The opioid epidemic could kill hundreds of thousands in the next decade. But America can beat it.
The scale of America’s opioid epidemic is shocking.
It is the deadliest drug overdose crisis in US history. In 2016 alone, drug overdoses killed more Americans in one year than the entire Vietnam War. In 2015, drug overdoses topped annual deaths from car crashes, gun violence, and even HIV/AIDS during that epidemic’s peak in 1995. In total, more than 170 people are estimated to die from overdoses every day in the US, and most of the deaths are linked to opioids.
Yet so far, there’s been a lack of policy action to end the opioid epidemic. Much of what has been done has focused on reducing the amount of prescription painkillers out there, yet the latest federal data shows prescriptions were still three times what they were in 1999. Other prevention efforts have focused on stopping heroin and fentanyl from entering the US, but they have so far failed to make a dent in the flow of these drugs. And experts say President Donald Trump’s emergency declaration will fall far short of what’s necessary to deal with the crisis, unlocking only a limited set of tools.
The only major bill passed by Congress on the crisis appropriated $1 billion to drug treatment over two years — far from the tens of billions a year that studies suggest the crisis actually costs. And Congress could still revive a health care bill that, by repealing Obamacare, would cut access to addiction treatment for potentially millions of people struggling with drug addiction.
But even if Congress does appropriate the money to attack the crisis, do we know what to do with it? Opioid addiction is a complex, stubborn problem — and history is littered with policies meant to fight drug use that only made the situation worse.
So I reached out to drug policy and public health experts across the country for answers. My questions: If we dedicated every resource needed to deal with opioids, what should we do? And looking at addiction more broadly, how would we not just stop the current epidemic but prevent the next crisis?
What’s important to understand, experts said, is that the opioid epidemic is in fact the story of two crises — which Keith Humphreys, a Stanford University drug policy expert, explained as the dual problems of “stock” and “flow.”
On one hand, you have the current stock of opioid users who are addicted; the people in this population need treatment or they will simply find other, potentially deadlier opioids to use if they lose access to painkillers. On the other hand, you have to stop new generations of potential drug users from accessing and misusing opioids.
This is what much of the public discussion about the opioid epidemic has wrong. The two sides of the epidemic are often described as if they’re in conflict: One side pushes for more action on cracking down on the supply of opioid painkillers, while the other insists that the real solution is to massively expand addiction treatment. The truth is that policymakers need to look at both, because each represents a unique population with different needs.
If you understand this, you can start to slowly peel back the solutions necessary to solve the epidemic — and why the proper responses can quickly get so complicated. They demand that we balance several big issues: the lessons of the opioid crisis, the needs of pain patients, and the enormous shortfalls in how the country approaches addiction and its underlying causes. They ask that Americans truly begin to think of addiction not as a moral failure — as has been entrenched in US society for decades — but as a real medical problem. And they will require a massive public investment to meet the big health care and socioeconomic needs facing millions of Americans.
That investment, however, will need to come soon. Because there’s another alarming statistic: If the opioid epidemic continues unabated, one high-end forecast by STAT estimates that 650,000 more people will die from opioid overdoses in the next 10 years — more than the entire population of Baltimore.
Here’s what we’ll need to do to stop that from happening.
A recent report from the Centers for Disease Control and Prevention (CDC) produced an alarming statistic: “In 2015, the amount of opioids prescribed was enough for every American to be medicated around the clock for 3 weeks.”
This proliferation of painkillers is the root of the current drug crisis — and one of the first issues policymakers need to address to stop it from getting worse.
The opioid epidemic began in the 1990s, when doctors became increasingly aware of the burdens of chronic pain. Pharmaceutical companies saw an opportunity, and pushed doctors — with misleading marketing about the safety and efficacy of the drugs — to prescribe opioids to treat all sorts of pain. Doctors, many exhausted by dealing with difficult-to-treat pain patients, complied — in some states, writing enough prescriptions to fill a bottle of pills for each resident. The drugs proliferated, landing in the hands of not just patients but also teens rummaging through their parents’ medicine cabinets, other family members, friends of patients, and the black market.
