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The scale of America's opioid epidemic is shocking.
It is the deadliest drug overdose crisis in US history. In 2016 alone, drug overdoses likely 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 140 people are estimated to die from drug overdoses every day in the US. About two-thirds of these drug overdose 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.
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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 drug 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 drug 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 STATestimates 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.
1) Prevent new generations of opioid users
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.
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. 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."
2) Make addiction treatment easier to access than opioid painkillers and heroin
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 is currently a 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.
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 programs that make attract more doctors and 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. She explained, "Why don't we recruit these young people and say, 'Hey, we'll pay back your med school loans, in part, if you spend a couple years in rural West Virginia treating people with addiction'? We need to come up with creative ways like that to bring people into the workforce."
Dr. Leana Wen, the health commissioner of Baltimore, suggested changing the structure of how care is provided. She envisions widespread emergency room services not just for physical health, as is already common, but also for mental health, including addiction.
"In the ER, people will often come in seeking help for their addiction," Wen said, drawing from her own experience as a doctor. "But we will tell them that, unfortunately, we're unable to get them into a treatment slot for three weeks or a month. … That individual, if they're unable to get treatment that day at the time that they're requesting, may have no other choice but to go out and use drugs [to avoid withdrawal] and maybe overdose and die."
3) If we can't stop people from doing drugs, we can make it less dangerous
An unfortunately reality with drugs is that addiction is tenacious. Even if policymakers got everything right on the treatment and prevention front, there are simply going to be some situations in which people will use and get addicted to drugs anyway.
So the goal shouldn't be solely to prevent and stop the use of dangerous drugs but also to limit the harms attached to these substances.
One example: prescription heroin.
The method, which has been successfully tried in several countries, is simple: A certain segment of opioid users are going to use heroin no matter what. For whatever reason, traditional therapies just aren't going to work for them — just like some treatments for, say, heart disease or cancer don't work for some patients. So if that happens, it's better to give them a safe source of the drug they're seeking and a safe place to inject it, rather than letting them pick it up on the street — laced with who knows what — and possibly overdose without medical supervision.
The evidence backs up the approach. Researchers credit the European prescription heroin programs with better health outcomes, reductions in drug-related crimes, and improvements in social functioning, such as stabilized housing and employment. Canadian studies also deemed prescription heroin effective for treating heavy heroin users. A review of the research — which included randomized controlled trials from Switzerland, the Netherlands, Spain, Germany, Canada, and the UK — reached similar conclusions, noting sharp drops in street heroin use among people in the treatment.
Consider the story of John Pinkney, a patient at the Providence Crosstown Clinic in Vancouver, Canada. Pinkney, now in his 50s, traces his drug use back to the age of 6, when he began using Ritalin to treat his ADHD. As a child, Pinkney was shuffled from home to home, and his adoptive parents were violent. As a teenager, he ran away and lived on the streets — losing his Ritalin prescription and turning to harder drugs to fill the void. As an adult, he went to prison for robberies he committed to buy heroin.
He tried treatment, including medication-assisted therapy. Nothing worked, and he kept using drugs. His life started tough, and it wasn't getting better.
Then Pinkney ended up at the Crosstown Clinic, where he now gets heroin — paid for by government insurance — two or three times a day. He doesn't have to steal to get the drug anymore. He now has the stability he needs to maintain a part-time job, live in an apartment with furniture and a TV, and do some advocacy work. As he recently told me, "You know, it's like I got my life back."
In other areas, there are many possible steps to reduce harm among the segment of the population that continues using illicit drugs. Needle exchange programs could let people trade in used syringes for new ones, reducing the risk a needle will carry HIV, hepatitis C, or some other disease. Supervised injection facilities could provide a place for drug users to inject illicit substances, with medical staff ready in case something goes wrong.
The opioid overdose antidote, naloxone, could be made much more accessible — not just to first responders but also to friends, family, and perhaps even out in the open in busy public streets.
In Baltimore, Wen in 2015 issued a standing order for naloxone, letting anyone in the city get the drug without a prescription from a doctor. With more funding, she would like to see that expanded further so naloxone is also affordable or free for everyone — an idea she describes, using naloxone's brand name, as "Narcan for all."
"In Baltimore city alone, our everyday residents have already saved over 950 lives in the last two years," Wen said. But "we are limited in our efforts because of resources. We simply don't have the money to buy Narcan for everyone who may encounter someone who's overdosing."
One concern with harm reduction strategies, echoed by anti-drug groups like the Drug Free America Foundation, is that removing some of the risk to using harder drugs will perhaps make some people more likely to use dangerous substances.
