If we don’t provide even the bare minimum in evidence-based treatment, this crisis will keep getting worse.
America’s opioid epidemic keeps getting worse, with the latest data showing that drug overdose deaths in the US climbed by roughly 21 percent between 2015 and 2016 — from a record high of more than 52,000 to a new record of nearly 64,000. About two-thirds of those overdoses were linked to opioids.
To understand how this crisis keeps growing, take a look at an insightful map by amfAR, an advocacy group dedicated to the fight against HIV/AIDS. The map shows three things: the availability of facilities that treat drug addiction, the facilities that provide at least one medication for opioid addiction (marked as MAT, or medication-assisted treatment, on the map), and the facilities that provide all three kinds of medications for opioid addiction.
Clearly, there are a lot of gaps in coverage. In a post on Health Affairs, Austin Jones, Brian Honermann, Alana Sharp, and Gregorio Millett of amfAR looked at 2016 data from the Substance Abuse and Mental Health Services Administration and found that only 41.2 percent of the more than 12,000 drug addiction treatment facilities in the US offered at least one kind of medication for opioid addiction. Only 2.7 percent offered all three.
These medications are widely considered by experts to be the gold standard in opioid addiction care. Studies, including systematic reviews of the research, have found that opioid addiction medications in general cut all-cause mortality among opioid addiction patients by half or more. The Centers for Disease Control and Prevention, National Institute on Drug Abuse, and World Health Organization acknowledge their medical value. That doesn’t mean these medications are for everyone ( they’re not), but there’s a lot of good evidence for their general efficacy.
So it is pretty bad that a majority of addiction treatment facilities don’t provide access to any of these medications. It is similarly bad that even more of these facilities don’t offer access to more than one kind of medication; the individual types of medications don’t work for everyone — nothing in addiction treatment does — so it’s important to provide multiple options.
We are, as a country, nowhere close to that goal.
If the US isn’t making good use of even the bare minimum of evidence-based treatment, it’s no wonder the opioid crisis keeps getting worse.
One caveat: The map likely understates the amount of addiction treatment that is available in some parts of the US. For one, physicians can gain the ability to prescribe buprenorphine through a special waiver, but those kinds of practices wouldn’t appear in a map solely dedicated to drug addiction treatment facilities. Still, other data collected by amfAR shows that there are big swathes of the country without doctors who can prescribe buprenorphine.
There’s also other data that exposes America’s big gaps in addiction treatment. 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 any treatment — which can lead to waiting periods of weeks or even months.
More than showing the specific counties and states that don’t have access to some kinds of treatment and medications, amfAR’s map shows that America isn’t truly serious about dealing with its opioid epidemic.
Given that we know these medications are highly effective for opioid addiction, providing access to them should be the low-hanging fruit for dealing with a drug overdose epidemic fueled by opioids. Coverage remains sparse, and there’s been little attention to changing that.
A major reason for that is stigma. These medications are often characterized as “replacing one drug with another” — say, replacing heroin use with methadone use.
This fundamentally misunderstands how addiction works. The problem is not drug use per se; most Americans, after all, use caffeine, alcohol, and medications without major problems. The problem is when drug use becomes a personal or social burden — for example, putting someone at risk of overdose or leading someone to commit crimes to obtain drugs.
Medications for opioid addiction, by staving opioid withdrawal and cravings without leading to a significant risk of overdose, mitigate or outright eliminate those problems — treating the core concerns with addiction.
Another reason for the treatment gap is a lack of federal attention. In the past few years, for example, the only new federal effort to dedicate a serious amount of money to the opioid crisis was the Cures Act, which committed $1 billion over two years.
Even that sum fell woefully short of the tens of billions annually that experts widely agree is necessary to deal with the opioid epidemic. 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 addiction treatment costs. So even an investment of tens of billions could save money in the long run by preventing even more in costs.
As Stanford drug policy expert Keith Humphreys previously told me, “Crises in a nation of 300 million people don’t go away for $1 billion. 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.”
America has not gone big, at least yet. So the opioid epidemic continues, killing tens of thousands of people in the process every single year.
For more on the opioid epidemic, read Vox’s explainer .