Eventually, some painkiller users moved on to other opioids, like heroin or fentanyl and its analogs. Not all painkiller users went this way, and not all opioid users started with painkillers. But statistics suggest many did: A 2014 study in JAMA Psychiatry found 75 percent of heroin users in treatment started with painkillers, and a 2015 analysis by the CDC found people who are addicted to painkillers are 40 times more likely to be addicted to heroin. (Although a more recent study found that while a majority of people in treatment for opioid use disorder in 2015 still started with painkillers, an increasing amount started with heroin compared to the decade before.)
In response to all of this, different levels of government have focused on preventing the overprescription of opioids with various policy levers. Some states have limited how many opioids doctors can prescribe. The federal government put some opioids on a stricter regulatory schedule. Law enforcement has threatened doctors with incarceration and the loss of their medical licenses if they prescribe opioids unscrupulously.
And the CDC released guidelines that, among other proposals, ask doctors to avoid prescribing opioids for chronic pain except in some circumstances. The agency noted that the evidence for opioids treating long-term, chronic pain is very weak (despite their effectiveness for short-term, acute pain), while the evidence that opioids cause harm in the long term is very strong. In short, the risks vastly outweigh the benefits for most chronic pain patients.
The result is opioid prescriptions have declined since 2010. But there’s still a lot of work to be done: In 2016, there were enough pills prescribed to fill a bottle for every adult in the US. And in 2015, the amount of opioids prescribed per person was more than triple what it was in 1999, according to the CDC.
Given that, some experts have proposed stricter measures. A recent report from the National Academies of Sciences, Engineering, and Medicine issued several proposals to the Food and Drug Administration (FDA), including that the agency conduct a review of opioids already on the market and strengthen its post-approval oversight of opioids — while also considering the potential harms of yanking opioids from patients who really need them.
The report said, “Steps to this end should include use of Risk Evaluation and Mitigation Strategies that have been demonstrated to improve prescribing practices, close active surveillance of the use and misuse of approved opioids, periodic formal reevaluation of opioid approval decisions, and aggressive regulation of advertising and promotion to curtail their harmful public health effects.”
Ideally, doctors should be able to get painkillers to patients who truly need them — after, for example, evaluating whether the patient has a history of drug addiction. But doctors, who weren’t conducting even such basic checks, are now being pressured to give more thought to their prescriptions. The hope is this will prevent new generations of people getting addicted to opioids.
There are limits to prevention: With the existing population of opioid users, cutting them off from painkillers could be dangerous. Although they shouldn’t be a first-line treatment, opioids can be the only source of relief for a few chronic pain patients. If someone is suddenly yanked from a high dose of opioids, they could undergo painful withdrawal. (This is why experts say careful tapering is necessary for a patient getting off opioids — to ensure the process is as painless as possible.) And people who lose access to painkillers could decide that rather than deal with pain from withdrawal or chronic conditions, they’re going to get other opioids — such as heroin and fentanyl, which are deadlier than painkillers and would likely lead to even worse outcomes.
That’s why, experts say, it’s a mistake to only focus on curtailing prescriptions.
“Let’s say you only focus on curtailing overprescribing to prevent people getting addicted, but you do nothing to expand treatment,” Andrew Kolodny, an opioid policy expert at Brandeis University, said. “Then heroin and fentanyl will keep flooding in, and overdose deaths will remain at historically high levels until the generation that became addicted ultimately dies off.”
The primary problem with the opioid epidemic is simple: It is much easier to get high than it is to get help.
“For the people who are addicted, you want the treatment to be much easier to access than prescription opioids, heroin, or fentanyl,” Kolodny said.
