Health leaders blame addiction for US opioid crisisBMJ 2017; 359 doi: https://doi.org/10.1136/bmj.j4814 (Published 17 October 2017) Cite this as: BMJ 2017;359:j4814
Alternative pain treatment options, reducing overprescribing, and destigmatizing misuse were among the potential solutions to the US opioid epidemic cited by healthcare leaders in a panel discussion sponsored by the National Academy of Medicine on 16 October as part of its annual meeting.
“This is an addiction issue, not an opioid issue,” said panelist Kathleen Sebelius, the former US secretary of health.
“We know that mass incarceration and criminal justice have not solved the issues of either supply or demand, or cured individuals,” Sebelius said. “What we have done absolutely has failed miserably, for decades, and it costs a whole lot of money.”
“Treatment is essential,” she said in ticking off the first of five ways “to move the needle” toward a more effective response. Other points included best practice guidelines to rein in the initial overprescribing of pain treatments; not vindictively cutting off social services for people who misuse drugs and seek treatment; stopping unnecessary deaths with wider availability of naloxone to counter opioid overdose; and more research to improve treatment of chronic pain.
Stigma “affects almost every element of this,” said Charles Baker, a former healthcare executive who became aware of the broad scope and social effects of substance misuse while campaigning for governor of Massachusetts. A committee he appointed came back with a 55 point plan, most of which the state has implemented.
Baker said that we need “to treat this and talk about it as an illness to be dealt with and not as a character flaw.” Stigmatization affected patients’ willingness to admit to and discuss issues of substance misuse, and physicians were uncomfortable dealing with behavior that had been criminalized, he said. Massachusetts has launched two separate campaigns to destigmatize substance misuse.
Another key element of reform in the state was to add mandatory instructions on opioids and pain management at every level of healthcare training and certification. Massachusetts also upgraded its capacity to monitor opioid prescriptions. Within two years the number of such prescriptions fell by 25%. The state also increased spending on addiction treatment facilities by 50%.
Baker said that fentanyl had been a huge new challenge. In 2014 it represented 14% of the deaths from overdose in the state, but in 2017 this had increased to 81%.
Almost all fentanyl entered the country illegally “through the dark web,” in small packages through the mail and other delivery services, said Scott Gottlieb, commissioner of the Food and Drug Administration. He recently announced a tripling of the number of inspectors at key entry sites, from eight to 22, and the number of packages that could be pulled from 10 000 to 40 000, though he said that the FDA was hampered by space limitations at customs facilities.
The volume of fentanyl and illegal opioids “that they are pushing through the mail system is so large that it is just a cost of doing business” for the suppliers, said Gottlieb.
In June the FDA ordered the withdrawal of the opioid formulation Opana ER because of its risk for misuse.1
Gottlieb said that the FDA had an important role in reducing total exposure to opioids by reducing the number of prescriptions written and the duration they were written for. He believed that changes in packaging, similar to the Z pack that is common for some antibiotics and contains just five days’ worth of pills, and barriers to greater and longer prescribing of opioids could help achieve that.
Baker acknowledged the complexity of the issues and the need for support from all parts of the community. But he also pointed to the federal government’s unique role in shaping medical education and licensure; conducting research on what works and doesn’t in terms of intervention and alternative treatment of pain; and paying for substance misuse treatment and the integration of medical and social services care.
A video of the panel discussion will be available as part of the coverage of the National Academies of Sciences, Engineering, and Medicine’s annual meeting at www.nas.edu.