The opioid epidemic, explained

If nothing is done, we can expect a lot of people to die: A forecast by STAT concluded that as many as 650,000 people will die over the next 10 years from opioid overdoses — more than the entire city of Baltimore. The US risks losing the equivalent of a whole American city in just one decade.

That would be on top of all the death that America has already seen in the course of the ongoing opioid epidemic. In 2016, more than 64,000 people died of drug overdoses in America — with synthetic opioids (such as fentanyl), heroin, and traditional painkillers (like Percocet and OxyContin) topping other causes of overdose, according to new data from the Centers for Disease Control and Prevention. That’s a higher death toll than guns, car crashes, and HIV/AIDS ever killed in one year in the US, and a higher death toll than the entirety of US military casualties in the Vietnam and Iraq wars combined.

If you want to understand how we got here, there’s one simple explanation: It’s much easier in America to get high than it is to get help.

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In talking about this, Brandeis University opioid policy expert Andrew Kolodny draws a comparison to New York City’s fight against tobacco. In his telling, the city took a two-prong approach: It made tobacco less accessible — by banning smoking in public spaces and raising taxes to make cigarettes much more expensive. But it also made alternatives to tobacco more accessible — by opening a phone line that people can use to get in touch with a clinic or obtain free nicotine patches or free nicotine gum. It has seen its smoking rate steadily drop, from 21.5 percent in 2002 to 14.3 percent in 2015.

Essentially the opposite has happened with opioids. Over the past couple of decades, the health care system, bolstered by pharmaceutical companies, flooded the US with painkillers. Then illicit drug traffickers followed suit, inundating the country with heroin and other illegally produced opioids, particularly fentanyl, that people could use once they ran out of painkillers or wanted something stronger. All of this made it very easy to obtain and misuse drugs.

Meanwhile, there has been little attention to getting people into treatment. According to the surgeon general’s 2016 report on addiction, only 10 percent of people suffering from a drug use disorder get specialty treatment. The report attributed the low rate to shortages in the supply of care, with some areas of the country lacking affordable options for treatment — which can lead to waiting periods of weeks or even months just to get help.

When you put these two issues together, you get the recipe for a disaster — one that has been only further accentuated by the socioeconomic and mental health issues that have plagued the US for years.

This is the story of the opioid epidemic: a crisis that has already taken hundreds of thousands of lives, and is likely to kill hundreds of thousands more over at least the next decade if nothing is done.

How America’s opioid epidemic began

The opioid epidemic began in the 1990s, when doctors became increasingly aware of the burdens of pain. Pharmaceutical companies saw an opportunity, and pushed doctors — with misleading marketing about the safety and efficacy of the drugs — to prescribe opioids to treat all sorts of pain. Doctors, many exhausted by dealing with difficult-to-treat pain patients, complied — in some states, writing enough prescriptions to fill a bottle of pills for each resident.

The drugs proliferated, making America the world’s leader in opioid prescriptions. As Stanford drug policy expert Keith Humphreys previously noted, “Consider the amount of standard daily doses of opioids consumed in Japan. And then double it. And then double it again. And then double it again. And then double it again. And then double it a fifth time. That would make Japan No. 2 in the world, behind the United States.”

The statistics really do back this up. Japan is one of the lowest prescribers of opioids in the developed world (for reasons outlined by Ella Nilsen for Vox). And the US absolutely dwarfs anyone else in terms of opioid prescriptions, with Japan not even showing up in the top 25:

While the federal government has added some spending to addiction care (including $1 billion over two years in the 21st Century Cures Act), it’s nowhere near the tens of billions every year that Kolodny and other experts argue is necessary to fully confront the crisis. For reference, a 2016 study estimated the total economic burden of prescription opioid overdose, misuse, and addiction at $78.5 billion in 2013, about a third of which was due to higher health care and drug treatment costs. So even an investment of tens of billions could save money in the long run by preventing even more in costs.

For opioids, much of that funding needs to go to medication-assisted treatment (MAT), when medicines like methadone, buprenorphine, and naltrexone are used to combat opioid cravings. Several studies have found that MAT can cut mortality among opioid addiction patients by half or more. The CDC, the National Institute on Drug Abuse, and the World Health Organization all acknowledge its medical value. And experts often describe it as “the gold standard” for opioid addiction treatment — although, they caution, the medications won’t work for everyone, and other treatments should be available.

