The opioid crisis is a wicked problem

Wicked problems are endemic complex systems with components that interact in complicated, poorly understood and unpredictable ways. Interventions into the system produce downstream consequences that cannot be known in advance and cannot be undone. It is impossible to establish a single locus for a wicked problem because changing one element of the system changes the dynamics of the entire system. The wicked problem definition changes depending on both the focal point of interventions and the responses that any proposed solution generates. The opioid overdose epidemic meets the criteria for a wicked problem. According to the Centers for Disease Control and Prevention (CDC), the number of overdose deaths involving opioids quadrupled since 1999. From 2000 to 2015, more than half-a-million people died from drug overdoses. Ninety-one Americans die every day from an opioid overdose. On October 26, 2017, President Donald Trump directed the Department of Health andHuman Services to declare the opioid crisis a public health emergency. To gain a broader, multiple stakeholder perspective on defining and tackling the opioid crisis, I consulted with Omar Manejwala, MD, MBA, Senior VP and Chief Medical Officer of Catasys. According to Dr. Manejwala, no simple solution will work. Those who advocate for reducing opioid prescribing fail to see the Ohio experience where opioid use simply went underground or shifted to illicit drugs. Those who advocate for no adjustment to opioid prescribing fail to see the correlation between prescribing and overdoses observed in many communities. Those who argue that this is purely a problem of social determinants of health fail to see the overdose and addiction rates in affluent communities. Those who argue that medication assisted treatment (MAT) will solve the problem fail to see that most patients who are prescribed MAT do not continue it, and in fact relapse to opioids. Buprenorphine is a tool, but it will no more solve the opioid overdose epidemic than antihypertensive medications have solved the hemorrhagic stroke problem engagement of the patient is key. Those who push an access-to-care argument fail to see that access is just the first step we need appropriate utilization of resources. Those who are going after the “opioid crisis” fail to see that over 50% of opioids in the US are prescribed to people with mental health conditions and unless we treat those underlying mental disorders, we cannot solve this problem. Ultimately, we need solutions with shared value creation that combine sensible prescribing, social determinants of health, decriminalization, evidence-based interventions including MAT, and treatment of comorbidities. Most importantly, innovative engagement strategies such as community care coordinators, telephonic coaching, and digital apps are necessary to attract patients to care, develop trust, form partnerships, and support long-term recovery.