A Five-Step Approach to the Opioid Epidemic, Part 2 of 2
As intractable as the darkness may seem, there are pathways out of it.
Posted Oct 31, 2017
According to the US Centers for Disease Control and Prevention (CDC), in 2016, 65,000 people in the United States died from drug overdoses—more than were killed in the Vietnam War—an increase of nearly 19 percent over the 54,786 deaths recorded just the previous year. The vast majority of these overdose deaths resulted from opioids.
On October 26, 2017, President Trump directed the US Department of Health and Human Services to declare the nation’s opioid crisis a public health emergency under the Public Health Services Act. As important as this announcement is, it fell short of authorizing any emergency federal funding or laying out any concrete strategies. It also contradicted the promise the President made in August to declare a national emergency on opioids, a designation that would have precipitated the allocation of federal funding. Moreover, he made little mention of the need for the costly expansion of addiction treatment availability that is essential to addressing the epidemic.
Make no mistake: there are no magic bullets and no quick fixes to this crisis. However, there are several critical steps that can be taken to mitigate its damage to individuals, families, and communities, and help us make meaningful progress toward solutions.
1) Prioritize addiction treatment over arrest and incarceration
Among the most fundamental problems sustaining the opioid epidemic is that it is much easier to get high than it is to get help. Repealing the Affordable Care Act (ACA, a.k.a. Obamacare) would only enlarge this gap, eliminating Medicaid-funded treatment for tens of thousands of people struggling with addiction. Other efforts to reduce Medicaid funding will have the same effect. Rather than continuing to attempt to destroy the ACA, funding that makes addiction treatment more accessible needs to be increased, and more states need to encouraged adopt the ACA’s available Medicaid expansion.
Law enforcement agencies in 30 states now participate in the Police Assisted Addiction and Recovery Initiative (PARRI), which offers treatment for drug users who request assistance from law enforcement authorities. Instead of focusing on the crime resulting from addiction, through PARRI, the law enforcement focuses on getting people help they need, an effort that costs less and presages more positive results than arrests (often repeated) and incarceration.
2) Support and expand medication-assisted treatment (MAT)
Increasing research suggests that one of the most effective methods of treating opioid addiction is through replacement medication therapies using methadone and buprenorphine. As part of an approach that seeks to reduce harm rather than insist on complete abstinence, the use of these medications helps to decrease relapse as well as addiction-related medical problems, enhancing people’s ability to function and rebuild their lives. Unfortunately, only a minority of addiction treatment programs in the US currently has this option.
MAT is not without its downsides, however. Methadone and buprenorphine are themselves both opioids with their own potential for addiction—although somewhat less so for buprenorphine, a partial (as opposed to full) opioid agonist. Ideally, MAT is utilized as a bridge that helps people gradually and progressively taper off the replacement meds and transition to abstinence. As much as possible, it should be time-limited rather than a life-long replacement regime.
3) Increase the availability of naloxone
Opioid users need to be kept alive long enough to seek treatment. Although now authorized in some states and an increasing number of municipalities to carry and administer it, first responders and emergency rooms often lack adequate supplies of naloxone—the medication that counteracts opioid overdoses. Naloxone is an opioid antagonist—meaning that it binds to opioid receptors and can reverse the effects of opioids. It can literally bring someone back to life, restoring normal breathing for people whose respiration has dramatically slowed or stopped as a result of overdosing on prescription opioids or heroin. Federal and state health agencies need to negotiate lower prices and further expand access to naloxone. Importantly, as of the time of this writing, CVS is reportedly offering naloxone without a prescription in 43 states and Walgreens has announced it will make prescription-free naloxone available at all of its stores.
4) Expand other harm reduction resources
The government also needs to spend more on needle exchange and clean syringe programs to combat the infectious diseases spread by sharing needles. Escalating injection drug use by people who shifted from opioids in pill form to heroin is precipitating a dramatic increase in hepatitis C infections. From 2010 to 2015, the number of new hepatitis C virus infections reported to CDC has nearly tripled. Hepatitis C currently kills more people than any other infectious disease reported to CDC. Nearly 20,000 Americans died from hepatitis C-related causes in 2015, the majority of people ages 55 and older. New hepatitis C virus infections are increasing most rapidly among young people, with the greatest number of new infections reported among 20 to29-year-olds.
5) Teach and significantly expand the availability of holistic, multimodal opioid-free approaches to addressing chronic pain
When it comes to opioids, addressing the root causes of addiction will also require addressing the reason many people were exposed to opioids in the first place—chronic pain. The addictive potential of opioids in combination with the lack of research-based evidence of their efficacy in treating chronic pain, necessitates that part of the solution lies in making alternative pain treatments much more accessible. This will require a paradigm shift for healthcare services and insurance coverage.
Nearly 50 million American adults have significant chronic pain or severe pain, according to the National Institutes of Health’s National Center for Complementary and Integrative Health (NCCIH). Based on data from the 2012 National Health Interview Survey (NHIS), the study estimates that within a previous three-month period, 25 million U.S. adults had daily chronic pain, and 23 million more reported severe pain.
There are opioid-free options for dealing with chronic pain, including non-opioid medications, specialized physical therapy, stretching, and physical exercises, alternative and complementary medicine approaches such as acupuncture, chiropractic, massage, hydrotherapy, yoga, chi kung, tai chi, and meditation. In fact, for the first time, the American College of Physicians is advising treating back pain with nondrug measures like these before resorting to over-the-counter or prescription pain relievers. A recent Consumer Reports nationally representative survey shows many people with back pain found alternative therapies useful. The survey of 3,562 adults found that almost 90 percent of those who tried yoga or tai chi reported that these methods were helpful; 84 percent and 83 percent, respectively, reported the same with regard to massage and chiropractic.
An opioid-free approach to chronic pain also involves learning and practicing separating pain—the signal transmitted through the central nervous system that “something is wrong,” from the suffering—the interpretation or meaning given to that pain signal—so often attached to it. Suffering results from mental and emotional responses to pain, and includes the internal self-talk and beliefs about it which then drive emotional reactions.
These methods require people to be more active participants in their pain recovery process. None of them are likely to eliminate or “kill” someone’s chronic pain. However, in combination and with practice they can make substantial positive differences in the subjective experience of pain, the ability to self-regulate, and the overall quality of life.
Copyright 2017 Dan Mager, MSW
Author of Some Assembly Required: A Balanced Approach to Recovery from Addiction and Roots and Wings: Mindful Parenting in Recovery (coming July, 2018)
 Richard Nahin, “Estimates of Pain Prevalence and Severity in Adults: United States, 2012,” The Journal of Pain, August 2015 Volume 16, Issue 8, Pages 769–780 DOI: http://dx.doi.org/10.1016/j.jpain.2015.05.002