This instructor’s note was originally developed by the Global Health Education and Learning Incubator at Harvard University. It is used and distributed with permission by the Global Health Education and Learning Incubator at Harvard University. The Incubator’s educational materials are not intended to serve as endorsements or sources of primary data, and do not necessarily reflect the views of Harvard University.

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Instructor’s Note Opioids and Public Health 2017

Overview Since 2000, the use of prescription opioids has skyrocketed in the United States, leading to a surge in overdose deaths and addiction treatment. Understanding the historical drivers of the current rates of opioid use—including the scaling of interventions based on tenuous science and the undue influence of for-profit industries in shaping physicians’ prescribing habits—has helped public health professionals in the U.S. put trends into a broader historical context, and highlighted both the complexities underlying the current crisis and the challenges they present for future responses.

This instructor’s note provides a framework for using the “Opioids and Public Health” teaching pack, which centers on an analysis of the opioid epidemic from both a U.S.-based and global perspective. Students will gain a nuanced understanding of the complexities underlying the opioid epidemic by considering factors that contribute to both opioid addiction and underuse, as well as the advantages and potential unintended consequences of current response efforts.

This teaching pack is composed of this Instructor’s Note as well as the following companion materials:

Teaching Materials

• Lesson: “An Opioid Epidemic for Whom?” • Required Reading: Kolodny A et al. The Prescription Opioid and Heroin Crisis: Public Health Approach

to an Epidemic of Addiction. Annual Review of Public Health 2015; 36: 559-574. http://www.annualreviews.org/doi/pdf/10.1146/annurev-publhealth-031914-122957.

• Required Reading: The Problem of Pain. The Economist 2016; May 28. https://www.economist.com/news/international/21699363-americans-are-increasingly-addicted-opioids-meanwhile-people-poor-countries-die.

Additional Resources

• Opioids and Public Health: Annotated Bibliography • Opioids and Public Health: Glossary of Terms

Learner Level

• Undergraduate, Graduate

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Opioids and Public Health: Instructor’s Note

Learning Objectives 1. To define the contrasting ways opioid use is perceived in U.S. and global settings, and identify key

drivers at the individual, medical, and societal levels. 2. To assess potential implications of current responses to the opioid epidemic in the United States

through a global lens by considering varying perspectives of different key stakeholders. 3. To use existing evidence to hypothesize potential consequences that current strategies may have on

vulnerable populations in low-resource settings.

This lesson plan was originally developed by the Global Health Education and Learning Incubator at Harvard University. It is used and distributed with permission by the Global Health Education and Learning Incubator at Harvard University. The Incubator’s educational materials are not intended to serve as endorsements or sources of primary data, and do not necessarily reflect the views Harvard University.

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Lesson Plan An Opioid Epidemic for Whom? 2017 Purpose The purpose of this lesson plan is to learn about the various factors contributing to the opioid epidemic in the United States, and to place it within a larger global context. Prior to this lesson, students will be assigned two articles to read: one academic paper for public health professionals that provides an overview of the crisis from an American perspective, and an article from The Economist geared towards lay audiences that draws a contrast between the opioid epidemic in the U.S. and the dearth of pain relief medications available in low- and middle-income countries. Through a structured role-play activity, students will discuss the complex ways responses to the epidemic in the U.S. may impact the provision of palliative care globally.

Learner Level

Undergraduate, Graduate

Time

One 1-hour session

Required Materials

• Dry-erase board or chalkboard • The Problem of Pain. The Economist 2016; May 28.

https://www.economist.com/news/international/21699363-americans-are-increasingly-addicted-opioids-meanwhile-people-poor-countries-die.

Required Pre-Reading

Prior to this lesson, students must complete the following two readings. Class activities will be centered on the article from The Economist; however all students must read and be familiar with the content in the review article as well, as it provides necessary background information that will be reflected in their contributions to class discussions.

• Kolodny A et al. The Prescription Opioid and Heroin Crisis: Public Health Approach to an Epidemic of Addiction. Annual Review of Public Health 2015; 36: 559-574. http://www.annualreviews.org/doi/pdf/10.1146/annurev-publhealth-031914-122957.

• The Problem of Pain. The Economist 2016; May 28. https://www.economist.com/news/international/21699363-americans-are-increasingly-addicted-opioids-meanwhile-people-poor-countries-die.

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Case Summary Approaches taken to address the opioid epidemic in the United States can be considered within a broad public health prevention framework involving primary, secondary, and tertiary prevention efforts. Within the realm of primary prevention (i.e. reducing the incidence of addiction), strategies have involved education campaigns and mandatory trainings aimed at teaching physicians about the dangers of opioid addiction in order to change prescribing practices, as well as regulations around discarding excess drugs, and education campaigns teaching the public about the risks of overuse. In terms of secondary prevention (i.e. treating addiction before it causes serious impairment to one’s health and well-being), efforts have focused on early identification and referral of addicted individuals for treatment, which has been historically challenging since patients often do not present clear outward signs of drug-seeking behaviors. Lastly, tertiary prevention approaches (i.e. treating individuals facing addiction to prevent overdose deaths, health complications, or transitions to injection drug use) have generally focused on addiction treatment, including residential treatment programs and the use of rehabilitative pharmacotherapies like methadone or naltrexone, as well as harm reduction strategies such as the use of naloxone (i.e. Narcan) during acute overdoses to prevent death.

Much of what is known about the opioid epidemic has been informed by the experiences of countries like the United States. In low- and middle-income countries, however, where access to life-saving drugs and medications for pain relief are limited, issues around opioid use are quite different. While over-prescription and overuse are pervasive problems in the U.S., in other parts of the world, access to pain relief medications is limited by availability and cost, leading many to receive little to no palliative care in the face of painful, life-threatening illnesses. Despite this stark juxtaposition of experiences and the influence high-income countries have on the health infrastructures globally, the current U.S.-based epidemic is rarely considered within a broader global landscape.

Learning Goals 1. To define the contrasting ways opioid use is perceived in U.S. and global settings, and identify key

drivers at the individual, medical, and societal levels. 2. To assess potential implications of current responses to the opioid epidemic in the United States

through a global lens by considering varying perspectives of different key stakeholders. 3. To use existing evidence to hypothesize potential consequences current strategies may have on

vulnerable populations in low-resource settings.

Procedure Warm-Up Activity (10 Minutes)

Start class with a warm-up activity to get the students to think about what they have learned about the opioid epidemic outside of this assignment using the prompts below. This activity is intended to set the stage for the comparative discussion that will be the focus of the class by demonstrating how students’ pre-existing perceptions about the opioid crisis were very likely shaped by a predominantly American lens. This exercise is also designed to get students thinking beyond the limits of their preconceptions and to consider all relevant actors influencing or being influenced by the epidemic.

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Sample Script and Questions

Today, we will spend our time discussing opioid addiction and the potential consequences of response efforts. Before we dive into our group activity, we will brainstorm together for a few minutes to get a sense of what our group baseline understanding is of this issue, particularly in light of what we may have heard through the media, or even through our own personal interactions with folks battling addiction.

Write the phrase “opioid epidemic” in the center of the board.

When you hear the term “opioid epidemic” what comes to mind? What sources of information have informed your perceptions?

As students share out their observations, jot notes on the board, grouping ideas together that are conceptually related. Remember, this activity is intended to be student-driven, so try to be a passive listener and note-taker rather than an active participant. If necessary, encourage students to elaborate on their points, but do not steer the conversation in any particular direction.

What do you notice about our general ideas about the opioid epidemic before coming into class today? Do you see any obvious trends? Are there any gaps of knowledge or perspectives not represented here?

The purpose of this warm-up activity is to provide the class with a concrete reference point to assess their learning over the course of the rest of the lesson. If there are specific points that emerge during the subsequent discussions that relate back to these initial impressions, point them out and briefly mention how they may support or refute what was initially brainstormed.

Group Activity: Key Stakeholder Role Play (20 Minutes)

For this activity, students will be divided into five groups. Each group will be assigned one of the following key stakeholders, whose position towards opioid use and addiction they will be considering. In advance of this lesson, students should have read the assigned reading by Kolodny and colleagues briefly summarizing the history, determinants, and responses to opioid epidemic in the U.S., and should feel comfortable discussing these in their groups.

1. Advocates for the Reform of Prescription Opioids, an organization comprised of “bereaved parents, children, siblings and spouses, families of those suffering through an addiction, pain patients, doctors, and citizen advocates working towards more balanced care for patients who suffer from chronic pain, without causing harm to them and the general public.” (http://www.rxreform.org)

2. Purdue Pharma, the U.S.-based makers of OxyContin with a global reach in more than 30 countries around the world. For more information about Purdue’s stance on the opioid epidemic, see: Opioids & Corporate Responsibility.

3. The Indian Medical Association (IMA), an organization of physicians in India that makes recommendations for clinical practice based, in part, on evidence from public health authorities, including the Centers for Disease Control and Prevention (CDC) in the United States. In 2016, the IMA endorsed the CDC’s recommendations for opioid prescription, supporting the assessment that, “for

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the vast majority of patients, the known serious and too-often fatal risks [of opioid use] far outweigh the unproven and transient benefits.” (Frieden & Houry, 2016)

4. A hypothetical patient advocacy group in India working to protect and advance patients’ rights, particularly among underserved populations (e.g. those living in rural communities and the urban poor) with limited access to consistent, high-quality healthcare.

