conducts research dedicated to studying substance addiction and is part of an active body of professionals on Duke’s campus working to combat opioid misuse.

“Reducing over-prescription is the first step, but it’s only the first step," she said. "As the opioid crisis has gotten deeper, more and more people take opioid medication, more misuse them, more become addicted. What we need now are addiction treatment services.”

In addition to treatment for addiction and overdose, however, the collaboration aims to produce strategies to reduce or eliminate chronic opioid therapy in patients who are not benefiting from it. At the same time, the team wants to ensure opioid access for those who are benefiting from the prescriptions.

Treatment strategies will be tested on patients with chronic non-cancer pain. One such intervention involves motivational interviewing.

Schramm-Sapyta explained that the purpose of motivational interviewing is to ask patients what their real goals are. The goal of opiate medication has usually been for the medication to be a pain-free, but she said that it should not necessarily be the goal. Whereas motivational interviews are used to identify what patient’s true goals are, cognitive behavioral therapy can help patients identify triggers that stimulate their own pain and cause them to take more medication.

Professor of Medicine Lawrence Greenblatt, another Duke-affiliated professional who is studying the opioid epidemic, noted that five years ago, an increased number of Medicaid recipients were attempting to obtain pain medication.

“It was often the same group going every few days, with the reason for the visit changing,” said Greenblatt, who is also co-leader of the Duke Opioid Safety Task Force. “We were seeing more and more in the news being written about opioid abuse and overdose death. This wasn’t a topic of conversation amongst healthcare providers, and it wasn’t being talked about at conferences, but we were seeing it and we knew it was happening.” 

In response, Greenblatt and his team approached the Medication Safety Committee at Duke, suggesting that the University establish policies and procedures around opioid safety. Greenblatt and his colleagues formed the temporary Duke Opioid Safety Task Force and ultimately produced a modified version of the North Carolina Medical Board’s endorsed guidelines. 

Through this set of rules, providers who are administering long-term opioid therapy are encouraged to have a commitment with the patient stipulating that the patient only receive the medication from that provider. Patients are also asked to use the state database of controlled substances—the Controlled Substances Reporting System—to ensure that no patients are being prescribed a drug that would negatively interact with the opioid.

Signed into law by Governor Roy Cooper in June, the Strengthen Opioid Misuse Prevention (STOP) Act was geared toward reducing the supply of unused, misused and diverted opioids accessible in North Carolina. The act sought to improve care by requiring those who prescribed opioids to use tools and resources such as the Controlled Substances Reporting System to prevent inappropriate prescribing. 

Greenblatt emphasized the importance of the system—a database that records all controlled substance prescriptions dispensed in outpatient pharmacies. Prescribers are also now required to review a patient’s 12-month history in the system before issuing an initial prescription for an opioid beyond a five-to-seven-day prescription. 

The reporting system will be improved and then integrated into the electronic medical record systems utilized in healthcare institutions, so prescribers can quickly access this information when interacting with patients, Greenblatt explained.

“The STOP Act is going to improve safety in our state and hopefully result in lower numbers of overdose deaths than we would have seen,” he said. 

Even more recently, President Donald Trump declared the opioid crisis a public health emergency in October.

“I think that President Trump did a good job by declaring it a public health emergency,” Schramm-Sapyta said. “That’s how it needs to be treated, and it opens up more treatment resources for patients and removes barriers to treatment. Addiction treatment services are the best outcome of this declaration.”

However, Greenblatt noted that the weight behind this declaration might not be great enough to stimulate actual progress.

“I think President Trump fell short by declaring the opioid crisis a public health emergency. It brought media attention but didn’t commit any resources to a very complicated problem that cannot be fixed with media,” he said. “It will need the investment of resources and training. Treatment for those who need it is expensive, and by calling it what [President Trump] did rather than a national emergency, it didn’t commit any resources.”