The first step in recovery from our national opioid epidemic is probably the hardest: To accept that addiction is not a moral failing, but rather “a chronic disease of the brain,” as described by Surgeon General Vivek Murthy. In an interview with Ariana Huffington for the Huffington Post, Murthy called the opioid addiction epidemic one of the most “important public health challenges of our time.”
In order to address this public health challenge, we have to first accept that it is a health challenge, and not a criminal one. Here are a few steps that might help.
Step one is so obvious that it should have been done years ago: Declare victory in the War on Drugs and send the troops home. Move the drug scheduling to the office of the surgeon general (we might consider demilitarizing that position as well as those supervised by the surgeon general, since public health really should not involve military ranking) in concert with the National Institutes of Health and save a bunch of money.
And we will need that money as we move our drug policy from a criminal issue to one of medicine. You cannot incarcerate an addiction. You must treat it at the same time you are working to prevent it.
So step two would be to begin early education on addiction as a health issue in primary schools. Children in elementary schools should be taught about addiction just as they are taught about cancer or diabetes, i.e., as a serious health threat, not a failure of willpower.
But children are not the only ones who need an education in addiction.
Doctors rarely receive any training in addiction medicine during medical school.
A report in 2012 by the National Center on Addiction and Substance Abuse revealed that medical schools devoted little time to teaching addiction medicine—only a few hours over four years.
Thanks to the efforts of Dr. Anna Lempke, the director of its addiction medicine fellowship, Stanford University is taking steps to rectify its own shortcomings in this area, making addiction training a separate unit instead of a single lecture. Addiction medicine has now been recognized as a subspecialty field by the American Board of Medical Specialties. Many challenges remain, including the low insurance reimbursement rates that can discourage young doctors from entering the field. And there is still the cultural perception of addiction to overcome.
Medical faculties have traditionally eschewed teaching about addiction, in part because many physicians viewed the subject as a personal vice, not a disease. Some consider it difficult – sometimes impossible – to treat in a medical setting.
Step three is to start building more rehabilitation facilities and start closing some prisons. The data supplement to the 2015 National Drug Control Strategy reveals that in 1980, there were 478,793 clients in substance abuse treatment facilities, both inpatient and outpatient. In 2013 there were 1,249,629 (Table 66). There may be as many as 2 million rehab beds in the United States, but there are about 20 million Americans over the age of 12 that need them.
Meanwhile, 16 percent of those in our state prisons, and 45 percent of those in our federal prisons, are there with a drug charge as their most serious offense (Table 61). Perhaps instead of closing the prisons, we should simply convert many of them into treatment facilities.
Step four would be to regulate a pharmaceutical industry that appears to have absolutely no self control when it comes to profit. When a manufacturer can increase the cost of its EpiPen by 400 percent after spending $4 million to successfully lobby Congress for the 2013 School Access to Emergency Epinephrine Act to encourage schools to stock their product, and then move its corporate headquarters to the Netherlands to avoid paying U.S. taxes, something is seriously wrong with our relationship with this industry.
The manufacturers of naloxone have increased the price on this life-saving opioid overdose antidote. Some versions have become 17 times more expensive in just the last two years. Unlike the EpiPen, there are multiple manufacturers who produce different versions of naloxone, but the increased competition has not resulted in lower prices. They continue to climb.
If they can increase prices on drugs like these without any real justification, what is going to happen to the chronic pain sufferers when Purdue Pharma, or the other manufacturers, decide that they too, need a greater profit margin?
Step five would be to recognize that since addiction is a disease, some treatments will work better for some people than they will for others. A 12-step program may be the therapy that can help Patient A deal with his addiction and return to full health. Patient B may find no help at all with that program, but can benefit from medication-assisted treatment through the use of methadone or buprenorphine.
"We have tons of experience with patients who remain in treatment for months and years, who do very well on relapse-prevention medicines," says Dr. Marc Fishman, medical director at Maryland Treatment Centers in Baltimore. He says among his patients, primarily young people, about half remain with the program six months into treatment. Studies have shown far worse outcomes for patients who detox without follow-up medications, with relapse rates topping 90 percent.
Patient C may not want to take a relapse prevention medication, or may not do well on it, but could benefit from one-on-one counseling therapy. All options should be on the table when a patient meets with his doctor to decide on his treatment.
Step six: Be willing to learn from the experiences of others. In 2001, Portugal, in the middle of its own drug epidemic, decriminalized all of them, from marijuana to heroin.
Decriminalizing drugs didn’t mean letting drug use run rampant, or even that drugs are legal. The system works so that someone caught with drugs in a public place are escorted by police to a police station, where they will confiscate the drugs, weigh them, and determine whether the amount exceeds a certain threshold. If it does, the person might be suspected to be a dealer and sent to the criminal justice system. If not, the person is instead sent to the Ministry of Health.
“Drug use is still prohibited, but you won’t get penalized or sent to jail,” Goulão states. “The police can catch you using drugs, but you don’t get a criminal record, you don’t go to jail, you don’t have a criminal procedure.”
Almost 1 percent of Portugal’s population was addicted to heroin before the drug was decriminalized and the addiction treated as a disease. Recognizing that the war on drugs was a complete failure, Dr. João Goulão makes clear that the success that Portugal has achieved over the past 15 years is not due to decriminalizing the drugs, but to their recognition that drug addiction was a health issue. Ninety cents of every anti-drug dollar that Portugal spends is for medical care for addicts. Only a dime is spent on punishment.
And while it is hard to say that the steps Portugal took are working any better than steps taken by other European nations, Brendan Hughes, principal scientific analyst at the European Monitoring Centre for Drugs and Drug Addiction, is quoted as noting that the program is apolitical. There is no desire by any political party to end the program. Which is, in itself, an indicator that the Portuguese seem to think it is working.
Here in the States, the opioid epidemic has crossed party lines as well. My friend Mac, whose son has battled a heroin addiction for a dozen years, is a conservative Republican who watches more Fox News than is good for him, but is willing to sit down with a flaming liberal to discuss the issue in calm, thoughtful tones. It was my discussion with him that led not only to a better understanding of this epidemic on a personal level, but to the appeal that Donald Trump’s call for building a wall has for those who have dealt with a heroin addiction in the family. For some, like Mac, it is not a matter of keeping immigrants out of the country, it is instead, a grasping at the possibility that it can keep the heroin out of the country.
Of course, it won’t. The traffickers will always be able find another way to bring the product into the country as long as the demand remains high. But it is typical of Trump’s policy positions—slogans without substance.
Hillary Clinton’s plans are far more nuanced and developed. She is a firm believer in early education for children, in treatment and recovery programs to help the patient, in providing first responders with naxolone, and prescribing physicians with ongoing training, and prioritizing treatment over prison.
We’re not just now ‘discovering’ this problem. But we should be saying enough is enough. It’s time we recognize as a nation that for too long, we have had a quiet epidemic on our hands. Plain and simple, drug and alcohol addiction is a disease, not a moral failing—and we must treat it as such.
Hillary, September 2, 2015