But this simply has no foundation in the evidence. For example, a 1998 study from researchers at Johns Hopkins University found needle exchange programs generally reduced the spread of HIV without increasing drug use. A 2004 study from the World Health Organization, which analyzed two decades of evidence, produced similar results.
Harm reduction efforts will not prevent all deaths. They won't make all heroin use safe. But they will reduce the amount of harm done by these drugs.
"Sometimes, [addiction] is just terminal," Lembke said. "Even if it's not and doesn't lead to death, there are people who will never be able to get better." She added, "We have a holier-than-thou, black-and-white thinking about it. It really is hard to embrace the idea that that's the best we can do. But you know what? Sometimes the middle of the road is the best we can do for some people. Not everybody is going to overcome their addiction, write a memoir, become famous, [and] be on Oprah. That's just not going to happen."
4) Address the other problems that lead to addiction
With addiction, what you see is not always what you get. Behind drug use are issues that, at face value, may not seem related — what some experts call the root causes of addiction.
There's a classic experiment behind this idea: the Rat Park. Some of the original experiments on cocaine and heroin addiction were conducted under animal testing settings in which rats were caged off and socially isolated, with drugs as their only real form of recreation. These experiments suggested the drugs were extremely addictive, leading rats to use them literally to their deaths.
So Bruce Alexander, a Canadian researcher, decided to see what would happen if drugs were instead offered in a bigger cage in which rats could interact with other rats. His results were striking: While rats in cramped, isolated cages preferred drug-laced water, rats in healthier, more social environments preferred plain water — even when the drug-laced water was made intensely sweet. The results suggest that it's not just the presence of drugs but other variables that drive people to use these substances.
This has led experts in the addiction field to point to the many social, environmental, and psychological issues that can contribute to drug use. As Maia Szalavitz, a longtime addiction journalist and author of Unbroken Brain: A Revolutionary New Way of Understanding Addiction, put it to me, "Anything that makes you miserable is going to increase the risk of addiction for quite obvious reasons." For her part, she said there are three major contributors to addiction: other mental health problems, past trauma, and existential and economic despair.
Leo Beletsky, a professor of law and health sciences at Northeastern University, said that this part of the issue needs much more attention in discussions about the opioid crisis. He told me that although opioid overprescribing may have contributed to the current epidemic, he believes that, among other issues, "changes in welfare policy, changes in the economy, and social isolation" played bigger roles. He points to the fact that the US has seen rises in other deaths of despair, such as suicide and alcohol-related deaths, as proof that something deeper has gone wrong in American life.
"We have a lot of complex problems in this country," Beletsky said. "Without really addressing all of those physical, emotional, and mental health problems, just focusing on the opioid supply makes no sense — because people still have those problems."
Some places have put such ideas into policy. Iceland built an anti-drug plan that focuses largely on providing kids and adolescents with after-school activities, from music and the arts to sports like soccer and indoor skating to many other clubs and activities. Iceland coupled this approach with other policies — setting drinking and smoking ages, banning alcohol and tobacco advertising, enforcing curfews for teenagers, and getting parents more involved in their kids' schools — to further discourage and fight drug use.
Researcher Harvey Milkman told journalist Emma Young, who profiled Iceland's experiment, that it's "a social movement around natural highs: around people getting high on their own brain chemistry … without the deleterious effects of drugs."
As a result, Iceland, which had one of the worst drug problems in Europe, has seen adolescent consumption fall. The number of 15- and 16-year-olds who got drunk in the previous month fell from 42 percent in 1998 to just 5 percent in 2016, and the number who ever smoked marijuana dropped from 17 percent to 7 percent in the same time frame. In a similar time period, from 1997 to 2012, the percentage of 15- and 16-year-olds who participated in sports at least four times a week almost doubled — from 24 to 42 percent — and the number of kids who said they often or almost always spent time with their parents on weekdays doubled, from 23 to 46 percent.
Approaches will differ. Iceland, after all, is a fairly small, homogeneous country. What works there may not work in the US, and what works in some parts of the US may not work in others. But the general idea, experts said, is sound.
When I asked experts for specific proposals for dealing with root causes of drug addiction, each person seemed to have dozens of ideas: developing stronger social safety net policies, creating new job programs, offering better wraparound social services, better integrating mental health care with the rest of the health care system, encouraging non-drug sources of relaxation and entertainment, and on and on.
"It will really require rebuilding communities from the ground up," Lembke said. "We have to help communities rebuild families. We have to give people meaningful work. We have to give people some opportunity for play — and by that I mean alternative sources of dopamine, so people have something else to replace the drugs or prevent them from turning to drugs in the first place."
