For the first time in over 50 years, U.S. life expectancy decreased for the second consecutive year in 2017. This decline is in part due to the drastic rise in opioid-related deaths, which increased by 21% in the past year. From 1999 to 2015, there were more than 183,000 prescription opioid overdoses. While prescription drugs have long been a cause of morbidity and mortality, this recent uptick in overdoses is in large part due to the increase in prescriptions from health care providers. Indeed, prescriptions for opioids quadrupled from 1999 to 2010. Despite this increase, Americans did not report an increase in the amount of pain during this time. Clearly, there seems to be a mismatch between the number of opioid prescriptions and the appropriate indications for these medications.
Many attempts at curbing the opioid epidemic have been made. These attempts have ranged from greater distribution of opioid substitution therapies, such as methadone and buprenorphine, to better access to the opioid-reversal drug naloxone. One such attempt has been under particular scrutiny given its questionable efficacy and its human rights violations: compulsory drug treatment. Compulsory drug treatment involves inpatient or outpatient centers where patients are mandated by court order to engage in drug abstinence and engage in various forms of therapy. Compulsory treatment, exclusively abstinence-based, happens both within the criminal justice and civil systems, through drug courts and civil commitment laws. While drug abstinence may seem beneficial in theory, a recent meta-analysis has shown that existing compulsory drug treatment programs are not beneficial and may in fact increase rates of recidivism. Moreover, compulsory drug treatment centers, particularly in Asian cultures such as China, Cambodia, and Thailand, violate human rights issues, specifically the rights to bodily integrity and health.
Given the magnitude of the opioid crisis, much can and should be done to improve the current situation. First, we must acquire more information regarding effective treatment and prevention programs. In 430 studies analyzing effectiveness of compulsory treatment through drug courts in the United States, only 9 met the scientific standard to be considered credible studies. We need to learn more about the efficacy of these programs before we continue to encourage potentially harmful treatments.
Second, harm reduction programs should be expanded. Harm reduction encourages safe needle use, implementation of opioid substitution therapies, and community and peer advocacy. Harm reduction programs do not encourage abstinence, and evidence shows that harm reduction programs are associated with thousands of life-saving naloxone reversals. More information and ways to get involved with harm reduction efforts can be found here at http://harmreduction.org/ and http://www.drugpolicy.org/.
One specific type of harm reduction program that has already shown to be effective is the Law Enforcement-Assisted Diversion, or LEAD, program. Rather than getting plugged into the already overwhelmed criminal just system, minor offenders are diverted away from this system and instead are linked with a case manager as part of the LEAD program. The case manager helps the minor offender find housing, health services, and transportation and facilitates his or her engagement with the community. In these cases, complete abstinence is not required nor is enrollment in a drug treatment program. The program is more self-directed in nature as participants have more autonomy with the recovery process. The results have already been quite positive: in the cities undergoing pilot programs, individuals diverted to the LEAD program demonstrated a 60% decrease in recidivism compared to those who were not. Clearly, case management and personalized self-directed reintegration into society is an essential component of harm reduction.
Third, we need more support and funding from local and federal policymakers. Congress did pass a rare bipartisan bill in September 2018, which is a step in the right direction. However, most critics believe that the bill falls far short of what is needed to slow the epidemic. Moreover, pharmaceutical companies such as Purdue, which manufactures the opioid oxycodone, continue to deflect responsibility for false advertising and understate their drugs’ addictive potential. Purdue and other pharmaceutical companies spent almost 900 million dollars from 2006 to 2015 on lobbying and political donations. The companies are now beginning to exploit vulnerable populations in international markets. Given this expansion of the opioid industry overseas, it is essential that policies be in place to prevent further worsening of the opioid crisis.
Fourth, health care providers should undergo additional training in medication-assisted treatment. Health care professionals are often the gatekeepers when it comes to access to opioids. They need to be educated and made aware about the risks of prescribing opioids with the understanding that they are still appropriate for certain patients. Medical, physician assistant, and nursing students should also be trained on pain management, addiction prevention, and effective administration of naloxone. Physicians and associate providers can undergo 8 and 24 hour trainings, respectively, to have buprenorphine prescription-writing privileges. Given the thousands of hours of training that health care professionals undergo, these short trainings seem well worth the extra time, so that physicians can more appropriately treat opiate use disorder. With additional training, health care providers would also be able to better determine which patients truly need opiates, such as patients on palliative care or with severe cancer-related pain.
Thomas is a fourth-year medical student at the Geisel School of Medicine at Dartmouth and a member of the PHR Student Advisory Board.
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