The use of mind and mood altering substances is certainly not unique to our modern post-industrialized society. Epidemics of substance use and addiction have ravaged communities for hundreds of years. Homo Sapiens and their ancestors have sought relief from suffering for as long as suffering has attended our existence. Such unpleasant truisms beg obvious questions concerning the current epidemic of opiate dependence. What is unique about it? Why is it happening now? How, and by what means, will it end?
Many of our previous epidemics entailed the abuse of legal or illicit substances presumed to hold little or no medical or rehabilitative value. Nicotine and alcohol are among the most prominent examples of this class, and they continue to curtail the lives of their users and to cause collateral damage valued in the billions of dollars annually. The Centers for Disease Control and Prevention reports excessive alcohol consumption cost the U.S. approximately $223.5 billion in 2006. This was attributed largely to reduced work productivity, health and legal expenditures and motor vehicle accidents (Centers for Disease Control and Prevention, 2017). Worldwide costs associated with tobacco use and nicotine dependence are nearly incalculable. Cocaine, hallucinogens, cannabinoids and countless other illicit drugs continue to exact a great toll on our healthcare and criminal justice systems. Moreover, they expose deep fissures in our national drug policies and the prevailing attitudes and political sensibilities underpinning them.
Opiates are unique, however, inasmuch as their proliferation was borne of a complicit medical establishment and pharmaceutical industry. Until recently, legal access to opiate medications was limited to individuals who experienced exceptionally severe pain associated with debilitating or terminal health conditions. In 2001, the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) established new standards in response to this unduly conservative approach to pain management. These standards required organizations subject to JCAHO’s oversight to educate their practitioners in pain management and to respect patients’ “right to pain management” (Joint Commission on Accreditation of Healthcare Organizations, 2016). Hospitals and healthcare organizations were subsequently evaluated (and reimbursed) in accordance with their success in alleviating patients’ pain as measured by the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) and other tools (Blumenthal & Kaplan, 2017). These trends inevitably stimulated a market for opiate-based analgesics and a symbiosis between manufacturers and purveyors. The pharmaceutical industry, reputed for its rapacious marketing tactics, found a receptive audience within a medical establishment driven by changing regulations and incentive structures. It was, in short, a perfect storm. During the past 16 years we have witnessed a threefold increase in the volume of opiate prescriptions, and this has been accompanied by a similar rise in the use of illicit opiates such has heroin and fentanyl. In addition, more than 50% of opiate prescriptions are issued to individuals experiencing anxiety and depression, the two most common mental illnesses in the U.S. (Blumenthal & Kaplan, 2017). The most vulnerable among us, including individuals living with mental illness, poverty and other stressors, are at elevated risk of opiate dependence. In this respect the current epidemic is no different from its predecessors.
A successful campaign against this epidemic requires nothing less than an honest and transparent acknowledgement of the foregoing factors that have perpetuated it. To this end, local, state and federal governments must reevaluate a host of policies and payment structures that have incentivized the wanton proliferation of opiate drugs. These same actors must also support a broad array of evidenced-based interventions that would reduce our collective dependence on these substances. There have been auspicious developments on these fronts. A handful of counties in New York State have recently initiated legal actions against drug manufacturers, alleging they employ deceptive marketing tactics to promote opiate-based medications (Mahoney, 2017). This might serve as a bellwether for others to follow in holding the pharmaceutical industry accountable for its role in this crisis. A major pharmaceutical retailer (CVS) recently announced it will limit the quantities of opiates dispensed to seven days (excepting certain circumstances). New York and other states have adopted prescription drug monitoring programs in order to prevent “doctor shopping” (i.e., filling multiple opiate prescriptions issued by different doctors). In addition, the Substance Abuse and Mental Health Services Administration (SAMHSA) and Office of Alcoholism and Substance Abuse Services (OASAS) have funded numerous initiatives that address social determinants of health and their role in this crisis. (Social determinants of health include various conditions and life circumstances that influence individuals’ overall health and wellbeing. These include housing, socioeconomic status, education, social support networks, and a host of other factors inextricably linked to this epidemic.) Perhaps not surprisingly, opiate dependence is more prevalent in economically distressed communities with a large working class and high rates of unemployment. One writer characterizes fatal overdoses within these communities as “deaths of despair” (Monnat, 2016) and suggests this epidemic will persist until all of its root causes are addressed.
These root causes are surely numerous and complex, and they require a continuing and concerted response from the public and private sectors. Most importantly, they require our collective resolve to overcome the political inertia that threatens to perpetuate this crisis.
The author may be reached by phone at (914) 428-5600 (x9228) or by email at abrody@searchforchange.org.
