Today, 120 people will lose their life to a drug overdose -- to put that number in perspective, it is the about equivalent to a fatal airplane crash happening every day. Unfortunately, this devastating epidemic is not new -- it has been growing for at least a decade. What is new is that there is at last strong, sensible, non-partisan action at hand.
Last week, President Barack Obama addressed the nation about the epidemic of opiate addiction and related overdose deaths. Speaking from West Virginia, a state that has seen a target five-fold increase in heroin overdoses in the past five years, President Obama reminded us all that addiction is a disease that does not discriminate.
I applaud the president for publicly acknowledging the discrimination and "treatment gap" that have prevented so many families from getting lifesaving treatment for their addicted loved ones. Last week's forum was an indication that our federal leadership gets it; that they are not waiting for the "silver bullet," and they now have the top-level leadership that will require and empower them to address these significant but solvable public health problems. There is finally direct, non-partisan, research-proven plan of action to reduce the twin epidemics of opioid overdose deaths and addiction that have put the public at a crisis point.
As a 40-year researcher in the field of addiction, a short-term policy maker in federal drug control and a parent who has lost a son to overdose, I am taking this opportunity to explain the rationale behind the three priorities outlined by the president's team -- and why they are so critical for reducing overdose and addiction.
Priority 1: Increase Access to Medical Assisted Treatment (MAT)
Recommended ACTION: Stop licensing and funding treatment programs that offer only parts of the effective care continuum
There has been an enduring misunderstanding about the nature of the devastating "condition" of opioid addiction. Given the often irresponsible and dangerous behaviors of those addicted, it is understandable why for so long, most viewed opioid addiction as a series of bad choices resulting from poor parenting, or a dissolute, antisocial lifestyle. Science has now shown that the drug seeking behaviors of addicted individuals are no longer driven by the same level of judgment and voluntary control as when the opioid use originally started -- explaining why punishment alone rarely reduces the addiction.
There is a need for interventions that will change the brain function of an individual with an addiction. And there are effective medications, behavioral therapies, social services and monitoring practices that, if properly applied and sustained, can significantly reduce substance use and improve health and social function even among the most serious cases. We know enough to make recovery an expectable result of modern, comprehensive, continuing care.
But one of our biggest obstacles is recognizing that most existing drug treatment "programs" were never designed, organized, or funded to provide the type of comprehensive continuing disease management that is needed. There are very few programs that can provide most of the evidence-based clinical practices.
No state government wants an antiquated, disjointed, uncoordinated, ideologically rigid care system. But by repeatedly licensing and providing funding for programs that can only give partial care has inadvertently fostered and maintained just such a system. It does not have to be this way.
Suppose the state licensing and regulatory agency -- the primary purchaser of care -- announced that they will license and fund only programs that have the capability to provide the full range of evidence-based care. What if organizations able to provide the full continuum would get the highest rates, with lower rates for partial care programs? Or even better would be to provide financial incentives to care systems conditioned on their ability to attract, retain and demonstrably reduce the substance use of their addicted patients. Those provisions could promote the reorganization and delivery of the same kind of continuing, personalized care management that is now routinely offered to patients with other chronic illnesses.
Priority 2: Change Prescribing Practices
Recommended ACTION: Require medical, nursing and pharmacy schools to train students on substance use disorders.
Because substance use disorders have never been perceived, treated or insured like other illnesses, very few contemporary physicians, nurses or pharmacists have been trained in this area. This lack of training may explain why 20-50 percent of existing patients in most health care systems have substance use problems that go undetected and untreated. The results of this failure to educate our health care professionals have been expensive (about $120 billion dollars annually in wasted or misapplied health care) and a significant cause of poor quality in the care of the many illnesses affected by excessive substance use -- particularly all chronic illnesses. (J. Paul Steale, et al., 2010; Soteri Polydorou, et al., 2008)
Getting a course in substance use disorders into any medical school is as much a political process as it is a clinical or scientific one. So bringing about educational change will require a very significant incentive. I suggest applying additional requirements to the federal scholarships to students attending medical, nursing and pharmacy schools -- such that they could only be used in schools with at least a one-semester course in substance use disorders. This curriculum incentive change wouldn't be designed to produce more "addiction doctors" -- but rather to produce better doctors (and other health care professionals).
Priority 3: Increase Access to Naloxone
Recommended ACTION: Make naloxone more available to physicians and first responders - but ultimately to the public.
Any opioid (legal or illegal), when taken at a high enough dose can produce respiratory depression sufficient to stop breathing. Overdosing individuals may look like they are simply sleeping but they are gradually losing oxygen and dying. Overdoses do not happen only to addicted individuals. In fact overdoses are less likely to happen to addicted individuals than to those who have just begun to use opioids, or are taking opioids in combination with alcohol or another drug that also produces respiratory depression. This is because addicted individuals have become tolerant to most opioid effects.
Naloxone is an opioid receptor blocker -- it prevents any opioid from reaching the brain's opioid receptors and producing respiratory depression. The medication is not expensive compared with most other drugs, has very few side effects, and is available in pill, injection and nasal spray form. When administered to an opioid-induced, unconscious person, the medication produces immediate reversal of the respiration depression and the individual literally comes back to life. The medication has been used in many medical contexts for over 50 years but for many ideological, political and budgetary reasons, it has not been unanimously accepted or available.
Some action has taken place, and now that agencies are beginning to determine it is safe for broad use, there is hope. By providing proper instructions, individuals and family members can now have an on-hand tool to intervene in an emergency.
There are many good policy ideas out there and even more ideas should be tried. But these are a damn good start. The critical issue now is action -- collaborative, cross-agency action to move beyond strategy and beyond press awareness to the broad delivery of these sound, science-based steps. If these three steps provide even half their potential impact -- it will give what the government and the public at large needs most -- the confidence and hope that can fuel an even more comprehensive effort to reduce the harms, costs and tragic losses produced by opioids and other drugs of abuse.
Need help with substance abuse or mental health issues? In the U.S., call 800-662-HELP (4357) for the SAMHSA National Helpline.