As overdose deaths mount, leading to a decline in US life expectancy 2 years in a row, my New Year’s wish is for more people to appreciate this statement: Not all well-intentioned approaches to addressing the opioid epidemic are good ideas. Some are based on evidence and experience, others on misunderstanding, blame, fear, or frustration. What’s needed in 2018 is the wisdom—and the courage—to tell the difference.
The use of the opioid agonists methadone and buprenorphine reduces overdose, illicit drug use, crime, and transmission of infectious diseases. A common misconception, however, is that these medications are part of the problem. Even in the field of addiction treatment, many still believe that those who take methadone or buprenorphine are “trading one addiction for another,” “in bondage,” or taking a “cop-out.” The majority of privately funded treatment programs for opioid use disorder do not offer patients the chance to use medications. In addition, Narcotics Anonymous allows chapters to block people who take medications from telling their stories at support meetings. Some judges order patients off medications or allow social services agencies to remove children from parents doing well on medications in treatment.
The consequence of these attitudes and actions? More fatal overdoses. A must-read investigation by journalist Jason Cherkis, a finalist for the Pulitzer Prize, found that the ideology against medications can be so fierce that it leads some to shrug off a greater risk of death.
For 2018, I ask for greater understanding that medications can help—not hinder—an individual in taking responsibility for his or her own recovery. Indeed, many patients who take medication explain that it clears their mind of intense cravings and allows them to focus on making amends and rebuilding their lives. Programs such as the Hazelden Betty Ford Foundation that historically promoted “abstinence only” are now incorporating effective medications into their programs. This is not new ground: Medication use and personal responsibility coexist for many other conditions, from diabetes to nicotine addiction.
An expanded appreciation of the role of medications would support the growing bipartisan interest in broadening access to all of the FDA-approved options. Consistent with the approach taken by the Obama Administration, President Trump’s Commission on Combating Drug Addiction and the Opioid Crisis emphatically endorsed treatment that includes medications, and US Food and Drug Administration Commissioner Scott Gottlieb recently testified: “We should not consider people who hold jobs, reengage with their families, and regain control over their lives through treatment that uses medications to be addicted. Rather, we should consider them to be role models in the fight against the opioid epidemic.”
It is now recognized by many across the political spectrum—including the Koch brothers—that the arrest and jailing of millions of Americans for their addiction has complicated efforts to address the opioid epidemic. Charging nonviolent individuals for possessing small amounts of drugs strains the courts and jails and tags people with addiction with criminal records that hinder recovery. Yet as overdoses have spiked—in large part due to heroin laced with fentanyl—several states have again increased penalties for possessing small amounts of drugs, and some prosecutors have turned overdoses into crime scenes, charging friends and family with murder. The instinct to “get tough” is understandable, but users rarely know the content of their drugs, and the result is likely to be fewer people calling for help.
There is also the very real danger of overdose after incarceration. In most jails across the country, individuals with an opioid use disorder are forced to endure a painful (and occasionally fatal) withdrawal. While incarcerated, they lose their tolerance to opioids, raising the chance of overdose when opioids become available again. Studies document up to 10-fold elevations of risk of death upon release from detention.
In 2018, I hope for far wider adoption of alternative approaches: fewer arrests for drug use and much greater access to treatment within the corrections system. There are some inspiring examples. Innovative police departments and prosecutors in Massachusetts, New York, Washington, Vermont, and elsewhere are diverting nonviolent users of drugs to treatment instead of detention. Initial results of some of these efforts show substantial declines in recidivism.
In addition, states including Rhode Island and Connecticut are beginning to offer access to effective treatment with medications to detainees, with transitions to community care upon release—a promising approach supported by evidence from other countries and consistent with the recommendations of the President’s Advisory Commission.
Health Care System
There is now broad understanding that the overprescribing of opioids has contributed to today’s opioid epidemic. There is much less appreciation, however, that some responses to this insight can make the overdose problem worse. At a time when most insurers still do not provide adequate reimbursement for nonpharmaceutical approaches to pain or treatment for opioid use disorder, overly restrictive prescribing policies risk pushing patients with pain or addiction to illicit drugs, a transition many have made. A few distraught patients have even committed suicide.
The good news is that tools and evidence-based guidelines and coverage policies are available to reduce excessive prescribing of opioids, while preserving the ability to provide individualized care. In 2018, I hope that medical community rapidly adopts a recently released set of quality metrics that was designed to support these thoughtful approaches.
I also hope that in the new year, more health care organizations embrace their responsibility not only to cause less of the opioid problem (by reducing excessive prescribing for pain) but also to contribute more to the solution (by expanding access to addiction treatment). A randomized trial found double the rate of short-term treatment success when emergency departments offered buprenorphine therapy and a warm handoff to ongoing treatment. Similarly, starting treatment with medications on the wards is far better than the oft-provided “detox,” which is associated with a risk of death from overdose.
An inspiring example for the new year? Massachusetts General Hospital, which recently began training emergency department physicians to start treatment on the spot.
Looking to Evidence
On opioids, it can sometimes seem that there are 3 bad ideas for every good one. Public officials have supported limiting the number of naloxone resuscitations and afterwards letting people die, requiring drug testing before enrolling in Medicaid, and launching stigmatizing public relations campaigns that can reduce the chance people will seek treatment. Can we leave such approaches behind in 2017?
Worth holding onto are approaches by states like Rhode Island, where the Governor asked a team of local experts to listen to the public, consult the evidence, and provide recommendations for priority strategies. As one Rhode Island expert told an assembled group, “Our goal here is not to make everybody in this room happy. Our goal is to cut down on overdose deaths.” Three years later, after developing a terrific dashboard, investing in access to effective treatment, developing programs to improve prescribing of opioids and benzodiazepines, and setting standards for hospital activities, the state is one of a few actually seeing a decline in overdoses.
The sheer scale of the opioid epidemic is staggering. There needs to be much more work on understanding and addressing the root causes of this problem, as well as greater willingness to try out promising approaches to the emerging threats of fentanyl and related compounds.
To get started on the right foot in 2018, the opioid epidemic demands much more of what works, and much less of what does not—as do our friends, family, and neighbors who are struggling for their very lives.
About the author: Joshua M. Sharfstein, MD, is Associate Dean for Public Health Practice and Training at the Johns Hopkins Bloomberg School of Public Health. He previously served as Secretary of the Maryland Department of Health and Mental Hygiene, as the Principal Deputy Commissioner of the US Food and Drug Administration, and as Commissioner of Health for Baltimore. He is a consultant for Audacious Inquiry, a company that has provided technology services and other support to Maryland’s Health Information Exchange. A pediatrician, he lives with his family in Baltimore.
About The JAMA Forum: JAMA has assembled a team of leading scholars, including health economists, health policy experts, and legal scholars, to provide expert commentary and insight into news that involves the intersection of health policy and politics, economics, and the law. Each JAMA Forum entry expresses the opinions of the author but does not necessarily reflect the views or opinions of JAMA, the editorial staff, or the American Medical Association. More information is available here and here.