On October 26, President Trump addressed the nation about the opioid crisis, officially declaring the so-called epidemic “a national public health emergency under federal law.” Showing how little he understands about addiction, Trump asserted that, based on his own experience of never having had a drink, “If we can teach young people – and people, generally – not to start, it's really, really easy not to take [drugs.]”
Although in Part 1 and Part 2 of this series, I shared evidence that just a small percentage of people prescribed opioid painkillers become addicted to them and that they are not the main driver of the current crisis, the truth is that it’s relatively easy to start using drugs (alcohol included) and, more often than we’d like, to become addicted to them. In the case of opioid medications, they ease physical pain and can make you feel relaxed and euphoric. According to the National Institute on Drug Abuse, opioid medications can produce a sense of well-being and pleasure because they affect brain regions involved in reward. They act by attaching to specific proteins called opioid receptors found on nerve cells in the brain, spinal cord, gastrointestinal tract, and other body organs. Over time (with opioids, it doesn’t take very long), when used repeatedly, tolerance can develop resulting in the need for a higher dose to get the same effect. When used for pain management, physiological dependence on such drugs is not the same as “addiction” or an opioid use disorder (OUD), the latter caused by intentional misuse of the drugs.
The same phenomenon can take place with illicit opioids such as heroin, which as noted in earlier articles in this series and in a VICE article by Maia Szalavitz, is not usually started by individuals “innocently” using opioids prescribed to them. Her article opens with, “Just like they did in the 80s, Americans are increasingly going straight to heroin, skipping prescription opioids. Too bad US policy doesn't reflect that.” She notes that the government’s focus on prescription drugs is off the mark because they are not currently driving the opioid crisis.
What Can Be Done?
An entire book could be written about what can and should be done about the opioid problem. In addition to the recommendations of the recently released President’s Commission on Combating Drug Addiction and the Opioid Crisis, we now have numerous U.S. government agencies (most housed within the Department of Health and Human Services or HHS), including the Centers for Disease Control and Prevention, Food and Drug Administration (FDA), Substance Abuse and Mental Health Services Administration (SAMHSA), National Institute on Drug Abuse, as well as the National Academy of Sciences that have set forth recommendations and goals for countering the opioid crisis.
I was told by a spokesperson that all the agencies have the same endgame, but different ways of going about it and collaborating with each other. A number set forth their efforts in testimony to HHS this past October.
Following Are Just Some Considerations:
- Make medications for opioid use disorders (OUDs) more accessible.
The good news is that we have some of the best treatments available for opioid use disorders in comparison to other types of addictions. For instance, the medications methadone and buprenorphine (most commonly known as Suboxone) normalize brain chemistry, block the euphoric effects of opioids, and relieve drug cravings. A large body of scientific literature shows that these medications decrease death rates related to opioids, increase treatment retention, and lower the risk of relapse as well as illnesses such as HIV and hepatitis C. Naltrexone is another medication used for OUDs. Unlike methadone and buprenorphine, which activate opioid receptors in the body that suppress cravings, naltrexone binds and blocks opioid receptors, thereby blocking the euphoric and sedative effects of opioids. In comparison, we have no approved medications to help people addicted to methamphetamine or cocaine.
Access is a major problem with medications for OUDs. According to the President’s report, a 2017 survey of physicians indicated that prior authorization requirements by third party payers were the most commonly reported barrier to prescribing these medications. Another barrier, most patients on methadone have to go daily to a clinic to get their dose. And many areas of the country have no nearby methadone clinics. As for buprenorphine – which can be prescribed in a primary care setting and requires far fewer medical visits – not only is there a shortage of prescribers, but doctors are underusing it. (Physicians are required to complete only an eight-hour training to qualify for a waiver to prescribe and dispense buprenorphine.) It’s believed that slow adoption of these important remedies is partly due to misconceptions about substituting one drug for another as well as discrimination against patients who use these medications, despite state and federal laws clearly prohibiting it. (For instance, many sober living facilities and even a number of rehabs will not accommodate people on these medications.)
- Provide better education for physicians and other medical personnel about both pain management and addiction.
Earlier parts of this series addressed how the recommendations in the CDC guideline for prescribing opioids for chronic pain are being taken as mandates when, in fact, they are just suggestions. The result is that many chronic pain patients are suffering and some are even taking their own lives. I witnessed a physician deny even a weak opioid to a recently sober (from alcohol) patient in terrible pain because of her “addictive personality,” when in fact there is no such thing.
