The “War on Recovery” shines light on a shameful opioid policy response
On March 5, 2024, Lev Facher of STATNews reports on the desolate state of the US response to over 1 million drug overdose deaths in an extensively reported piece “How the U.S. is sabotaging its best tools to prevent deaths in the opioid epidemic”
I recommend reading it and I’ll share my take. It’s a report all the more discouraging because I have been blunt about the imbalanced US policy response since 2016, with harms jointly accruing to both people with addiction and people with pain.
The topline from STATNews is this:
“Virtually every sector of American society is obstructing the use of medication that could prevent tens of thousands of deaths a year”
My addiction colleagues and I have long condemned the self-sabotaging US response to our home-grown opioid/overdose crisis. It involved an addictively-attractive intellectual shortcut (pun intended).
The attractive view from 2016 onward was that if prescribing opioids excessively had contributed to the crisis (and my own research, along with many others, show that is true), then the #1 policy priority should be to get nearly every patient off of them. Yes, to be sure, treatment was always mentioned, and time-limited funds were allocated by Congress, but “time-limited” tells the story.
Vermont’s governor Pete Shumlin captured the zeitgeist of 2016:
“We didn’t have a heroin crisis in America before OxyContin was approved and started being handed out like candy..If politicians would lead a more rational conversation about how we manage pain in America, we could fix the majority of this problem with a click of our fingers” (NY Times, 10/19/2016).
Patients with pain, patients on opioids, who feared what would happen to them were seen as “hooked” and maybe even deluded.
“These patient groups are being very effectively manipulated by what I would refer to as the opioid lobby” (Bend Bulletin, 7/24/18)
But the patients weren’t wrong to be afraid. Ample research documented widespread acceleration of abrupt opioid stoppages, even when — at times — patients suffered consequences, sometimes suicide, which my team researches, although I warn against simplifying suicide down to the result of a prescription change.
Writing in 2019 in the journal Addiction, Adam Gordon and I condemned the “imbalance between strong prescription control and weak pain and addiction treatment expansion”. We projected two outcomes:
(a) rising overdose deaths
(b) harm to pain patients.
I wish we had been wrong.
In STATNews, Facher describes a collective self-sabotage by a nation still divided on whether treating addiction with medicines that bind to opioid receptors is okay.
That war entails both active and passive policies of government agencies, hospitals and medical schools, pharmacies, insurers, and even mutual help groups like Narcotics Anonymous. I would say that, all of us are — at a minimum- acceding to a war on treating opioid use disorder with medication, even though 1 million Americans have died of overdose since 2000.
The two most effective medications — methadone and buprenorphine- are estimated to reduce all-cause mortality by 59% and 38%, respectively. But only 1 in 5 adults with opioid use disorder receive them. But, as Facher notes, the US remains prejudiced against the use of medications to treat opioid use disorder.
The Director of the National Institute on Drug Abuse, Dr. Nora Volkow is quoted:
“We have these very effective medications, and the question is why are they not being implemented….I estimate that we would have at least 50% less people dying, and that’s conservative.”
At present, most doctors often don’t offer buprenorphine. Facher reports that 40% of chain pharmacies decline to stock it. Many hospitals aren’t ready to offer such medicines in the emergency department. Federal regulations and state boards prohibit professionals from receiving it (On March 2, NBC reported on an attorney ordered by Kentucky’s bar to stop buprenorphine)
Jails and prisons, with exceptions from a few states like New York and Rhode Island, don’t offer these medicines to inmates. As a result, death by overdose is particularly common in the first 2 weeks after release.
Facher notes that Narcotics Anonymous takes a hard line against these life-saving medicines, which are seen as “substituting one addiction for another”. He writes, correctly, “In any other medical field, favoring prayer over proven medication would be considered malpractice. Yet for addiction treatment in the U.S., it’s simply the way things work.”
Methadone clinics, which can be a source of recovery for some, often stand in the way of recovery for others. These licensed programs hold a federally-guaranteed monopoly on provision of methadone for addiction. The clinics, mostly for-profit, now lobby to retain laws that prohibit provision of methadone for addiction treatment by addiction specialists like me, even though every doctor can prescribe methadone for pain, any day of the week. Patients, patients I know, can’t necessarily get to those clinics or endure the humiliation they impose. That means they don’t get treated.
Still yet more hospitals and medical schools have declined to offer training in addiction or to prescribe addiction medicine to patients. At the federal level, Facher characterizes the US Drug Enforcement Administration as hostile to access to these medicines. The policing mission winds up, to my view, at odds with assuring access both for addiction care and for pain. Reckless overprescribing, a different kind of collective failure, was real.
However, it’s not the situation today, with opioids per capita below levels last seen in the year 2000. Years ago, I saw that patients with long-term opioid receipt for pain were medically compromised, and some died as doctors reduced and stopped.
We should have been open to recognizing that the “easy fix” is often not the real solution. Reducing prescriptions became an industry that overpromised and underdelivered.
In late 2016, in the Substance Use and Addiction (SAJ) Journal, I wrote this:
The dominant priority should be the assurance of subsidized access to evidence based medication-assisted treatment for opioid use disorder. Such treatment is lacking across much of the United States at this time. Further aggressive focus on prescription reduction is likely to obtain diminishing returns while creating significant risks for patients
What was true then remains true now. I urge people to read Lev Facher’s powerful report. It’s worth it.
I’m a professor of medicine a University of Alabama at Birmingham Heersink School of Medicine and a Veterans Affairs medicine doctor who conducts research on care of underserved and vulnerable populations. Views here are my own, and don’t reflect those of any government agency. On X: @StefanKertesz. Our suicide research is described here: www.csiopioids.org.
