The opioid addiction and overdose epidemic that has ravaged America for two decades now has left almost no one untouched. From 1999 to 2017, more than 400,000 people in the United States have died from overdoses related to opioids. According to a poll by the American Psychiatric Association, nearly a third of Americans say they know someone who is or has been addicted to opioids. It has been in the headlines, the subject of Congressional investigations and local town hall meetings, and top-of-mind for healthcare professionals and law enforcement personnel as they work tirelessly to contain it.
The epidemic began with ready availability to prescription opioids, but we’ve seen it shape-shift as efforts to reduce unnecessary exposure to prescription opioids took effect. Guidelines for the treatment of pain were issued, Prescription Drug Monitoring Programs (PDMPs) were enhanced and promoted, and take-back programs were increased. As a result, the overall national opioid prescribing rate declined from 2012 to 2017, and in 2017, the prescribing rate fell to the lowest it had been in more than 10 years.
Reducing the supply of prescription opioids, however, did not treat those who had already developed opioid use disorder (OUD). Unfortunately, the black market was ready to supply cheaper heroin and, eventually, synthetic opioids to meet the need for opioids by people afflicted with OUD. Overdose death rates continued to climb into 2017, driven by increases in deaths involving synthetic opioids. Despite the strong evidence of the effectiveness of medication treatment for OUD, only a third of people who present for treatment of an OUD are offered such medication in our current treatment system.
One of the biggest and most perplexing challenges to addressing the epidemic is reducing the stigma associated with OUD so that more people will seek treatment and more healthcare professionals will be willing to provide it. The yawning treatment gap – in 2018, less than 20% of people with OUD received specialty treatment – is due in part to the historical separation of addiction treatment from mainstream medical care. Stigma and misunderstanding about the disease relegated its treatment to the shadows for decades. Physicians and other healthcare professionals in training did not learn how to help prevent, recognize, or treat OUD, because they would not be expected, or paid, to do so in practice. Raising awareness about the effectiveness of treatment can reduce stigma, embolden patients to seek treatment, motivate clinicians to provide it, and inspire families to demand effective treatment for their loved ones.
Reducing stigma is necessary but not sufficient to close the treatment gap. We also need to train more healthcare professionals to prevent, recognize, and treat addiction competently and compassionately. According to a recent survey, only 1 in 4 clinicians received training on addiction during their medical education. Less than one-third of emergency medicine, family medicine, women’s health or pediatric providers felt “very prepared” to screen, diagnose, provide brief intervention for, or discuss or provide treatment for OUD. Perhaps most troubling, less than half of emergency medicine, family medicine and internal medicine clinicians in that survey believed that OUD is treatable. These insights make it clear that we need to take bold action to equip all of America’s healthcare professionals to respond this crisis.
Further, to close the treatment gap and build a sustainable workforce, we also must ensure that there is a sufficient number of highly skilled specialists to lead treatment teams, provide addiction consultation services, oversee treatment programs, train residents and fellows, and directly treat the most complex patients until they are stable enough to be transferred to a trained primary care clinician. There are currently far too few addiction specialist physicians to meet these needs, and too few opportunities for medical students to study and specialize in addiction treatment.
A trained and willing workforce can only be effective if evidence-based addiction treatment services are made available to patients through their health plans.
Despite the fact that federal law has mandated coverage of addiction treatment on par with coverage for general medical services for more than a decade, we know that insurers still may not cover or pay for addiction treatment services fairly. Health benefit plans, in both the public and private sectors, should include comprehensive coverage of evidence-based addiction treatment services without arbitrary limits or unfair utilization controls. When it comes to OUD, it is critical that plans facilitate patient access to medications such as methadone, buprenorphine, and extended-release naltrexone. Too often, utilization management techniques – such as prior authorization – restrict patient access to these life-saving treatments. A delay of just one day is enough time for a patient to relapse, overdose, or suffer other consequences that can adversely affect their treatment outcome.
Ultimately, we need comprehensive policy solutions that increase access to evidence-based treatment and bolster the treatment workforce to provide it. Patients, families, and healthcare professionals all have a role to play in advocating for policy changes and resources to rein in the current epidemic of OUD and opioid-related overdose deaths, as well as lay the groundwork for prevention and treatment systems that can more effectively respond to the next addiction-related crisis.
Dr. Selzer is the Medical Director of Committee for Physician Health, New York’s physician health program. He is also the Director of the Northwell Health System’s Physician’s Resource Network, a confidential counseling program for the health system’s practicing physicians, physician trainees, and medical students. Dr. Selzer is the Chair of the New York State Psychiatric Association’s Addiction Psychiatry Committee, Secretary of the American Society of Addiction Medicine (ASAM), and Chair of ASAM’s Public Policy Committee. He is a Distinguished Fellow of both the American Psychiatric Association and the American Society of Addiction Medicine.
References
- Scholl L, Seth P, Kariisa M, Wilson N, Baldwin G. “Drug and Opioid-Involved Overdose Deaths – United States, 2013-2017.” WR Morb Mortal Wkly Rep. ePub: 21 December 2018. https://www.cdc.gov/mmwr/volumes/67/wr/mm675152e1.htm?s_cid=mm675152e1_w
- American Psychiatric Association. ”APA Public Opinion Poll – Annual Meeting 2018.” Conducted March 23-25, 2018. Available at: https://www.psychiatry.org/newsroom/apa-public-opinion-poll-annual-meeting-2018
- Centers for Disease Control and Prevention (CDC). National Center for Injury Prevention and Control. U.S. Opioid Prescribing Rate Maps. Available at: https://www.cdc.gov/drugoverdose/maps/rxrate-maps.html
- Scholl L, Seth P, Kariisa M, Wilson N, Baldwin G. Drug and Opioid-Involved Overdose Deaths — United States, 2013–2017. MMWR Morb Mortal Wkly Rep 2019;67:1419–1427. DOI: http://dx.doi.org/10.15585/mmwr.mm675152e1
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- Substance Abuse and Mental Health Services Administration. (2019). Key substance use and mental health indicators in the United States: Results from the 2018 National Survey on Drug Use and Health (HHS Publication No. PEP19-5068, NSDUH Series H-54). Rockville, MD: Center for Behavioral Health Statistics and Quality, Substance Abuse and Mental Health Services Administration. Retrieved from https://www.samhsa.gov/data/
- Caroline Davidson, Chetna Bansal, Shannon Hartley “Opportunities to Increase Screening and Treatment of Opioid Use Disorder Among Healthcare Professionals.” Available at: https://www.shatterproof.org/press/shatterproof-rize-massachusetts-and-ge-foundation-release-survey-massachusetts-healthcare
- Abelson R. Mental Health Treatment Denied to Customers by Giant Insurer’s Policies, Judge Rules. The New York Times. March 5, 2019. Available at: https://www.nytimes.com/2019/03/05/health/unitedhealth-mental-health-parity.html
