medical bottle and pills on background (DimaSobko)
Amid a prescription opioid abuse and heroin use epidemic largely fueled by overprescribing among doctors, President Obama has suggested allocating $1.1 billion to expand affected individuals’ access to care— a proposal that has garnered bipartisan support. Although some experts question whether throwing money at the issue will be enough, many believe that, if used properly, the funding has the potential to save lives.
According to the Centers for Disease Control and Prevention (CDC), nearly half a million Americans died from drug overdoses between 2000 and 2014. Opioid overdose deaths, including those from heroin, hit record highs in 2014 and saw a 14 percent increase in only one year.
Baltimore City Health Commissioner Dr. Leana Wen, who has worked as an emergency room doctor in one of the nation’s opioid addiction hotspots, said the proposal signals a shift in thinking about addiction as an individual’s problem best controlled with law enforcement, to a chronic medical condition like diabetes or heart disease that can be prevented and treated.
“That science has been around for decades, and society’s perception has caught up,” Wen told FoxNews.com.
“A pill for every pain”
In 2014, 259 million opioids— or enough for every American adult— were prescribed, according to the CDC. The most commonly prescribed opioid pain relievers were natural or semi-synthetic opioids like oxycodone and hydrocodone, which are involved in the most overdose deaths among opioids. The CDC recorded 813 more deaths, a 9 percent increase, from these types of opioids in 2014 than 2013.
Over the last decade, overall deaths resulting from opioid abuse and abuse of illegal narcotics like heroin have quadrupled.
A study published in the November 2015 issue of the journal Proceedings of the National Academy of Sciences suggested overdoses from drugs like opioids is one of the main reasons why deaths of middle-age white Americans are rising while the overall death rate in the United States has fallen.
“There are people in suburban and rural areas who are dying of overdose,” Wen said. “Unfortunately, it’s taken this level of people dying to get us to where we are, but I do think a sea of change is occurring, and we are seeing how overdose kills.”
Although multiple factors have contributed to the epidemic, Wen and other experts have argued that a culture of “a pill for every pain” has played a key role.
Dr. Melinda Campopiano, a medical officer at the Substance Abuse and Mental Health Services Administration (SAMHSA), who both prescribes opioids and treats patients who have become addicted to them, said when she was in medical school in the ’90s, professors taught students using the sickest of patients. That approach may have skewed the risk-benefit factor for stronger drugs like opioids versus over-the-counter medication like nonsteroidal anti-inflammatory drugs (NSAIDs) or acetaminophen, she said.
An assumption at the time that pain was undertreated in America overall led many doctors to readily prescribe opioids as it was.
Campopiano added that the trend of overprescribing opioids may also have emerged from a well-intentioned effort to standardize care across the board. At that point, evidence emerged that pain in minorities particularly was being undertreated—a bias that data suggest still affects minority and less-wealthy patients today.
“You want professionals to overcome their inherent biases, but you can’t count on that, so by being systematic in treating pain, the intention was to eliminate the suffering that was the result of racial and ethnic biases that people had,” Campopiano told FoxNews.com.
That systematic approach persisted through the 1990s and 2000s, and was accompanied by a push from the federal government for doctors to better address their patients’ pain in its “Pain as the Fifth Vital Sign” campaign. Researchers at Brandeis University, New York University and others, argued in the January 2015 edition of The Annual Review of Public Health that Big Pharma’s campaign throughout those decades downplayed the risks of long-term opioid abuse and encouraged their use. In 2007, OxyContin producer Purdue Pharma paid $634.5 million in fines for harmful advertising of the drug.
Data shows opioids are among the most addictive drugs on the market. Although experts dispute their efficacy for chronic pain and there’s no perfect pill for every type of pain, the drugs change the way the brain and nervous system respond to pain, generating a euphoric or relaxing effect. But the longer and more frequently an individual takes an opioid, the more they’ll need to take to get the same sense of relief.
Despite increased public knowledge of opioids’ risks, ideals pushed by Big Pharma and the federal government still persist in doctors’ offices. All too often, doctors don’t offer patients alternatives to opioid prescriptions, nor do they always ask about their mental health or addiction history, Campopiano said. Patients want to get better and trust their doctors, so they often don’t challenge their judgment.
“A big downfall in provider education is we don’t teach health professionals to ask about and address mental health and substance use disorder issues consistently and effectively,” Campopiano said. “On that side of the issue, I would include informed consent of patients so that patients have the opportunity to make fully informed decisions about their treatment options.”
Educating the public about opioid risks
In May 2015, the CDC urged doctors to prescribe fewer painkillers and encouraged patients to ask questions themselves about alternatives.
Another question some doctors may not ask is what other drugs patients are taking. One out of every three unintentional deaths involved a harmful combination of opioids and benzodiazepine, a medication that can help relieve everything from muscle spasms to anxiety and sleep problems, Wen said.
