Untangling the web of opioid addictions in the USA

June 26, 2017

The US President’s Commission on Combating Drug Addiction and Opioid Crisis met for the first time on June 16, 10 days ahead of the June 26 International Day against Drug Abuse and Illicit Trafficking. The USA is in the midst of a so-called opioid epidemic and although public health experts warned that there was little new to learn from convening a commission, the multifaceted challenges facing the country are staggering. Of the 20·5 million Americans aged 12 years or older who had a substance use disorder according to the 2015 National Survey on Drug Use and Health, 2 million involved prescription pain relievers and 591 000 had a substance use disorder involving heroin, a fifth of whom were adolescents. The lethality of the opioid epidemic has further overwhelmed the public health response. In 2015 alone, there were about 52 404 deaths in the USA due to drug overdose (63·1% attributed to opioids)—a three-fold rise from 1999. Death counts from overdose, however, are likely underestimated because older adults who overdose rarely have toxicology performed and their death certificates most often list a cause based on underlying conditions.

In stark contrast with the situation in the USA, worldwide, around 80% of patients still have no access to adequate pain management for reasons including strict government policy against narcotics or high prices. Access to pain management is a fundamental human right and inadequate pain management has serious mental, physiological, and societal implications. The Lancet Commission: Global Access to Pain Control and Palliative Care, due for publication later this year, will report on these issues.

Contributing to the US epidemic is the context, and the way, in which Americans gain access to opioids. In the USA, oxycodone analgesics are generally used in all adult age ranges post surgery or for chronic pain. By contrast, morphine is typically prescribed for serious or end-of-life pain management. But many practitioners, for lack of addiction training, continue to overprescribe or misprescribe. For younger adults aged 18-45 years, initial addiction also occurs through medical prescriptions but they tend to turn to heroin to financially maintain their addiction. Since 2011, with the introduction of potent illicit synthetic fentanyl sold as heroin into the market, a rise in deaths in the younger adult group has been witnessed. It is also the inconsistency of approach by and towards the pharmaceutical industry that continues to confound public health treatment and prevention efforts. This month, the US Food and Drug Administration requested that Endo Pharmaceuticals remove its reformulated opioid pain medication Opana ER (oxymorphone hydrochloride) from the market on the basis of concerns about the potential for abuse by injection raised by postmarketing surveillance. Meanwhile, intense marketing and lobbying have allowed Vivitriol, a costly injectable sustained release form of the opioid-blocker naltrexone, to the market with limited data on long-term effectiveness.

How then to navigate the conflict between pain management—a human right—and strengthening the response to the opioid epidemic in the USA? According to Andrew Kolodny, addiction physician and opioid policy expert at Brandeis University, preventing new addictions through rational access and use—and effectively and compassionately treating those who are addicted—is still the way forward. Currently, 10–12 million Americans are on long-term opioids for chronic pain and many might not be able to come off them. Although methadone or buprenorphine are effective options to treat opiate addiction, few have access to insurance coverage or to a clinician able to prescribe them because of state limits on the number of prescriptions per provider. Reassuringly, experts on the President’s Commission agree with evidence-based management, with Mitchell Rosenthal of the National Council on Alcoholism and Drug Dependence stating: “Treatment works. We just have to provide it.”

President Trump’s current budget proposal calls for an additional US$103 million for the Department of Justice to fight illicit drugs and has endorsed the previously committed $500 million to improve addiction treatment. But several experts in attendance at the President’s Commission fear that the American Healthcare Act is working its way through the US Senate and any repeal of Medicaid is a repeal of coverage that exists to treat addiction now and in the future. Furthermore, calls to intensify punitive policies towards heroin and other opioid users, such as imprisonment for drug use and possession, are also likely to be detrimental. Echoing the calls of The Lancet US Series 2017, to achieve health-care equality, evidence-based approaches are needed that treat health as a human right—and are the only way for addiction treatment and prevention efforts to succeed in the long term.

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