Solving the Opioid Epidemic
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https://www.nytimes.com/2017/10/07/opinion/sunday/opioid-epidemic.html Version 0 of 1. To the Editor: Re “Breaking America’s Opioid Addiction” (editorial, Oct. 1): Substance use, like many health challenges, results from a complex interplay of forces. These include medical prescribing, pain, neurophysiologic susceptibility, and life stress and hardship. To stem the opioid epidemic, an all-in, population health approach is required. This means working across sectors — health care and public health, economic development, housing, public safety and education — and ensuring equal access to effective treatment among diverse groups. Complementing the eight steps outlined, root causes of hopelessness and despair must be tackled by creating economic opportunity in hard-hit rural and urban communities. And we must invest more in programs to prevent and blunt the effect of adverse childhood events that make children vulnerable to substance use in later life. Throughout history, epidemics have marked inflection points: Polio catalyzed public health infrastructure for vaccinations and fueled the disability rights movement; AIDS amplified activist voices in drug development and treatment. The tragedy of the opioid epidemic offers such an opportunity. By taking a population health approach, we can halt the epidemic and transform how we address the complex forces that determine health. MARC N. GOUREVITCHSUE KAPLAN, NEW YORK Dr. Gourevitch is a professor and chairman of the department of population health at N.Y.U. Langone Health. Ms. Kaplan is a research associate professor in the department. To the Editor: Having lost my 24-year-old son to a heroin overdose in 2012, I thank you for your editorial. I am taken by the total lack of awareness of the 2008 mental health parity law by the public and the medical world at large. Regarding “insurers that cheat”: My husband and I have a continuing lawsuit against the insurers that decided that saving our son’s life wasn’t “medically necessary.” Your suggestion to “combat stigma” referred to the Centers for Disease Control and Prevention’s response to the AIDS epidemic in the 1980s. That response should be replicated now for the opiate epidemic. As you suggest, a brochure should be sent “to every residential mailing address in the United States to dispel myths and help Americans seeking treatment” for addiction and substance use disorder. MARGOT HEAD, NEW YORK To the Editor: A 2011 Institute of Medicine report found that acute and chronic pain affects about 100 million American adults. I run online support groups for people with chronic pain conditions, some of whom take opioids to allow them to participate in daily living. They are not addicts. The restrictions put on opioids for addicts limit access to the medications that people with legitimate chronic pain conditions need to function every day. While the use of opioids has gotten out of hand, allowing for the spread of addiction, its control cannot restrict access for people who need them to function. Addressing opioid addiction must take a balanced approach that considers that some people need opioids to control their pain so they can function daily. Declaring that everyone who takes opioids is an addict is like proclaiming that everyone who drinks is an alcoholic. BARBARA L. KORNBLAU ARLINGTON, VA. The writer is a professor of occupational therapy at Florida A&M University. To the Editor: Eight critical steps were outlined, but the most vital step of all was hardly mentioned: access, care education and care coordination. What patients and family members need most is ready access to a caring, knowledgeable human being, rather than the internet, for assistance in understanding and navigating the confusing maze of treatment options and exclusions. As a doctor whose care navigator regularly helps patients with opioid addiction to get connected to the best care possible, I can say without reservation that the single most urgent step we must take to stem this crisis is to provide vigorous, dedicated care navigators and care coordinators to every suffering patient and family member lost in the maze. ELI MERRITT, SAN FRANCISCO To the Editor: I always find it interesting that therapists, including social workers and mental health workers, are left out of the equation. Many mental health workers (with master’s degrees!) are earning low wages working in the drug and alcohol sector, and they are on the front lines of this crisis, many times alerting medical professionals of the needs of their patients who are using drugs, on methadone maintenance and so on. Yet this is not mentioned in your editorial, and it’s often left out of many suggestions for next steps in this crisis. JOHNNA MARCUSPHILADELPHIA The writer is a social worker. To the Editor: Excellent editorial. Overlooked, however, is the control insurers have in access to care. It’s easier to prescribe opiates than nonaddictive alternatives because approval from insurance companies is required for the alternatives, taking days. It’s time to let clinicians and patients decide on immediate treatments. Time to get the insurance companies out of the prescriber’s office. This is easily done. “Medically necessary” should be determined by providers with patients, and the prior authorization process should be eliminated. GEORGE SIGELNORWOOD, MASS. The writer is a psychiatrist. To the Editor: Another factor that figures significantly in the low level of treatment requires much more emphasis: the stigma associated with the programs. Too many Americans, including many of our leaders, view methadone or buprenorphine maintenance as simply “changing from one addiction to another.” This is as wrong as viewing diabetics who take insulin all their lives as insulin addicts. The following should be the criteria for judging the success of treatment: Are these patients in the streets buying heroin, fentanyl or other dangerous drugs and dying from an overdose? Or are they holding down responsible jobs, getting married and raising families, and generally behaving like responsible people? I have little doubt, based on evidence in the medical literature, that a vast majority of treated patients are not dying from drug overdoses and are responsible citizens contributing to our society. It is therefore imperative that these programs be encouraged and expanded to treat as many opioid addicts as possible. ERIC J. SIMON, HACKENSACK, N.J. The writer, a retired opioid researcher, is professor emeritus of psychiatry, biochemistry and pharmacology at the N.Y.U. School of Medicine. To the Editor: Re “Insurers Putting Cost Over Safety With Painkillers” (front page, Sept. 18): You exposed an essential element of the opioid epidemic. When payer policies leave patients and physicians with few choices but prescription opioids, it puts everyone in an untenable position: Either prescribe opioids when not warranted, or watch as patients suffer in pain. Treatment choices should be based on balancing benefits and risks to patients, not the interests of the insurance company. Patients with chronic pain deal with payers who make it difficult to obtain certain nonopioid medications or nonpharmacologic pain treatments, or do not reimburse them. While physicians have made strides in prescribing more judiciously, prior authorization delays often mean increased suffering or other harm. The American Medical Association and our Opioid Task Force urge physicians to provide comprehensive, multimodal pain care, talk to patients about expectations for managing pain, and prescribe opioids only when benefits outweigh risks. To improve lives and end the opioid epidemic, all stakeholders must call for an end to policies that hurt patients’ access to effective pain care. DAVID O. BARBE, CHICAGO The writer, a doctor specializing in family medicine, is president of the American Medical Association. |