5. A hypothetical new World Health Organization task force on palliative care aimed at increasing access to pain relief medications in low- and middle-income countries.

Within their groups, students should consider the following questions:

• What constituency is your stakeholder representing? • From this constituency’s perspective, what is the core health problem they identify in relation to

opioids? Alternatively stated, how does this group see opioids impacting population health? Summarize their stance in one sentence.

• What does this constituency perceive as the key drivers or determinants of opioid over/under use? Use the following table to organize your main points, and be sure to describe how the determinant influences the angle of opioid over/under use you are interested in as specifically as possible:

Level Detailed Description of Determinant Examples

Societal

• Multinational industries or organizations

• Global influences

Medical Settings

• Physician’s prescribing practices • Medical professionals’ knowledge

of the risks and benefits of opioid use

Individual

• Health conditions • Personal attitudes towards

opioids

• Based on the table above, what are potential responses this constituency would support to address the opioid issue in their setting?

• Next, recall the strategies discussed in the Kolodny article that are currently being implemented in the United States to stem the tide of opioid addiction. Focusing particularly on the issue of greater regulation of the pharmaceutical industry and efforts targeting physicians, how would your constituency respond to these recommendations? What would they perceive as potential advantages and disadvantages? Complete the following table to summarize your group’s key points:

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Response Advantages Disadvantages

Increased regulation of the pharmaceutical

industry

Increasing physician education of the risks associated with opioid

(over)prescription

Placing limitations on physicians’ prescribing

practices

Class Discussion (30 Minutes)

Each group should designate one member to report the key points from their discussion. Before having students report out, the instructor should emphasize that the goal of this exercise is to understand that the way we define an issue may vary depending on the perspective we adopt. Going around the room, each group should summarize the following points to the class in 2-3 minutes: 1. What group were they assigned to, and what core constituency does their stakeholder represent? 2. How do issues related to opioid use impact that constituency? 3. What is the stakeholder’s stance regarding restricting opioid access/prescriptions and why?

Encourage students who are not presenting to think about how their group’s discussion may align or diverge from other stakeholders’ views. After each group has summarized their discussion for the class, the instructor should facilitate a conversation around advantages and disadvantages related to current U.S.-based strategies to address the opioid epidemic. To help students synthesize key points, consider writing a list of pros and cons on the board, focusing particularly on the impact they may have on patients globally as well as in the U.S. In the last 5-10 minutes of class, pose the following open question: In light of the complex issues we discussed today, what do you think is our best path forward? Remind students that there is no right or wrong answer to this question, but it is rather designed to give them an opportunity to form an educated opinion based on their understanding of the issue and potential consequences for different populations.

Summary

The purpose of this lesson plan is to highlight that while the opioid epidemic is portrayed monolithically as an issue of addiction in the U.S., it takes on a very different form in the global context. Students should be

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challenged to think about the global influence the United States holds—both with respect to medical practice and the pharmaceutical industry—and consider the intended and unintended consequences that responses in the U.S. context may have on palliative care practices around the world. By analyzing the issue of opioid over/under use, its determinants, and potential responses advocated by varying stakeholders, students should leave this lesson with a nuanced understanding of the complexities underpinning the opioid epidemic.

This annotated bibliography was originally developed by the Global Health Education and Learning Incubator at Harvard University. It is used and distributed with permission by the Global Health Education and Learning Incubator at Harvard University. The Incubator’s educational materials are not intended to serve as endorsements or sources of primary data, and do not necessarily reflect the views of Harvard University.

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Annotated Bibliography Opioids and Public Health 2017 This bibliography is a selective sampling of educational resources that introduce students to issues surrounding opioid use and the global pain epidemic. The multidisciplinary materials may be suitable for students at the high school, undergraduate college, and public health graduate school levels. Learning objectives and supporting materials will vary depending on how the material is used in a course. Brief annotations provide a cursory summary, and indicate where certain materials may be particularly relevant. Within each section, dated publications are listed in chronological order. This bibliography accompanies a lesson focused on the global pain epidemic. The materials listed here represent a diversity of viewpoints and opinions and do not necessarily reflect the viewpoints and opinions of the Incubator. This annotated bibliography includes:

• Basic Reads • Reports • Articles and Briefs • Data Publications, Portals, and Interactives • Country Profiles and Fact Sheets • Topic Portals and Organizations • Multimedia and News • Teaching Material

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Selected Resources – At a Glance

BASIC READS Report. Knaul FM et al. Alleviating the Access Abyss in Palliative Care and Pain Relief—an Imperative of

Universal Health Coverage: The Lancet Commission Report. The Lancet 2017. http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(17)32513-8/fulltext.

Article. Kolodny A et al. The Prescription Opioid and Heroin Crisis: A Public Health Approach to an Epidemic of Addiction. Annual Review of Public Health 2015; 36: 559-74. http://www.annualreviews.org/doi/abs/10.1146/annurev-publhealth-031914-122957.

News. The Problem of Pain. The Economist 2016; May 28. https://www.economist.com/news/international/21699363-americans-are-increasingly-addicted-opioids-meanwhile-people-poor-countries-die.

News. Keefe PR. The Family That Built an Empire of Pain. The New Yorker 2017; Oct 30. https://www.newyorker.com/magazine/2017/10/30/the-family-that-built-an-empire-of-pain.

REPORTS Report. Global State of Pain Treatment: Access to Medicines and Palliative Care. Human Rights Watch

2011. https://www.hrw.org/report/2011/06/02/global-state-pain-treatment/access-medicines-and-palliative-care.

Report. Community Management of Opioid Overdose. World Health Organization 2014. http://www.who.int/substance_abuse/publications/management_opioid_overdose/en.

Report. Global Atlas of Palliative Care at End of Life. World Palliative Care Alliance, World Health Organization 2014. http://www.who.int/ncds/management/palliative-care/palliative-care-atlas/en.

Report. “Pain Tears Me Apart”: Challenges and Progress in Ensuring the Right to Palliative Care in Morocco. Human Rights Watch 2016. https://www.hrw.org/report/2016/02/04/pain-tears-me-apart/challenges-and-progress-ensuring-right-palliative-care-morocco.

Report. A Second Chance: Overdose Prevention, Naxolone, and Human Rights in the United States. Human Rights Watch 2017. https://www.hrw.org/report/2017/04/27/second-chance/overdose-prevention-naloxone-and-human-rights-united-states.

Report. Knaul FM et al. Alleviating the Access Abyss in Palliative Care and Pain Relief—an Imperative of Universal Health Coverage: The Lancet Commission Report. The Lancet 2017. http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(17)32513-8/fulltext.

Report. “Punishing the Patient”: Ensuring Access to Pain Treatment in Guatemala. Human Rights Watch 2017. https://www.hrw.org/report/2017/05/17/punishing-patient/ensuring-access-pain-treatment-guatemala.

Report. World Drug Report 2017. United Nations Office on Drugs and Crime 2017. https://www.unodc.org/wdr2017/index.html.

ARTICLES AND BRIEFS Article. Van Zee A. The Promotion and Marketing of Oxycontin: Commercial Triumph, Public Health

Tragedy. American Journal of Public Health 2009; 99(2): 221-7. http://ajph.aphapublications.org/doi/full/10.2105/AJPH.2007.131714.

Brief. Ending Needless Suffering in Francophone Africa. Human Rights Watch 2015. https://www.hrw.org/news/2015/10/09/ending-needless-suffering-francophone-africa.

Article. Kolodny A et al. The Prescription Opioid and Heroin Crisis: A Public Health Approach to an Epidemic of Addiction. Annual Review of Public Health 2015; 36: 559-74. http://www.annualreviews.org/doi/abs/10.1146/annurev-publhealth-031914-122957.

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Article. Patel V et al. Addressing the Burden of Mental, Neurological, and Substance Use Disorders: Key Messages from Disease Control Priorities, 3rd Edition. The Lancet 2015; 387: 1672-1685. DOI: http://dx.doi.org/10.1016/S0140-6736(15)00390-6.

Article. Florence CS et al. The Economic Burden of Prescription Opioid Overdose, Abuse, and Dependence in the United States, 2013. Medical Care 2016; 54(10): 901-6. http://journals.lww.com/lww-medicalcare/Abstract/2016/10000/The_Economic_Burden_of_Prescription_Opioid.2.aspx.

Article. Frieden TR, Houry D. Reducing the Risks of Relief—the CDC Opioid-Prescribing Guideline. The New England Journal of Medicine 2016; 2016(374): 1501-4. http://www.nejm.org/doi/full/10.1056/NEJMp1515917.

Article Series. Substance Use in Young People. The Lancet Psychiatry 2016. http://www.thelancet.com/series/adolescent-substance-misuse.

Article. Powell RA et al. Palliative Care in Humanitarian Crises: Always Something to Offer. The Lancet 2017; 389(10078): 1498-9. http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(17)30978-9/abstract.

