The simple idea that could help end America’s opioid epidemic

I spent a lot of 2018 reporting on complex systems and policies that could help end the opioid epidemic, which is now the US’s deadliest drug overdose crisis ever.

But behind all the reporting that I did was a simple idea: America needs to see addiction as a medical condition, and approach addiction treatment like any other form of health care.

This simple idea was at the core of every problem and solution I wrote about: Virginia reworking its Medicaid program to confront the opioid crisis, private insurers neglecting addiction treatment, prisons failing to provide opioid addiction medications, and special training programs helping doctors get involved in addiction care. It’s also at the core of some other stories I’m currently working on, including an upcoming piece on California’s efforts to offer addiction treatment in emergency rooms.

Understanding this simple idea gets you a long way to solving America’s opioid crisis. Once addiction is seen as a medical condition that requires health care services, many of the solutions start to seem obvious: Of course people with addiction should have access to proven medications. Of course they should be able to get access to care in the emergency room, urgent care, or at a doctor’s office. Of course health insurance should pay for their treatment.

It’s helpful to draw comparisons to other chronic medical conditions.

Consider one statistic: According to the 2016 surgeon general’s report, just 10 percent of people with a substance use disorder get specialty treatment for their addiction — in large part because local treatment options don’t exist, or if they do exist, they are unaffordable or have waiting periods of weeks or even months.

Just think, for a moment, if this was true for another medical condition, like heart disease. Imagine a world in which 90 percent of Americans with heart problems are allowed to suffer and even die without any access to health care. Imagine that a person suffering a heart attack could go to an emergency room only to be told that the ER doesn’t have any way to treat him. Imagine that the ER does have a way to help, but the patient who just had a heart attack will have to wait weeks or months to get into any care. Imagine if this patient went to a doctor’s office for some care only to be told that the providers there don’t see his kind.

This would be a public health catastrophe. America’s leaders would do everything they can, under public demand, to remedy such huge gaps in health care.

Yet this is the reality with addiction in America, even as the current overdose crisis breaks records for deaths year after year.

Stigma is still the biggest barrier

The core reason for this problem is a mix of stigma and misconceptions about addiction.

For a long time, addiction in America has been viewed not as a medical condition, but as a moral failure. This is how I have come to understand emails such as this one, which argue that people suffering from drug addiction deserve to die: “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.”

It would be obviously ridiculous for anyone to argue anything like this for other medical conditions, including those like heart disease, diabetes, and lung cancer that can also be caused by unhealthy actions and behaviors. But with addiction, it’s something I’ve heard repeatedly throughout my reporting — a result of a culture, society, and legal system that have for more than a century treated addiction as a moral and criminal problem.

There is no clearer example of this than the misconceptions surrounding buprenorphine and methadone, which stave off withdrawal and cravings to stabilize a person’s drug use. These are highly effective medications for opioid addiction treatment: Studies show that they reduce the all-cause mortality rate among opioid addiction patients by half or more and do a far better job of keeping people in treatment than non-medication approaches.

In Richmond, Virginia, Fawn Ricciuti told me about how buprenorphine helped her get her life back on track. After years of struggling with painkiller and heroin use, buprenorphine helped her stop using. She told me about how her recovery gave her “a better relationship with my daughter, my mom,” and about her dreams of starting a water ice shop. “I got a business idea. I just want to do a couple classes and make sure that I have everything set so I’m not jumping into something over my head,” she said.

Julia Rendleman for Vox

If you had any medication that could halve death rates among heart disease or cancer patients or produce results like Ricciuti’s for other conditions, it’d be outrageous to not make it available to the people in need. And if the medication is proven to be better than other treatment options, then it would be downright unethical and immoral to not provide it through the health care system.

But with addiction, things aren’t so straightforward. A lot of people, including major addiction treatment providers and the former secretary of health and human services, question whether someone who takes any drug, including a medication, is truly in recovery. Instead, taking buprenorphine or methadone is often viewed as “substituting one drug with another.” By viewing a person’s struggles with addiction as a moral problem, it suddenly becomes possible to dispute the basic concept that medications can treat medical diseases and disorders.

Some of this is rooted in a genuine misconception of addiction: the myth that someone is addicted simply because he’s using drugs. But the problem with addiction isn’t drug use per se. The problem is when drug use turns compulsive and harmful — creating health risks, leading someone to neglect family and children, driving someone to commit crimes, and so on.

As Ricciuti’s story shows, buprenorphine addresses these issues by letting her get a handle on her drug use without such negative outcomes, even if it needs to be taken indefinitely. The medications don’t work for everyone, with data from France and Vermont suggesting that up to half of the people with opioid addictions won’t take up the medications even when they’re widely available. But helping just half the people in the US who are addicted to opioids would translate to potentially hundreds of thousands of lives saved over a decade.

Yet stigma remains, keeping these medications inaccessible. Federal data suggests, for example, that fewer than half of treatment facilities offer any opioid addiction medications. These are the facilities primarily tasked with offering addiction treatment in the US, and a majority don’t offer the best-known treatment for opioid addiction in the midst of an opioid crisis.

