We Must Get this Right if We Are Going to Start Saving Lives
By, Dr. Rick Barnett
We Must Get this Right if We Are Going to Start Saving Lives
The number of drug overdose deaths continues to rise and is not expected to go down anytime soon. In 2017 there were ~70,000 drug overdose deaths. Over 49,000 of these deaths were opioid-related with fentanyl-related deaths doubling from 2016-2017. However, an estimated 23,000 (nearly 1/3) drug deaths did not involve opioids. Of the 49,000 opioid-related deaths, nearly 11,000 involved benzodiazepines and almost 15,000 involved cocaine.
Put simply, many drug overdose deaths in 2016 and 2017 involved drugs (including alcohol) other than– or in combination with– opioids. Add to this that alcohol is indirectly or directly involved in nearly 100,000 deaths per year. Lastly, one report estimates that prescription medications whether used as prescribed, taken in error, or misused may account for over 125,000 deaths each year.
Our response to the drug overdose epidemic has been focused on opioids. Intuitively, this seems to make sense. It is generally widely accepted that opioids caused these problems and a focus on opioids is the solution; this is misguided and lacks nuance. This new public health version of the war on drugs has become a battle waged in two arenas: supply and demand. We have become opioid-focused AND opioid-phobic.
On the supply side, our opioid-phobic response has been prescription drug monitoring programs, threatened sanctions for prescribing opioids over a certain limit, and misinterpreted pain management guidelines. One major consequence is “pain refugees” – chronic pain patients being subject to forced-tapers despite successful control of their pain with opioids. This tactic is reported to have likely increased illicit opioid use, depression and suicide.
On the demand side, our opioid-focused response has been a massive push to expand opioid-based treatment for opioid use disorder. There is a robust research literature that shows opioid maintenance medications as being able to cut overdose death rates by 50% or more. The problem with the studies is that there is “a large potential for confounding in comparisons of crude mortality risk in and out of treatment” and there is lack of data on “overdose mortality when opioid substitution treatment was obtained on illicit drug markets”. Nevertheless, opioid medications have become the gold-standard for widely promoted medication-assisted treatment or MAT.
We are now going “all-in” with these strategies, sometimes to the abandonment of other worthwhile initiatives. Over 25 years ago, pharmaceutical companies funded massive campaigns to treat pain as a 5th vital sign. Over the past decade, pharmaceutical companies spent far more than any other industry to influence politicians – close to $2.5bn into lobbying and funding members of Congress. These companies fund medical schools, medical journals, research, and provide free training for medical providers to prescribe drugs for addiction treatment.
Today, the effort to influence policymakers and the medical field continues to have a significant impact on public opinion on the recognition and treatment of addiction. The moralization of the brain-disease model of addiction pushes opioid use disorder medications into every facet of health care, social services, and the criminal justice system. The narrative has morphed our morals from seeing addictive behaviors as a moral weakness or flaw to seeing addiction as a biologically driven disease state over which one has no control. Our new moorings of morality demand that we offer unrestricted access to medications to address opioid use regardless of setting: in the emergency departments, on the street, in prisons, in primary care offices, and in clinics across the country. This would be fantastic if it weren’t also flawed.
Drug deaths aren’t solely related to opioids. Medications are intended as a crude tool to help stabilize people. Drug treatments that focus exclusively on opioids are doomed to fail because they don’t address a broader and more nuanced perspective of our current culture. Neither opioid use disorder, treatment medications, nor the systems or settings described above in which these medications are delivered, effectively treat mental health, polydrug use, or social determinants of health, and collective despair, as exemplified by Jonathan C. Lee:
Buprenorphine is a tool, but it will no more solve the opioid overdose epidemic than antihypertensive medications have solved the hemorrhagic stroke problem engagement of the patient is key. Those who push an access-to-care argument fail to see that access is just the first step we need appropriate utilization of resources. Those who are going after the “opioid crisis” fail to see that over 50% of opioids in the US are prescribed to people with mental health conditions and unless we treat those underlying mental disorders, we cannot solve this problem. Ultimately, we need solutions with shared value creation that combine sensible prescribing, social determinants of health, decriminalization, evidence-based interventions including MAT, and treatment of comorbidities. Most importantly, innovative engagement strategies such as community care coordinators, telephonic coaching, and digital apps are necessary to attract patients to care, develop trust, form partnerships, and support long-term recovery.