Article. Sharkey L et al. National Palliative Care Capacities Around the World: Results From the World Health Organization Noncommunicable Disease Country Capacity Survey. Palliative Medicine 2017. https://www.ncbi.nlm.nih.gov/pubmed/28677988.

Brief. Weiss AJ et al. Patient Residence Characteristics of Opioid-Related Inpatient Stays and Emergency Department Visits Nationally and by State, 2014. Agency for Healthcare Quality and Research 2017. https://www.hcup-us.ahrq.gov/reports/statbriefs/sb226-Patient-Residence-Opioid-Hospital-Stays-ED-Visits-by-State.pdf.

DATA PUBLICATIONS, PORTALS, AND INTERACTIVES Data Portal. CDC Data Portal: Drug Overdose Deaths and Opioid-Involved Deaths. Centers for Disease

Control and Prevention. https://www.cdc.gov/drugoverdose/data/index.html. Data Portal. Databases on Noncommunicable Diseases and Mental Health. World Health

Organization. http://www.who.int/nmh/databases/en. Data Interactive. Annual Prevalence of Use of Drugs in 2015 (or Latest Year Available). United Nations

Office on Drugs and Crime 2017. https://www.unodc.org/wdr2017/en/interactive-map.html. Data Publication. Annual Surveillance Report of Drug-Related Risks and Outcomes – United States, 2017.

Centers for Disease Control and Prevention 2017. https://stacks.cdc.gov/view/cdc/478321. Data Interactive. Medicare Part D Opioid Prescribing Mapping Tool. Centers for Medicare & Medicaid

Services 2017. https://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/Medicare-Provider-Charge-Data/OpioidMap.html.

Data Interactive. Trends in Opioid-Related Hospitalizations. Agency for Healthcare Research and Quality 2017. https://www.ahrq.gov/news/opioid-hospitalization-map.html.

COUNTRY PROFILES AND FACT SHEETS Fact Sheet. Information Sheet on Opioid Overdose. World Health Organization 2014.

http://www.who.int/substance_abuse/information-sheet/en. Fact Sheet. Palliative Care. Fact Sheet. World Health Organization

2016. http://www.who.int/ncds/management/palliative-care/palliative-care-NCDs/en. County Profiles. County Profiles of Opioid Use and Related Outcomes. Indiana State Department of

Health 2017. http://www.in.gov/isdh/26680.htm. Fact Sheet. Opioid Prescribing: Where You Live Matters. CDC Vital Signs

2017. https://www.cdc.gov/vitalsigns/pdf/2017-07-vitalsigns.pdf. TOPIC PORTALS AND ORGANIZATIONS Topic Portal. Management of Substance Abuse. World Health Organization.

http://www.who.int/substance_abuse/en. Topic Portal. Opioid Overdose. Centers for Disease Control and Prevention.

https://www.cdc.gov/drugoverdose/index.html.

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Organization. Opioid Policy Research Collaborative. The Heller School for Social Policy and Management, Brandeis University. http://heller.brandeis.edu/opioid-policy/index.html.

Topic Portal. Palliative Care. Human Rights Watch. https://www.hrw.org/topic/health/palliative-care. Topic Portal. Palliative Care. World Health Organization. http://www.who.int/palliativecare/en. Organization. Worldwide Hospice Palliative Care Alliance. http://www.thewhpca.org. MULTIMEDIA AND NEWS Documentary. Heroin and the War on Drugs. Retro Report 2015.

https://www.retroreport.org/video/heroin-and-the-war-on-drugs. News. The Problem of Pain. The Economist 2016; May 28.

https://www.economist.com/news/international/21699363-americans-are-increasingly-addicted-opioids-meanwhile-people-poor-countries-die.

News. Allen G, Kelly A. Trump Administration Declares Opioid Crisis a Public Health Emergency. National Public Radio 2017; Oct 26. http://www.npr.org/2017/10/26/560083795/president-trump-may-declare-opioid-epidemic-national-emergency.

Podcast. Faces of Fentanyl. Out in the Open With Piya Chattopadhyay. CBC Radio 2017; Oct 1. http://www.cbc.ca/radio/outintheopen/faces-of-fentanyl-1.4302209.

Infographics. The Lancet Commission on Global Access to Palliative Care and Pain Relief. The Lancet 2017. http://www.thelancet.com/commissions/palliative-care.

News. Keefe PR. The Family That Built an Empire of Pain. The New Yorker 2017; Oct 30. https://www.newyorker.com/magazine/2017/10/30/the-family-that-built-an-empire-of-pain.

News. Kolodny A. The Opioid Epidemic in Six Charts. The Conversation 2017; Oct 4. https://theconversation.com/the-opioid-epidemic-in-6-charts-81601.

News. Lopez G. The Opioid Epidemic, Explained. Vox 2017; Oct 26. https://www.vox.com/science-and-health/2017/8/3/16079772/opioid-epidemic-drug-overdoses.

Infographic. Medicaid’s Role in Addressing the Opioid Epidemic. Kaiser Family Foundation 2017. https://www.kff.org/infographic/medicaids-role-in-addressing-opioid-epidemic.

Playlist. Playlist (11 Videos): Rx Awareness. Centers for Disease Control and Prevention 2017. https://www.youtube.com/playlist?list=PLvrp9iOILTQYcHqukShtAIqk01FTDGV9m.

Photo Essay. Montgomery P, Talbot M. Faces of an Epidemic. The New Yorker 2017; Oct 30. https://www.newyorker.com/magazine/2017/10/30/faces-of-an-epidemic.

Infographics. Opioid Overdose: Shareable Graphics. Centers for Disease Control and Prevention 2017. https://www.cdc.gov/drugoverdose/resources/graphics.html.

News. Stopka TJ. Opioid Epidemic Causing Rise in Hepatitis C Infections and Other Serious Illnesses. The Conversation 2017. https://theconversation.com/opioid-epidemic-causing-rise-in-hepatitis-c-infections-and-other-serious-illnesses-82040.

TEACHING MATERIAL Teaching Case. Li Z et al. Safe Needles Save Lives. Western Public Health Casebook. Public Health

Casebook Publishing 2016. http://www.schulich.uwo.ca/publichealth/cases/Western%20MPH%20Casebook%202016.html.

Lesson Plan. Gonchar M, Crosson Gilpin C. Investigating the Heroin and Prescription Opioid Epidemic: A Lesson Plan. The New York Times 2017. https://www.nytimes.com/2017/05/04/learning/lesson-plans/investigating-the-heroin-and-prescription-opioid-epidemic-a-lesson-plan.html.

Teaching Case. Sibbald S, Shelley JJ. Policy Meets Practice – People Who Inject Drugs. Western Public Health Casebook. Public Health Casebook Publishing 2017. https://www.schulich.uwo.ca/publichealth/cases/2017_Case_12.pdf.

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Annotated Bibliography BASIC READS

Alleviating the Access Abyss in Palliative Care and Pain Relief—an Imperative of Universal Health Coverage: The Lancet Commission Report Report. Knaul FM et al. Alleviating the Access Abyss in Palliative Care and Pain Relief—an Imperative of Universal Health Coverage: The Lancet Commission Report. The Lancet 2017. http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(17)32513-8/fulltext. The Prescription Opioid and Heroin Crisis: A Public Health Approach to an Epidemic of Addiction Article. Kolodny A et al. The Prescription Opioid and Heroin Crisis: A Public Health Approach to an Epidemic of Addiction. Annual Review of Public Health 2015; 36: 559-74. http://www.annualreviews.org/doi/abs/10.1146/annurev-publhealth-031914-122957. The Problem of Pain News. The Problem of Pain. The Economist 2016; May 28. https://www.economist.com/news/international/21699363-americans-are-increasingly-addicted-opioids-meanwhile-people-poor-countries-die. The Family That Built an Empire of Pain News. Keefe PR. The Family That Built an Empire of Pain. The New Yorker 2017; Oct 30. https://www.newyorker.com/magazine/2017/10/30/the-family-that-built-an-empire-of-pain.

