Facing the opioid epidemic An ecosystem approach to a wicked problem

05 April 2017

Six degrees of separation applies to the opioid crisis as well—most people are only a few steps away from someone who’s struggled with addiction. Kevin Bingham discusses the massive amount state and federal agencies are spending to combat this epidemic, as well as the resulting innovative solutions.

The impact and the statistics of what this means to your workforce, to the families that work for you, is pretty critical. All across the country, whether you’re rural or urban, there are people who are being adversely impacted by this.

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TANYA OTT: I’m Tanya Ott, and this is the Press Room, Deloitte University Press’s podcast on the issues and ideas that matter to your business today.

Every day in the United States, 91 people die of opioid overdose.1 That includes prescription opiates and heroin. Over a year, that’s more than 10 times the number of people who died on 9/11.

You know the Six Degrees of Kevin Bacon game? The basic idea is everyone in Hollywood—no matter how famous or fringe—is connected to the actor by six or fewer acquaintances. Chances are your connection to the opioid crisis is even closer. Most of us are only a few steps away from someone who’s struggled.

For me, that connection is a young woman named Cassidy Cochran and her parents Chris and Charla. I’ve known them for years but had no idea what they were going through. The problems started when Cassidy was 15.

CHRIS COCHRAN: She was extremely depressed. She was really upset. And she came to us and said that she needed help. She said she was afraid she was going to hurt herself. So we took her to the hospital, and they put her in a psychiatric unit. The next day, they called Charla and I to come down and speak with them. Cassidy was in the room, and she said that she had been using heroin.

TANYA OTT: What did you think?

CHRIS COCHRAN: I didn't believe it to begin with. I thought that maybe she was just trying to get attention. We went home and took apart her room, pulled the drawers out, and we found just mountains and mountains of evidence, proof that she was telling the truth. And we were literally floored. We just sat there, and we looked at all of the evidence, looked at each other, and we said, “What are we going to do now?”

TANYA OTT: What they did was start a seven-year journey to get Cassidy well. I’d known Cassidy since she was in elementary school. Our kids did community theatre together. Over the years, I watched her ups and downs on Facebook. She finished a month at a residential drug treatment center in Alabama, then they shipped her off to southern Utah, where she spent a year at a therapeutic boarding school. She had counseling, took up meditation, did a lot of rock climbing and hiking.

CHRIS COCHRAN: I think that was probably the happiest time in her life.

TANYA OTT: Not long after leaving the school, Cassidy relapsed. She moved to California, fell in with a group of users, and things fell apart. After a particularly bad overdose, she developed a seizure disorder. I remember seeing photos of her in and out of the hospital. Eventually, she moved back to Alabama, and things were pretty up and down.

CHRIS COCHRAN: November 11 of last year. I was at the house, and it had been a great day, actually. Cassidy had been clean and sober for several months at that point in time. And we talked that day. She seemed to be doing great. While we were on the phone, I got a business phone call and told her I had to go. And I said, “I love you.” And she said, “I love you more.” And I said, “I'll talk to you later.”

That was the last conversation that we had. At about 3 o'clock in the morning, I heard the knocking on the door, and it woke me up. I went downstairs, and it was the police. It's funny how your brain works when I first saw the police officers at the door. I thought, or I guess I hoped, that I had left the parking brake off of my car, and it had rolled down the street. That was my very first thought: “Please let it be something like that.” Then I saw my car sitting in front of the house, so I knew before I opened the door, but I still hoped that it wasn't true. They came in, and they said, “Does Cassidy Cochran live here?” [I was] trying to listen to words, and what I heard is that she's still alive.

TANYA OTT: Because they used the present tense . . .

CHRIS COCHRAN: Correct. So I actually turned from just despair to hope, and I was like, “Oh no, she actually goes with her fiancé.” I guess the other officer could tell that this was not going the way that they wanted it to. So he immediately said, “We're here because she's dead.”

TANYA OTT: Cassidy was 22 years old. When Chris spoke to a local TV station about her death, the post went viral. In the last six months, he’s shared her story with state and national governmental leaders and advocacy groups around the country, hoping to destigmatize addiction. It helps, he says, that she’s not the image of an addict. She was young, from an upper middle-class family, blond hair, blue eyes – a beauty pageant contestant.

But that’s not all that unusual, according to Kevin Bingham. He writes and speaks about opiate addiction, and he says addicts today aren’t just living on the margins of society. They’re your neighbor, your employee, your family. He first took notice of the problem when he was working as an actuary at a large insurance company.

KEVIN BINGHAM: I was starting to see claim files showing that there were workers actually passing away from addictions that ultimately were driven by prescriptions [related to] injuries—and it really got my interest piqued. And you want to do everything in your power to help battle this.

TANYA OTT: These days Kevin’s a principal at Deloitte Consulting LLP. He leads Deloitte’s Claim Predictive Modeling and Medical Professional Liability practices—and he’s written an article titled Fighting the opioid crisis: An ecosystem approach to a wicked problem.