The U.S. Food and Drug Administration (FDA) has already added a boxed warning, the most serious type, to immediate-release opioid painkillers, but it hasn’t yet added warnings to benzodiazepines and opioids to warn doctors and the public of their harmful reactions. Wen and other health officials have petitioned the FDA to do so.
Prescription drug monitoring programs (PDMPs), which are used in 49 states, can help doctors monitor what their patients have been prescribed, effectively helping prevent patients from experiencing harmful drug reactions or racking up pills.
The CDC considers them one of the most effective tools for preventing opioid abuse, but states haven’t yet fine-tuned these systems.
"There isn't yet a single state in the country that has an optimal prescription drug monitoring program that works in real time, actively managing every prescription," CDC director Dr. Tom Frieden said in a press conference in March.
Brendan Saloner, assistant professor of health policy and management at Johns Hopkins Bloomberg School of Public Health, said states could use the proposed funding to better integrate pre-existing programs like these.
“What we have now is not really a system so much as a fragmented network of specialty providers who oftentimes don’t work that well with physical health providers, with human service providers, and with the criminal justice systems— all of these entities that we know are very closely aligned with these populations,” Saloner told FoxNews.com.
He added that one of the administration’s most promising propositions for the funding would be to subsidize physician training in areas of need.
If passed, Obama’s proposal would allocate $920 million to expand their treatment capacity and make services more affordable, $50 million in National Health Service Corps funding to expand access to substance use treatment providers, and $30 million toward researching the efficacy of treatment programs in place and then improving them.
Overcoming stigma
That opioids are often a bridge to heroin abuse has made the epidemic even more pressing for health officials to address. Eighty percent of people who use heroin started doing so by using prescription pain medication, according to government data. This may happen when a patient can no longer obtain pricier opioids and turns to the street for potentially tainted painkillers or heroin.
CDC data suggests deaths linked with illegal fentanyl, a strong, less expensive opioid commonly added to or disguised as heroin, are increasing.
In Baltimore, where 527 people died of heroin-related causes in the first nine months of 2015, combatting the epidemic has involved expanding availability of anti-overdose antidotes narcan and naloxone. Wen has issued a blanket prescription to everyone in Baltimore, where residents can take a 10-minute online training course to learn how to administer them.
“The most important thing is if a patient is given an opioid, they should be given naloxone,” Wen said. “There should be clearer guidelines about combining the two.”
In Vermont, officials use a state dashboard to monitor capacity in addiction treatment centers and send alerts when more resources are needed. Saloner said integrating the criminal justice system to help individuals start treatment upon incarceration or to continue treatment after they leave jail could be another interesting prospect for affected cities. Whether that treatment is adhered to is one of the strongest predictors of a patient’s recidivism, Saloner said.
Many experts like Saloner argue that criminalizing addiction, which is listed in the Diagnostic and Statistical Manual of Mental Disorders (DSM)— as part of the nation’s ‘war on drugs’— has failed, leading to recidivism and wasted tax dollars.
“We tried criminalizing addiction, and we didn’t make a dent in the epidemic—and in some ways, we made it worse by driving a lot of harmful behaviors in the ground,” Saloner said. “You don’t make a meaningful or sustained impact on this problem until you create a collaborative and person-centered model, until you recognize this is someone with a medical condition.”
The Affordable Care Act (ACA) required plans in the Health Insurance Marketplace to cover substance use disorder services, but overcoming stigma is one of the biggest hurdles faced by doctors and patients affected by opioid addiction.
“What our best evidence would suggest is that using rhetoric that really stigmatizes or creates a kind of a moralistic set of overtones about addiction is not helpful in getting those people into treatment,” Saloner said, “so if were really serious about getting those people into treatment, we need to focus on a more positive and inclusive message.”
Officials in Baltimore have implemented a 24/7 hotline that residents can call to seek treatment, and the city is starting a stabilization center to provide around-the-clock emergency room care for addiction and mental health. They also are aiming to prevent addiction from happening in the first place and reduce stigma through ad campaigns, like the city’s “Don’t Die” campaign, online and on billboards.
Leveling the playing field
For officials like Wen, who have been fighting this epidemic long before it surpassed the bounds of inner cities, the government’s proposed funding offers promise for more equality in health care.
“We’ve had people of color dying in inner cities for decades, and it’s often been said that if they’re poor and insured, that it is their choice and that becomes a criminal justice issue, but if someone is wealthy and insured, then it becomes a medical issue,” Wen said. “It’s reached jurisdictions across the country, but at the same time we’re glad that there is national attention for this public health crisis.”
Ultimately, combatting the epidemic will mean arming doctors and patients with the right resources and knowledge.
“I’ve yet to meet a doctor or any provider of any kind who wants to get their patients addicted to drugs or wants their patients to overdose,” Wen added, “So it’s not about keeping doctors in check, it’s about giving them the tools they need to allow them to make the best decisions for their patients.”