REPORTS

Global State of Pain Treatment: Access to Medicines and Palliative Care Report. Global State of Pain Treatment: Access to Medicines and Palliative Care. Human Rights Watch 2011. https://www.hrw.org/report/2011/06/02/global-state-pain-treatment/access-medicines-and-palliative-care. This report from Human Rights Watch examines the barriers to availability of palliative care and pain treatment worldwide. In 1961, countries adopted the Single Convention on Narcotic Drugs, which stated narcotic drugs are “indispensable for the relief of pain and suffering.” However, access to these pain relieving drugs remains limited for the world’s most vulnerable. Surveying palliative care experts in 40 countries, the report weaves together expert insights on health policy, education of health care workers, and drug availability related to palliative care, and analyzes publicly available data on opioid consumption to treat chronic pain. The report finds a large unmet need for pain treatment, shaped by both health policy and pharmaceutical trade. Community Management of Opioid Overdose Report. Community Management of Opioid Overdose. World Health Organization 2014. http://www.who.int/substance_abuse/publications/management_opioid_overdose/en. This report from the World Health Organization shares best practices for responding to an overdose. According to the report, an opioid overdose is frequently reversed with naloxone and basic life support. Although these resources are typically only available through medical institutions, community members who are likely to witness these overdoses should have access to appropriate response. Naloxone—while a life-saving response—should not be seen as a replacement for medical care. Global Atlas of Palliative Care at End of Life Report. Global Atlas of Palliative Care at End of Life. World Palliative Care Alliance, World Health Organization 2014. http://www.who.int/ncds/management/palliative-care/palliative-care-atlas/en. This report from the World Palliative Care Alliance and the World Health Organization provides basic information and statistics about palliative care, the global need for expanded and more effective palliative

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care, barriers to pain treatment, existing models of palliative care across resource settings, and opportunities for further work. “Pain Tears Me Apart”: Challenges and Progress in Ensuring the Right to Palliative Care in Morocco Report. “Pain Tears Me Apart”: Challenges and Progress in Ensuring the Right to Palliative Care in Morocco. Human Rights Watch 2016. https://www.hrw.org/report/2016/02/04/pain-tears-me-apart/challenges-and-progress-ensuring-right-palliative-care-morocco. This report from Human Rights Watch examines challenges people with life-limiting illnesses in Morocco face in accessing palliative care. The report indicates positive policies to expand palliative care in the country, specifically two national health policies: one that adapts medical curriculum within the country and the other that reduces reduce regulatory barriers to accessing opioids. Despite such progress, only two public hospitals have palliative care units, and services are not available to those with non-oncological conditions. As the burden of chronic illness rises, more specific attention on palliative care and pain treatment is needed. A Second Chance: Overdose Prevention, Naxolone, and Human Rights in the United States Report. A Second Chance: Overdose Prevention, Naxolone, and Human Rights in the United States. Human Rights Watch 2017. https://www.hrw.org/report/2017/04/27/second-chance/overdose-prevention-naloxone-and-human-rights-united-states. This report from Human Rights Watch explores the role of naloxone in responding to opioid overdoses in the United States. The report highlights the steps needed to curb and prevent overdose deaths: ensuring people who use drugs have naloxone access; prescription rule reforms to expand naloxone access to community members; encouraging reports of overdoses by protecting overdose reporters from criminal prosecution; and equipping law enforcement officials with naloxone. Alleviating the Access Abyss in Palliative Care and Pain Relief—an Imperative of Universal Health Coverage: The Lancet Commission Report Report. Knaul FM et al. Alleviating the Access Abyss in Palliative Care and Pain Relief—an Imperative of Universal Health Coverage: The Lancet Commission Report. The Lancet 2017. http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(17)32513-8/fulltext. GHELI repository link: http://repository.gheli.harvard.edu/repository/11818 This Lancet Commission report calls on the global health community to alleviate the global burden of health-related human suffering by providing equitable, worldwide access to palliative care and pain relief. The practice of palliative care, defined as a core component of universal health care, has been ignored in most parts of the world, especially in the failure to provide pain-relieving medicines such as morphine and other opioids to sick and dying people. The report describes current global conditions, outlines challenges and opportunities, and presents a framework and methodology to achieve universal access goals. It emphasizes that overcoming the access abyss requires collective international action, and it sets forth recommendations and strategies for global implementation. These include integrating a cost-effective package of essential medicines and equipment into universal health coverage, adopting a metric for health-related suffering to describe the state of the world’s health, and amending inflexible regulatory policies that inhibit the medical distribution of opioids. The commission report is accompanied by two comments and a profile, as well as two audio interviews. “Punishing the Patient”: Ensuring Access to Pain Treatment in Guatemala Report. “Punishing the Patient”: Ensuring Access to Pain Treatment in Guatemala. Human Rights Watch 2017. https://www.hrw.org/report/2017/05/17/punishing-patient/ensuring-access-pain-treatment-guatemala. This Human Rights Watch report reviews Guatemala’s drug control system and examines access to pain medication within the country. The report finds that due to limited and inconsistent access to opioid analgesics, many patients with pain suffering needlessly. In addition to issues with pharmacy supplies, all of the doctors with the ability to prescribe morphine work in Guatemala City—placing the immense burden of distance on individuals who live in rural areas.

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World Drug Report 2017 Report. World Drug Report 2017. United Nations Office on Drugs and Crime 2017. https://www.unodc.org/wdr2017/index.html. This annual report by the United Nations Office on Drugs and Crime (UNODC) provides an overview of drug demand and supply; cultivation of plant-based drugs; analysis of global synthetic drug markets; and the nexus of drug use and organized crime. In particular, the report highlights that opioids, including heroin, remain the most harmful drug type—a majority of avoidable, premature deaths related to drugs are associated with opioids. In 2015, 70 percent of the global burden of disease attributable to drug use disorders were related to opioids.

ARTICLES AND BRIEFS

The Promotion and Marketing of Oxycontin: Commercial Triumph, Public Health Tragedy Article. Van Zee A. The Promotion and Marketing of Oxycontin: Commercial Triumph, Public Health Tragedy. American Journal of Public Health 2009; 99(2): 221-7. http://ajph.aphapublications.org/doi/full/10.2105/AJPH.2007.131714. This article highlights the public health risks of highly prescribed, controlled drugs, using the promotion and marketing of OxyContin as a case example. The author provides in-depth analysis of Purdue Pharma’s heavy marketing of OxyContin after its introduction in 1996; with increased availability, OxyContin became the most prevalent abused prescription opioid by 2004. The author shines a light on physician ethics as well as the need for enhanced oversight of the pharmaceutical industry at the U.S. Food and Drug Administration. Ending Needless Suffering in Francophone Africa Brief. Ending Needless Suffering in Francophone Africa. Human Rights Watch 2015. https://www.hrw.org/news/2015/10/09/ending-needless-suffering-francophone-africa. This brief from Human Rights Watch documents the challenges and opportunities for palliative care services in Francophone Africa. In particular, the brief highlights that 16 of 22 Francophone African countries lacked any health providers that offer palliative care for adults and children requiring pain relief for the management for chronic illnesses. The Prescription Opioid and Heroin Crisis: A Public Health Approach to an Epidemic of Addiction Article. Kolodny A et al. The Prescription Opioid and Heroin Crisis: A Public Health Approach to an Epidemic of Addiction. Annual Review of Public Health 2015; 36: 559-74. http://www.annualreviews.org/doi/abs/10.1146/annurev-publhealth-031914-122957. This article shares a public health approach to reduce opioid-related morbidity and mortality. In particular, the article describes the scope of the public health crisis, its historical context, and framework of interventions to address the growing epidemic of opioid addiction. Addressing the Burden of Mental, Neurological, and Substance Use Disorders: Key Messages from Disease Control Priorities, 3rd Edition Article. Patel V et al. Addressing the Burden of Mental, Neurological, and Substance Use Disorders: Key Messages from Disease Control Priorities, 3rd Edition. The Lancet 2015; 387: 1672-1685. DOI: http://dx.doi.org/10.1016/S0140-6736(15)00390-6. GHELI repository link: http://repository.gheli.harvard.edu/repository/11075 This article describes findings from the third edition of Disease Control Priorities (DCP-3) on the burden of mental, neurological, and substance use disorders, and the relative effectiveness and cost-effectiveness of interventions. The primary goal of Disease Control Priorities in Developing Countries, first published by the World Bank in 1993, is to provide evidence that will assist decision makers in allocating limited resources in a way that maximizes health benefits to the population. In DCP-3, interventions were included for five groups of disorders (adult mental disorders, child mental and developmental disorders, neurological disorders, alcohol use disorder, and illicit drug use disorders) and for suicide and self-harm, a health outcome strongly associated with

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these disorders. One of several novel features of DCP-3, compared to previous editions, is the inclusion of how interventions can be packaged together across a range of delivery platforms and channels. The Economic Burden of Prescription Opioid Overdose, Abuse, and Dependence in the United States, 2013 Article. Florence CS et al. The Economic Burden of Prescription Opioid Overdose, Abuse, and Dependence in the United States, 2013. Medical Care 2016; 54(10): 901-6. http://journals.lww.com/lww-medicalcare/Abstract/2016/10000/The_Economic_Burden_of_Prescription_Opioid.2.aspx. This article estimates the economic burden of prescription opioid overdose, misuse, and dependence to help decision makers assess the cost-effectiveness of their approaches addressing the opioid crisis in the U.S. The analysis, based on data from 2013, estimates the total economic burden to be $78.5 billion, with over one-third of the amount due to increased health care and substance abuse treatment costs. Substance Use in Young People Article Series. Substance Use in Young People. The Lancet Psychiatry 2016. http://www.thelancet.com/series/adolescent-substance-misuse. GHELI repository link: http://repository.gheli.harvard.edu/repository/11132 This Lancet Series examines the increasing global problem of substance use among young people, looking at the clinical and epidemiological picture as well as exploring the knowledge regarding prevention, early intervention, harm reduction, and treatment. The use of tobacco, alcohol, and illicit drugs during adolescence carries potential short- and long-term impacts on physical, mental, and social well-being. Series papers include:

• The Increasing Global Health Priority of Substance Use in Young People • Why Young People's Substance Use Matters For Global Health • Prevention, Early Intervention, Harm Reduction, And Treatment of Substance Use in Young People

Palliative Care in Humanitarian Crises: Always Something to Offer Article. Powell RA et al. Palliative Care in Humanitarian Crises: Always Something to Offer. The Lancet 2017; 389(10078): 1498-9. http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(17)30978-9/abstract. This article calls for holistic palliative care as an essential part of responding to humanitarian crises. The authors describe four humanitarian contexts where palliative care would aid in alleviating suffering: in long-term humanitarian crises for patients with life-limiting illnesses; in mass casualty events where individuals are triaged based on likelihood of survival; in infectious disease outbreaks with high mortality and limited resources for response; and in camps for refugees and displaced people where palliative care is required during transition to the camp. National Palliative Care Capacities Around the World: Results From the World Health Organization Noncommunicable Disease Country Capacity Survey Article. Sharkey L et al. National Palliative Care Capacities Around the World: Results From the World Health Organization Noncommunicable Disease Country Capacity Survey. Palliative Medicine 2017. https://www.ncbi.nlm.nih.gov/pubmed/28677988. This article assesses country capacity globally to address palliative care for noncommunicable disease (NCD) patients. Analyzing results from the World Health Organization Noncommunicable Disease Country Capacity Survey, the article indicates that a minority of countries have national policies for NCDs that include palliative care. Furthermore, palliative care is usually poorly funded compared to other NCD management approaches, and there remains a large country-income gradient for palliative care funding and treatment availability at the primary care level.

