A simple idea that can help end the opioid epidemic

I spent a lot of 2018 reporting complex systems and policies that could help end the opioid epidemic, which is now a crisis of drug overdose in the US.

But behind all the reporting I did was a simple idea: Americans need to see addiction as a medical condition, and an addiction treatment approach like other forms of health care.

This simple idea is at the heart of every problem and solution that I wrote about: Virginia reworked her Medicaid program to deal with the opioid crisis, private insurance companies ignored addiction care, prisons that failed to provide opioid addiction drugs, and special training programs that helped doctors are involved in addiction treatment. It is also at the heart of several other stories that I am working on, including the forthcoming part of California's efforts to offer addiction care in the emergency room.

Understanding this simple idea leaves you far from resolving the American opioid crisis. Once addiction is seen as a medical condition that requires health care services, many solutions begin to appear clear: Of course people with addiction must have access to proven drugs. Of course they must be able to get access to emergency care, emergency care, or at the doctor's office. Of course health insurance must pay for their care.

It is helpful to make a comparison with other chronic medical conditions.

Consider one statistic: According to a 2016 general surgeon report, only 10 percent of people with drug use disorders get special treatment for their addiction – mostly because there are no local treatment options, or if they exist, they are not affordable or have weeks of waiting or even months.

Think for a moment, is this true for other medical conditions, such as heart disease. Imagine a world where 90 percent of Americans with heart problems are allowed to suffer and even die without access to health care. Imagine that someone who has a heart attack can go to the emergency room only to be told that the ER has no way to treat it. Imagine that the ER has a way to help, but patients who have just had a heart attack have to wait weeks or months to get any treatment. Imagine if this patient went to the doctor's office for treatment only to be told that the provider there did not see the type.

This will be a public health disaster. American leaders will do everything they can, under public demand, to improve the huge gap in health care.

But this is a fact with addiction in America, even when the crisis of overdose is now breaking the record of death year after year.

Stigma is still the biggest barrier

The main reason for this problem is a mixture of stigma and misunderstandings about addiction.

For a long time, addiction in America has been seen not as a medical condition, but as a moral failure. This is how I understand e-mail like this, which argues that people who suffer from drug addiction deserve to die: "Darwin's Theory says survival of the fittest. Let these lost souls pay the price of criminal and criminal choices. they act. People don't owe a lot of medical resuscitation from their own poor judgment, criminal activities, and injuries sustained themselves. "

It is obviously ridiculous for anyone to argue like this for other medical conditions, including those such as heart disease, diabetes, and lung cancer which can also be caused by unhealthy actions and behaviors. But with addiction, it is something that I have heard repeatedly throughout my reporting – the results of culture, society and the legal system that treats addiction for more than a century as a moral and criminal problem.

There is no clearer example of this than the misunderstanding surrounding buprenorphine and methadone, which prevents withdrawal and the desire to stabilize one's drug use. This is a very effective drug for the treatment of opioid addiction: Research shows that they reduce mortality due to all causes among patients with opioid addiction to half or more and do a much better job of keeping people on treatment than non-drug approaches.

In Richmond, Virginia, Fawn Ricciuti told me about how buprenorphine helped him restore his life. After years of struggling with painkillers and heroin use, buprenorphine helped him stop using. He told me about how his recovery gave him a "better relationship with my daughter, my mother," and about his dream of starting an ice water shop. "I have a business idea. I just want to do a few classes and make sure that I have arranged everything so that I don't jump onto something above my head, "he said.

Julia Rendleman for Vox

If you have any medicine that can reduce the death rate among patients with heart disease or cancer or produce results such as Ricciuti for other conditions, it would be too much to not provide it to people in need. And if the drug proves to be better than other treatment options, it would be very unethical and immoral not to provide it through the health care system.

But with addiction, things aren't so easy. Many people, including major addiction care providers and former health and human services secretaries, question whether someone who uses any drug, including medicine, is truly in recovery. Conversely, using buprenorphine or methadone is often seen as "replacing one drug with another." By looking at someone's struggle with addiction as a moral problem, it suddenly becomes possible to refute the basic concept that medicine can treat diseases and medical disorders.

Some of them are rooted in the real misconception about addiction: the myth that someone is addicted just because he uses drugs. But the problem with addiction is not just drug use. The problem is when drug use changes to become compulsive and dangerous – creating health risks, directing someone to ignore family and children, encouraging someone to commit a crime, and so on.

As the Ricciuti story shows, buprenorphine overcomes this problem by allowing it to control drug use without such negative results, even if it needs to be done indefinitely. Medicines do not work for everyone, with data from France and Vermont showing that up to half of people with opioid addiction will not use drugs even when they are widely available. But helping only half of those in the US who are addicted to opioids will translate to potentially hundreds of thousands of lives saved more than a decade.

