Lives We Can Save

https://www.nytimes.com/2023/02/21/briefing/opioids.html

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It is a public health crisis that kills hundreds of Americans a day. Effective treatments could bring down the death toll. But many doctors and patients are not using those treatments.

Regular newsletter readers might think I’m talking about Covid. But the description also applies to drug overdoses. They don’t get nearly as much attention, but they’re a similarly major public health problem, and they have neglected solutions.

More than 100,000 Americans die each year from overdoses, mostly from opioids, according to C.D.C. data released last week. That is higher than the toll from gun and car crash deaths combined. While medications like methadone and buprenorphine can sharply reduce deaths among opioid addiction patients, only about a quarter of people who could benefit from these treatments receive them.

Decades into the overdose crisis, tens of thousands of people whose lives might be saved are instead dying from opioids.

America’s addiction epidemic did not have to unfold this way, and it highlights the health care system’s continued resistance to providing addiction care.

Treatment can be very expensive, and it’s often not covered by insurance. Addiction doctors have complained to me that they can spend hours of their workday on the phone with insurers asking them to pay for a medication, and sometimes insurers say no anyway. Patients have shared similar experiences.

The federal government has sometimes exacerbated the problem. Until last year, doctors had to go through special training and obtain a waiver to be able to prescribe buprenorphine, the medication for opioid addiction. At the same time, federal officials have failed to enforce laws requiring that insurers cover addiction treatment.

A comparison to France, which faced its own opioid crisis in the 1980s and ’90s, is instructive. In 1995, French officials deregulated buprenorphine so more doctors could prescribe it. Over four years, overdose deaths fell 79 percent.

It is a sharp contrast to the U.S. Rather than impose extra requirements for addiction care, French officials greatly relaxed rules during a crisis. And through the country’s government-run health care system, officials made sure that the treatment was widely available and paid for.

On top of America’s bureaucratic problems are more personal ones.

Some doctors hold stigmatizing views about addiction and the patients afflicted by it, and refuse to provide treatment. Many doctors say they lack the confidence to treat addiction because they don’t have enough training or access to specialists who can help guide them. Drug users can also resist treatment. Some think of medications for addiction as merely replacing one drug with another, though experts reject that framing because the medications replace drugs that do harm with drugs that can help.

All of these problems lead to the underuse of effective addiction treatments in the U.S., and so it is easier to get high than it is to get help.

Some of the problems are specific to addiction. But others are broader. Obesity and mental health conditions are often undertreated, too. Flu seasons are consistently worse than they have to be because not enough people get their annual shots. While Americans’ overuse of health care frequently receives attention, underuse is a problem in many situations as well.

Why is this the case?

Often, people, including doctors, have outsize fears about the downsides of some treatments, especially new ones. With Covid, doctors worry about Paxlovid’s interactions with other drugs — a real problem but largely a manageable one. With opioid addiction, patients make the mistake of thinking of a prescribed medication, like buprenorphine, as just another drug, even though it can save their lives.

The American health care system’s fragmented nature also makes it easier for problems to fall through the cracks. In France, officials can leverage the country’s universal health care system to overcome hesitancy to new treatments by guaranteeing they’re widely available and by strongly pushing for their use. In the U.S. system, there is no centralized authority, so medical authorities struggle to coordinate care even when the best practices seem clear.

As a result, drug overdoses are both a major public health problem in their own right — they are one reason U.S. life expectancy fell in 2020 and 2021 — and representative of the system’s larger struggles. The U.S. spends far more per person on health care than any other country and also has lower life expectancy than Canada, Japan, South Korea, Australia and much of Western Europe.

Related: Opioid overdoses are killing thousands of people in New York each year. The surging death toll is the city’s “new normal.”

President Biden’s visit to Ukraine was a direct challenge to Vladimir Putin and his worldview.

Putin said in a nationwide address that Russia would suspend participation in its last major nuclear arms control treaty with the U.S. Biden is expected to speak later today.

Biden took a surreal journey to Kyiv, traveling by train with reporters who were sworn to secrecy and deprived of their phones.

He committed more military aid during his trip, energizing the war-weary capital.

China bristled at U.S. claims that it may provide “lethal support” to Russia.

