By Dr. Richard Juman
We already have most of the tools we need.
Last week, Professional Voices revisited an issue that The Fix has been focused on since its inception: the public health debacle caused by the overprescribing of opioid pain medications, and the related increase in heroin use and overdose, which has contributed to the deaths of tens of thousands of U.S. citizens. By now, the underlying issues that developed the epidemic are well-known, which makes the fact that we are still deeply embedded in the crisis that much harder to stomach.
The response to this crisis has been tragically sluggish, because we actually already have the knowledge and the tools that we need to drastically improve matters. We know what needs to be done to keep those who are already addicted alive. We know how to help people who are struggling with addiction enter recovery. We know how to stop creating more problems with prescribed opioids. But we also know that we just haven’t done a good job so far, and that now would be a good time to start.
First, keep people who are already addicted to opioids alive by making all of the effective
tools available in this regard. Naloxone, a drug that reverses opioid overdose, should be made as widely available as possible. Just as those who are allergic to bees or other allergens carry around an EpiPen, those who use opioids should be able to have Naloxone on hand.
Good Samaritan laws, which protect people from criminal prosecution when they call 911 because somebody is overdosing, can save lives and should be the law of the land. Syringe exchange programs and safe injection sites should be widely available. All of these efforts keep people alive.
Second, make sure that all patients have access to the evidence-based, addiction medicine interventions that most opioid-dependent individuals are not receiving right now. Part of the reason for that is the stigma around addiction, which has placed restrictions on the mechanisms through which addiction medications are delivered. Methadone, for example, is doled out in clinics- what other medication can you think of that is delivered that way? Although patients can receive buprenorphine from private doctors, there are significant restrictions on the number of patients that physicians can prescribe buprenorphine to. Methadone, Suboxone, naltrexone and Vivitrol are all evidence-based treatments that are not being used by thousands of people who would benefit from them. According to Mark Willenbring, MD., “The main deficiency of current actions to address opioid addiction is the lack of access to prompt, professional opioid maintenance treatment with buprenorphine or methadone. Opioid maintenance therapy is the only proven effective treatment for established opioid addiction, but government and mainstream healthcare organizations have not mobilized to make this life-saving and cost-effective treatment widely accessible and affordable.”
Third, provide enhanced training for physicians so that they become more adept at screening for, recognizing and treating addiction. We need to make sure that physicians have the kind of training in addiction medicine that will help interrupt the flow of newly-created prescribed opioid addictions. According to Kevin Kunz, M.D., M.P.H., the Executive Vice President of The American Board of Addiction Medicine, “We can no longer afford to focus only on treating advanced cases of addiction and its complications; we need to focus on prevention. In addition to the monitoring and control measures that many states have put in place, we believe the most effective long-term strategy is a shift in medical training and practice that builds a workforce of physician experts in addiction medicine who can both provide treatment for all addictive substances for those who need it and educate other physicians about the nature of addiction, how to prevent it, its appropriate treatment, the dangers of addiction involving prescribed drugs, how to screen for patients at risk and appropriately intervene, and how to secure quality specialty care for treatment and disease management.”
Fourth, make sure that all prescribers have access to Prescription Monitoring Programs and that they use them. Although almost all states now have some type of electronic database that physicians can consult prior to prescribing opioid pain medications, not all states make it a requirement that they do so. Given what we know about the lethality of prescription pain medications, it seems both wise and inevitable that more and more states will make it a requirement—why not now? Given what we also know about how laws of this type frequently come to pass, because of the heartfelt, intense, grassroots efforts of people who have lost loved ones, why not make the use of these databases a requirement now, and save those lives and the agony of those who will be left behind? We should make the conditions for putting newly prescribed opioids into the system very stringent, and make sure that prescribers who knowingly circumvent the safeguards are taken out of the system.
(At the same time, we need to make sure that the people for whom these medications were intended continue to have access to them. As noted by Michael Friedman, Adjunct Associate Professor at Columbia University School of Social Work, “there are people who cannot work, socialize, or be responsible family members because the pain they experience is intolerable. A complete campaign to prevent opioid addiction needs to address this fact as well as the fact of over-prescription of a dangerous drug.”)
Fifth, make it as difficult as possible for opioid pain medications to be used in ways other than the ways they were intended or prescribed. As examples, we could stop approval of any new opioid painkillers that are not clearly safer than existing ones and remove from the market all high dose opioid analgesics that are easily crushed.
Sixth, educate the public about the risks of prescription pain medications. The path to addiction to opiates often comes from friends and family- often directly from the medicine cabinet. We all know people whose kid came back from the oral surgeon with an unreasonably large supply of Vicodin. So it is imperative that the public be aware of the dangers of prescription pain medications and especially the need to properly dispose of any unused opioids that remain after an episode of acute pain management. We know that “over 70% of people who abused prescription pain relievers got them from friends or relatives."
Last, but certainly, in my view, not least: we need to make sure that people suffering from opioid addiction, as with other forms of addiction, have access to the kind of evidence-based psychotherapy that is so conducive to ongoing recovery. Unfortunately, we know that all of our efforts to reduce or even eliminate the overprescribing and misuse of prescription pain medications can only go so far, because people will always have access to heroin.
There are so many opioids out there now, in both prescribed form and heroin, that there are limits as to how effective our efforts focused on the prescription side can be. As journalist Maia Szalavitz notes, "You can't solve this problem on an enforcement level, even if you put a tracking device on every chronic pain patient in the U.S." We need to do a better job treating addiction as the complex and devastating clinical issue that it is. And, word to the wise, improving our approach to addiction will also “cut state and local spending, lower crime, traffic accidents, suicides, domestic violence, homelessness, birth defects and a host of other devastating and costly health and social ills.” Most people struggling with an addiction aren’t receiving any treatment at all.
As in all cases of addiction, “the object of study should be the individual, rather than the substance,” according to psychologist/psychoanalyst Debra Rothschild, PhD. We need to treat the real problem instead of simply dealing with its inevitable consequences.
Every patient brings to treatment a unique history, biology and relationship to their drug use. A thorough treatment for opioid addiction should afford a stable, ongoing, non-stigmatizing treatment alliance with a primary therapist that patients work with on a regular basis. I believe that this type of therapeutic relationship, with a licensed mental health provider who has a sense of overall responsibility for their care, and who is able to help the patient come to an understanding of their addiction in the context of a variety of other factors, is essential. We know that addiction is often found along with other mental health issues such as trauma, depression and anxiety, not to mention the patient’s underlying personality. So our patients “require professionals trained in mental health, skilled in psychotherapy, knowledgeable about the full range of psychological treatments, and fluent in the use of both addiction and psychiatric medications. "
We can have a transformative impact, in the very near future, on the epidemic of opioid addiction and on addiction more generally. Let’s do everything in our power to make it a reality.
Richard Juman—a licensed clinical psychologist who has worked in the integrated health care arena for over 25 years providing direct clinical care, supervision, program development and administration across multiple settings—is also former President of the New York State Psychological Association. [email@example.com] Find him on twitter— @richardjuman