Suicide deaths have risen dramatically in the past 20 years, alongside a fragmented mental health care system with a massive psychiatric workforce shortage. We’ve seen a surge in alcohol use especially among women and sharp increases in cocaine and methamphetamine deaths. We also see poor and worsening conditions in the places where people live, learn, work, and play. These realities affect a wide range of health outcomes especially with addiction and its treatment. Medication-assisted treatment must be re-engineered for it to have a more measurable impact on the incidence and prevalence of drug and alcohol use disorders.
Our current system needs to change– here are some practical ways to redirect and improve it.
Mental Health and Peer Recovery Supports
An overwhelming majority of patients with a substance use disorder (alcohol, cocaine, opioids, etc..) have what’s called a co-occurring or comorbid mental health condition that meets diagnostic criteria for anxiety disorders (this includes post-traumatic stress disorder, generalized anxiety disorder, and panic disorder), mood disorders such as depression or bipolar, attention-deficit disorder, personality disorders. Compared to the general population, people with schizophrenia have much higher rates of drug, alcohol, and tobacco use disorders than the general population.
Still, contrary to what some believe, and contrary to some may think mental health providers believe, mental health care must not be mandatory to access medications for withdrawal and the chance to stabilize a life. Medications must be offered as an option or simply as a tool. The substance use disorder arm of the health care system must always prioritize the availability of highly skilled mental health clinicians, licensed alcohol and drug counselors, and peer recovery supports. This provider and peer group is best positioned to be an attractive option for many. Some patients may just want buprenorphine. However, many people want time, attention, a safe place to process emotions, and a chance to talk to others who’ve been there and are now doing well. Time and attention are the most underutilized and most healing aspect of our current and traditional medically-driven healthcare system. Krishnamurti once wrote that “to pay attention means we care, which means we really love”.
Polypharmacy and Polydrug Use
Mental health care is often tracked and misconstrued as prescribing an evidenced-based (or off-label) medication for depression, anxiety, trauma or thought disorders. Medication-assisted treatment is focused on reducing harm from opioid misuse that leads to death, infectious disease and other medical problems, and legal problems. Adding medications that treat mental health conditions to medications to treat addiction creates a serious problem called polypharmacy which can increase the risk of death or medical problems. On top of this, many people on medications for opioid use disorder continue to use other street drugs like cocaine, ecstasy, methamphetamine or other opioids as well as misusing prescription medications like benzodiazepines like Xanax or Klonopin or stimulants like Adderall or Ritalin. This is often called polydrug use.
The “less is more” concept in drug and alcohol use disorder treatment must be a strong consideration. We mustn’t “kick people out” of treatment for any infraction but we must do a better job addressing addiction and mental health issues non-pharmacologically. Drugs to treat comorbid physical or mental health conditions while someone is being treated or in recovery from an addictive disorder can be kept to a minimum. While new drugs to treat addictive disorders and mental health conditions continue to be approved and promoted, let us direct our attention to other resources for healing, health, and stability. Non-pharmacological approaches to treat mental health and addictive disorders are effective and, for many, may have longer and better results than medications without side effects or adverse drug reactions.
Social Determinants of Health (SDOH)
Employment, educational resources, housing, childcare, community support systems and all other non-medical and non-mental health factors in a person’s life must be a central feature of helping people to recovery from substance use disorders. This may be the most troubling aspect of the healthcare system and the most challenging to improve upon. While many clinical providers feel strongly that SDOH are essential to patient health, many say it falls outside of their responsibility as clinicians and therefore are unable to make a difference with these social issues.
The Road Ahead
The road ahead may, by necessity, be the road less traveled. We must adopt a PEP paradigm: Perspective, Empathy, and Persistence. Methadone has been used to treat opioid use disorder for five decades. Buprenorphine is quickly approaching its fourth decade in Europe and third decade in the United States. The psycho-pharmacological revolution will continue unabated. With time and experience comes perspective. From perspective comes empathy and greater awareness of the need for growth and change. With greater awareness and the need for change, we may find an unrelenting persistence. As we travel in this manner, we will lean towards a new paradigm that will decrease the tragic and preventable deaths from drugs and alcohol and improve individual, community, and cross-cultural well-being.
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Dr. Rick Barnett is a clinical psychologist and addiction specialist in private practice in Stowe. He founded CARTER Inc. to expand addiction-related resources in Vermont. He is legislative chair and a past president of the Vermont Psychological Association and serves as a member of several state health, mental health and addiction policy groups.