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Patient Residence Characteristics of Opioid-Related Inpatient Stays and Emergency Department Visits Nationally and by State, 2014 Brief. Weiss AJ et al. Patient Residence Characteristics of Opioid-Related Inpatient Stays and Emergency Department Visits Nationally and by State, 2014. Agency for Healthcare Quality and Research 2017. https://www.hcup-us.ahrq.gov/reports/statbriefs/sb226-Patient-Residence-Opioid-Hospital-Stays-ED-Visits-by-State.pdf. This brief from the Agency for Healthcare Quality and Research indicates that although large metropolitan areas in the U.S. had the highest rate of opioid-related inpatient stays, the rate of opioid hospitalizations increased the most in small metropolitan areas during the 2005 to 2014 period. In 2014, communities with the lowest income had the highest rates of opioid-related inpatient stays.

DATA PUBLICATIONS, PORTALS, AND INTERACTIVES

CDC Data Portal: Drug Overdose Deaths and Opioid-Involved Deaths Data Portal. CDC Data Portal: Drug Overdose Deaths and Opioid-Involved Deaths. Centers for Disease Control and Prevention. https://www.cdc.gov/drugoverdose/data/index.html. GHELI repository link: http://repository.gheli.harvard.edu/repository/11811 This data portal hosted by the Centers for Disease Control and Prevention depicts how drug overdose deaths and opioid-involved deaths continue to increase in the United States; overdose deaths from opioids have more than quadrupled since 1999. Opioids are a drug class that contains heroin as well as prescription pain relievers such as oxycodone, hydrocodone, morphine, codeine, fentanyl, and others; these substances interact with specific brain receptors to reduce the intensity of pain. Deaths from drug overdoses are up within nearly all population groups – men and women, all races, and nearly all adult age cohorts—and opioids are involved in more than three out of every five overdose deaths. This portal offers data about drug overdose rates for different types of opioids, prescription rates, and encounters with the highly potent fentanyl, which is increasingly being mixed with heroin and prescription opioids and has contributed to this dramatic rise in overdose deaths. The portal also offers information about overdose prevention, pain management guidance for health care providers and individuals, evidence-based strategies for states seeking to curb the opioid epidemic, and more. Databases on Noncommunicable Diseases and Mental Health Data Portal. Databases on Noncommunicable Diseases and Mental Health. World Health Organization. http://www.who.int/nmh/databases/en. GHELI repository link: http://repository.gheli.harvard.edu/repository/11269 This data portal, maintained by the World Health Organization (WHO), contains links to key databases on chronic disease and risk factors, mental health and substance abuse, suicide, and tobacco use. Annual Prevalence of Use of Drugs in 2015 (or Latest Year Available) Data Interactive. Annual Prevalence of Use of Drugs in 2015 (or Latest Year Available). United Nations Office on Drugs and Crime 2017. https://www.unodc.org/wdr2017/en/interactive-map.html. This interactive map from the United Nations Office on Drugs and Crime (UNODC) presents the annual prevalence of drug use in 2015 or the late year available for specific countries. The data can be disaggregated by country and by drug group. The Interactive accompanies the World Drug Report 2017. Annual Surveillance Report of Drug-Related Risks and Outcomes – United States, 2017 Data Publication. Annual Surveillance Report of Drug-Related Risks and Outcomes – United States, 2017. Centers for Disease Control and Prevention 2017. https://stacks.cdc.gov/view/cdc/478321. GHELI repository link: http://repository.gheli.harvard.edu/repository/11808 This report summarizes the latest information available for various health outcomes, health behaviors, and prescribing patterns related to the drug problem in the United States. This report covers latest data available on rates of opioid prescribing, substance use disorder, nonfatal hospitalizations and emergency department

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visits, and overdose deaths. National information, and some state information, is presented to serve as a resource to help address the ongoing national problem of drug abuse, addiction, and overdose.

Medicare Part D Opioid Prescribing Mapping Tool Data Interactive. Medicare Part D Opioid Prescribing Mapping Tool. Centers for Medicare & Medicaid Services 2017. https://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/Medicare-Provider-Charge-Data/OpioidMap.html. This data interactive from the Centers for Medicare & Medicaid Services (CMS) shares information about opioid prescribing rates based on Medicare Part D opioid prescription claims. Users can explore data at the state, country, and ZIP code levels, as well as see both the number and percentage of opioid claims in specific localities. The interactive map is based on 2013 and 2014 de-identified Medicare Part D claims. Trends in Opioid-Related Hospitalizations Data Interactive. Trends in Opioid-Related Hospitalizations. Agency for Healthcare Research and Quality 2017. https://www.ahrq.gov/news/opioid-hospitalization-map.html. This data interactive from the Agency for Healthcare Research and Quality shares statistics and trends about opioid-related hospital care between 2009 and 2014. Data on hospitalizations in 2014 are disaggregated by patient age, sex, geographic area, and income.

COUNTRY PROFILES AND FACT SHEETS

Information Sheet on Opioid Overdose Fact Sheet. Information Sheet on Opioid Overdose. World Health Organization 2014. http://www.who.int/substance_abuse/information-sheet/en. This fact sheet from the World Health Organization provides information about opioid overdoses worldwide, outlining effects of opioids, physical symptoms of overdose, risk factors, and emergency responses to it. The fact sheet also highlights gaps in access to effective opioid dependence treatment as well as gaps in access to naloxone, a medication that can reverse opioid overdose. Palliative Care Fact Sheet. Palliative Care. Fact Sheet. World Health Organization 2016. http://www.who.int/ncds/management/palliative-care/palliative-care-NCDs/en. GHELI repository link: http://repository.gheli.harvard.edu/repository/11808 This fact sheet from the World Health Organization (WHO) provides information on the critical need, availability, and accessibility of palliative care around the world. Palliative care is an essential component of a comprehensive response to noncommunicable diseases, as outlined in the WHO Global Action Plan for the Prevention and Control of NCDs 2013–2020. Yet, nearly 85 percent of people in need of palliative care do not receive it. In 2014, the first-ever global resolution on palliative care, World Health Assembly Resolution WHA67.19, called upon the WHO and Member States to improve access to palliative care as a core component of health systems. County Profiles of Opioid Use and Related Outcomes County Profiles. County Profiles of Opioid Use and Related Outcomes. Indiana State Department of Health 2017. http://www.in.gov/isdh/26680.htm. These county-level profiles from the Indiana State Department of Health share detailed information about opioid use and related outcomes in the state. In 2015, Indiana experienced the worst HIV outbreak in state history, which many health officials attribute to intravenous drug use, state-level cuts to HIV testing, and reticence to needle exchange policies. The county profiles share the number and incidence rate of HIV, HCV, and STDS, as well as the total number and incidence rate for drug overdoses and deaths.

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Opioid Prescribing: Where You Live Matters Fact Sheet. Opioid Prescribing: Where You Live Matters. CDC Vital Signs; U.S. Centers for Disease Control and Prevention 2017. https://www.cdc.gov/vitalsigns/pdf/2017-07-vitalsigns.pdf. This fact sheet from the Centers for Disease Control and Prevention highlights how opioid prescribing remains high and varies county to county in the United States. In particular, the highest prescribing counties prescribed six times more opioids per person than the lowest prescribing counties in 2015. Higher prescribing counties tended to be small cities or large towns, with a higher percentage of white residents, more uninsured or underemployed citizens, and more people with chronic conditions.