KEVIN BINGHAM: I'll share a couple of statistics. I always like to reference the Centers for Disease Control and Prevention (CDC): Roughly 52,000 Americans die every year, and 63 percent of that pool is from the opiate epidemic.2 If you drill a little deeper, it's amazing to see that, in the US, we've got 5 percent of the world's population, but we consume over 80 percent of the world's opiate supply.3 So you start to dig down, hear about that stuff. As you see more studies being done about the concentration in different counties across the country and the impacts on so many different organizations and governmental agencies, it just blows your mind. You'll see what happens with families and friends and so forth, and that really [gets] to the theme of the article we opened about, the Six Degrees of Kevin Bacon. Unfortunately, opiates has become one degree because pretty much everybody knows somebody impacted by the crisis.

TANYA OTT: Obviously, the health care industry and criminal justice have been on the frontlines of this epidemic. But it's at a level now, as you allude to, that affects a much broader range of folks, and you cite a staggering amount of resources that state and federal agencies are spending to fight addiction.

KEVIN BINGHAM: Yes, it's incredible how much time and energy goes into the prevention [and] treatment, all the different types of topics. But what's been really exciting about that is you'll see in March of last year, the CDC announced some new prescribing guidelines that a number of states have started to pay attention to. You'll see that the surgeon general of the United States actually sent a letter to every prescriber in the nation. If you visit www.turnthetiderx.org, it lists some helpful information about how you use opioids in dealing with crime pain.

There's a lot more going on. If you know SAMHSA, which is the Substance Abuse and Mental Health Services Administration, they pushed a lot of efforts to try and find ways to fight this epidemic. You can now go download applications for your phone that help you understand the epidemic, locate treatment facilities. So there's a lot of good, hard effort going in there to help fight this problem.

TANYA OTT: You mentioned the things happening in states around the country. There have been a lot of measures that states have taken. You've got everything from mandatory prescription drug-monitoring programs—you've got expanded access to the overdose antidote. You’ve got treatment programs for prisoners. Prosecution for doctors who prescribe opioids illegally. It's still a really big problem though, and it's not just a personal problem. It's a problem for workforce and economic development. Give us a sense of how it seeps over into that world.

KEVIN BINGHAM: That is a really important area, because that's actually where part of my journey began. When you think about workers’ compensation, it's all about insuring the workforce and having healthy people in the population. It's known that about one in six unemployed individuals are struggling with a substance use disorder.4 It's really important that we do what we can to help people get back into the workforce, and be healthy and productive citizens. To give an example of why that's so important, when you look at child-welfare and child-support programs, when you have individuals [who] cannot hold a job or struggle with addiction, they are then unable to fulfill their roles—whether they have to make child-support payments, or be part of a productive family and raise their children. So that's why this is so important to really focus on this.

TANYA OTT: You argue that what we really need is a wide-scale integrated solution with lots of different players. Tell me what that looks like.

KEVIN BINGHAM: You really need to involve a number of different players, because doing it in silos is really difficult. So this would be government officials,  folks involved in the criminal justice system, workers that touch children and families. It also would be the hospitals and emergency-room departments that all come together. But you bring that thinking together so that you can make recommendations at all different levels, so you can really come up with a solution that benefits everyone. That's absolutely critical. We don't want siloed solutions.

TANYA OTT: How is that different than the way things have been the last 5 or 10 years?

KEVIN BINGHAM: I think, if you go back 10 years or so, this problem really has emerged, and the number of efforts that we'll see across the country with governors and task forces has really helped this. But, I think in the early days, people were just struggling to deal with it as the epidemic broke, and people finally started to realize and treat this as a disease. So I think the solutions originally were more siloed.

TANYA OTT: Anytime you bring together a whole bunch of stakeholders or a whole bunch of people who are interested in a topic and dealing with an issue like this, you're bound to get some really great ideas that bubble up out of that. But you're also very often going to have people who see the root of the problem as being different, who see the best way to address it as being different. How do you square all of those different perspectives when you're trying to work in this larger ecosystem?

KEVIN BINGHAM: Yes, you're absolutely spot on. As you bring a lot of people together, the areas where people want to focus will definitely be different. Some folks will be really excited about prevention. Some may be focusing on the back end, which would be treatment and helping people in recovery. There's also the enforcement issue, and is there a way to take individuals who may be in the prison system and help them get out and get them treatment? So what you need to do is have a pretty open dialogue and try to figure out ways that you can balance some of these, because everything is pretty much controlled by the amount of funding or resources you have to tackle the problem. You've got to get a balancing act. It's not easy, but I think as you've seen with different state efforts, they then can put together a long list of strategies and hopefully then do different types of partnerships, maybe public-private, to then take action on these and have success.

