While the term “existential crisis” sometimes gets overused, it’s no exaggeration in describing the current epidemic of opioid addiction gripping our nation.
The disease of addiction has claimed so many young lives and shows no signs of relenting. Today, overdoses are the leading cause of death in Americans under the age of 50.
In 2005, nearly 15,000 Americans died of an opioid overdose. But in 2015, U.S. fatalities more than doubled to 33,000, with Ohio accounting for 2,700 of those deaths—more than five times the state’s 2005 total.
As an Ohio resident, I see a state reeling from the crisis. News outlets regularly report on Montgomery County, which is tragically gaining a reputation as the “overdose capital of America”. Bodies pile up at the county’s morgue, with the coroner estimating that 60-70% of them are due to opioid overdose.
As a medical toxicologist and emergency medicine physician practicing addiction medicine at Northland Intervention Center in Milford, Ohio, I have witnessed the damage first-hand.
Last month, President Trump declared the opioid epidemic a national emergency, acting on an interim report from the special Commission on Combating Drug Addiction and the Opioid Crisis. Besides recommending the declaration, the commission also proposed several other actions.
In addition to my work at Northland, I also serve as the Editor-in-Chief of Point of Care Content at Elsevier. Our goal is to offer substantial resources that aid in the diagnosis and treatment of addiction and to provide extensive information to families and caregivers of those who suffer from this disease. Between my roles at Elsevier and Northland, I believe I can offer a unique perspective on each of the commission’s recommended actions.
Eliminating barriers to treatment
The commission recommends rapidly increasing treatment capacity and granting waiver approvals for all 50 states to quickly eliminate barriers to treatment resulting from the federal Institutes for Mental Diseases DRAFT 3 exclusion within the Medicaid program. This will immediately open treatment to thousands of Americans in existing facilities in all 50 states.
But the Medicaid program has strict limitations on the coverage of inpatient treatment for mental diseases, preventing many of those suffering from addiction from receiving inpatient treatment. Almost all of my patients have access only to outpatient treatment, leaving many of them to return to dangerous situations and environments every day. The risk of relapse in uncontrolled settings is much higher, and with the emergence of fentanyl and its analogs being mixed with most of the heroin, a single relapse is frequently fatal.
While expanding coverage for inpatient stays is a commendable goal, finding open beds will likely be a challenge. Providing additional money to pay for a service won’t help if there is no access. Most drug treatment inpatient centers have long waiting lists, so perhaps more existing hospital beds could be opened for patients suffering from addiction rather than looking only to dedicated treatment centers. This would require hospitals to increase resources and provide more specialized treatment. More funding will also be required to build additional inpatient treatment centers to meet the increasing demand.
The commission also suggests mandating prescriber education initiatives with the assistance of medical and dental schools across the country to enhance prevention efforts along with mandating medical education training in opioid prescribing and risks of developing a substance abuse disorder. This could be done by amending the Controlled Substance Act to require all Drug Enforcement Administration registrants to take a course in proper treatment of pain. Furthermore, the U.S. Department of Health and Human Services should work with partners to ensure additional training opportunities, including continuing education courses for professionals.
Another commission recommendation is to immediately establish and fund a federal incentive to enhance access to Medication-assisted treatment (MAT) and require that all modes of MAT are offered at every licensed MAT facility and those decisions are based on what is best for the patient. The commission also suggests partnering with the National Institutes of Health and the industry to facilitate testing and development of new MAT treatments.
Medication-assisted treatment has been shown to be very effective when used appropriately, and there is a clear need to increase access to it. However, there are not enough trained and authorized providers to provide what is required. Many of the currently approved providers only administer MAT without providing any of the other services required to increase the chance of long-term sobriety. Primary care physicians with a DEA number can be “trained” to administer MAT and can add revenue to their practices by seeing these patients. The added revenue entices many to participate, but many have no experience in addiction medicine.
I do fear that with an over-reliance on MAT, we are simply replacing “pill mills” of the past with “strip mills” (buprenorphine often is in a soluble strip formulation). If a provider can make a substantial amount of money by seeing patients monthly and refilling prescriptions without ensuring other aspects of treatment, this presents a yet another new problem to solve.
Providing model legislation for states to enact is another commission recommendation. Such legislation would allow naloxone dispensing via standing orders, as well as require the prescribing of naloxone with high-risk opioid prescriptions. This is, as the commission writes, an effort to “equip all law enforcement in the United States with naloxone to save lives.”
In addition to providing naloxone to those at high risk of opioid overdose, the drug also should be readily available to family and friends of those at risk, including known opioid addicts and patients on high-dose opioid treatment. We also need to consider having naloxone available at public places, like airports and shopping centers, as we do for defibrillators. Librarians in Philadelphia describe “drug tourists” overdosing in the restrooms as heroin addicts flock to the city to find more potent drugs. But in response, the city’s librarians are armed with naloxone and conduct overdose drills.
Despite naloxone’s impact, some still oppose its use, particularly multiple doses in a patient who has had multiple overdoses. This is another unfortunate manifestation of a belief that addiction is a moral failing and not a disease. It’s also something we don’t observe in relation to other diseases. If a patient returns to the emergency department multiple times with an exacerbation of emphysema, we don’t limit the number of breathing treatments we give because the patient continues to smoke. Why should the administration of naloxone be any different?
Patience and persistence is required
We need to understand that opioid addiction is a multifactorial problem with multifactorial solutions. This crisis didn’t appear overnight and neither will any meaningful solutions. While President Trump’s declaration of emergency should produce more available resources, let’s hope the resulting action isn’t mired in a tangle of red tape. If there are more bureaucrats involved in the administrative aspects than there are addicts getting help, we are fighting a losing battle.
We must recognize that changing prescribing habits may be beneficial for the future, but unlikely to help those already in the throes of addiction. Educating the public, recognizing that addiction is a disease, and providing access to more effective treatment are all weapons we can use in this fight. We also need to arm ourselves with knowledge about the history of this crisis. At one time, the government mandated more extensive treatment of pain and linked reimbursement to the effectiveness of pain management. Every patient was asked about pain and told to choose a number on a pain scale. The faster that pain was treated, the more hospitals and providers were paid.
The idea that suddenly reversing this attitude will do much to curb our current problem is impractical, at best. If clinicians hadn’t been given such wide latitude in treating pain, things might be different in my state and across the nation. But limiting opioid prescribing has caused the price of prescription opioids on the street to skyrocket as availability decreased. This change in supply and demand hasn’t caused a sudden surge in addicts seeking treatment centers. Instead, it forces them to find a cheaper, more potent, and widely available alternative: heroin. The law of unintended consequences runs rampant when one looks at the history of this epidemic.
There must be increased discussion of alternatives to opioids in the treatment of pain, which can help to decrease the triggering of addiction. Chemical dependency can be triggered by appropriate or inappropriately prescribed medication: The disease of addiction does not know the difference. Unless we can prevent surgery, accidents, broken bones, and other common sources of pain, opioids will be hard to avoid, and without government working efficiently and effectively with physicians, hospitals, social workers, and families, it will be impossible to prevent opioid addiction.
Click the link to read Part 2 of Dr. Dye’s examination of the federal response to the opioid crisis.
Here is a link to other TDWI posts on substance abuse and addiction.