He drew a comparison to how New York City dealt with tobacco. In his telling, the city took a two-prong approach: It made tobacco itself less accessible — by banning smoking in public spaces and raising taxes to make cigarettes much more expensive. But it also made alternatives to tobacco more accessible — by opening a phone line that people can use to get in touch with a clinic or obtain free nicotine patches or free nicotine gum.
This is similar, Kolodny argued, to what the US should do with opioids.
So far, the US has tried to make opioids less accessible with prevention strategies, as outlined above.
But the country hasn’t done much to increase access to alternatives to opioids — specifically, medication-assisted treatment, when medicines like methadone, buprenorphine, and naltrexone are used to reduce opioid cravings. There are still places with no treatment clinics whatsoever, much less affordable options.
According to a 2016 report by the surgeon general, just 10 percent of Americans with a drug use disorder obtain specialty treatment. The report attributed the low rate to severe shortages in the supply of care, with some areas of the country lacking affordable options for treatment — which can lead to waiting periods of weeks or even months.
Congress has added some spending to addiction care (including $1 billion over two years in the 21st Century Cures Act), but it’s nowhere near the tens of billions every year that Kolodny and other experts argue is necessary to fully confront the crisis. For reference, a 2016 study estimated the total economic burden of prescription opioid overdose, misuse, and addiction at $78.5 billion in 2013, about a third of which was due to higher health care and drug treatment costs. So even an investment of tens of billions could save money in the long run by preventing even more in costs.
“Crises in a nation of 300 million people don’t go away for $1 billion,” Humphreys said, referring to the Cures Act funding. “This is the biggest public health epidemic of a generation. Maybe it’s going to be worse than AIDS. So we need to go big.”
So what exactly would all that money go to?
For one, it should go to treatment that has strong evidence behind it. For opioids, that means, above all, medication-assisted treatment.
There’s a widespread stigma against this kind of treatment — particularly, that using medications, especially opioids like methadone and buprenorphine, to treat opioid addiction is simply substituting one drug with another.
Former Health and Human Services Secretary Tom Price echoed this myth earlier this year, saying, “If we’re just substituting one opioid for another, we’re not moving the dial much. Folks need to be cured so they can be productive members of society and realize their dreams.” (A spokesperson for Price later walked back the statement, saying Price supports all kinds of drug addiction treatment.)
But this fundamentally misunderstands how addiction works.
The danger isn’t whether someone is merely using drugs; most Americans, after all, use caffeine or alcohol regularly throughout their lives with few problems. According to the definition in the Diagnostic and Statistical Manual of Mental Disorders, drug use transforms into addiction when habitual drug use begins hurting someone’s function — by, for example, leading them to steal or commit other crimes to obtain heroin, or, in the worst case scenario, resulting in death.
While medication-assisted treatment does involve continued drug use, it turns that drug use into a safer habit. When taken as prescribed, medications like methadone and buprenorphine can eliminate someone’s cravings for opioids and withdrawal symptoms without producing the kind of euphoric high that heroin or traditional painkillers can. It addresses the core problem of addiction, even if in some cases it does mean a patient will have to use a certain drug for the rest of his life. But the alternative isn’t a drug-free patient; the alternative is a continually relapsing patient — one who has to salve their addiction with dangerous street drugs.
This isn’t just hypothetical. Decades of research have deemed medication-assisted treatment effective for treating drug use disorders, with several studies finding it can cut mortality among opioid addiction patients by half or more. The CDC, the National Institute on Drug Abuse, and the World Health Organization all acknowledge its medical value. Experts often describe it as “the gold standard” for opioid addiction treatment — and agree that it needs to be made much easier to obtain.
More money could also go to other kinds of evidence-based treatment, programs that attract more doctors, and policies that create more infrastructure for addiction care.
Anna Lembke, an addiction doctor who wrote Drug Dealer, MD, a book on the opioid crisis, told me of an innovative solution to the problem: what she calls an AmeriCorps for addiction treatment.