TANYA OTT: And there are, of course, people who would argue that given the political climate right now, it's even more challenging

KEVIN BINGHAM: That is true. But at the same time, one thing that I've seen unite politicians across the country is the topic of the opiate epidemic. There are a lot of great quotes from different governors. I do remember some in the northeast who really talked about how they didn't go into being or running for governor with this topic in mind, but every meeting, every county they went to, this was a top issue on the minds of people coming up and sharing stories. So I think this is the one area that unites everybody, because, at the end of the day, we want to prevent opiate dependency and addiction before it ever happens. So that is something that I'm encouraged by: At the end of the day, everybody has, I think, the same mission in mind, which is to end this.

TANYA OTT: You talk about some of the innovation that can come out of this idea of bringing lots of different players together. One of the things that I thought was really interesting is using analytics. Using workers’ compensation claims as advanced detection tools: That’s kind of interesting.

KEVIN BINGHAM: I know. That's a great topic. Recently in the Wall Street Journal5and also in the claims magazine Insurance Journal,6 they shared stories of how the workers’ compensation industry has been ahead of the curve because they're using analytics to help better guide and get physicians who were treating injured workers to think about the potential risks of opiate addiction. You can build models that help you identify who's potentially likely to take an excess amount of opioids over the course of their treatment and try to push them towards options that will be non-opiate alternative, so you avoid that risk of addiction. More importantly, with the way some of the regulations are going, you prescribe a proper amount of opioids that would be in line with the CDC guidelines. New Jersey just passed a law that really limits [prescriptions] to five days for some of the non-chronic pain [conditions].7

TANYA OTT: What are some of the other really innovative things that you're seeing that have you kind of excited?

KEVIN BINGHAM: I've also seen pain clinics. An example will be a large pain clinic in Tennessee where they have been actively pushing to stop the use of opiates, and they're recognizing that switching to alternatives is a good way to go, and there are a lot of options. So they're trying to fight the epidemic that way. There's a New Jersey emergency room that basically has now decided to use opioids as a last resort. They've recognized that opiates can be ground zero for potentially leading to some addiction habit. So what they're trying to do for things like migraines and kidney stones and fractures and that stuff is really focused on opiate addiction. I think that's really exciting. Then some other things that states are using now finally, as well as some of the health care plans, is: Let's analyze the data that's out there on prescribers and get a better feel, for example, geographically if a physician or urgent care center is treating somebody, and they're coming from a 150 or 200 miles away, maybe we should look into that a little more because that doesn't really seem to make sense.

TANYA OTT: So actually looking at the geography, there might be something a little hinky going on there.

KEVIN BINGHAM: Absolutely. You can use anomaly detection or outlier detection and say, listen, you've got an urgent care center where most people are coming from 100 or 150 miles away, when you and I know that if our child tripped and fell, we're not going to drive 150 miles. We're going to go to the closest clinic around us. Analytics are being used to really research if an urgent care center or a physician is acting in a way that would be—I think the old term is—a pill mill.

TANYA OTT: This is one of those issues that has evolved over the years, because you can do the carrot, or you can do the stick. For a long time, they were doing the stick, it was very law-enforcement based. Mow there seem to be some attempts at carrots: paying for success, prize-based challenges.

KEVIN BINGHAM: In terms of prize-based challenges, there's a lot of great efforts out there. One that came to mind for me is the Substance Abuse and Mental Health Services Administration. They put out a couple of opiate-related apps challenges. They went out to the development community and were trying to get people to focus on how can you develop apps that people could put on PDAs to become educated. They had an app challenge where they were looking at people to build a product that could educate users, show them what recovery time is, where they could get support, and so forth. Another one was a prevention app that really focused on some of the five essential steps that responders use. They're really powerful because they share this [app] with the caseworkers. You can have this on your phone. You can bring up information; you can actually help locate where these folks can go get treatment right on your PDA.

TANYA OTT: Thank you, Kevin Bingham, for your time. We really appreciate it.

KEVIN BINGHAM: Thank you as well. Have a wonderful day.

TANYA OTT: Traditionally, the opioid addiction problem has fallen on the shoulders of government agencies, community groups, and health care providers. But corporate America is starting to take notice. Perhaps that shouldn’t be surprising. The economic cost is overwhelming, for society at large and for individuals like Chris Cochran. He says he spent more than $100,000 trying to get his daughter Cassidy clean.

CHRIS COCHRAN: I can't tell you how much time I personally missed from work just trying to help my daughter survive. And I'm not the only one. It's more than lost productivity. It's lost income, it's taxes, it's money that could be spent in other areas that are being spent on treatment and sometimes wasted on treatment, because the treatment is not effective, and it hasn't ever been proven effective.  There's a saying that if you keep doing the same thing over and over and over again, and you want a different result, that's a sign of insanity. Well, I would say the same thing is true for those of us who are trying to help people that have substance use disorder. If we keep trying the same thing over and over to get them better, and it's not working, then we need to try something different.

TANYA OTT: Deloitte’s Kevin Bingham writes about some of the ways government, corporations, the tech industry, and others are tackling the problem in his article Fighting the opioid crisis: An ecosystem approach to a wicked problem. It’s at dupress.deloitte.com, along with a huge archive of podcast episodes about issues that will affect your bottom line. I’m Tanya Ott for the Press Room. Have a great day!

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