Last month, multiple news outlets reported on the dangers of rainbow fentanyl and how these brightly colored pills targeted teens and young adults. Fentanyl is both highly addictive and deadly, and the story speaks to America’s ongoing overdose epidemic, which has claimed over a million lives since 1999.

The opioid epidemic affects both urban and rural America and engenders bipartisan attention in both the House and the Senate. Multiple pieces of legislation hoping to curtail the opioid crisis sit before Congress. For the first time in several years, there is a bill with bipartisan support that may become law: The Non-Opioids Prevent Addiction in the Nation (NOPAIN) Act (S. 586 / H.R. 3259).

Bipartisan support in a divided Congress

Originally cosponsored by Senators Shelley Moore Capito (R., W.Va.), Jeanne Shaheen (D., N.H.), Rob Portman (R-Ohio), and Joe Manchin (D., W.Va), the bill now has 49 cosponsors in the Senate. Similarly, the House version of the bill was originally cosponsored by Terri Sewell (D., Ala.), David McKinley (R., W.Va), Ann Kuster (D., N.H.), and Brian Fitzpatrick (R., Pa.) and now has 114 cosponsors. West Virginia, Ohio, and New Hampshire have suffered the most in the opioid crisis, with West Virginia leading the nation at 81.4 deaths per 100,000 people in 2020.

West Virginia led the nation in drug overdose rates per capita. Pennsylvania, Kentucky, Ohio, Tennessee, Maryland, Delaware, and Louisiana follow the Mountain state in drug overdose mortality rates. Data reflects state-reported mortality statistics for 2020. (Source: CDC)

The scope of the opioid crisis

In 2012, more than 255 million prescriptions for opioids were dispensed in the United States, nearly enough for every American over 18 to have a prescription. While that number fell to 142 million prescriptions by 2020, overdose deaths remained alarmingly high. In 2021, the Centers for Disease Control and Prevention (CDC) estimated that over 107,000 Americans died of a drug overdose over a 12-month period, with three-quarters of those deaths from opioids. That would mean an average of 220 Americans died from an opioid-related drug overdose every day in that time.

For many patients, the road to addiction starts innocently enough after undergoing routine surgery. Approximately 51 million Americans undergo inpatient surgery annually, and over 80 percent of patients receive opioids after low-risk surgery, usually oxycodone or hydrocodone. An estimated four million Americans will begin long-term opioid use following such procedures. The NOPAIN Act rewards physicians for prescribing non-opioid treatments instead of opioids after treatment.

What does the NOPAIN Act do?

The NOPAIN Act temporarily establishes separate payments for specific non-opioid treatments under the Medicare prospective payment system for hospital outpatient department services and the payment system for ambulatory surgical center services. The bill applies to pain management treatments that can replace or reduce opioid consumption demonstrated through clinical trials or data.

Researchers from the University of Michigan, the Department for Veterans Affairs, and the CDC assessed patterns in non-opioid pain medication prescribing after the publication of the 2016 CDC guidelines for prescribing opioids for chronic pain. Their findings noted modest increases in non-opioid medication prescription after 2016: 3.0 percent increase in post-guideline year one; 8.7 percent in post-guideline year two; and 9.7 percent in post-guideline year three. Although modest, the results showed steady improvement over time.

While alternative forms of legislation seek to co-administer overdose reversal agents like naloxone–commercially known as Narcan–with opioids, such actions only manage the problem rather than trying to curtail its onset.

Common flaws in opioid legislation

In June, Reps. French Hill (R., Ark.) and Debbie Dingell (D., Mich.) introduced the Preventing Overdoses and Saving Lives Act 2.0, which would require co-prescribing opioid overdose reversal drugs alongside prescriptions for opioid-based painkillers. While the intent behind this legislation is admirable, the bill assumes that continuing to prescribe opioids at such high rates is best for patients. Even with overdose reversal drugs like Narcan co-administered, the patient’s opioid addiction still exists.

The second flaw in this approach is that it has been tried in the past to little avail. In the last decade, Congress dedicated millions of taxpayer dollars to combat the opioid epidemic, but deaths continued to climb. That money supported first responders, increased access to treatment for substance use disorders, and ensured widespread availability of Narcan.  Despite these efforts, record-breaking numbers of Americans die yearly from opioid-related drug overdoses.

What does Narcan do?

Narcan rapidly reverses the biological effects of an opioid overdose. Naloxone acts as an opioid antagonist, meaning that it attaches to opioid receptors in the body and blocks opioid molecules from binding to the receptors to induce a reaction. When opioids bind with cell receptors, their physiological effects lead to slowed breathing and a depressed respiratory system that can lead to death, as opioids affect the part of the brain that regulates breathing. By blocking cell receptors from opioids, naloxone can restore normal breathing to a overdosing person if their breathing has slowed or stopped.

Naloxone helps reverse the effects of an opioid overdose. Working as an antagonist, naloxone prevents opioids from attaching to receptors in the brain that regulate heart rate and breathing. The result is that patients do not die from heart or respiratory failure. (Source: Partners for Prevention in Allegheny County)

Rural areas suffer disproportionately from opioid epidemic

Using the Census Bureau's definition of rural–an area with fewer than 50,000 people–approximately 19 out of 100 people live in a rural areas in the United States. In 2017, the rate of drug overdose deaths in rural areas surpassed that of urban enclaves. According to the CDC mortality data, deaths from unintentional injuries–such as drug overdoses, falls, or motor vehicle accidents–are 50 percent higher in rural areas. From 1999 to 2015, the opioid death rates in rural areas quadrupled among those 18 to 25 years old and tripled for female rural residents.

In rural areas, the lack of economic opportunity, social isolation, and boredom may lead Americans to illicit opioid use. But for many others, the innocuous start of taking pain medication after surgery leads to a dangerous spiral.

September was National Recovery Month to honor those lost and celebrate the 22 million Americans in recovery. The NOPAIN Act may help to steer providers and patients away from opioid prescriptions whenever possible.