The United States Opioid Epidemic
Approximately 30,000 people died from opioid overdose in 2014, a dramatic increase since the 1990s. The reason for this epidemic is multi-faceted, including changes in the way medicine is practiced, regulated, and paid for, changes in the nation’s safety net support for low income or disabled persons, and industry efforts to expand the use of opioid medications. It is generally agreed upon that the heavy reliance upon opioids as first-line therapy for all types of pain resulted in millions of Americans who were unlikely to have accessed heroin becoming dependent upon opioids. The challenge we face today is not just to reduce the number of people becoming newly dependent upon opioids while ensuring those who need opioids do not lose access, but also to care for those who have developed opioid use disorders in the context of wide availability of prescription opioids. This population includes not just patients, but also people who were accessing diverted opioid medications, but now are forced to access heroin or other street-produced opioids. The situation has been further complicated by changes in the illicit opioid market – the emergence of highly potent synthetic opioids such as fentanyl and its analogues.
The President’s newly announced “Prescription Opioid and Heroin Epidemic Awareness Week” (September 18-24, a few weeks after International Overdose Awareness Day on August 31), is consistent with his close attention to humane efforts to manage this crisis. The announcement focuses on expanding substance use treatment and increasing the patient limit for providers who utilize buprenorphine in treatment of opioid use disorder. President Obama has also strongly supported the expansion of naloxone availability for opioid overdose prevention, alongside opioid stewardship interventions such as prescription drug monitoring programs. An essential element to these efforts is to never abandon patients.
The core of President Obama’s effort recognizes that substance use disorders closely resemble other chronic diseases like type 2 diabetes. Both diseases have strong genetic components. Much like diet, inactivity, and lack of access to fruits and vegetables contribute to diabetes, lifestyle and environmental factors contribute to substance use disorders. Just as weight loss and exercise might turn around diabetes when caught early, behavioral interventions may help someone with a mild to moderate substance use disorder. However, we would never withhold medication from a person with advanced diabetes…and we would never stop that medication once their glucose was under control. We have several medications to help people with opioid use disorders and we need to use them widely. There is a long way to go before we truly treat substance use disorders as a medical problem, but the President’s initiative is a good first step.
The conflicting demands of the opioid crisis are particularly apparent in HIV care, as many patients and providers lived through the era when HIV was a palliative care disease. Given the short life expectancy of persons living with HIV in the 1980s and 1990s, few were concerned about patients developing opioid use disorders. However, HIV care improved so dramatically that many of these patients survived and even thrived. Now, with changing prescribing practices resulting in less prescribed opioids, many can no longer access opioid medications and are forced to manage pain and/or opioid use use disorder through other means. This creates a very high-risk time of transition, in which providers trying to fix problems created by the healthcare system may in fact cause additional harm. Patients may drop out of care. Efforts to reduce HIV transmission may suffer.
The opioid epidemic did not occur overnight and will not go away tomorrow. We now have millions of citizens with opioid use disorders who need support and are at high risk for complications including death. The situation has only gotten worse in recent years with the emergence of highly-potent synthetic opioids in the street market, resulting in thousands of additional deaths particularly in the eastern half of the country. There is no easy way out of this situation, and it is clear that relying on the criminal justice system would be both inhumane and inconceivably expensive. There is however, a bright spot in the President’s efforts to treat people with dignity and respect.