Another powerful earthquake shook Turkey and Syria, trapping more people in rubble and panicking survivors of the quake this month that killed at least 46,000 people.

Tens of thousands of people in Jerusalem again protested Israel’s plan for a judicial overhaul.

The Philippines is strengthening its ties with the U.S. as it worries about Chinese aggression.

Saudi Arabia is expanding its crackdown on dissent, with prison sentences of up to 45 years for those seen as criticizing the government on social media.

Republican lawmakers in Mississippi want to create a separate court system for mainly Black parts of the capital, Jackson, reviving old racial divisions.

“Not an extremist”: Chris Sununu, New Hampshire’s governor, is testing a potential presidential campaign message that rejects Trumpism.

Prosecutors downgraded the charges against Alec Baldwin in the “Rust” case, reducing possible prison time.

The anchor Don Lemon will return to CNN’s morning show after being disciplined for comments about women and aging.

Some people are outraged that Roald Dahl’s books have been rewritten to remove potentially offensive language.

An “extremely disruptive” winter storm is expected to hit much of the northern U.S. this week.

The Supreme Court will hear a case today about whether social media companies are liable for what their users post.

A Catholic bishop in Los Angeles was killed in his home and the authorities arrested his housekeeper’s husband.

Public funding is supporting some private Hasidic schools in New York.

American English is indebted to immigrants, Ilan Stavans argues.

America’s chronic pain problem is emotional and physical, Rachel Zoffness argues on “The Ezra Klein Show.”

Housing boom: The next hot market is in the metaverse.

Alligator in Brooklyn? The four-foot-long animal found in Prospect Park was probably once a pet.

Emma Chamberlain: The YouTube star is leaving the platform behind.

Ancient royal jewelry: Cambodia recovered necklaces that officials believe were looted by tomb raiders.

Advice from Wirecutter: Don’t buy a Keurig. (There are better options.)

Lives Lived: Huey “Piano” Smith wrote memorably rambunctious songs, like “Rocking Pneumonia and the Boogie Woogie Flu” and “Sea Cruise.” He died at 89.

Dodging serious injury: Giannis Antetokounmpo, an N.B.A. M.V.P. contender, hurt his wrist just before All-Star Weekend, but further testing revealed he did not suffer any serious damage.

Youth movement: The Philadelphia Phillies are considering a 19-year-old for a starting rotation spot.

Tournament watch: They were the preseason No. 1 team in the country, but the North Carolina men’s basketball team is at risk of missing the N.C.A.A. Tournament.

Layoffs and budget cuts are hurting the once-booming podcast industry. “The dumb money era is over,” as Eric Nuzum, co-founder of the podcast studio Magnificent Noise, puts it.

Spotify spent more than $1 billion in recent years on acquisitions and exclusive deals with celebrities like Joe Rogan and Kim Kardashian. In January, though, it reduced its podcast staff for the third time in five months. Amazon, SiriusXM and NPR have also cut their budgets.

It’s not that podcasts have become less popular; downloads continue to rise. But a slowdown in advertising has led companies to roll back their spending and their ambitions. “The name of the game has been to ‘do less with less,’” said one NPR producer. The Times’s Reggie Ugwu has more details.

This Tunisian chickpea soup has a kick from harissa and a bright squeeze of lemon.

Peel back the layers of São Paulo, Brazil, with these books.

Revisit Marlon Brando in “A Streetcar Named Desire.”

The pangram from yesterday’s Spelling Bee was mahogany. Here is today’s puzzle.

Here’s today’s Mini Crossword, and a clue: Really put one’s foot down (five letters).

And here’s today’s Wordle.

Thanks for spending part of your morning with The Times. See you tomorrow. — German

P.S. The New York Times won three George Polk Awards for its coverage of Ukraine and for an investigation into Hasidic Jewish schools in New York.

Here’s today’s front page.

“The Daily” is about companies making products in Mexico.

Matthew Cullen, Lauren Hard, Lauren Jackson, Claire Moses, Ian Prasad Philbrick, Tom Wright-Piersanti and Ashley Wu contributed to The Morning. You can reach the team at themorning@nytimes.com.