TOPIC PORTALS AND ORGANIZATIONS

Management of Substance Abuse Topic Portal. Management of Substance Abuse. World Health Organization. http://www.who.int/substance_abuse/en. This topic portal from the World Health Organization highlights timely data, reports, research, and news associated with alcohol, drugs, and addictive behaviors and their implications for health and well-being. Opioid Overdose Topic Portal. Opioid Overdose. Centers for Disease Control and Prevention. https://www.cdc.gov/drugoverdose/index.html. This topic portal from the Centers for Disease Control and Prevention (CDC) shares information about opioid use, current, data, and overdose prevention efforts specific to the United States. The portal also shares up-to-date information regarding the CDC’s ongoing efforts to address the country’s opioid overdose epidemic and the most recent prescribing guidelines for the drug. Opioid Policy Research Collaborative Organization. Opioid Policy Research Collaborative. The Heller School for Social Policy and Management, Brandeis University. http://heller.brandeis.edu/opioid-policy/index.html. The Opioid Policy Research Collaborative (OPRC) at Brandeis University’s Heller School for Social Policy and Management advances needed scholarship on public health interventions to address the opioid addiction epidemic. The OPRC focuses on providing timely research evaluate local, state, and national interventions and policies; offering evidence-based policy recommendations to address the crisis; convening stakeholders across disciplines to develop coordinated strategies addressing the epidemic; and sharing findings of specific innovations to broader, non-academic audiences. Palliative Care Topic Portal. Palliative Care. Human Rights Watch. https://www.hrw.org/topic/health/palliative-care. This topic portal from the Human Rights Watch includes reports, videos, and briefs that focus on the unmet need globally for palliative care and pain relief. Resources highlight the human rights implications of leaving pain untreated, particularly in the context of a global surge in chronic illnesses such as cancer, diabetes, and heart disease. Palliative Care Topic Portal. Palliative Care. World Health Organization. http://www.who.int/palliativecare/en. This topic portal from the World Health Organization (WHO) provides key infographics, news, and reports focused on palliative care. Access to pain and symptom control is a part of the fundamental right to health, and resources in the topic portal address role of health systems and universal health coverage in achieving this vision. Worldwide Hospice Palliative Care Alliance Organization. Worldwide Hospice Palliative Care Alliance. http://www.thewhpca.org. GHELI repository link: http://repository.gheli.harvard.edu/repository/11184

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The Worldwide Hospice Palliative Care Alliance (WHPCA) is a global action network focusing exclusively on hospice and palliative care development worldwide. Its members are national and regional hospice and palliative care organizations and affiliate organizations supporting hospice and palliative care. The WHPCA is in official relations with the World Health Organization (WHO) and co-produced the first Global Atlas of Palliative Care at the End of Life, mapping the unmet need worldwide. It defines palliative care, articulates why it is a human rights issue, and advocates for education and training, guidelines and policies, and integrated services and delivery models. WHPCA is the international arm for ehospice, an international palliative care news and information service.

MULTIMEDIA AND NEWS

Heroin and the War on Drugs Documentary. Heroin and the War on Drugs. Retro Report 2015. https://www.retroreport.org/video/heroin-and-the-war-on-drugs. This documentary shares the historical context of the “War on Drugs” in the United States and how it connects to the present-day opioid epidemic. During the 1970s, approaches to drug use focused on punitive, criminal justice approaches to targeting the heroin epidemic. These approaches disproportionately targeted lower income, black Americans and inflated the prison system. The documentary follows policy shifts over the last 40 years that have led to conceptualizing heroin addiction as a public health issue affecting white, rural populations. (14:00) The Problem of Pain News. The Problem of Pain. The Economist 2016; May 28. https://www.economist.com/news/international/21699363-americans-are-increasingly-addicted-opioids-meanwhile-people-poor-countries-die. This news story depicts the challenges surrounding prescription pain medication. It shares personal narratives to illustrate how rich countries, like the United States, overprescribe pain medication which can lead to addiction and death. In contrast, developing countries have restrictive laws, limited knowledge, and strong stigma against pain medication. More work must be done to balance this discrepancy, by educating both doctors and patients on the disadvantages of pain medication over-use in rich countries, as well as the significant benefits of pain medication in developing countries. Trump Administration Declares Opioid Crisis a Public Health Emergency News. Allen G, Kelly A. Trump Administration Declares Opioid Crisis a Public Health Emergency. National Public Radio 2017; Oct 26. http://www.npr.org/2017/10/26/560083795/president-trump-may-declare-opioid-epidemic-national-emergency. This news story examines the current policy surrounding the U.S. opioid epidemic. In October 2017, President Trump declared the opioid epidemic as a public health emergency; however, it was not declared as a national emergency. This distinction means that new addiction treatments will not be receiving additional funding from the U.S. government—a worrying issue as the Public Health Emergency Fund is almost empty. There are still many questions on how the president will continue the plan for addressing opioids and how that plan will be funded. Faces of Fentanyl Podcast. Faces of Fentanyl. Out in the Open with Piya Chattopadhyay. CBC Radio 2017; Oct 1. http://www.cbc.ca/radio/outintheopen/faces-of-fentanyl-1.4302209. This podcast explores fentanyl usage in Canada. In this episode, fentanyl users talk about addiction and family members share personal narratives of opioid use. Narratives touch on topics from opioid use in First Nations communities to paramedics using naloxone to reverse overdoses.

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The Lancet Commission on Global Access to Palliative Care and Pain Relief Infographics. The Lancet Commission on Global Access to Palliative Care and Pain Relief. The Lancet 2017. http://www.thelancet.com/commissions/palliative-care. These infographics accompanying the Lancet Commission on Global Access to Palliative Care and Pain Relief depict the global inequity in access to pain medications, chart the unmet need of immediate-release morphine in developing countries, and illustrate the overall inequity in quality of palliative care. The infographics are located on the right hand side of the web portal. The Family That Built an Empire of Pain News. Keefe PR. The Family That Built an Empire of Pain. The New Yorker 2017; Oct 30. https://www.newyorker.com/magazine/2017/10/30/the-family-that-built-an-empire-of-pain. This news story in The New Yorker examines the Sackler family, whose fortune was built through the family business, Purdue Pharma. Purdue Pharma developed OxyContin, a heavily-marketed prescription painkiller that is now controversial due to its oversized role in the current opioid abuse epidemic. Many Americans have died from overdosing on OxyContin, and research by the American Society of Addiction Medicine suggests that the majority of people who use heroin initially began with prescription drugs. This news story takes a step back, to look at the inaccuracy in marketing to healthcare professionals and patients that led to opioid addiction across America. The Opioid Epidemic in Six Charts News. Kolodny A. The Opioid Epidemic in Six Charts. The Conversation 2017; Oct 4. https://theconversation.com/the-opioid-epidemic-in-6-charts-81601. This news story depicts the opioid epidemic through six charts. These charts illustrate various trends in the opioid epidemic: the rise of opioid use in recent years, the overdose deaths from opioid use, demographic breakdown of opioid users, rise of fentanyl use, oxycodone consumption, and medication-assisted therapy for heroin addicts by age group. The Opioid Epidemic, Explained News. Lopez G. The Opioid Epidemic, Explained. Vox 2017; Oct 26. https://www.vox.com/science-and-health/2017/8/3/16079772/opioid-epidemic-drug-overdoses. This news article explores the opioid epidemic in America, noting the steady increase in opioid use through recent years. This has been exacerbated by the lack of attention to addiction treatment and misleading marketing about the safety of prescription pain medication. The United States has the highest opioid consumption around the world, fueled by the combination of aggressive pharmaceutical marketing and increased pressure on doctors to treat pain more seriously. In addition to prescription painkillers, heroin and fentanyl pose a risk of addiction and overdose. The article underscores the need to educate individuals on the challenges of addiction as well as to make changes to policy in order to save lives and overcome this epidemic. Medicaid’s Role in Addressing the Opioid Epidemic Infographic. Medicaid’s Role in Addressing the Opioid Epidemic. Kaiser Family Foundation 2017. https://www.kff.org/infographic/medicaids-role-in-addressing-opioid-epidemic. This infographic illustrates the role of Medicaid in the opioid epidemic. Medicaid can help to control the opioid epidemic since it can cover low-income individuals who are fighting addiction and help them receive proper treatment. The infographic shows the challenges of the opioid epidemic and how broadened Medicaid coverage can address these challenges. Playlist (11 Videos): Rx Awareness Playlist. Playlist (11 Videos): Rx Awareness. Centers for Disease Control and Prevention 2017. https://www.youtube.com/playlist?list=PLvrp9iOILTQYcHqukShtAIqk01FTDGV9m. This YouTube playlist by the Centers for Disease Control and Prevention (CDC) shares personal video narratives of individuals who were affected by the opioid epidemic.

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Opioids and Public Health: Annotated Bibliography

Faces of an Epidemic Photo Essay. Montgomery P, Talbot M. Faces of an Epidemic. The New Yorker 2017; Oct 30. https://www.newyorker.com/magazine/2017/10/30/faces-of-an-epidemic. This photo essay from The New Yorker uses images to portray the problems of addiction and overdose on daily American life, focusing on the epidemic’s impact on Montgomery County, Ohio. Opioid Overdose: Shareable Graphics Infographics. Opioid Overdose: Shareable Graphics. Centers for Disease Control and Prevention 2017. https://www.cdc.gov/drugoverdose/resources/graphics.html. These infographics by the Centers for Disease Control and Prevention (CDC) illustrate recent trends in opioid use and prescription in the United States. One infographic shows how some states have decreased opioid prescription through the use of regulated pain clinics. Another shows how opioid prescriptions are still widespread, despite these recent regulations. The last infographic depicts the rise of fentanyl use and the increasing challenges associated with fentanyl overdose. Opioid Epidemic Causing Rise in Hepatitis C Infections and Other Serious Illnesses News. Stopka TJ. Opioid Epidemic Causing Rise in Hepatitis C Infections and Other Serious Illnesses. The Conversation 2017. https://theconversation.com/opioid-epidemic-causing-rise-in-hepatitis-c-infections-and-other-serious-illnesses-82040. This news story explores the relationship between the opioid epidemic and rising rates of hepatitis C and HIV. These diseases interact with and exacerbate each other among vulnerable populations in what’s known as a syndemic or synergistic epidemic, increasing the public health burden on society. Mapping hotspots can help to measure disease burden to pinpoint locations with the most need and inform health policy decisions. Government and foundations will need to continue collaboration in order to educate physicians, pharmacists, and patients on hotspots, and increase disease testing, in order to address this health crisis.