Health care systems still don’t do enough

The stigma and misconceptions run deep, culminating in a health care system that’s ill-equipped to treat addiction.

This applies to individual health care providers, who under federal law have to go through special courses to prescribe buprenorphine. According to the White House opioid commission’s 2017 report, 47 percent of US counties — and 72 percent of the most rural counties — have no physicians who can prescribe buprenorphine. Only about 5 percent of the nation’s doctors are licensed to prescribe buprenorphine.

It applies to emergency rooms, the great majority of which do little to nothing to treat addiction. The result is the equivalent of having a person come in with a heart attack, and telling them that they’re on their own — because the hospital doesn’t have any cardiologists or other specialists on-staff.

It applies to health care in other settings, such as prisons. When I surveyed state prison agencies about whether they offer medications for opioid addiction, for example, only Rhode Island — just one state — reported offering the three medications (buprenorphine, methadone, and naltrexone). That remains true to this day, although some states are now experimenting more with the idea.

It applies to health insurers, who often resist paying for addiction treatment. In Virginia, addiction treatment programs were notoriously underpaid by Medicaid, which covers low-income people, until recent reforms to the program boosted reimbursement rates — leading to both an increase in the number of people getting treated and a drop in ER visits for opioid use disorder, suggesting that there was a sizable population of underserved and undertreated people before.

Photos by Mandy; collage by Javier Zarracina/Vox

In Illinois, I also talked to one patient, Mandy, who struggled to get her private health insurer to pay for her buprenorphine prescription. As a result, Mandy had to shell out more than $200 a month out of pocket — until, after a lengthy appeals process, Blue Cross and Blue Shield of Illinois finally agreed to pay up.

There are, of course, problems with insurance companies refusing to pay for what they’re supposed to all the time, even outside the addiction space. But with addiction treatment, the problem is particularly bad, as demonstrated by the fact that these issues still surface time and time again even after the federal government and states passed laws effectively requiring insurers to cover addiction treatment.

At the core of each of these examples is the same problem: The health care system often isn’t doing even the bare minimum for addiction treatment, because we haven’t expected it to do anything about this issue — thanks to stigma and misconceptions — for as long as it has existed.

Once that expectation really changes, America will start to see notable progress in solving its opioid crisis. (Indeed, some of the states that saw declines in drug overdose deaths in 2017, like Vermont, Rhode Island, and Massachusetts, moved in this direction.) It’s not going to be easy; policymaking is still hard, health care systems are complex, and how it all works on the ground can get messy.

But it’s ultimately all rooted in a simple concept: approaching addiction treatment like any other form of health care.

A look back at my 2018 stories on opioids

I spent a lot of the year traveling, reporting, and writing about the opioid epidemic. If you want to dive deeper into the topic, here are some of the major stories I wrote this year:

• We really do have a solution to the opioid epidemic — and one state is showing it works: I traveled to Virginia to see how the state has reformed its Medicaid program to boost access to addiction treatment. The big finding: By boosting reimbursement rates, Virginia Medicaid appeared to get more people into addiction treatment and seemed to see fewer emergency room visits related to opioid addiction.
• How America’s prisons are fueling the opioid epidemic: I surveyed all 50 state prison agencies to find out whether they provided full access to medications for opioid addiction. Only Rhode Island did, and one early study indicated that the program helped cut overdose deaths among released inmates by more than half.
• America’s doctors can beat the opioid epidemic. Here’s how to get them on board: I went to New Mexico to see how Project ECHO helps train health care providers to offer opioid addiction treatment, particularly buprenorphine. Some of the barriers are stigma, but a lot of the problems are more typical misconceptions about addiction and how difficult it is to actually do this kind of work.
• Needle exchanges help combat the opioid crisis. But stigma remains: Needle exchanges are one of the most well-supported public health interventions, backed by decades of evidence and major health care organizations. But in Orange County, California, government officials forced the only needle exchange to close. The whole story offers a very important lesson in stigma towards people who use drugs and drug addiction.
• A Vermont needle exchange isn’t just giving out syringes. It’s offering treatment on the spot: As the opioid epidemic continues, more places are looking to make addiction treatment as accessible as possible. In Vermont, one needle exchange is even offering treatment on the spot — a rare, innovative approach. It’s an example of how the current crisis requires an all-hands-on-deck effort.
• Solving America’s painkiller paradox: One of the root causes of the opioid epidemic was the proliferation of painkiller prescriptions. But how do you pull back painkillers without hurting the pain patients who are truly benefiting from them? I talked to a bunch of experts about it, landing on a mix of solutions that involves nudging, not mandating, health care providers to prescribe less and offering better alternative treatments for pain in the longer term.

That’s just a small sample of some of the work I’ve done. For more, check out Vox’s hub page and storystream for the opioid epidemic. Thanks for reading!

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