What’s to Be Done to End the Opioid Epidemic?

On January 24, on the heels of the first ever Surgeon General Report on addiction, CSIS hosted then Surgeon General Dr. Vivek H. Murthy to discuss evolving public health approaches to the opioid epidemic. The event was inspiring, so much so that audience members swarmed the Surgeon General in its aftermath. CSIS Global Health Policy Center events do routinely draw large and passionate crowds, feature charismatic speakers, and inspire, but the Surgeon General and his novel approach evoked particularly passionate responses. Dr. Murthy spoke compellingly of the human price of the opioid epidemic, outlined steps to end the epidemic, and pointed to a critical underlying condition: social isolation.

Opioid abuse and overdose has reached epidemic levels in the United States. A record 33,000 Americans died of opiate overdoses in 2015. Opioid overdose has surpassed car accidents as the leading cause of accidental death in the United States, and in 2015, heroin caused more deaths in the United States than did guns. Only about 1 in 10 Americans with substance use disorder (clinically significant impairment caused by recurrent alcohol or drug use) receive treatment in the U.S., a woeful number when compared with treatment rates for other chronic diseases, such as diabetes or cancer.

Opioid addiction is widespread in the United States, cutting across virtually all health, racial, socioeconomic, and geographic boundaries. The epidemic shows no sign of abating, despite significant financial and infrastructural investment, change of consciousness, bipartisan mobilization, and public health and law enforcement initiatives devoted to combatting it. How, amid a highly polarized debate over healthcare reform, can the United States sustain momentum and advance both programmatic and political progress towards controlling the epidemic?

The Surgeon General laid out five essential steps. First, physicians need to tighten prescribing practices without letting the pendulum swing too far in the direction of denying people with legitimate pain needs timely access to medication. The epidemic’s origins lie in over-prescription of opioids by physicians, many of whom acted with the worthy goal of alleviating pain and without adequate knowledge of opioids’ addictive properties, and has been building since the introduction of long-acting opioids in 1996.

In 2013, U.S. health care providers wrote over 249,000,000 prescriptions for opioids, enough to provide every adult in America a bottle of pills. The Surgeon General noted that while the quantity of prescribed opioids nearly quadrupled from 1999 to 2014 in the United States, there was no corresponding reported decline in patient pain. Meanwhile, deaths from prescription opioids have more than quadrupled since 1999. In March 2016, the Centers for Disease Control and Prevention (CDC) issued a new guideline for prescribing opioids for chronic pain that focuses on reducing the risk of opioid use disorder through the lowest possible effective dosages and alternative treatment for chronic pain, such as physical therapy or nonopioid medication. As prescribing practices tighten and the medical community strikes a better balance between risking addiction and fulfilling a real obligation to treat pain, illicit opioids like heroin, fentanyl, and carfentanil are filling the gap. Although more than half of opioid overdose deaths in 2015 were linked to illicit opioids, prescription opioids may continue to act as gateways: approximately three of four new heroin users abused prescription drugs prior to heroin.

Physicians are under increasing pressure to adhere to strict prescribing practices and connect those with opioid use disorder to evidence-based treatment. Last summer, Dr. Murthy launched Turn the Tide Rx, a national campaign to educate health care providers and learn from their experiences addressing opioid use disorder. As part of the campaign, the Surgeon General mailed a letter and pocket card to 2.3 million prescribers and clinicians, asking providers to exercise their unique power to end the epidemic. Pocket cards guide health care professionals on how to safely and effectively prescribe opioids. It is through education, training, and technology that physicians can reach a middle ground between over- and under-prescribing opioids. Public education is a critical piece of this solution, so that patients are fully cognizant of opioids’ addictive potential.

In addition to tighter prescribing practices, Dr. Murthy proposed expanding access to treatment. Over one million people with opioid misuse disorders are not receiving treatment, although evidence-based medication-assisted treatment and recovery programs exist. He also stressed the importance of more effectively providing first responders with naloxone, a lifesaving overdose reversal drug.
Lastly, the Surgeon General argued that opioid misuse and addiction remain highly stigmatized, despite improved understanding of addiction’s biological basis, attempts to conceptualize it as a chronic illness rather than moral failing, and public awareness of the opioid epidemic. During one of the Surgeon General’s cross-country tours, he spoke with parents whose tight-knit, usually supportive communities offered few words of comfort when their son died of an opioid overdose. Neighbors, uncertain of what to say and fearful of embarrassing the parents, at times avoided the family altogether. Addressing such stigma is crucial to encouraging those with opioid use disorder to seek and access treatment. The Surgeon General called on health care providers to use their position as leaders in society to change negative perceptions of addiction.
Dr. Murthy also placed the opioid epidemic in the context of his broader campaign for mental and emotional well-being. In his view, the opioid epidemic threatens American individual and community health and is connected to larger trends of societal dislocation in the United States. Surprisingly, Dr. Murthy said the most common illness he sees in America is not heart disease or cancer but social isolation. With a mortality similar to that of smoking or obesity, isolation constitutes a serious but often overlooked public health threat. Dr. Murthy believes this threat must be elevated and addressed by tackling both the external and internal factors that contribute to emotional wellbeing. This entails confronting poverty and economic insecurity, while at the same time helping individuals become more resilient. Lauding the health benefits of love and compassion, “the oldest medicines,” he called upon all individuals to make those around them feel like part of a community.

At the political level, Dr. Murthy called for a unified approach to ending the opioid epidemic. He argued that because disease does not discriminate, public health is an inherently unifying endeavor; “the truth is epidemics like the opioid epidemic…don’t discriminate between conservatives and liberals and independents. Zika-carrying mosquitoes don’t decide who to bite depending on their political persuasions.” The opioid crisis has inspired an unusually high degree of bipartisan cooperation, often but not always bridging the divide between Republicans and Democrats, and the Executive Branch and Congress. Continued and expanded bipartisan support will be necessary to maintain gains and further progress towards stemming the epidemic. The opioid epidemic should figure prominently in repeal and replacement of the Patient Protection and Affordable Care Act, as Medicaid rollback could jeopardize treatment gains—nearly 1.3 million Americans take advantage of expanded Medicaid’s mental health and substance abuse disorder treatment benefits. Additionally, rollback of Medicaid expansion would affect states hardest hit by the opioid epidemic, such as Ohio, Kentucky, and West Virginia.

In this critical and uncertain period, how do we protect gains against the opioid epidemic and sustain forward momentum? As the Surgeon General explained, the complexity and magnitude of the American epidemic necessitate a public health and multi-sectoral approach. Adequate funding by Congress for these efforts, despite the polarized debate over the future of America’s health system, remains critical. The Surgeon General’s talk was distinctive for not only its clear delineation of steps but also its tone of community empowerment and compassion. While law enforcement certainly has an important role to play in stemming supply of illicit opioids, the United States should not lessen its insistence upon an evidence-based, compassionate public health approach to combatting the epidemic.