TEACHING MATERIAL

Safe Needles Save Lives Teaching Case. Li Z et al. Safe Needles Save Lives. Western Public Health Casebook. Public Health Casebook Publishing 2016. http://www.schulich.uwo.ca/publichealth/cases/Western%20MPH%20Casebook%202016.html. GHELI repository link: http://repository.gheli.harvard.edu/repository/11469 This case highlights the harm reduction practices of providing clean needles and syringes to prevent the spread of blood-borne diseases among drug users in Ontario, Canada. It considers a needle exchange program effort in collaboration with a homeless prevention program that aimed to keep public areas free of discarded needles. When a six-year-old boy got a needle-stick injury in a public toilet in 2014, the resulting public panic sparked public discussion to improve existing efforts. The case helps students to understand project details and review the comparative landscape of community programs, policies, and activities related to needle/syringe disposal. Investigating the Heroin and Prescription Opioid Epidemic: A Lesson Plan Lesson Plan. Gonchar M, Crosson Gilpin C. Investigating the Heroin and Prescription Opioid Epidemic: A Lesson Plan. The New York Times 2017. https://www.nytimes.com/2017/05/04/learning/lesson-plans/investigating-the-heroin-and-prescription-opioid-epidemic-a-lesson-plan.html. GHELI repository link: http://repository.gheli.harvard.edu/repository/11764 This lesson plan from The New York Times explores the causes, effects, and potential solutions for addressing the prescription opioid crisis in the United States. The lesson includes a short film about an overdose survivor, relevant news articles to discuss within class, and a discussion guide for brainstorming possible solutions.

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Opioids and Public Health: Annotated Bibliography

Policy Meets Practice – People Who Inject Drugs Teaching Case. Sibbald S, Shelley JJ. Policy Meets Practice – People Who Inject Drugs. Western Public Health Casebook. Public Health Casebook Publishing 2017. https://www.schulich.uwo.ca/publichealth/cases/2017_Case_12.pdf. GHELI repository link: http://repository.gheli.harvard.edu/repository/11738 This case study illustrates how a health policy for the treatment of infective endocarditis may increase health risks for persons with intravenous drug addictions. It follows an infectious disease physician in decision-making about aggressive antibiotic treatment for people who inject drugs (PWID) and may be homeless. The case would be suitable for use in health courses that consider clinical decision-making and the role of community health workers in addressing the health needs of persons with addictions or those facing socioeconomic challenges such as homelessness and domestic displacement.

This glossary was originally developed by the Global Health Education and Learning Incubator at Harvard University. It is used and distributed with permission by the Global Health Education and Learning Incubator at Harvard University. The Incubator’s educational materials are not intended to serve as endorsements or sources of primary data, and do not necessarily reflect the views of Harvard University.

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Glossary of Terms Opioids and Public Health 2017

This short glossary is designed to accompany a teaching pack on the global pain epidemic, focusing specifically on opioid use and palliative care. The Global Health Education and Learning Incubator at Harvard University has also developed companion teaching materials on this subject, including an annotated bibliography on the global pain epidemic, as well as a lesson plan that incorporates an instructor’s note and learning objectives.

Note: Sources for terms below are noted in parentheses at the end of each entry, with additional information at the end of this document. Acute pain: Pain that usually starts suddenly and has a known cause, like an injury or surgery. It normally gets better as your body heals and lasts less than three months. (Centers for Disease Control and Prevention 2017) Addiction: Combination of the physical dependence on, behavioral manifestations of the use of, and subjective sense of need and craving for a psychoactive substance, leading to compulsive use of the substance either for its positive effects or to avoid negative effects associated with abstinence from that substance. (Substance Abuse and Mental Health Services Administration 2005) Agonist: A substance that acts at a neuronal receptor to produce effects similar to those of a reference drug; for example, methadone is a morphine-like agonist at the opioid receptors. (World Health Organization 1994) Analgesic: A compound that alleviates pain without causing loss of consciousness. Opioid analgesics are a class of compounds that bind to specific receptors in the central nervous system to block the perception of pain or affect the emotional response to pain. Such compounds include opium and its derivatives, as well as a number of synthetic compounds. Chronic administration or abuse of opioid analgesics may lead to addiction. (Substance Abuse and Mental Health Services Administration 2005) Basic pain medicines: Non-opioid pain medicines suitable for mild pain. These include paracetamol (also known as acetaminophen), aspirin, diclofenac, and ibuprofen. (Human Rights Watch 2011) Benzodiazepines: Sometimes called “benzos,” these are sedatives often used to treat anxiety, insomnia, and other conditions. Combining benzodiazepines with opioids increases a person’s risk of overdose and death. (Centers for Disease Control and Prevention 2017)

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Opioids and Public Health: Glossary of Terms Buprenorphine: A partial opioid agonist for the treatment of opioid addiction that relieves drug cravings without producing the “high” or dangerous side effects of other opioids. (National Institute on Drug Abuse 2014) Chronic pain: Pain that occurs over weeks, months, or years, rather than a few hours or a few days. Because of its duration, moderate to severe chronic pain should be treated with oral opioids rather than repeated injections, especially for children and people who are emaciated by diseases such as cancer and HIV/AIDS. (Human Rights Watch 2011) Cognitive-behavioral treatments: A set of treatments that focus on modifying thinking, motivation, coping mechanisms, and/or choices made by people. (National Institute on Drug Abuse 2016) Continuum of care: An integrated system of care that guides and tracks a person over time through a comprehensive array of health services appropriate to the individual’s need. A continuum of care may include prevention, early intervention, treatment, continuing care, and recovery support. (United States Office of the Surgeon General 2016) Craving: Urgent, seemingly overpowering desire to use a substance, which often is associated with tension, anxiety, or other dysphoric, depressive, or negative affective states. (Substance Abuse and Mental Health Services Administration 2005) Drug: A chemical compound or substance that can alter the structure and function of the body. Psychoactive drugs affect the function of the brain. (National Institute on Drug Abuse 2016) Essential medicines: Essential medicines are intended to be available within the context of functioning health systems at all times, in adequate quantities, in the appropriate dosage forms, with assured quality and adequate information, and at a price the individual and community can afford. The WHO Model List of Essential Medicines (WHOML) is intended to be flexible and adaptable to many different situations; the precise definition of the medicines that are regarded as essential remains a national responsibility. (World Health Organization, Health Action International 2008) Fentanyl: Pharmaceutical fentanyl is a synthetic opioid pain medication, approved for treating severe pain, typically advanced cancer pain. It is 50 to 100 times more potent than morphine. However, illegally made fentanyl is sold through illegal drug markets for its heroin-like effect, and it is often mixed with heroin and/or cocaine as a combination product. (Centers for Disease Control and Prevention 2017) Harm reduction: In the context of alcohol and other drugs, harm reduction refers to policies or programs that focus directly on reducing the harm resulting from the use of alcohol or other drugs, both to the individual and the larger community. The term is used particularly for policies or programs that aim to reduce the harm without necessarily requiring abstinence. Some harm reduction strategies designed to achieve safer drug use may, however, precede subsequent efforts to achieve total abstinence. Examples of harm reduction include needle/syringe exchanges to reduce rates of needle-sharing among injecting drug users. (United Nations Office for Drug Control and Crime Prevention 2000) Hepatitis C: Viral disease of the liver that is the leading cause of cirrhosis in the United States and a particular concern in medication-assisted treatment because of the high incidence of the disease and spread of the infection among people who inject drugs. (Substance Abuse and Mental Health Services Administration 2005) Hospice: A specialist medical facility that provides palliative care. Hospices can be residential or outpatient facilities. (Human Rights Watch 2011)

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Opioids and Public Health: Glossary of Terms