But MAT remains inaccessible, in large part due to strict policies surrounding it. For example, the federal government still caps how many patients doctors can prescribe buprenorphine to, with strict rules about raising the cap. A HuffPost analysis found that even if every doctor who can prescribe buprenorphine did so at the maximum rate in 2012, more than half of Americans with opioid use disorders could not get the medication.

Even if all of this is fixed, however, the reality is some people will still misuse and get addicted to drugs. That’s one reason experts have also called for harm reduction efforts: Prescription heroin, which has been tried successfully in Canada and Europe, could let people access a clean supply of the drug. Supervised injection facilities could provide a space for drug users to inject illicit substances, with medical staff ready in case something goes wrong. Needle exchange programs could let people trade in used syringes for new ones, reducing the risk that a needle will carry HIV, hepatitis C, or some other disease. The opioid overdose antidote naloxone could be made more accessible across the country.

One concern with harm reduction strategies, echoed by anti-drug groups like the Drug Free America Foundation, is that removing some of the risk to using harder drugs will perhaps make some people more likely to use dangerous substances.

But this simply has no foundation in the evidence. For example, a 1998 study from researchers at Johns Hopkins University found needle exchange programs generally reduced the spread of HIV without increasing drug use. A 2004 study from the World Health Organization, which analyzed two decades of evidence, produced similar results.

Harm reduction efforts will not prevent all deaths. They won’t make all heroin use safe. But they will reduce the amount of harm done by these drugs.

The policy solutions have to address all of these issues

As I explained in a longer piece about how to stop the opioid epidemic, real policy solutions will have to address all of these gaps in America’s response to addiction. Experts say that prevention, treatment, and harm reduction all have a role to play.

Some experts argue the policy response will have to go even further — to also address the lack of access to adequate pain care and the root causes of addiction, particularly the socioeconomic and mental health problems that are commonly linked to drug use.

When I asked experts for specific proposals to deal with the root causes of drug addiction, each person seemed to have dozens of ideas: developing stronger social safety net policies, creating new job programs, offering better wraparound social services, better integrating mental health care with the rest of the health care system, encouraging non-drug sources of relaxation and entertainment, and on and on.

“It will really require rebuilding communities from the ground up,” Lembke said. “We have to help communities rebuild families. We have to give people meaningful work. We have to give people some opportunity for play — and by that, I mean alternative sources of dopamine, so people have something else to replace the drugs or prevent them from turning to drugs in the first place.”

In short, there’s no one silver bullet. America will have to do a lot at once.

There’s really wide agreement on this, yet so far governments haven’t done much. Despite Trump’s claim that the epidemic is “a national emergency,” there hasn’t been much in the way of actual policy changes to stop the crisis. While some states have boosted treatment and prevention, others, like Louisiana, Indiana, and Florida, have focused on ineffective “tough on crime” policies. And the public doesn’t seem to be putting much, if any, pressure on lawmakers to do anything about the crisis. As New York Times columnist Nicholas Kristof noted in his recent op-ed, opioids are “a mass killer we’re meeting with a shrug.”

Experts attribute this apathy to stigma: While doctors and experts know addiction is a medical condition, much of the public views it more as a moral failure.

I get emails to this effect all the time. Here, for example, is a fairly representative reader message: “Darwin’s Theory says ‘survival of the fittest.’ Let these lost souls pay the price of their criminal choices and criminal actions. Society does not owe them multiple medical resuscitations from their own bad judgment, criminal activity, and self-inflicted wounds.”

Some lawmakers share this sentiment. Missouri state Sen. Rob Schaaf, a Republican, once remarked that when people die of overdoses, that “just removes them from the gene pool.”

Perhaps the solution here is to educate people on the basic realities of addiction and why it needs our attention. The public needs to understand, as Lembke put it, that “if you see somebody who continues to use despite their lives being totally destroyed — losing their jobs, losing loved ones, ending up in jail — nobody would choose that. Nobody anywhere would ever choose that life. So clearly it is beyond this individual’s control on some level.”

Until Americans understand that, it’s likely the policy response will remain inadequate. And hundreds of thousands could die needlessly as a result.

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