But the stigma remains, keeping these drugs inaccessible. Federal data show, for example, that less than half of care facilities offer opioid addiction drugs. This is a facility primarily tasked with offering addiction care in the US, and the majority do not offer the most well-known treatment for opioid addiction in the midst of an opioid crisis.

The health care system is still not enough

Stigma and misunderstandings run in, culminating in a health care system that is not well equipped to treat addiction.

This applies to individual health care providers, who under federal law must go through a special course to prescribe buprenorphine. According to the White House opioid commission report in 2017, 47 percent of US districts – and 72 percent of the most rural districts – do not have doctors who can prescribe buprenorphine. Only about 5 percent of national doctors are licensed to prescribe buprenorphine.

This applies to emergency rooms, most of which do nothing to treat addiction. The results are equivalent to someone coming in with a heart attack, and telling them that they themselves – because the hospital does not have a staff of cardiologists or other specialists.

This applies to health care in other settings, such as prisons. When I surveyed state prison institutions about whether they offered drugs for opioid addiction, for example, only Rhode Island – only one country – reported offering three drugs (buprenorphine, methadone, and naltrekson). That remains true to this day, although some countries are now experimenting more with that idea.

This applies to health insurance, which often refuses to pay for addiction treatment. In Virginia, the well-known addiction treatment program was paid low by Medicaid, which included low-income people, until recent program reforms increased reimbursement rates – which led to an increase in the number of people treated and a decrease in ER visits for opioid use. disruption, indicating that there is a sizeable population of underserved and previously cared people.

Photo by Mandy; collage by Javier Zarracina / Vox

In Illinois, I also spoke with one patient, Mandy, who struggled to get his personal health insurance company to pay for his buprenorphine recipe. As a result, Mandy had to spend more than $ 200 a month from pocket – until, after a lengthy process of appeal, Blue Cross and Blue Shield of Illinois finally agreed to pay.

Of course there are problems with insurance companies that refuse to pay for what they should do at any time, even outside the addicted space. But with addiction treatment, the problem is very bad, as shown by the fact that this problem still arises repeatedly even after the federal and state governments passed laws that effectively required insurance companies to cover addiction care.

The essence of each of these examples is the same problem: The health care system often does not even carry out minimal care for addiction, because we do not expect to do anything about this problem – thanks to stigma and misunderstanding – as long as it exists.

Once that hope really changes, America will begin to see important progress in resolving its opioid crisis. (Indeed, some states that experienced a decline in deaths from overdoses in 2017, such as Vermont, Rhode Island, and Massachusetts, are moving in this direction.) That won't be easy; policy making is still difficult, health care systems are very complex, and how all this works in the field can be messy.

But in the end everything is rooted in a simple concept: approaching addiction treatment like other forms of health care.

Looking back on my 2018 story about opioids

I spent many years traveling, reporting, and writing about the opioid epidemic. If you want to explore this topic more deeply, here are some of the main stories I wrote this year:

• We really have a solution to the opioid epidemic – and one country shows it works: I traveled to Virginia to see how the country has reformed the Medicaid program to improve access to addiction care. Big findings: By increasing reimbursement rates, Virginia Medicaid seems to make more people go through addiction treatment and it seems that fewer visit emergency rooms related to opioid addiction.

• How American prisons trigger an opioid epidemic: I surveyed all 50 state prison institutions to find out if they provide full access to drugs for opioid addiction. Only Rhode Island did it, and a preliminary study indicated that the program helped reduce overdose deaths among prisoners freed more than half.

• American doctors can defeat the opioid epidemic. Here's how to enter them: I went to New Mexico to see how Project ECHO helped train health care providers to offer opioid addiction treatment, especially buprenorphine. Some obstacles are stigmatized, but many problems are a more general misconception about addiction and how difficult it is to really do this kind of work.

• Needle exchange helps fight the opioid crisis. But the stigma remains: Needle exchanges are one of the most supported public health interventions, supported by decades of evidence and major health care organizations. But in Orange County, California, government officials forced the only needle exchange to be closed. The whole story offers very important lessons in stigma against people who use drugs and drug addiction.

• Vermont needle exchanges don't only distribute needles. This offers care in place: As the opioid epidemic continues, more places to seek to make addiction treatment can be accessed as much as possible. In Vermont, one syringe exchange even offers on-site care – a rare and innovative approach. This is an example of how the current crisis requires full effort.

• Solving the paradox of American pain relief: One of the root causes of the opioid epidemic is the proliferation of prescription painkillers. But how do you take back painkillers without hurting sick patients who really benefit from them? I spoke with a group of experts about it, landing on a mixture of solutions involving encouragement, not mandating, health care providers to prescribe fewer and offer better alternative treatments for pain in the long run.

That's just a small example of some of the work I've done. For more, see the Vox hub page and the storyline for the opioid epidemic. Thanks for reading!

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