As panel after summit after commission after white paper is put forward claiming to solve the overdose crisis, you’d think that somewhere there’d be a short, sensible guide for how to improve our health care system to better manage addiction and pain.
But most of these reports and discussions dance around the edges and bureaucratic obstacles to change. Few address the fact that deep systemic change is needed.
I’d like to lay out the rudiments of what would actually help—and which measures matter most. I’ll start with the most immediately practical and move on to what is needed long-term.
We have two drugs that are proven to cut the death rate from opioid addiction by half or more when used long term: methadone and buprenorphine. Anyone who is addicted to opioids and wants to get even a single dose once should be able to access these medications on demand—in hospitals, doctor’s offices, emergency rooms and syringe exchange programs. Minimal restrictions, for example, to prevent people from getting more than one dose per day, may be justified—but that’s it. No urines or counseling or abstinence from opioids or other substances should be required to get these drugs, just as those barriers are not imposed on people with other disorders who need medication.
Possession and sales of buprenorphine should be decriminalized, as is being done informally in Burlington, Vermont. It’s far better for someone to buy this medication illegally than for them to buy and use heroin or pills likely to be contaminated with fentanyl. The DEA and state prosecutors also need to stop targeting buprenorphine prescribers, regardless of whether they are providing optimum care. Simple access to the medication saves lives: Get out of the way!
Ultimately, of course, we need to provide access to other medical opioids as well for people with addiction who would otherwise take street drugs. This means hydromorphone (Dilaudid), which has already been studied in Canada and found helpful; injectable methadone, which is used in the UK; and perhaps others so that people can find what works for them. Heroin itself should be made available by prescription, but given the legal obstacles to getting anything (including marijuana!) out of the completely illegal category (Schedule 1) this seems unlikely to be possible soon.
In response to the overdose crisis, in 2016 the Centers for Disease Control released a set of guidelines intended to reduce overuse of opioids in the treatment of chronic pain in primary care. Quite predictably— to anyone who has observed the extreme swings of American opioid policy in the past—these were rapidly “weaponized” as Dr. Stefan Kertesz of the University of Alabama put it in an excellent paper that recently summarized the resulting problems.
No evidence shows benefit from forced taper; some suggests severe harm.
Basically, the guidelines are now seen as the national standard of care—and stepping outside the maximum recommended dosages is viewed as flirting with medical board or even prosecutorial scrutiny, even for specialists. Their recommendations are being applied indiscriminately, with even some cancer and end-of-life patients being denied adequate pain relief.
Simultaneously, afraid of losing their licenses and/or their freedom, many doctors have simply decided to stop prescribing opioids, period. States are also creating rigid policies while insurers and pharmacies are increasingly restricting what they will allow, often citing the guidelines. The result is tens of thousands of patients—many of whom were formerly medically stable—being left in pain, increased disability and withdrawal. Dozens of suicides by pain patients have been reported. People with addictions whose prescriptions are cut are not being helped either. This simply makes their addiction more dangerous by pushing them to street drugs. It is not treatment.
Medical abandonment when a patient is medically stable on opioids or has been caught misusing them is not care. First, reduce harm, rather than causing it. And, please, leave legacy pain patients who are doing well on opioids alone: Provide support if they want to try to taper and suggest taper with support if they aren’t doing well, but don’t force it.
No evidence shows benefit from forced taper; some suggests severe harm. The only realistic way to reduce reliance on opioids for chronic pain—which is still necessary for some patients and will continue to be in the foreseeable future—is to provide effective alternatives for particular patients that are covered by insurance and actually locally accessible.
Stopping the shift from medical to non-medical opioids caused by this crackdown will save lives and reduce disability.
There are three primary uses of medication treatment: harm reduction, stabilization and ongoing care. Consequently, we need three separate tracks of programming to meet each of these specific needs. States and insurers need to incentivize providers to create this kind of system of care.
For harm reduction, what’s needed is a welcoming place where people can simply get a dose of medication and see some friendly faces. This track is low-threshold and has no requirements of regular participation—but it also provides rapid access and guidance into care for those who decide they do want additional help.
If you are successfully managing any ongoing mental health issues, you don’t need to keep showing up at a clinic.
For stabilization, people who want to put their lives back together need easy access to services that meet their particular needs, such as counseling, medication-friendly peer support, psychiatric care, housing and job training. This track is “medium threshold”—meaning that regular participation is expected and the goal is no use of non-prescribed opioids, but it is flexible and nonjudgmental. For example, in an effective system, non-medical marijuana use would be ignored: Some research says it improves or at least does not worsen outcomes for people taking methadone or buprenorphine for opioid addiction.
After people have been stabilized, however, they will need the third track, which is also a low-threshold approach but does not create risk via unavoidable interaction with people who are still actively addicted. If you have a job and family and are successfully managing any ongoing mental health issues, you don’t need to keep showing up at a clinic or get further counseling. This track—sometimes called “medical maintenance”—basically requires a once-a-month check-in to get medication via a primary care doctor and ensure all is well.
People will often need to move back and forth between these levels—and ideally, some level of continuity of care would be available. In Vermont, this is provided by a “hub and spoke” system: People who want intensive services start at the hub and move to a spoke once they are doing well and require less support. If they relapse and need additional care again, they can go back to the hub. Those who aren’t willing or able to stop chaotic drug use receive harm reduction services at syringe exchanges and ER’s. This is one potential model; others should be explored as well.
The idea that people who are stable on medication who are not using additional substances somehow “contaminate” abstinence-focused programs is sheer prejudice. When people are stable on medication, they are indistinguishable from people who are abstinent or who are taking other needed psychiatric medications.