Also, it’s not true that people addicted to one substance are “cross addicted” to all addictive substances. In September, the FDA announced that training be made available (not required) to health care providers who prescribe immediate-release opioids, including training on safe prescribing practices and consideration of non-opioid alternatives. FDA’s new Opioid Policy Steering Committee is also considering whether there are circumstances when the FDA should require some form of mandatory education for health care professionals concerning such issues as making certain that doctors are properly informed about appropriate prescribing recommendations.
- Provide more and better treatment for people with substance use disorders, including OUDs.
In my book, Inside Rehab, I address the many shortcomings of the addiction treatment system in this country – from failure to use evidence-based treatment methods to relying on inadequately trained counselors. (To become a credentialed substance abuse counselor in some states, the minimum requirement is just having a high school diploma [or GED] or an Associate’s degree.)
In Szalavitz’s VICE article, mentioned above, she discusses research suggesting, “Early life stress, trauma, and mental illness – not the first drug someone happens to try – are the real gateways to addiction… If America doesn't address why people find opioid escape so compelling right now, cutting the supply of medical drugs with known strength and purity may just push users to more dangerous and unpredictable street substitutes like fentanyl.” As such, good treatment involves truly providing treatment of co-occurring psychological disorders, which occur in many (if not most) who enter treatment, including for OUDs, by qualified mental health professionals.
According to Stanford University’s Mark McGovern, PhD, a psychologist and leading expert on co-occurring disorders, many addiction treatment facilities say they treat “co-occurring disorders” or are “dual diagnosis,” even though this really doesn’t reveal much of anything. He explained that most of what we know about the treatment of co-occurring substance use and mental health disorders comes from information that addiction treatment programs report about themselves in national surveys. His research suggests that both addiction and mental health facilities tend to see themselves as more capable of treating people with co-occurring problems than they actually are. One woman I interviewed who had experienced terrible childhood trauma told me she specifically asked a famous rehab she was considering if they offered EMDR, an evidence-based treatment for trauma. The answer was affirmative but in order to receive EMDR, several weeks into treatment, she had to advocate for herself in order to receive it.
- Provide better insurance coverage and access to alternative approaches to pain.
Consider mindfulness for pain relief. A recent meta-analysis revealed that although pain intensity is not affected by this intervention, perceived pain control is significantly improved. But good luck finding a mindfulness program or professional in a rural area or getting your insurance company to pay for it.
A recent New York Times article pointed out that insurers tend to restrict payment for painkillers that are less addictive but more expensive than routinely prescribed opioids. An example is Butrans, a painkilling skin patch that contains buprenorphine – not only used for people recovering from OUDs but also for pain relief. Knowing about evidence that yoga can help chronic back pain, I signed up for group classes, which I had to quit because many of the exercises hurt my back. Do you think my insurance company would pay for individual yoga sessions designed for me because of my back problems?
The Cost of Fighting the Opioid Crisis
I could go on and on with a much longer list including the need for better distribution of naloxone (a life-saving medication to reverse opioid overdose) and the importance of educating people not to mix drugs that increase the risk of overdose. But all of the things necessary to reverse the opioid problem cost a lot of money.
We’ve been here before. The powers-that-be should take a look at the evidence that anti-drug ads don’t work and may even have the opposite of their intended effect.-Anne Fletcher
In a recent NPR interview with US Surgeon General Jerome Adams, the commentator stated that Patrick Kennedy, a former Congressman who served on the White House Opioid Commission, suggested that it would take at least $10 billion to fight the opioid crisis. She asked Dr. Adams if he expected the president to ask for that money from Congress.
His somewhat vague response was that the president has asked Congress for “a significant amount of money in his pleas to Congress” and that partnership with multiple parties, including business and law enforcement communities as well as state and local government are needed. The truth is that it’s unclear where the money would come from.
So far, I’ve heard lots of talk about advertising campaigns. As recently reported in The Hill, Trump said, “One of the things our administration will be doing is a massive advertising campaign to get people, especially children, not to want to take drugs in the first place because they will see the devastation and the ruination it causes to people and people's lives.” We’ve been here before. The powers-that-be should take a look at the evidence that anti-drug ads don’t work and may even have the opposite of their intended effect. As noted in a Popular Science article on this topic, “When anti-drug ads say ‘don't do drugs,’ they inherently bring up the implicit question ‘should I do drugs?’” I guess we’ll have to wait and see how big a dent Trump’s ad campaign, which certainly won’t be cheap, makes in the opioid crisis and hope that other sources of funding are found to help the people who are in dire need of help.
Additional Reading: The Opioid Crackdown: Have We Gone Too Far? (Part III)
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