Injection: Taking a substance into the skin, subcutaneous tissue, muscle, blood vessels, or body cavities—usually by means of a needle. (National Institute on Drug Abuse 2016) Injection drug use: Taking drugs directly into blood vessels using a hypodermic needle and syringe. Also called intravenous drug use. (National Institute on Drug Abuse 2016) Life-limiting illness: A broad range of conditions in which painful or distressing symptoms occur; although there may also be periods of healthy activity, there is usually at least a possibility of premature death. (Human Rights Watch 2011) Medication-assisted treatment (MAT): Treatment for opioid use disorder combining the use of medications (methadone, buprenorphine, or naltrexone) with counseling and behavioral therapies. (Centers for Disease Control and Prevention 2017) Methadone: The most frequently used opioid agonist medication. Methadone is a synthetic opioid that binds to “mu” opiate receptors and produces a range of mu agonist effects similar to those of short-acting opioids such as morphine and heroin. (Substance Abuse and Mental Health Services Administration 2005) Morphine: A strong opioid medicine, the gold standard for treatment of moderate to severe pain. Morphine is considered an essential medicine by the World Health Organization in its injectable, tablet, and oral solution formulations. Oral solution mixed from morphine powder is the cheapest formulation. (Human Rights Watch 2011) Naloxone: A prescription drug that can reverse the effects of opioid overdose and can be life-saving if administered in time. The drug is sold under the brand name Narcan® or Evzio®. (Centers for Disease Control and Prevention 2017) Needle-sharing: The use of syringes or other injecting instruments (e.g. droppers) by more than one person, particularly as a method of administration of drugs. This confers the risk of transmission of viruses (such as human immunodeficiency virus and hepatitis B) and bacteria. Many interventions such as methadone maintenance and needle/syringe exchanges are designed partly or wholly to eliminate needle-sharing. (World Health Organization 1994) Neonatal abstinence syndrome (NAS): NAS occurs when heroin from the mother passes through the placenta into the baby’s bloodstream during pregnancy, allowing the baby to become addicted along with the mother. NAS requires hospitalization and treatment with medication (often a morphine taper) to relieve symptoms until the baby adjusts to becoming opioid-free. (National Institute on Drug Abuse 2014) Neuron (nerve cell): A unique type of cell found in the brain and throughout the body that specializes in the transmission and processing of information. (National Institute on Drug Abuse 2016) Non-opioid therapy: Methods of managing chronic pain that does not involve opioids. These methods can include, but are not limited to, acetaminophen (Tylenol®) or ibuprofen (Advil®), cognitive behavioral therapy, physical therapy and exercise, medications for depression or for seizures, or interventional therapies (injections). (Centers for Disease Control and Prevention 2017) Opiate: One of a group of alkaloids derived from the opium poppy (Papaver somniferum) with the ability to induce analgesia, euphoria and, in higher doses, stupor, coma, and respiratory depression. The term opiate excludes synthetic opioids.

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Opioids and Public Health: Glossary of Terms Opioid: Natural or synthetic chemicals that interact with opioid receptors on nerve cells in the body and brain, and reduce the intensity of pain signals and feelings of pain. This class of drugs includes the illegal drug heroin, synthetic opioids such as fentanyl, and pain medications available legally by prescription, such as oxycodone, hydrocodone, codeine, morphine, and many others. Opioid pain medications are generally safe when taken for a short time and as prescribed by a doctor, but because they produce euphoria in addition to pain relief, they can be misused. (Centers for Disease Control and Prevention 2017) Opioid dependence: Physical dependence experienced by a patient treated with opioids over time, such that withdrawal symptoms occur if the opioid is stopped abruptly. Physical dependence is treated by gradually reducing the opioid dose. It is distinct from addiction, a pattern of behaviors including compulsive use of drugs despite harm, which is uncommon in patients receiving opioid pain treatment. (Human Rights Watch 2011) Opioid treatment program: In the U.S., a Substance Abuse and Mental Health Services Administration (SAMHSA)-sponsored program, usually comprising a facility, staff, administration, patients, and services, that engages in supervised assessment and treatment, using methadone, buprenorphine, or naltrexone, of individuals who have opioid use disorders. An OTP can exist in a number of settings, including but not limited to intensive outpatient, residential, and hospital settings. Services may include medically supervised withdrawal and/or maintenance treatment, along with various levels of medical, psychiatric, psychosocial, and other types of supportive care. (United States Office of the Surgeon General 2016) Overdose: Injury to the body (poisoning) that happens when a drug is taken in excessive amounts. An overdose can be fatal or nonfatal. (Centers for Disease Control and Prevention 2017) OxyContin®: Long-acting class II opioid drug usually obtained by prescription for treatment of pain. OxyContin is one of several prescription opioids increasingly obtained by illicit means and abused by people addicted to opioids. (Substance Abuse and Mental Health Services Administration 2005) Pain management: Treatment of acute or chronic pain by various treatment methods, often including administration of opioid medications. (Substance Abuse and Mental Health Services Administration 2005) Palliative care: Health care that aims to improve the quality of life of people facing life-limiting illnesses, through pain and symptom relief, and through psychosocial support for patients and their families. Palliative care can be delivered in tandem with curative treatment but its purpose is to care, not to cure. (Human Rights Watch 2011) Prescription drug abuse: The use of a medication by someone other than for whom it is prescribed, in ways or amounts other than intended by a doctor, or for the experience or feeling it causes. (National Institute on Drug Abuse 2016) Prescription drug monitoring programs (PDMPs): State-run electronic databases that track controlled substance prescriptions. PDMPs help providers identify patients at risk of opioid misuse, abuse and/or overdose due to overlapping prescriptions, high dosages, or co-prescribing of opioids with benzodiazepines. (Centers for Disease Control and Prevention 2017) Primary healthcare facility: A medical facility that a patient will usually attend first in a non-emergency situation, such as a clinic or health care center. Many patients globally only have access to primary-level health care. (Human Rights Watch 2011) Relapse: In drug addiction, relapse is the resumption of drug use after an attempt to stop taking it. Relapse is a common occurrence in many chronic disorders, including addiction, that require frequent behavioral and/or pharmacologic adjustments to be treated effectively. (National Institute on Drug Abuse 2016)

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Opioids and Public Health: Glossary of Terms

Stigma: Negative association attached to an activity or condition; a cause of shame or embarrassment. Stigma commonly is associated with opioid addiction and medication-assisted treatment. (Substance Abuse and Mental Health Services Administration 2005) Substance use disorder: Maladaptive pattern of drug or alcohol use manifested by recurrent, significant adverse consequences related to the repeated use of these drugs or alcohol. The substance-related problem must have persisted and occurred repeatedly during a 12-month period. It can occur sporadically and mainly be associated with social or interpersonal problems, or it can occur regularly and be associated with medical and mental problems, often including tolerance and withdrawal. (Substance Abuse and Mental Health Services Administration 2005) Tertiary hospital: A large hospital at the peak of a hierarchy of hospitals. A tertiary hospital provides all of the major medical services available in a country and admits patients referred from smaller hospitals that provide fewer services. (Human Rights Watch 2011) Tolerance: Condition of needing increased amounts of an opioid to achieve intoxication or a desired effect; condition in which continued use of the same amount of a substance has a markedly diminished effect. (Substance Abuse and Mental Health Services Administration 2005) Withdrawal syndrome (or withdrawal): Predictable constellation of signs and symptoms after abrupt discontinuation of or rapid decrease in use of a substance that has been used consistently for a period. Signs and symptoms of withdrawal are usually opposite to the direct pharmacological effects of a psychoactive substance. (Substance Abuse and Mental Health Services Administration 2005) Wrap-around services: Wrap -around services are non-clinical services that facilitate patient engagement and retention in treatment as well as their ongoing recovery. This can include services to address patient needs related to transportation, employment, childcare, housing, legal and financial problems, among others. (United States Office of the Surgeon General 2016)

SOURCES

Although the terms included in this glossary have been selected from sources believed to be reliable, no warranty expressed or implied is made regarding accuracy, completeness, legality, reliability, timeliness, or usefulness of any information. Appendix C: Glossary. Medication-Assisted Treatment for Opioid Addiction in Opioid Treatment Programs. Center for Substance Abuse Treatment. Substance Abuse and Mental Health Services Administration 2005. https://www.ncbi.nlm.nih.gov/books/NBK64166. Commonly Used Terms in Addiction Science. Media Guide. National Institute on Drug Abuse 2016. https://www.drugabuse.gov/publications/media-guide/glossary. Demand Reduction: A Glossary of Terms. United Nations Office for Drug Control and Crime Prevention 2000. http://www.unodc.org/pdf/report_2000-11-30_1.pdf. Global State of Pain Treatment: Access to Medicines and Palliative Care. Human Rights Watch 2011. https://www.hrw.org/report/2011/06/02/global-state-pain-treatment/access-medicines-and-palliative-care.

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Opioids and Public Health: Glossary of Terms Glossary. Facing Addiction in America: The Surgeon General’s Report on Alcohol, Drugs, and Health. United States Office of the Surgeon General 2016. https://addiction.surgeongeneral.gov/glossary-and-abbreviations.pdf. Glossary. Measuring Medicine Prices, Availability, Affordability, and Price Components. World Health Organization, Health Action International 2008. http://www.who.int/medicines/areas/access/medicines_prices08/en. Glossary. Research Report Series: Heroin. National Institute on Drug Abuse 2014. https://www.drugabuse.gov/publications/research-reports/heroin/glossary. Opioid Overdose: Commonly Used Terms. Centers for Disease Control and Prevention 2017. https://www.cdc.gov/drugoverdose/opioids/terms.html. WHO Lexicon of Alcohol and Drug Terms. World Health Organization 1994. http://www.who.int/substance_abuse/terminology/who_ladt/en.