The continuing propagation of anti-medication ideology will be much reduced if we stop paying for it.
While it does make sense to reduce interactions between people with active addiction and those who are early in stable recovery, this does not require banning medication. Instead, it requires managing full relapse (not a single “slip”) with referral to appropriate harm reduction services—not abandonment.
The continuing propagation of anti-medication ideology will be much reduced if we stop paying for it.
And there remains no sensible reason why insurers and governments should pay for self-help people can already get for free, instead of funding effective alternatives (such as cognitive behavioral therapy or motivational enhancement therapy) that do not raise issues related to moral judgment (“character defects”) or the First Amendment. All humans could probably benefit from moral inventory, making amends and service to others: the problem is making these 12 step practices a requirement to treat the unique badness of all people with addiction, rather than one pathway for social support and growth out of a menu of options..
In order to save lives, we need safer consumption spaces (or better yet, call them “overdose prevention sites”) in areas where drug use and sales are concentrated; syringe exchange programs scaled to meet demand; and increased access to supplies like fentanyl-checking test strips.
We also need shelters and housing, separate from those aimed at stabilization and abstinence, for people who are actively addicted, many of whom are also mentally ill and have symptoms related to severe trauma. When people have safe places to live and to use drugs, they are both much more likely to survive and much more likely to find ways to sustained recovery.
People with addiction have a wide range of individual needs and institutional “programs” will never be able to meet all of them. Moreover, once a treatment “bed” is labeled as such, it generally becomes more expensive than an ordinary, safe place to stay. “Sober homes” also tend to be based on a 12-step ideology, which is fine for those who find that pathway amenable, but not for those who don’t—and not when that ideology is interpreted to stigmatize and discourage medication use.
The mental health field has recognized that institutionalization is generally harmful.
For most illnesses, medical and psychiatric, people recover better when they can stay in their own home with their friends and family nearby. This can be more complicated in addiction if friends and family are not supportive of recovery, or are actively addicted themselves. But many people with addiction are not in that situation and all will eventually need to manage cues and other sources of stress in the community where they live.
Consequently, “beds” are only really needed for people who are either homeless, living in an unsafe situation or psychiatrically or medically complicated enough to require inpatient medication stabilization. This is not the majority of people with addiction, even with opioid addiction.
The mental health field has recognized that institutionalization is generally harmful and that when needed, should only be used for the shortest possible time. Addiction treatment needs to catch up.
We need a system that provides a menu of individualized options—not residences staffed mainly by non-medical people that charge inpatient hospital care rates.
For all the problems with psychiatric drugs and their regulation, at least before they are sold they are required to be proven effective with minimal harm—and if harms are later discovered, they can be pulled from the market. The same is not true for talk therapies: Anyone can claim anything is effective and it’s extremely hard to “recall” harmful approaches—like the confrontation and humiliation that are still used in some addiction and teen programs.
If we want evidence-based psychological treatments for addiction and mental illness, we need a much better way of identifying them and making them widely available. While there are obvious First Amendment obstacles to banning forms of speech as therapy, many states have already banned harmful “gay conversion” therapy and there’s a difference between banning common speech and regulating tactics and approaches sold as treatment by professionals.
Addiction is not caused by any particular drug. It is caused by people discovering that altering their consciousness in certain ways helps them cope in particular environments—and then continuing to do so after it has become more harmful than helpful. Typically, the most traumatized and severely mentally ill people use many different drugs in many combinations—and when someone’s goal is to obliterate, rather than alter, their consciousness, reducing risk can be challenging.
All services aimed at people with addiction need to consider the needs of polydrug users, while also recognizing that for some, one drug is problematic while another can be managed successfully or even used to reduce harm (e.g., marijuana instead of or in order to reduce opioids).
In 2017, according to the latest FBI report, just over 1.6 million people were arrested for drug-law violations, and 85 percent of these arrests were for possession, not sales. Despite legalization in some states, most of these arrests are still for marijuana—and the number of arrests actually rose that year.
The primary purpose of criminalization is to stigmatize drug use … And that stigma, of course, is a huge barrier to getting people into treatment.
While it is difficult to precisely calculate the costs here, according to the ACLU a single marijuana arrest costs $750 (there’s no estimate available for other drug arrests), excluding court and jail costs. Per day, jailing someone costs roughly $85 and if we assume at least 2 days in jail, we get to over $1.2 billion without even counting court costs and costs in lost jobs and other consequences from a criminal record.
Since possession arrests do not deter drug use, raise drug prices or treat addiction, every cent spent this way is wasted. But it’s actually more harmful than that. People arrested and jailed for opioid addiction lose their tolerance and are three-to-five times more likely to overdose after release than if they had not been incarcerated.
Worse, the primary purpose of criminalization is to stigmatize drug use and people who take drugs—if criminalization is to deter people, it must stigmatize. And that stigma, of course, is a huge barrier to getting people into treatment whether for addiction or for overdose; to making treatment more effective; to expanding harm reduction; and basically to everything we need to do to end the crisis.
Criminalization also makes services less user-friendly because so many people are coerced into treatment by legal sanctions. Ending this practice, or at least reducing it, would force providers to do more to attract patients—and the more compassionate and welcoming addiction treatment is, the more effective is.
While having a national health care system in the US once seemed to be a pipe dream, the increasing embrace of “Medicare for all” by Democrats and the fact that majorities now support it in polls means that—providing we survive the current administration—it may soon be possible.
Research shows that states that expanded Medicaid under the ACA (Obamacare) reduced depression and increased access to addiction care. If we really want to fight addiction in the long run, safe, evidence-based care must be available to everyone who needs it.