Not all experts are convinced. Humphreys, for instance, argued, "I think a lot of [these ideas] are worth doing because they're worth doing — fighting inequality, enriching people's lives, bringing jobs back to Pennsylvania and West Virginia. But I don't think it would have a big impact with addiction." He pointed out that British Columbia — which does a lot of the things experts want the US to do, from offering a stronger social safety net to prescription heroin to universal health care — is still suffering from a drug overdose crisis that killed a record 922 people in 2016.
When it comes to opioids, addressing the root causes of addiction will also require addressing chronic pain — the reason a lot of people were exposed to opioids in the first place. Given that the evidence on opioids' effectiveness for treating chronic pain is veryweak, part of the solution will require making alternative pain treatments much more accessible to help the 100 million US adults who suffer from chronic pain.
As Stanford pain specialist Sean Mackey previously told me, there are non-opioid options for dealing with pain, including non-opioid medications, special physical exercises, alternative medicine approaches (such as acupuncture and meditation), and learning how to self-manage and mitigate pain. (There's also evidence for medical marijuana reducing opioid overdose deaths, since cannabis can act as a painkiller. But Mackey is skeptical, pointing out there are hundreds of non-opioid medications already available.)
But to get these options, more patients will need to be able to see doctors like Mackey to help put them on the right treatment plan. Such specialists remain out of reach — too expensive, too far away — for many patients. This is a reason that opioids became so popular in the first place: It's much easier to give someone a pill than to get them into an expensive, complicated pain treatment program. Addressing the faults of the health care system, from lack of local options to lack of insurance, would help in this area.
Opioids may still be a good answer for a few chronic pain patients. When prescribed carefully on a schedule that works to diminish the excessive buildup of tolerance, they can work for some people. But Mackey cautions that opioids should not be a first-line treatment due to the grave risks, and alternatives should be tried first.
If these ideas do work, they will take time. Rebuilding a community and restructuring the health care system are years- or decades-long projects; they're not something we can do overnight. But addressing the root causes of drug use could at least help stop future epidemics, even if it'll come too late for the opioid crisis.
We know what to do, but we need to dedicate the resources to do it
For me, the most surprising part of reporting out this story was that a lot of it really isn't surprising. Experts tended to share a lot of the same ideas. There's a lot of good research backing up most of the proposed solutions. Simply put, we know how to stop the opioid epidemic.
Yet we haven't. Overdose deaths have climbed for years, and the official numbers for 2016 and 2017 are expected to be even worse.
I asked experts why. Time and time again, they had the same explanation: There's still a lot of stigma surrounding addiction. While doctors and experts understand it is a disease, much of the public does not — and views addiction as a moral failure instead.
I get emails to this effect all the time. Here, for example, is a fairly representative reader message: "Darwin's Theory says 'survival of the fittest.' Let these lost souls pay the price of their criminal choices and criminal actions. Society does not owe them multiple medical resuscitations from their own bad judgment, criminal activity, and self-inflicted wounds."
Some lawmakers share this sentiment. Missouri state Sen. Rob Schaaf, a Republican, once remarked that when people die of overdoses, that "just removes them from the gene pool."
Perhaps as a result of this kind of attitude, there's just not that much attention paid to the opioid epidemic. The issue was often drowned out during the 2016 presidential campaign by scandals and gaffes, particularly Hillary Clinton's emails. It's seldom come up in politics this year, as a record number have continued dying. And the public doesn't seem to be putting much, if any, pressure on lawmakers to do anything about it. As New York Times columnist Nicholas Kristof noted in his recent op-ed, opioids are "a mass killer we're meeting with a shrug."
Perhaps the solution here is to educate people on the basic realities of addiction and why it needs our attention. The public needs to understand, as Lembke put it, that "if you see somebody who continues to use despite their lives being totally destroyed — losing their jobs, losing loved ones, ending up in jail — nobody would choose that. Nobody anywhere would ever choose that life. So clearly it is beyond this individual's control on some level."
People like John Pinkney in Vancouver don't want to go to prison. They don't want to lose their jobs. They don't want to burden their friends and families. They don't want to spend all their waking moments thinking of ways to chase down a drug — just to feel okay for a few minutes or hours. They don't want to spend their lives taking from more than giving to society. This is something that, for whatever reason, has afflicted them.
The ideas experts cited won't stop all drug addiction forever. But they could save up to hundreds of thousands of people in the next 10 years, letting more Americans live the free, happy, productive lives that we all aspire to have.